Indonesia’s double burden

Joseph Cruickshank

Child playing in Raja Ampat, Indonesia – Iris Uijttewaal, Unsplash

When the BBC released an article titled, “Indonesia’s Papua Province children starving in a land of gold”, it could be said the area of focus was too limited. Across the resource-rich archipelago, increases of economic growth and income have not been enough to lessen Indonesia’s malnutrition crisis. A 2013 World Bank report indicated that 37.2% of young children in Indonesia are stunted – up from 35.6% in 2010 (Table 1). Yet undernutrition only represents half the story. It might surprise some readers that malnutrition includes individuals who are overweight and obese.  In Indonesia, such figures has doubled. This emergence of overnutrition, in the backdrop of stubborn rates of undernutrition, is Indonesia’s double burden. Solving the malnutrition crisis is a crucial step on Indonesia’s path towards development.

Malnutrition by age groups
Table 1: Malnutrition in Indonesia by age groups.
Source: The World Bank

Stunting is defined as being two standard deviations below the WHO Child Growth Standards median. In Indonesia, shortness is considered a hereditary norm. While being ‘short’ may not necessary be a problem – the relationship between a stunted child and their brain development is pernicious. Brain development is severely impacted by undernourishment, resulting in low grades and earnings across a lifetime. Yet being stunted as a child also puts them at higher risk of overnutrition in later life.  The child, whose body is accustomed to undernourishment, is at a greater risk of developing obesity and the associated non-communicable diseases, including heart-disease and diabetes in their adulthood.

“Stunted children with deficiencies
of iodine and iron may suffer
irreversible brain damage, impeding
them from reaching their complete
developmental potential.”

World Health Organisation 2018.

You would not be alone if ‘overweight’ or ‘obesity’ do not come to mind when thinking about Indonesia. From government bodies to NGOs, nutritional programmes have solely focused on undernutrition. While such programs are of tremendous importance, there is another emerging side to Indonesia’s malnutrition crisis: overnutrition. Today, 22% of Indonesian adults are overweight or obese. Yes, but overnutrition is disease of the rich, you could say, and yet ‘Gemukness’ (roughly translated as fatness) is increasing across all income groups in Indonesia (figure 1). 22% of adults in mall-dense Jakarta are considered ‘Gemuk’, roughly the same percentage as in Maluku, a region where poverty is double the national average.

Malnutrition and income

1: Levels of ‘Gemukness’ in Indonesian
women and men by income quantile, The World Bank.

The causes of Indonesia’s double burden are numerous.  Traditional customs for early marriage among Indonesian women (particularly in rural areas), put an end to her education and increase her children’s risk of being undernourished.  Cities in Indonesia are a hotbed for physical inactivity, with one study from researchers at Stanford University found that Indonesians walked the least of 46 countries studied (Readers who are familiar with an Indonesian city would not be surprised to hear this!). General increases in individual wealth across the nation have also led to consumption of processed foods high in complex sugars and fats.

Crowded streets in Bandung, Indonesia – Fikri Rasyid @fikrirasyid via Unsplash

Addressing malnutrition in Indonesia will require new thinking which addresses undernutrition and overnutrition and any link between the two.  Some recommendations are listed below:

  • Start with women: A woman who doesn’t have access to education, nutrition or proper health services is at a higher risk of having children who are malnourished.
  • Focus on the first 1,000 days: The first 1,000 days between a woman’s pregnancy and her child’s 2nd birthday provides an opportunity for the child’s brain development and immune systems to reach full potential.
  • Make Indonesian cities walkable:  Indonesia’s cities are made for cars and not for people. This leads to environments which are obesogenic.
  • Free-school lunches: Food helps students concentrate. For some students, a free lunch may be their only meal for the day.

Overcoming malnutrition is an investment for Indonesia’s future. While politicians and economists like to talk about Indonesia’s impeding ‘demographic dividend’ – the time when economic productivity will spike from a larger work force, malnutrition will only diminish such potential.  At level of the individual level,  the undernourished child, malnutrition is ultimately about limiting their potential, while its absence will be their freedom.

Yet Indonesia is only one of many regional countries that stand to gain from addressing malnutrition.

The 2018 Global Nutrition Report showed the issue of stunting is significant across Cambodia, Malaysia, Vietnam and Myanmar, with Malaysia also seeing 35 per cent of women become overweight. Nevertheless, the report concludes that we have never been better equipped to tackle malnutrition. As the number of people joining the middle class booms across ASEAN, awareness of healthier lifestyles is also expected to become more widespread. 

With concerted efforts from governments and popular support, we can hope to see a significant reduction in malnutrition across Southeast Asia in our lifetimes. ASEAN in particular can facilitate collaboration between the governments and the private sector to ensure greater availability and access to nutritious foods and the promotion of healthy food choices. 

Market Vegetables – Alexandr Podvalny, @freestockpro via Unsplash

About the Author

Joe is a recent graduate from the University of Sydney. He is based in Jakarta, Indonesia.


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