ReotN.712I I *BAPPENAS THE WORLD BANK OFFICE JAKARTA Indonesia Stock Exchange Building Tower 11/12-13th Fl. JI. Jend. Sudirman Kay. 52-53 Jakarta 12910 Tel: (6221) 5299-3000 Fax: (6221) 5299-3111 THE WORLD BANK The World Bank 1818 H Street N.W. Washington, D.C. 20433 USA Tel: (202) 458-1876 Fax: (202) 522-1557/1560 Email: feedback@worldbank.org Website: www.worldbank.org Printed in November 2013 Attribution - Please cite the work as follows: Shrimpton R. and C. Rokx, (2013) The Double Burden of Malnutrition in Indonesia, World Bank Jakarta, Report 76192-ID The Double Burden of Malnutrition in Indonesia is a product of staff of the World Bank. The findings, interpretation and conclusion expressed herein do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the government they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denomination and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement of acceptance of such boundaries. For any questions regarding this report, please contact Roger Shrimpton PhD. The Double Burdd.f Malnutrition in ric.n . Table of Contents Table of Contents Acknowledgements iv Acronymns v Glossary vii Executive Summary 1 Chapter 1 Introduction 5 1.1 What is the Double Burden of Malnutrition? 6 1.2 What are the consequences of the DBM? 7 Chapter 2 The Indonesian Context 9 2.1 The socio-demographic context 10 2.2 The political/administrative context 11 2.3 The economic context 11 Chapter 3 The Magnitude of the Malnutrition Problem 13 Chapter 4 Assessing the Causes of the Double Burden of Malnutrition 21 4.1 The health/biological environment 22 4.2 The economic/food environment 26 4.3 The physical/built environment 35 4.4 The socio-cultural environment 37 Chapter 5 Nutrition Capacity and Governance 41 Chapter 6 Conclusions 51 Chapter 7 Suggested Policy Actions for Consideration 55 References 58 Indonesia Health Sector Review Table of Contents List of Figure Figure 1. The Indonesian Archipelago 10 Figure 2. The levels of gemukness (BMI >25) in Indonesian men and women by income quintile (Riskesdas 2010) 17 Figure 3. Percentage of overweight and underweight in men and women over 45 years of age in Indonesian Family Life Surveys 18 Figure 4. Anaemia (% <12g Hb/dl) in adults (25-44 years) of the Indonesian Family Life Surveys in the last decade 19 Figure 5. Causes of Death (%) in Indonesia 1995-2007 23 Figure 6. Hypertension (%) in adults from the 2007 Indonesia Family Life Surveys 24 Figure 7. Prevalence of insufficient activity in the Indonesian population above ten years of age in 2007, by age group 37 Figure 8. The four essential functions of the nutrition system 42 List of Table Table 1. Malnutrition in Indonesia by age groups 14 Table 2. Provincial malnutrition rates by age group 16 Table 3. Comparison of indicators of obesity in adults in Indonesia across various demographic categories 17 Table 4. Indonesia's Food Balance sheet: Availability of food at the national level by year 27 Table 5. Average Daily per Capita Consumption of Energy (KCal) by Commodity Group 1999, 2002-2011 32 Table 6. WHO Recommended Population Nutrient Intake Goals 33 Table 7. Programme interventions for tackling the DBM across the life course 44 Table 8. The Four Overarching Pillars of DBM Nutrition Policy Framework 49 The Double Burden of Malnutrition in Indonesia Acknowledgernents Acknowledgements This paper was prepared by Professor Roger Shrimpton (Nutrition Expert) and Claudia Rokx (Lead Health Specialist, ECSH1), with substantial inputs and guidance from Leslie Elder (Senior Nutrition Specialist, HNPHE). Overall support was provided by Darren Dorkin (Senior Operations Officer, EASHH), Puti Marzoeki (Senior Health Specialist, EASHH), Rebekah Pinto (Human Development Consultant, EASHD) and Eko Pambudi (Research Analyst, EASHH). The team is grateful for the valuable technical assistance to the paper from Sonia Blaney (UNICEF) and to Megha Kapoor and Christina Sukmawati for editorial and production support. This work is based on interviews with key actors in Jakarta and Yogyakarta in late 2011, the assessment builds on the Government of Indonesia's Landscape Analysis Country Assessment (LACA) report completed in 2010 to examine the Indonesian situation and offer policy actions to help prevent and mitigate the Double Burden of Malnutrition (DBM) problems across the life course. The report was reviewed and approved by Indonesian stakeholders (policy makers and academics) in March 2012. The team would like to thank the Indonesian government for its excellent guidance on this paper and its recommendations. In particular, the team benefited from the guidance received from Dr. Nina Sardjunani, Deputy Minister for Human Resources and Cultural Affairs, State Ministry for National Development Planning (Bappenas), Dr. Minarto, Head of Nutrition, Ministry of Health, Dr. Soekirman and Dr. Fasli Jalal. This work also benefited from the discussion held under the SUN initiative. Special thanks are due to the Millennium Challenge Corporation (MCC) for financing the work. The work was conducted under the overall guidance of Toomas Palu, Sector Manager for Health, the East Asia and Pacific region. Indonesia Health Sector Review Acronymns Acronymns BAPPENAS Badan Perencanaan dan Pembangunan Nasional (Indonesian State Ministry of National Development Planning) BFHI Baby Friendly Hospital Initiative BMI Body mass index BMR Basal metabolic rate BPS Baden Pusat Statistics (Indonesia National Statistics Bureau) BULOG Badan Urusan Logistik (The Indonesian Bureau of Logistics) CED Chronic energy deficiency CONSEA Conselho Nacional de Segurana Alimentar e Nutricional (Brazilian National Council on Food and Nutrition Security) CVD Cardiovascular disease DBM Double burden of malnutrition DepSos Departemen Sosial (The Indonesian Ministry of Social Affairs) DPAS Global Strategy on Diet, Physical Activity and Health DPD Dewan Perwakilan Daerah, (Indonesian Regional Representative Council) DPR Dewan Perwakilan Rakyat (Indonesian People's Representative Council) FAO Food and Agriculture Organization of the United Nations FOAD Fetal origins of adult disease FPI Food Price Index of the FAO GATT General Agreement on Tariffs and Trade GDP Gross domestic product GOI Government of Indonesia ICN International Conference on Nutrition IMF International Monetary Fund INACG International Nutritional Anaemia Consultative Group LACA Landscape Analysis Country Assessment LBW Low birth weight LIFDC Low income food deficit country LMICs Low- and middle-income countries MDGs Millennium Development Goals MMS Multiple micronutrient supplementation MOH Ministry of Health MPR People's Consultative Assembly MUAC Mid-upper arm circumference NCDs Noncommunicable diseases NFSI Nutrition Friendly Schools Initiative NGO Nongovernmental organization NPAN National Plans of Action for Nutrition NSP Non-starch polysaccharides NTT East Nusa Tenggara PA Physical activity PCM Protein calorie malnutrition PKH Program Keluarga Harapan (Indonesian Hopeful Family Programme) PMTAS Pemberian Makanan Tambahan Anak Sekolah (Indonesian School Meals Programme) The Double Burden of Malnutrition in Indonesia Acronymns PNPM Program Nasional Pemberdayaan Masyarakat (Indonesian National Program for Community Empowerment) POSYANDU Pos Pelayanan Terpadu (Integrated Service Delivery Post) PUFAs Polyunsaturated fatty acids PUGS Pedoman Umum Gizi Seimbang (Indonesian Common Guide to Balanced Nutrition) RANPG Rencana Aksi Nasional Pangan dan Gizi (Indonesian National Action Plan for Food and Nutrition) RASKIN Beras masyarakat miskin (Indonesian Rice for the Poor Programme) RPJMD Rencana Pembangunan Jangka Menengah Daerah (Medium-Term Regional Development Plan) RPJMN Rencana Pembangunan Jangka Menengah Nasional (Medium-Term National Development Plan) SAPs Structural Adjustment Programmes SUN Scaling Up Nutrition TEF Thermic effect of food TFCs Transnational food corporations TVRI Televisi Republik Indonesia UIE Urinary iodine excretion UNICEF The United Nations Children's Fund VAD Vitamin A deficiency WC Waist circumference WHA World Health Assembly WHO World Health Organization WHR Waist to hip ratio WTO World Trade Organization YKAI Indonesian Children's Welfare Institute Indonesia Health Sector Review Glossary Glossary Acute phase proteins A class of proteins whose plasma concentrations increase or decrease in response to inflammation Adiponectin A hormone produced by adipose (fat) tissue that influences the metabolism of lipids and glucose Adiposity The quality or state of being fat Atherogenic Tending to promote the formation of fatty plaques in the arteries Atherosclerotic lesions A deposit or degenerative accumulation of lipid-containing plaques on the innermost layer of the wall of an artery Chemokines Cytokines with various immunoregulatory functions, including attracting white blood cells to sites of infection Cortisol Known more formally as hydrocortisone; a steroid hormone that is released in response to stress and a low level of blood glucocorticoids Cytokines Substances, such as interferon, interleukin, and growth factors, that are secreted by certain cells of the immune system and have an effect on other cells Disaccharides Sugars whose molecules contain two monosaccharide residues Dyslipidaemia High triglyceride and low LDL cholesterol levels in blood Epigenetic Resulting from external rather than genetic influences Gemuk Overweight/obese or"Fat" in Indonesian. Gemukness Deliberately unspecific term meaning overweight/obesity but in the Indonesian context where BMI cut-offs are probably much lower than 25/30. Gemukness is'hidden fatness' Gizi buruk Severe undernutrition (marasmus/kwashiorkor) HDL cholesterol High-density lipoproteins, a.k.a. the "good" cholesterol Hydrolysation The chemical reaction of a compound with water, usually resulting in the formation of one or more new compounds Hypercholesterolemia High blood cholesterol levels Hyperglycaemia High blood sugar levels Hypertension High blood pressure Hypertriglyceridemia High blood levels of triglycerides, the most abundant fatty molecule in most organisms Impaired glucose A pre-diabetic state of hyperglycaemia that is associated with insulin resistance and tolerance increased risk of cardiovascular disease Inflammatory state of A low-grade, chronic inflammation orchestrated by metabolic cells in response to excess obesity nutrients and energy Insulin resistance A name for a group of risk factors that occur together and increase the risk for coronary syndrome artery disease, stroke, and type 2 diabetes Ischaemic heart A disease characterized by reduced blood supply to the heart disease LDL cholesterol Low-density lipoproteins; a.k.a. the"bad" cholesterol Leptin A protein hormone that plays a key role in regulating energy intake and energy expenditure Metabolic syndrome Comprises a group of risk factors including abdominal obesity, dyslipidaemia, hypertension, and impaired glucose tolerance Monosaccharide Sugars (e.g., glucose) that cannot be hydrolysed to give a simpler sugar Myocardial infarction Irreversible injury to the heart muscle (heart attack) Obesogenic Factors tending to make individuals fat, such as environments that promote decreased physical activity and/or increased intake of energy dense foods Obesity A medical condition in which excess body fat reduces life expectancy and/or causes increased health problems The Double Burden of Malnutrition in Indonesia Glossary Overweight Having more body fat than is optimally healthy Pathophysiological Changes or alterations in function that accompany a particular syndrome or disease Postprandial During or relating to the period after a meal Stunting Excessively short, or below minus two standard deviations from median height for age of reference population Underweight Below minus two standard deviations from median weight for age of reference population Wasting Excessively thin, or below minus two standard deviations from median weight for height of reference population White adipocytes White fat cells White adipose tissue White fat Indonesia Health Sector Review Executive Summary Executive Summary The Double Burden of Malnutrition and Its Consequences A concept first presented just over a decade ago, the DBM is the coexistence of undernutrition and overnutrition of macronutrients and micronutrients across the life course in the same population, community, family and even individual. Of particular concern is the life-course dimension of the DBM, or the link between maternal and fetal undernutrition and increased susceptibility to overnutrition and diet related non communicable diseases later in life. The DBM is a global problem that affects rich and poor countries alike: 25% of the world's population is overweight, while 17% of pre-school children are underweight and 28.5% are stunted, 40% of women of reproductive age have anaemia, and one-third of the global population still suffers from iodine deficiency. Most lower-middle income countries (LMICs) are considered to be affected by the DBM, with overweight increasing faster than underweight is decreasing in most of them. While obesity has doubled globally in the last three decades, it has tripled in LMICs in just two decades. The consequences of the DBM are grave and manifest across the life course. Overall country development, improved water and sanitation practices, and increased vaccine coverage mean that more children are likely to survive their first two years of life, even if they have suffered undernutrition. For those that survive this critical period, however, the damage done by this early interval of undernutrition is seen throughout the life course. When this stunted length growth is followed by accelerated weight growth later in life, there is an increased risk for obesity and other diet-related NCDs, such as Type 2 diabetes and cardiovascular disease, later in life. NCDs are responsible for the majority of deaths worldwide, and are disproportionately high in LMICs, where nearly 80% of all NCD deaths occur. Indonesia's DBM problem is urgent There is evidence of overweight and underweight among young children, indicating that the DBM is already a concern in Indonesia. Stunting is the principal nutrition concern, a fact made more troubling given the links between early stunting and the risk of NCDs later in the life course, which are now the majority of the disease burden in Indonesia. This link between stunting and NCDs is not yet well understood or addressed by health workers and policy makers. Traditionally, Indonesia has prioritized undernutrition, paying special attention to "Gizi Buruk" or severe underweight as a way tojudge the national nutritional situation. However, by this measure alone, nutritional issues appear largely resolved, as the prevalence of gizi burukis just 5.4% in children under-five. That 36% of children under five are stunted is of greater concern given the lifelong consequences. The Indonesian Family Life Surveys, representative of 85% of the population, indicate that over a fifteen year period, the proportion of thin men and women decreased considerably while the proportion of "gemuk" (obese/overweight) men and women nearly doubled. This suggests that underweight is declining and overweight is increasing in Indonesian adults, much like it is in Indonesian children, where rates of"Gemuk" in the younger children (=27.0, which would seem appropriate for an Asian country since it is recognized that the international cut-off for obesity of 30.0 is unlikely to be applicable in Asian settingS52. However, the BMI >= 25 used to define overweight in Riskesdas is notbappropriate.The Indonesian Society for the Studyof Obesity has suggested that the BMI cut-off for obesity in Indonesia should be 25reg may and WHO has recommended a Indonesia Health Sector Review Chapter 3 The Magnitude of the Malnutrition Problem BMI >= 23 kg/M2 as the trigger for public health concern (i.e. the definition of overweight) for use in Asian populationss. More recent work has suggested the BMI cut-off for overweight in the Asia Pacific region should be >= 2156. Furthermore, the risk of hypertension appears to be greater for Indonesians than for Chinese and Vietnamese with the same BMI11. National averages hide the enormous variability of the malnutrition problem across Indonesia. In Table 2, the indicators of adequacy of physical growth by age group are listed by province. In order to rank the provinces in terms of the severity of their DBM problems, the rates of low birth weight (LBW), stunting, wasting and gemuk were categorized arbitrarily into three groups and given a colour code. For low birth weight: Best <10% (green), Medium >=10% to 15 %< (yellow), Worst >=1 5% (red); For wasting and gemukness: Best <10% (green), Medium >=1 0% to 15 %< (yellow), Worst >=1 5% (red), Really Worst >= 25% (blue); and for stunting: Best <30% (green), Medium >=30% to 40% < (yellow), Worst >=40% (red). East Nusa Tenggara (NTT) has the highest low birth weight rate in Indonesia at 19%, and there are ten provinces with a rate above 15%. NTT is also the province with the highest prevalence of stunting at 58%, and there are seven provinces with a stunting prevalence over 40%, categorized by WHO as "very high'. Young child wasting rates are also high, with eighteen provinces with a prevalence above 15%, which is considered by the WHO to be an emergency situation necessitating supplementary feeding programmes. Yet ten provinces also have young child gemuk rates over 15%, and in three provinces - Riau, Bengkulu, and Sulawesi Tengarra - both young child wasting and gemuk rates are over 15%. Adult gemukness is over 15% in all provinces except one (NTT) and is over 25% in eight (Sumatra Barat, Bangka Belitung, Kepuluhan Riau, Kalimantan Timur, Sulawesi Utara, and Gorontalo, Maluku and Maluku Utara). Although the problem of undernutrition early in the life course is of greater proportion in the outer islands than on Java, the rates of adult overweight/obesity are also of a similar if not greater magnitude on the outer islands. So while the largest concentration of gemukness is in Java, due to the size of the population, the greater DBM problem is in the outer islands where poverty rates are higher. In the outer islands, poor maternal and young child nutrition contributes to the increased risk of gemukness later in the life course among the increasing numbers of adults that survive childhood undernutrition and move to more obesogenic urban environments. Maternal undernutrition is an issue in Indonesia, as the Riskesdas 2007 data indicated that 14% of women have chronic energy deficiency as measured by mid-upper arm circumference (MUAC) <23.5 cm. Although this represents a decline in prevalence from the 2003 level of 17%, the prevalence remains greater than 15% in eight provinces. According to WHO", prevalence between 10-19% is considered a medium prevalence, indicating a poor nutrition situation. The problem with obesity in adulthood is not just the amount of body fat; it is the distribution of fat in the body that determines the associated health risks. Abdominal or visceral fat in adults appears to be more strongly associated with the cardiovascular risk factors of the metabolic syndrome. Waist circumference (WC) is the simple clinical measure for measuring abdominal fat and the one recommended for population assessment of the obesity risks of coronary heart disease, which include type 2 diabetes, impaired glucose tolerance, hypertension and dyslipidaemia. Areviewof the literature concerning the appropriateness of indicators for defining excess body weight found that measures of central obesity were more strongly associated with type 2 diabetes compared to body mass index (BMI), although this was not the case for hypertension and dyslipidaemia, which were similar for BMI, WC and waist to hip ratio (WHR)s". Furthermore, in Asia it has been recommended to use a WC cut-off of 90 centimetres for men and 80 centimetres for women60. A more recent publication suggests that a cut-off of 90 is equivalent to a BMI of 30 (i.e. obesity), and that a pre-obese or overweight category of WC is needed, which should be >84 and <90 centimetres, as the risk of CVD already increases from here in Asian populations". The Double Burden of Malnutrition in Indonesia Chapter 3 The Magnitude of the Malnutrition Problern Table 2. Provincial malnutrition rates by age group Sumnatera 39.8 14.0 12. 10.5 Utara Sumnatera 32.8 36.2 39.7 33.0 11.0 128 10.1 14.1 Barat Sumnatera 11437.8 32.9 146 10.7 10214.9 11.4 Selatan Bangka 10433.3 9.8 1. Belitung Kepuluan 1.1 33.9 105n1.r1. Riau Nusa 39at3 .6 3 3.7 13.9 11.9 02 1 00 12.54. JaTenga39 3. 3. 42 1. 1. 40 1. Nusa 3. 3.713.2 1. 1193. Tenggara Timur Kalimantan 13.9 39.7 14.6 14.6 14.7 10.8 Barat Kalimantan 39.6 13.4 8.4 12.1 Tengah Kalimantan 35 .3 Selatan Kalimantan 35.8 12.9 13.3 Timur Sulawesi 13.8 33.1# Utara Sulawesi 36.2 37.7 3. 14.8 11.5 102 10.2 Tengah Sulawesi 38.9 0 36.3 39.1 12.0 12.6 13.6 13.6 14.6 Selatan Selawesi 10.4 37.8 1.0 10.0 10.9 14.7 Tenggara Sulawesi 1.12911.8 Barat Source: Riskesdas 2010 Indonesia Health Sector Review Chapter 3 The Magnitude of the Malnutrition Problem Table 3. Comparison of indicators of obesity in AS Shown in Table 3, the Riskesdas 2007 adults in Indonesia across various demographic collected WC data, and using the Asia categories appropriate cut-offs, found that 19% of the Category Central Obesity Overweight populationover5yearsofagehadexcessive (WC abdominal fat, a rate similar to that of Female overweight/obesity based on BMI in adults. Age group 15-24 8.0 6.1 Obesity levels were greater in women (29%) than (years) 25-34 17.9 18.8 in men (8%), and increased with age (peaking at 35-44 24.4 26.4 26% in the 45-54 year age group) as well as 45-54 26.1 26.0 educational level, with 26% of higher education 55-64 23.1 19.6 graduates so affected. Housewives were the 65-74 18.9 12.6 workforce category most affected (36%) as were 75+ 15.8 7.7 urban dwellers (24%) in comparison to rural ones Gender male 7.7 13.0 (15%). female 29.0 22.8 Gemukness is not just a problem for the Residence Urban 23.6 22.7 wealthy. As shown in Figure 2, although the rates Rural 15.7 14.5 of gemukness increase with income, peaking at 23% in the upper wealth quintile, the lower wealth quintiles were also affected. Indeed there was little difference in the obesity rates in the bottom four wealth quintiles, such that the largest volume of obesity is in the poorer wealth segments of the population. Figure 2. The levels of gemukness (BMI >25) in Another source of information which shows Indonesian men and women by income quintile how the problem of gemukness has increased (Riskes2as 2010) in the last few decades is provided by the 40 Indonesian Family Life Surveys2. These surveys 35 were carried out in 321 communities in 13 30 Men provinces from 1993 through 2007, and are 25 Rd women considered to be representative of 85% of the 20 Indonesian population. As shown in Figure 3, over 15 the fifteen-year period the proportion of 10 underweight men and women (BMI<18.5) 5 decreased considerably while the proportion of gemuk men and women (BMI>25) almost doubled. Quitile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 There were more gemuk and underweight women Source: Riskesdas 2010 than gemuk and underweight men at all times, and the greatest increase was in gemuk women. We can conclude that underweight is declining and overweight is increasing in Indonesian adults,just as it is in under-five year old children.This is a global trend that is seen in most other LMICSa3. Micronutrient deficiencies are also common in Indonesia. A decade ago at least half of the population was considered to be suffering a deficiency of at least one micronutrient4. Vitamin A deficiency (VAD) was common in Indonesia until twice-yearly massive dose capsule distribution began in the seventies. By 1992 the clinical signs of VAD (xeropthalmia) were reduced to 0.33%, a level no longer considered to be a public health problem, even though 50% of children under five still had low serum retinol levels. Riskesdlas 2007 found that 72% of children 6-59 months old received a massive dose capsule during the last campaign, and Riskesdas 2010 reported that 52% of young mothers reported getting a massive dose vitamin A capsule during the birth of their last child in the last five years. There have been no further national representative serum retinol studies, however, so the current situation for VAD is not known. The Double Burden of Malnutrition in Indonesia Chapter 3 The Magnitude of the Malnutrition Problem Figure 3. Percentage of overweight and Iron deficiency, although still very common, underweight in men and women over 45 years of does seem to be improving. Anaemia affected age in Indonesian Family Life Surveys 50% of pregnant women in Riskesdas 1995, and 35 40% of pregnant women in Riskesdas 2001. The 31993 m1997 m2000 m2007 2007 Riskesdas data indicated that in urban areas 30 20% of non-pregnant women of reproductive age 25 (>14y) (<12gHb/dl), 13% of men (>14y) were 20 anaemic (<13gHb/dl), and 10% of children (<14y) 15 were anaemic ((<1lgHb/dl). Even though not entirely comparable data, this suggests that there 10 has been considerable improvement in the 5 prevalence of anaemia during the last two 0 decades. This improvement is further supported underweight overweight underweight overweight by the anaemia results obtained from the men men women women Indonesia Family Life Survey, which is summarized Source: Indonesia Family Life Survey 1993, 1997, 2000,2007 in Figure 4 below. This improvement may be the consequence of the consumption of foods made from iron fortified wheat flour, which was mandated in 2000, as discussed elsewhere in this report. The cut-offs for anaemia used in the Indonesian Family Life Survey are not the same as those used in the Riskesdas surveys, so cross study comparisons are not strictly possible, but both indicate a trend towards reduction of anaemia prevalence in adults. Despite this improvement, a quarter of women were still anaemic in 2007, although few men were so affected. Riskesdas 2010 reported that although 81% of women received iron/folic acid tablets during their last pregnancy, only 18% took at least 90 tablets during the last trimester of pregnancy as recommended by the Ministry of Health. Although iron deficiency has improved it is still a matter of concern. During the 1997/1998 financial crisis, mothers were the first to show signs of undernutrition, as reflected in increased prevalence of anaemia associated with reduced consumption of high quality food. This was also associated with increased wasting in their children born during this period6". A more recent study has suggested that 20% of early neonatal deaths in Indonesia could be attributed toa lackof iron and folic acid supplementation during pregnancy66 Part of the anaemia problem and its persistence is also likely to be related to the high rates of gastrointestinal parasite infestations, as has been shown in Central Java7. Iodine deficiency also used to be a serious problem in Indonesia. Since the 1980s, considerable investments have been made toward achieving universal salt iodation; consequently, the prevalence of clinical iodine deficiency in school children dropped from 28% in 1998 to 10.0% in 1999. Since then further urinary iodine surveys suggest a general improvement in iodine intake over the last two decades. While national median urinary iodine level was 146 pg/L in 1998, it rose to 229 pg/L in 2003. At that time it was found that 23% of school children still had inadequate urinary iodine levels6. This same level had been maintained in 2007 when Riskesdas data indicated a national median urinary iodine excretion (UIE) of 229 pg/L. In addition the distribution curve for UIE appears to be shifting to the right and narrowing6, which suggests that improvements are not due to excessively high intakes of iodine. However, Riskesdas 2007 still found that although 92% of households consumed iodized salt, only 62% consumed adequately iodized salt (>1 5ppm iodine). A study among urban families in Indonesia in 2004 found that non-use of adequately iodized salt was associated with a higher prevalence of child malnutrition and mortality in neonates, infants, and children under five years of age1o. Studies elsewhere in Asia have shown that the consumption of iodized salt improves birth weight7l, which helps to explain these findings. Much still remains to be done to eliminate iodine deficiency in Indonesia. Indonesia Health Sector Review Chapter 3 The Magnitude of the Malnutrition Problem Figure 4. Anaemia (% <12g Hb/dl) in adults (25-44 Among other micronutrients, zinc may be years) of the Indonesian Family Life Surveys in the deficient in the Indonesian population. last decade Although there are no population based surveys 45 E men to confirm this, a study of lactating mothers in 40 Ewomen East Jakarta found that while 40% were anaemic, 3 adults 29% had a low plasma zinc concentration, and 30 24% had a moderately low plasma vitamin A 25 concentration. Breast milk from 70% of the 20 women had a low concentration of vitamin A, and 25- 10 66% had a low concentration of zinC72 . A study of lactating mothers and their infants in West Java 0 found that 17% of the infants and 25% of the 1997 2000 2007 mothers were zinc deficient, together with Source: Indonesia Family Life Survey 1997, 2000, 2007 marginal vitamin A deficiency in 54% of the infants and 18% of the mothers, and anaemia in more than 50% of the mothers and infantS73 . Furthermore, in the same location, addition of zinc to standard iron and folic acid supplements for mothers during pregnancy reduced the number of diarrhoeal episodes in their infants during the first six months of lifeJ7. In another trial of zinc and beta-carotene supplementation during pregnancy, plasma retinol concentrations were higher six months postpartum in the women who received zinc during pregnancy than in women who did not7l. Infants born to mothers supplemented with beta-caroteneand zinc had higher plasma retinol concentrations, with the frequency of vitamin Adeficiency reduced byover 30% compared with theotherthreegroups. Studies in children showed that supplementation of zinc-iron, but not zinc alone, increased linear growth of stunted infants with low haenoglobin in Nusa Tengara Barat province 7 while zinc amlone and iron alone but not the two together improved linear growth in infants in Java77. Wheat flour has been fortified with zinc since 2002 and although fortified flour is known to improve zinc statuS7 there are no survey data yet which confirm this. The Double Burden of Malnutrition in Indonesia Chapter 3 The Magnitude of the Malnutrition Problem Indonesia Health Sector Review Chapter 4 Assessing the Causes of the Double Burden of MaInutrition Chapter 4 Assessing the Causes of the Double Burden of Malnutrition Understanding the risks associated with and the causes of the double burden of malnutrition (DBM) is not an easy task, not only because of the complexity of the issue, but also because of the rapidly evolving situation in most low- and middle-income countries (LMICs). The conceptual framework proposed by UNICEF79 in 1990 for analysing the causality of child undernutrition is now widely accepted and used globally, but it is not easily adapted to analysing the causality of both forms of malnutrition across the life course, especially considering that early life course undernutrition can facilitate overnutrition later in the life course. The life course approach to understanding chronic disease epidemiology is recognized to be methodologically challengingo. The difficulty is in separating out the joint neighbourhood effects of exposure to parent and offspring, as well as the sensitive periods later in the life course when changes are more plastic and some degree of mitigation may be possible. Various models have been proposed for trying to understand the causality of obesity. These examine how both human biology and the environments which populations inhabit can affect behavioural patterns and body composition81 82, with individual level factors as well as the socio-political, socio-cultural, socio- economic and socio-environmental contexts. A system map of obesity developed by the Foresight project in the UK has over one hundred variables with either direct or indirect influence on energy balance". These variables can be grouped into four crosscutting themes, which include: 1) the biological/health environment, consisting of an individual's starting point including the influence of genetics and ill health; 2) the economic/food environment, including factors which influence the availability and quality of food near to home as well as economic access to food which influences consumption; 3) the physical/built environment, including factors influencing individual activity behaviour; the type, frequency, and intensity of activity; and access to "healthy" food; and 4) the socio-cultural environment, including the influence of media, education, peer pressure or culture and how these impact individuals'drive for particular foods and consumption patterns, or physical activity patterns or preferences. None of these four themes are necessarily dependent on any other, especially because each may be operating differently at different times across the life course. In the analysis that follows, these four themes are used to categorize the DBM problem from a life course perspective. DBM issues are considered during the window of opportunity from conception to toddlerhood, as well as the period from childhood to adolescence, including issues of teenage pregnancy. 4.1 The health/biological environment The health/ biological environment is an individual's starting point, and includes the influence of diseases as well as genetic influences. As mentioned previously, Indonesia is well advanced in its demographic transition and has an ageing population with life expectancy improving from 48 years in 1970, to 62 years in 1990 and 68 years in 2009. In association with the demographic transition, the epidemiological transition is also underway. Infectious diseases were replaced by noncommunicable diseases (NCDs) as the most important causes of disability and mortality around the turn of the millennium. These health transitions are the results of many changes, including urban infrastructures and the changing patterns of work and travel associated with industrialization. 4.1.1 The health system and the disease burden The availability of health facilities and of water and sanitation services in Indonesia, although still with room for improvement, has made great progress to date. The relatively good distribution of health facilities in Indonesia was achieved during the 1980s and 1990s through the establishment of public hospitals at the district level and public health centres at the sub-district level, both staffed through a system of compulsory service for doctors, nurses and midwives. Indonesia's subsequent health policy, which emphasized giving priority to primary healthcare and boosting expenditures for health, has resulted in overall increases in public facilities and workforce numbers since the mid-1990s8. More recently, and especially since decentralization, these public sector staff also established solo-provider facilities for their Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition own private practice; these solo-provider facilities, of which nurses contribute almost half, comprise the largest category of outpatient care facilities, although most are not included in official statistics"". According to Riskesdas 2010, coverage of immunizations in children aged 12-23 months was 78% for BCG, 67% for polio, 62% for DPT-HB, and 74% for measles. While 57% of recent births were performed in health facilities, only 55% were by trained health personnel and 39% of those mothers had never had Tetanus Toxoid immunizations. Only 18% of women aged 10-59 years had never used contraception, 56% were currently using contraception, and the unmet need for family planning was only 14%.The population using improved drinking water sources increased from 72% in 1990 to 80% in 2006, while those using an improved sanitation facility only increased from 51% to 52%. The prevalence of gastrointestinal parasites is still high, with positivity rates among children reported in published literature varying from 60% to 90% 86 87 88 89 Figure 5. Causes of Death (%) in Indonesia 1995- The infant mortality ratio is reasonably low at 2007 34 per thousand live births, while the maternal mortality ratio is still moderately high at 228 Injuries per 100 thousand live birs According to Riskesdlas 2010, the proportion of total mortality Non-Communicable caused by NCDs in Indonesia surpassed that of diseases the communicable diseases around the turn of Communicable 0 2007 the millennium, and in 2007 NCDs accounted for Diseasesvirtually 60% of mortality, as shown in Figure 5. Diseaes U2001 Cardiovascular disease accounted for 31% of all perinatal/maternal 0n1995 NCD deaths, followed by cancer (13%), Chronic disorders Obstructive Pulmonary Disease (7%) and diabetes (3%)91. Stroke was the leading cause of death at 0 20 40 60 80 15%, followed by tuberculosis (7%), which was Source: Riskesclas 2010 the most common communicable disease cause of mortality. Although obesity does not figure in the list, this is probably because it is considered to be a risk factor or an underlying cause rather than a disease. The Landscape Analysis Country Assessment (LACA) report uncovered the limited capacity of the Indonesian health system for implementing nutrition interventions aimed at improving maternal and child undernutrition, and highlighted the lack of awareness both of stunting and of overweight/ obesity as problems among health professionals. Indeed there is considerable debate in the literature over whether or not obesity is a disease. Obesity has been described by some as the disease of the twenty first century92, but others have questioned the scientific basis for this, claiming that obesity lacks the symptoms and impairments of function that warrant characterization as a disease9(. Opponents argue that obesity is not a disease because it results from a person's chosen lifestyle, eating habits, and environment (i.e. residential location, social circle, economic status). Proponents stress that obesity is a disease because it is caused by genetics, biological factors or illnesses that cause weight gain, and by obesogenic environments. None of these arguments adequately convey the pending threat wrought by vast numbers of stunted impoverished people in today's LMICs that are now and will increasingly be exposed to obesogenic urban environments, particularly after suffering from constrained fetal and infant growth. Unless LMICs such as Indonesia treat obesity, or gemukness, as a disease, a health disaster of diet-related NCDs will surely unfold and the poorest will suffer most because they will not be able to pay for treatment. 4.1.2 Biological aspects Blood lipid levels are already considerably deranged at the population level in Indonesia. The most extensive data on blood lipid levels is provided by the Indonesia Family Life Surveys of 2007, which showed that women seem to be more affected by dyslipidemia than men. Of those aged 45 years and older, 22% of The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition women and 11% of men had high cholesterol levels, while 67% of men and 40% of women had low levels of HDL (high-density lipoprotein) cholesterol. These levels were the same across the life course in men, but the percentage of women with high total cholesterol doubled after 44 years of age and then remained the same. A study looking at the plasma lipid profiles of four Indonesian ethnic groups (Minangkabau, Sundanese, Javanese and Buginese) found that Minangkabau women over 40 years of age had the highest mean plasma total cholesterol (209.77 mg/dl) and LDL (low-density lipoprotein) cholesterol (146.02 mg/ dl), and the highest prevalence of dyslipidaemia based on category risk level of total and LDL cholesterol94. Diabetes is also a growing concern in Indonesia, as Riskesdas 2007 found that 5.7% of the population over 15 years of age had diabetes and 10.2% was pre-diabetic with an impaired glucose tolerance based on early morning blood samples taken before eating any food. Fortunately the importance of gemukness as being central to the problems of type 2 diabetes in Indonesia is already recognized by some experts, as is as the role of leptin and of the inflammatory state of obesity in adipose cell and energy metabolism95. The prevalence of the metabolic syndrome among adults was 28.4% in five areas of Jakarta in 2006, with no difference of prevalence between men and women.The prevalence of the metabolic syndrome increased with age, central obesity, and the level of glucose intolerance. The component most commonly found in men was hypertension while in women it was central obesity96. The only large study data on hypertension comes from the Indonesia Family Life Surveys indicating between 45.8% of men 53.4% of women over 45 years of age affected in 2007, with little change over the previous decade. As shown in Figure 6, hypertension is not only worse in women but it increases considerably with age, with three-quarters of women over 75 years of age affected. What is most concerning about the high prevalence of hypertension affecting the majority of Indonesian adults over 45 years age is that only 40% of women and 20% of men knew they had the condition, and more than 90% of them were not taking any medication. Obesity is associated with many impaired functions that classify it as a disease. These are related to alterations in the metabolism of steroid hormones, metabolic alterations including lipid and glucose levels, and increases in the turnover of free fatty acids that lead to insulin resistance syndrome97 98 99 10. In addition, excess adiposity has been linked to impaired immune function due to the increased cortisol secretion10, possibly influencing the adverse pathophysiological effects of environmental and psychological stress. Vitamin D insufficiency has also been found to be associated with the metabolic syndrome in a variety of different populations102 103, but whether there is any causality in the relationships and which direction that causality goes is as yet unclear. Figure 6. Hypertension (%) in adults from the 2007 While obesity is fundamentally a problem of Indonesia Family Life Surveys energy balance and, as such, can only develop 80 when energy (food) intake is in excess of total 70 energy expenditure, it is important to Emen recognize that the metabolic mechanisms 60 involved seem more suited to a hunter- 50 U women gatherer lifestyle than man's modern day 40 existence. Differences between intake and 30 expenditure are primarily buffered by changes in the amount of lipid deposited in the specialized 20 fuel storage organ, white adipose tissue (or white 10 fat) 104. White adipose tissue, and especially that in 0 visceral fat, is now recognized as the source of key 25-44y 45-54y 55-64y 65-74y 75+y hormones that play an important role in the Source: Indonesia Family Life Survey 2007 regulation of energy balance - particularly leptin - and a diverse range of protein factors and e rIndonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition signals termed "adipokines" which are involved in overall metabolic regulation. It seems that the decreased circulating leptin observed during energy restriction is related to increased sensations of hunger in human subjects. Obesity is also associated with a general state of inflammation, which appears to be part of the energy control mechanisms, but which can have far reaching consequences. A number of inflammation-related proteins are released by white adipocytes, as well as adiponectin, and these include cytokines, chemokines and acute phase proteins. It has been proposed that the inflammation of obesity is part of a mechanism for controlling energy metabolism'o during situations of energy imbalance, by controlling body fat distribution between subcutaneous and visceral fat06. The inflammatory state of obesity also seems to play a key causal role in the development of type 2 diabetes and the metabolic syndrome'07 1 109. Furthermore, the development of atherosclerotic lesions leading to myocardial infarction or stroke encompasses a cascade of cellular and molecular events that can also be characterized as a chronic immune mediated inflammation"0 111 There is evidence that the appetite mechanisms that evolved in our ancestral forefathers on a mixed diet mostly made up of fruits, nuts, vegetables and game are not suited to dealing with the high energy density "convenience foods" common in the modern Western diet, especially when they are eaten as "snacks" between meals112 113. A small extra amount of energy, as little as 150 kcal if consumed every day, can lead to the gradual accumulation of fat, which eventually becomes overweight and then obesity14. The difficulty is not just in losing that weight, however, but in keeping it off, as the body becomes used to having those reserves and continues to try to maintain them"'. It seems that decreases in leptin during energy-restricted weight-loss regimens may contribute to the strong propensity for weight regain' The inflammatory state of obesity is also a potential cause of anaemia. In the US, iron deficiency has been shown to be more common in obese children than normal weight children"' and in obese women than normal weight women". The iron deficiency found together with obesity and overweight in the US is not associated with anaemia, however'19, and so the reduced circulating iron in serum may just be a consequence of the chronic systemic inflammation state found in obese and overweight people120. However, several other studies have shown that increased adiposity is associated with increased risk of postpartum anaemia among women taking iron supplements during pregnancy in the US121, and a reduced response to iron fortification in women and children from transition countries22. The decrease in child undernutrition in Brazil during the 1990s, which was accompanied by increase in adult obesityl23, paradoxically saw an increase in anaemia124. This biological link between obesity and anaemia observed in the US and Brazil is unlikely to be the main reason for anaemia in Indonesia, where too low micronutrient intake is still the main cause, but as gemukness continues to increase over time it will become a factor. It has been suggested that the effects of the nutrition transition and the emergence of the DBM problems may also be influenced by genetic disposition of the populations concerned. The possibility has been raised that genetic factors could endow individuals that were able to efficiently collect and process food with the ability to deposit fat during periods of food abundance, which has been called the "thrifty genotype" hypothesis25. Genetic traits not only affect metabolic capacity to store energy, but also affect people's perceptions of hunger and satiety. Multiple studies of families, adoptees, twins and, most powerfully, adopted twins, have all confirmed that heritable factors are likely to be responsible for 45% to 75% of the inter-individual variation in BMI126. There is currently little evidence, however, that the ancestral genomes of native Asian or African populations carry particular risk alleles for obesity. Although a study of genetic polymorphism in Balinese women found a relationship between the Arg64 allele and obesity in rural women27, and in certain populations obesity may be related to one gene locus, the vast majority of obesity is related to more than one gene locus, reflecting the many different environmental situations that humans have adapted to in the last ten thousand years28. One useful way to think about the relationship between genes and obesity The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition was expressed by George Bray when he said, "the genetic background loads the gun, but the environment pulls the trigger"29. The sudden rise of obesity prevalence during the past few decades clearly cannot be accounted for by population genetic changes. Epigenetic contributions to obesity will need to be addressed through minimisation of the environmental triggers, rather than manipulation of the genetic guns"'. The "thrifty phenotype" hypothesis says that constrained fetal growth is strongly associated with a number of chronic conditions later in life"'. The influences of today's"modern diet"are likely to be greatest during the critical period of fetal and infant growth, when plasticity is greatest and epigenetic changes are most likely to determine the many NCD risksl32. We know that impaired embryonic, fetal and infant environments can lead to greater risk of visceral obesity and metabolic compromise in later life3'. Indeed relative visceral fat is already present from birth in small-for-gestational age childrenl34. This developmental plasticity, which is designed to permit the fetus to better adapt to the expected environment outside the womb35, is dangerous if an environmental mismatch occurs. Also known as the fetal origins of adult disease (FOAD) theory, it suggests that part of the DBM problem is due to a mismatch between the environment of the womb and that of the world outside when the child is born"36. Recent research further suggests that epigenetic effects really are related to a later propensity for obesity in childhood'. Humans today live in a nutritional environment that differs considerably from that for which our genetic constitution was selected. In the case of Indonesia in particular, and especially among its stunted populations that are migrating from rural to urban areas, the risks of such a mismatch are likely to increase greatly. Furthermore, this mismatch is not only between pre- and post-natal, but also between early childhood and later life. Decreasing infant mortality rates due to vaccinations and improved health services result in more children avoiding infections during the'window of opportunity'and surviving as stunted children. The fact that child stunting rates have remained stagnant around 30% for over a decade is probably a reflection of this accumulation, in addition to continued poor maternal and infant feeding practices. With economic growth and urbanization, these children are likely to suffer from accelerated weight growth during childhood, and so become even more susceptible to becoming gemuk and suffering from NCDs in the future. In fact, it is the most impoverished and most stunted segments of the population that are most likely to experience this FOAD phenomenon across their life courses. 4.2 The economic/food environment There are two components of the food system in a country that are important to understand in order to enact policy and programme interventions to reduce the DBM problems. The first concerns the sorts of foods either produced locally or imported and available for consumers to obtain, as well as the factors which influence this such as international trade agreements, food processing and distribution systems, food subsidies and prices. The second concerns the actual amounts and sorts of food acquired either through home production, exchange or purchase, how they are prepared and consumed, and the amounts of nutrients ingested. 4.2.1 Food availability and access Indonesia is considered to be a low income food deficit country (LIFDC) by FAO'". The LIFDC classification is determined by several criteria. First, a country should have a per capita income within the last five years that is below the ceiling used by the World Bank to determine eligibility for assistance and loans. The second criterion is based on the net (i.e. gross imports less gross exports) food trade position for a broad basket of basic foodstuffs (cereals, roots and tubers, pulses, oilseeds and oils other than tree crop oils, meat and dairy products) which are converted and aggregated by the calorie content of individual commodities. The food balance sheets produced by FAO are a summation of foods produced and food imported, less food exported, which allow the calculation of foods available for purchase at the national level. Table 4. Indonesia's Food Balance sheet: Availability of food at the national level by year Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition National Population and Available Food Characteristics Year 1967 1980 1990 2000 2007 Population (millions) 108.9 146.6 177.4 205.3 224.7 Energy (kcal/ capita /day) 1784 2220 2356 2498 2538 Protein (g/capita /day) 34.8 44.2 49.1 54.1 56.8 Fat (g/capita /day) 27.6 34.8 42.2 44.8 53.0 Animal food sources (% energy) 2.9 3.3 4.7 5.0 6.3 Fish and seafood (% energy) 1.1 1.1 1.3 1.8 1.9 Meat (% energy) 1.1 1.2 2.2 1.8 2.4 Milk (% energy) 0.2 0.4 0.3 0.4 0.6 Vegetable Oil (% energy) 5.8 6.1 6.7 6.4 8.6 Wheat (% energy) 0.8 3.1 2.8 5.5 6.1 Rice (% energy) 49.0 56.1 55.2 52.2 48.8 Source: FAO As shown in Table 4, food availability has increased considerably over the last four decades in Indonesia. While the population doubled in this period, availability of food energy on a per capita basis increased by almost a third. The percentage of energy coming from animal sources doubled, as did the availability of fat per capita. In the food available at the national level, the percentage of energy coming from rice during the period remained quite stable at around half, while that from fish and meat doubled, from milk tripled, and from wheat increased seven fold. All of the wheat and two-thirds of the milk is imported. The remarkable increase in food production, seen globally and in Indonesia during the last fifty years especially, has been made possible mainly due to the "Green Revolution" At the global level, while the population almost doubled from the early sixties to the late nineties, the supply of calories for human consumption rose by just over 20% on a per capita basis"'. The Green Revolution entailed adoption of crop rotation, the mass production and use of petroleum-based fertilizers and chemical pesticides, the use of petroleum driven machinery, expanded irrigation, and the introduction of genetically superior, disease- resistant cultivars (cultivated crops). However, after global grain production nearly tripled from 1950 to 1996, there was considerable concern when it seemed to reach a plateau during the early part of this last decade. Production fell short of consumption most years during the 1990s, and world cereal production in 2006 remained flat at approximately two billion tons - 2.4% less than in 2005. Still, there is no danger of there not being enough cereals for humans, since almost one-third of global production is being used to intensively rear cattle. World cereal production continued to climb in 2007. World cereal production has continued to climb since 2007 and FAO forecasted in 2011 a new record high world cereal productionl40. Food stocks also recovered in 2008, climbing back over 500 million tons for the first time since 2001, although they are still considered insufficient. Since 2000 the world food situation is being rapidly redefined by new driving forces, including income growth, climate change, and perhaps most importantly the increased production of bio-fuels motivated by higher oil prices141. The major driver of food prices is the price of oil142, and although the Food Price Index (FPI) of FAO fell progressively after the 1974 oil crisis, facilitating two decades of cheaper food, in 2007 it jumped 26% followed by another 24% increase in 2008, all linked to increases in oil prices. The cost of food reached an all-time high early in 2011, and the FPI is twice the level it was a decade ago143. Oil continues to cost around US$100 a barrel, and with the continued uncertainty in the Middle East region linked to the"Arab spring"it seems likely to remain priced around that level. It is estimated that global food prices will continue to increase by at least 10% a year over the next few decadesl44. The era of "cheap food" appears to be over. During the last four decades the Government of Indonesia (GOI) has invested heavily in trying to achieve food self-sufficiency, particularly with regard to rice, which was achieved for the first time in The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition 1984. In order to achieve this, subsidies were provided for fertilizer, pesticides and irrigation that amounted to approximately US$725 billion over the period of 1970 to 1984145. Such subsidies have persisted, with over fifty per cent of agriculture sector resources in 2008 directed to subsidies for seeds, credit, fertilizer, and rice, amounting to 0.4% of GDP146. The budget for fertilizer subsidies alone was almost double that of the budget of the Ministry of Agriculture at the central level. While most farmers benefit from fertilizer subsidies, they are regressive in nature, since the largest farmers, making up 40% of the total, captured 60% of the subsidy. Furthermore, there is evidence of a U-shaped relationship between fertilizer use and rice yields, with overuse causing reduced yields. There has been considerable variation in the policy regulating the price of rice in Indonesia over the last several decades. Rice is the most important commodity in Indonesia because it is the main staple food, and the single most important determinant of poverty. Prior to the Asian Financial Crisis of 1997 to 1999, rice import policy aimed to stabilise domestic rice prices at approximately the average international price, which allowed rice production to quadruple during the 1980s and 1990sl47. With the country's transition to a more democratic form of government, the successful lobbying power of pro-farmer political groups led first to heavy tariffs on rice imports. Then in 2004, rice imports were officially banned, although limited quantities of imports were periodically allowed. As a result of this policy, the price of rice within Indonesia increased during the last decade relative to other prices by approximately forty per cent48. Those who benefited from the higher rice prices brought on by the control of rice imports were undoubtedly the wealthier minority of farmers that owned larger farms, and not the poorer majority of the population49. In January 2011 the price of rice in Indonesia reached new record highs and was 23% above that of a year earlier. In late January, in order to ease rice prices and limit food inflation, the GOI announced the suspension of the import duty on rice until the main harvest in March, and since then has been actively buying rice in the international markets1so Since the early 1970s and the development of the"Washington Consensus"around the conditionality for Structural Adjustment Programmes (SAPs) from the International Monetary Fund (IMF), ILMICs have been increasingly forced to open up to free trade and to privatize national industries, as well as to reduce state support to local agricultural production"'. The conditionality for structural adjustment was the precursor to the conditions of free trade agreements including the General Agreement on Tariffs and Trade (GATT) and the North American Free Trade Agreement (NAFTA) through to the World Trade Organization (WTO). Free trade has meant an increase in food imports by most LMICs. Imported foods are cheap because of continued state support to the industrial agriculture sector in wealthy countries, allowing the dumping of cheaper food commodities onto the world market. In 2010, while the European Union paid E39 billion in direct agriculture subsidies, the US government spent US$21.3 billion to subsidize mainly large-scale farmers'52. Most of these subsidies contribute to making wheat and maize products cheaper. Agreement on the basis for agricultural sector trading has been a blocking point at successive Doha rounds of the WTO. In fact, food is now a major item of international trade with the aggregate value of agricultural exports at the world level expected to reach a record US$1.29 trillion in 2011, surpassing the trillion dollar mark for the third time in the past four years'13, and constitutes around 10% of all global trade'154. High food prices disproportionately affect LMICs, however, as they are expected to pay 30% more than last year as compared with wealthy nations whose food import bills are likely to rise by only 20% from 2010. Putting this in a broader perspective, expenditures on imported foodstuffs for LMICs could account for roughly 18% of all their expenditures on imports, compared to a world average of around 7%. The household level consequences of increases in food prices are most acutely felt in LIFDCs where a 50% rise in staple food prices causes a 21% increase in total food expenditure, increasing total food expenditures from 50% to 60% of income. In a high-income country this rise in prices causes a 6% rise in retail food expenditure with income expenditure on food rising from 10% to 11%'11. It seems that some of these distortions may have been caused by speculative trading in the commodities markets, contributing to rising food prices'56. Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition Trade liberalization can affect the availability of certain foods by removal of barriers to foreign investment in food distribution. It can also enable foreign investment in other types of food retail; multinational fast-food outlets have made substantial investments in middle-income countries. Availability of processed food has risen in developing countries after foreign direct investment by multinational food companies. Transnational food corporations (TFCs), franchises and manufacturers such as KFC, McDonalds, Kraft and Nestl, are all drivers of the fast-food market, processed foods and Western lifestyle that have become so widespread in developing countries"'. Policies of trade liberalization, which have facilitated the rising availability and consumption of meat, dairy products and processed foods,' are therefore contributing to the nutrition transition that is associated with rising rates of obesity and chronic NCDs such as cardiovascular disease (CVD) and cancer. At the same time the potential contribution of trade liberalization to increasing dietary diversity obviously has many positive sides that also need to be recognized and built upon. Access to food, particularly in urban areas, is greatly influenced by the sort of commercial outlets available. The trend the world over in urban areas is away from small family-owned shops and toward larger supermarket chains. Indeed the nutrition transition in LMICs is affected by this radical change in global food marketing and distribution systems associated with urbanization, which also seems to be underway in Indonesia, and will continue to be so as cross-border trade becomes increasingly more open. The emergence of supermarkets in developing countries is at the heart of this development, with Latin America taking the lead"'. In 2000, supermarkets had roughly 60% of the national retail sectors in South America and Mexico, up from 15% in 1990. This means that structural changes in the food distribution system that took fifty years in the United States have taken place in little more than a decade in Latin America. This rapid expansion was only possible as supermarkets moved far beyond their original niches, expanding from large to small and poor countries, from metropolitan areas to rural towns, and expanding their customer base from the upper/middle to the poorer working classes. This expansion of supermarkets now extends well beyond Latin America and is only about five to seven years behind in East and South-East Asia'60. Supermarkets are often the distribution channels for cheaper, unhealthy snacks and provide the platform for fast food chains and "junk"food. It must also be recognized that often and in addition to this supermarkets can also increase access to fortified processed foods, including complementary foods, and animal source foods. These trends are expected to continue, and may even accelerate, driven by a growing internationalization of food distribution systems; the spread of supermarkets and rapid urbanization are major factors behind that diffusion. It would seem important to ensure that these chains make fruits and vegetables from local farmers more available, in addition to fortified processed foods and animal foods as appropriate. Global economic policies concerning agriculture, trade, investment and marketing affect what the world eats. As high-income groups in LMICs accrue the benefits of more dynamic marketplace, lower- income groups may well experience convergence towards poor quality obesogenic diets, as observed in Western countriesl61. Health policy-makers should pay greater attention to these policies in order to address some of the structural causes of overweight/obesity and diet-related chronic diseases worldwide, especially among impoverished populations. 4.2.2 Food consumption Perhaps the most important aspects of food consumption are those that occur during the early part of the life course, when the young body is still being formed and biological mechanisms are being set for the rest of the life course. Unfortunately, infant and young child feeding practices in Indonesia are far from adequate and contribute to both undernutrition in early childhood as well as an increased propensity for overnutrition later in the life course. The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition The practice of breastfeeding is eroding fast in Indonesia. Riskesdas 2010 reported that only 15% of infants are exclusively breastfed for the first six months of life, as recommended by WHO and UNICEF. This is only half of the 32% reported to be exclusively breastfed in the 2007 DHS survey, and far less than the 40% reported in the 2002 DHS survey. In addition, only 43.9% of children start breastfeeding within an hour of birth and 64.6% receive a prelacteal feed. Mixed feeding is still common, however, with 83% of babies still being breastfed for six months, even if not exclusively. Complementary feeding practices are also far from optimal, with just 41.2% of infants aged 6-23 months achieving a minimum acceptable diet in the 2007 DHS survey. In addition, young children in Indonesia are receiving complementary foods too early. According to DHS 2007 more than half (52.9%) of infants 4-5 months of age are receiving some form of solid or semi-solid foods. Complementary feeding should start at six months and children should receive three or more food groups a minimum number of times according to their age group in addition to breast milk. DHS 2007 data indicate that only 52.5% of infants in Indonesia are optimally fed in this way. Only 67.0% of mothers offer complementary foods the minimum number of times per age group per day in addition to breast milk, and only 75.0% consume sufficient number of food groups, i.e., a diversified diet. Poor feeding practices also contribute to micronutrient deficiencies. According to the DHS 2007, only 87.4% and 69.7% of 6-35 month old children were reported to have received vitamin A and iron rich foods respectively in the past 24 hours. Indonesia has long supported the Baby Friendly Hospital Initiative (BFHI) promoted by UNICEF and WHO to ensure that all maternities, whether freestanding or in a hospital, become centres of breastfeeding support. UNICEF reported in 1995 that the number of hospitals declared baby-friendly in Indonesia had increased from 30 to 91162. A 2009 health bill further provided for the promotion of exclusive breastfeeding until six months and made any attempt to obstruct breastfeeding punishable with imprisonment up to one year and a fine of up to US$10,000, although the legal mechanisms were not clearly defined. Despite these various declarations and laws, the violation of nearly all provisions of the Code is still commonplace in Indonesia, with breast milk substitutes promoted in healthcare facilities, to healthcare professionals, to mothers and future mothers, and to the general public'6 . Riskesdas 2010 found that despite 84.0% of young mothers having carried out antenatal care with a health service professional, 82.0% having a medical professional assist the birth, and 55.0% having delivered in a health facility, 71.3% of young children had been given formula milk at birth. Evidence about the adequacy of food consumption in other parts of the life course is more difficult to evaluate. Both Riskesdas 2007 and Riskesdas 2010 reported on the reduced consumption of energy and protein among the population, with results that are somewhat difficult to interpret and reconcile. Riskesdas 2007 reported that 59.0% of households consumed less than the average household consumption of energy and 58.5% consumed less than the average household consumption of protein. What "below average consumption" means in terms of biological risk, be it for energy or for protein intake, is unclear and is not discussed. Furthermore, even among the highest wealth quintile 53.7% of households were below this level of energy intake and 48.0% were below average protein consumption. Riskesdas 2010 reported that 40.7% of individuals consumed less than their"minimum energy needs"and 37.0% consumed less than their "minimum protein needs" The most inadequate consumption ofenergy was seen in adolescents (54.0%) and of protein in seniors (49.5%), but even in the highest wealth quintile 34.6% had consumed below minimum requirements of energy intake, and 26.0% had consumed below minimum required protein intake. What the exact consequence of these "inadequate" intakes means is very hard to interpret and no indication is given in either of the Riskesdas publications. This paradoxical situation of increasing food availability, increasing overweight and obesity, yet apparent decreasing energy consumption has been observed elsewhere6 165, and it seems likely that this is dueto both energyexpenditures having decreased, and energy intakes being underestimated66. Indeed as discussed below, it seems certain that energy expenditures are much reduced in Indonesia today. Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition The National Statistics Bureau (Baden Pusat Statistics - BPS) also reports estimates of dietary energy consumption. These are likely to be more accurate than Riskesdas since BPS estimates are based on household expenditure surveys. It is well recognized that estimates of energy consumption from household expenditure surveys are generally greater than those obtained by 24-hour recall 167 as in Riskesdas, and that 24-hour recall tends to underestimate actual energy intakes' 16'. The BPS average consumption of energy by food commodity group is shown in Table 5, and shows that average daily energy consumption in 2007 was 2,015 KCal, as compared with 1,735 KCal reported by Riskesdas 2007, i.e. 16% higher. Table 5. Average Daily per Capita Consumption of Energy (KCal) by Commodity Group 1999,2002-2011 Commodity 1999 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Cereals 1 066.50 1 039.91 1035.07 1024.08 1,009.13 992.93 953.16 968.48 939.99 927.05 919.10 Tubers 60.73 55.43 55.62 66.91 56.01 51.08 52.49 52.75 39.97 37.05 43.49 Fish 36.04 42.53 46.91 45.05 47.59 44.56 46.71 47.64 43.52 45.34 47.83 Meat 20.07 35.01 41.71 39.73 41.45 31.27 41.89 38.60 35.72 41.14 44.71 Eggs & Milk 24.39 39.63 37.83 40.47 47.17 43.35 56.96 53.60 51.59 56.20 55.97 Vegetables 32.28 37.44 40.95 38.80 38.72 40.20 46.39 45.46 38.95 38.72 37.40 Legumes 52.40 71.66 63.93 62.24 69.97 64.42 73.02 60.58 55.94 56.19 54.17 Fruits 32.71 40.75 42.75 41.61 39.85 36.95 49.08 48.01 39.04 40.91 39.44 Oil and Fats 205.90 246.66 241.70 236.67 241.87 234.50 246.34 239.30 228.35 233.39 232.03 Beverage stuffs 103.35 120.00 115.54 114.75 110.73 103.69 113.94 109.87 101.73 100.29 97.69 Spices 15.42 18.28 15.89 16.41 19.25 18.81 17.96 17.11 15.61 16.00 16.14 Miscellaneous 28.76 41.66 39.60 40.16 52.84 48.14 70.93 66.92 58.75 59.18 59.70 food Prepared food 170.78 198.09 212.31 219.09 233.08* 216.83 246.04* 289.85 278.46*) 273.84*) 304.35*) Alcoholic bevraes0.04 0.09 0.09 0.09 - - - - - - - beverages Tobacco and bl a0 0 0 0 0 0 0 0 0 0 0 betel All 1,849.36 1,987.13 1,989.89 1,986.06 2,007.65 1,926.74 2,014.91 2,038.17 1,927.63 1,925.61 1,952.01 *) includes Alcoholic beverages Source: BPS 2012. National Socio Economic Survey. Available at:http://dds.bps.go.id/eng/tab_sub/view.php?tabel=1&daftar=1&id subyek=05¬ab=5 (Accessed 02 03 2012) According to BPS, average per capita energy consumption increased by 10% from 1999 to 2008, and then decreased 4% by 2011. Of the total energy consumption in 2011, 47.0% was in cereals, 15.6% was prepared foods, 11.9% was oils and fats, 7.6% was fish, meat, eggs and milk, and 6.7% was as vegetables, legumes and fruits. From 1999 to 2011, the greatest increase in contribution to total energy was in meat, fish and eggs (almost doubling from 4.3% to 7.6%) and prepared foods (from 9.6% to 15.6%), while the contribution of cereals and tubers fell (from 61.0% to 49.3%) and the contribution of vegetables, fruits and legumes (6.4% to 6.7%), and oils and fats (11.1% to 11.8%) remained the same. So not only has household energy consumption grown in the last decade, but such growth has come in the more expensive parts of the diet such as animal protein foods, as well as foods prepared outside of the home, most probably"snack"foods. But while the BPS household expenditure survey allows a better estimate of the quantities of food being consumed, it does not offer insight into the quality of the diet, nor whether qualitative dietary goals and targets are being met. Riskesdas 2007 reported that nationally, in the population over nine years of age, 94% did not eat sufficient vegetables and fruits during the preceding twenty-four hours (five portions a day during seven days), and this varied from 86.0% in DI Yogyakarta to 97.9% in Riau. Riskesdas 2010 also reported that 61.0% of dietary energy came from carbohydrates, 25.6% from fat, and 13.3% from protein. Unfortunately, the type of fat consumed was not discussed. The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition The qualitative diet-related results from the 2007 and 2010 Riskesdas are intended to assess the extent to which the national diet achieves dietary targets set by Ministry of Health in its Guide to a Balanced Diet, or "Pedoman Umum Gizi Seimbang" (PUGS). First established in 1993, and updated several times, the latest 2003 PUGS had the same thirteen basic messages"o. These included amongst others: eating a balanced and varied diet; with sufficient energy to meet needs; with carbohydrates being predominantly complex ones; and not more than 25% of energy from fats and oils; to only use iodized salt; eat iron rich foods; eat breakfast daily; exclusively breastfeed for 6 months; get exercise daily; avoid drinking too much alcohol; and avoid eating "risky foods'. Unfortunately the PUGS was not widely published and disseminated, and therefore there were effectively no dietary or nutrition guidelines in Indonesia from the 1990s through 2010. The thirteen messages were perceived to be overly complicated'7 and therefore not well understood, even by school children72. In 2011 a group of nutrition experts from various universities established a new nutrition guideline known as"Sehatdan Bugar berkat Gizi Seimbang"or Healthy and Fit Due to Balanced Nutrition71. In the foreword of the guide, Vice-Ministers of Education, Agriculture, as well as the Director General of Community Health of the Ministry of Health (MOH) recognized the new nutrition guide. Different from the previous guide published by the MOH in 2003, which was available only for government officials, the new guide is available for purchase in bookstores by the public. The present guide forgoes detailed messages and instead aims to educate the public about the four principals of balanced nutrition, which are: 1) eating a variety of foods (according to needs), 2) keeping clean and practising hygiene, 3) being physically active, and 4) monitoring weight'74. A more complete set of dietary goals and targets was set by the World Health Assembly (WHA) in 2004 when it endorsed the Global Strategy on Diet, Physical Activity and Health (DPAS)171. DPAS built upon the findings and recommendations of the expert consultation on diet, nutrition and the prevention of chronic disease'76, which reviewed and summarized the ample evidence available for the importance of diet and physical activity for the prevention of chronic disease. The WHA resolution 57.17 urged member states to adopt the following recommendations for populations and individuals: 1) To achieve energy balance and a healthy weight; 2) To limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans fatty acids; 3) To increase consumption of fruits and vegetables, and legumes, whole grains and nuts; 4) To limit the intake of free sugars; and 5) To limit salt (sodium) consumption from all sources and ensure that all salt is iodized. The WHO expert consultation Report No. 916 also provided guidance for a range of population nutrient intake goals to be used to drive the development of national dietary guidelines. The nutrient intake goals are as shown in Table 6. The recommendations for total fat are intended for countries where usual fat intake is above 30% as well as those where it may be very low, but 20% is considered consistent with good health. In Riskesdas 2010, the fat content of the Indonesian diet was 25.6%, which might be considered moderately high. Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition Table 6. WHO Recommended Population Nutrient Intake Goals Dietary Factor Goal (% of total energy unless otherwise stated) Total Fat Saturated fatty acids 16-30% Polyunsaturated fatty acids (PUFAs) <10% n-6 Polyunsaturated fatty acids (PUFAs) 6-10% n-3 Polyunsaturated fatty acids (PUFAs) 5-8% Trans fatty acids 1-2% Monounsaturated fatty acids (MUFAs) <1% By difference Total Carbohydrate Free sugars 55-75% <10% Protein 10-15% Cholesterol <300mg/day Sodium chloride <5g/day Fruit and vegetables >400g/day The quality of fat consumed is also important, and the diet should contain little or no trans fatty acids, and be low in saturated fat. Unsaturated fats that were prominent in traditional diets are being replaced by saturated fats as part of the Westernization of the diet. These dietary changes have affected both the type and amount of essential fatty acids as well the antioxidant content of food'17. The mass production of cheap snack foods relies on industrial hydrogenating of liquid unsaturated fats, such as soya and corn oil to make them into solid saturated fats for baking purposes. The hydrogenation process can lead to the formation of harmful trans fatty acids however, which are very atherogenic. Modifying the process of hydrogenation of vegetable oils can help in the elimination of trans fatty acid, and this has been largely achieved in most countries both through legislation and manufacturers complying with public health directives. The type of unsaturated fat consumed in the "modern" diet has also changed with increases in omega-6 fatty acids and decreases in omega-3 fatty acids, such that the ratio of omega-6 to omega-3 fatty acids has increased from 1:1 to greater than 15:11". This change is related to the increased consumption of meat of intensively reared animals fed on grain (rich in omega-6 fatty acids) instead of grass (rich in omega-3 fatty acids)179. Unsaturated fats should include both n-6/n-3 polyunsaturated fats in a ratio no greater than 3. However, it is not just the ratio but also the total amount of both that are important, as both are essential. It is hard to evaluate the quality of the dietary fat in Indonesia, however, as no analysis seems to have been done in this regard. It is likely that most of the oils and fats in Table 5 are palm oil, but whether or how much of this is refined is difficult to judge. Palm oil has been stigmatised as a hypercholesterolaemic fat because of its high saturated fat content, despite human studies that show it does not raise serum cholesterol levels'. In Mauritius, the government required a change in the commonly used cooking oil from palm oil to soybean oil, changing the population'sfatty acid intake and reducing their serum cholesterol levels"'. Much would seem to depend on the extent to which the natural palm oil is refined82. A prospective cohort study conducted in workers in East Kalimantan found the mean intake of trans fatty acid was 0.48% of total dietary calories, with fried foods contributing half of this. The consumption of fried foods was associated with an increased risk of hypertriglyceridaemia, a high ratio of total cholesterol/ HDL-cholesterol and dyslipidaemial". WHO Report 916 also recognized that higher intake of free sugars threatens the overall nutrient quality of the diet by adding significant energy without nutrients, or "empty calories" Free sugars are all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices. Addition of free sugars promotes a positive energy balance, and drinks rich in free sugars also increase overall energy intake by reducing appetite control. Wholegrain cereals, fruits and vegetables are the preferred sources of non-starch polysaccharides (NSP), and the recommended intake of fruit and vegetables together with the consumption of wholegrain foods is likely to provide >20g/d of NSP (>25g/day of total dietary fibre). Again, it is not possible to evaluate, The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition from Riskesdas or the BPS reports, the quality of the Indonesian dietary intake with regard to the type of carbohydrate consumed. Wheat flour is penetrating the Indonesian dietary pattern through instant noodles, one of the "prepared foods" in Table 5. Noodles are a traditional food in many Asian countries, and in the past were more of a luxury food, eaten in dishes prepared from fresh noodles made from rice flour. The advent of instant noodles made from wheat flour in the early fifties changed all that. Instant noodles are essentially a "fast food"as they are already partially cooked by frying in palm oil before being packaged so that they can be shipped and stored easily; they are prepared just by adding hot water, together with the sauce/ flavouring that is usually included in the package. Consumption of instant noodles grew strongly during the first half of the 1990s, rising from 4.7 billion packs in 1992 to almost 8.6 billion packs by 1997, making Indonesia the world's second largest consumer of instant noodles, behind only China. Because of instant noodles, wheat flour consumption has risen steadily in Indonesia through the last few decades, reaching 51.5 g per capita per day in 2008184. Indonesia represents 4% of total world wheat imports, and is in the top five leading wheat importing countries in the world, following only Egypt, Japan, and Brazil"'. Categorizing foods by their degree of processing is a relatively new and important concept with regard to understanding the potential obesogenicity of diets'16. Nearly all food requires processing in order to be eaten, even if only by washing it. But three food groups have been proposed based on the degree of processing, namely: Group 1 unprocessed or minimally processed foods such as fruits and vegetables; Group 2 processed culinary or food industry ingredients; Group 3 ultra-processed food products. Processing of Group 1 foods includes the removal of inedible fractions, grating, squeezing, drying, parboiling, fermentation (non-alcoholic), pasteurization, freezing, or wrapping and bottling. The processing of Group 2 foods includes the extraction and purification of components of single whole foods for use as culinary orfood industry ingredients, through pressing, crushing, milling, refining, hydrogenation, hydrolysation, extrusion and use of enzymes and additives. For example, these foods include vegetable oils, margarine, butter, whey, cream, lard, sugar, sweeteners, salt, flours, raw pastas and noodles, high fructose corn syrup, and gums. The processing of Group 3 products includes the combination of Group 2 ingredients with Group 1 ingredients through baking, battering, frying, curing, smoking, and pickling, in order to create durable accessible, convenient and palatable drinks and/or ready-to-eat or ready-to-heat food products. The problem is not the ultra-processing of foods, however; it is the balance between the consumption of each of these three food groups in the everyday diet of the population. Group 3 "convenience foods" require little if any preparation before cooking, and can be eaten as purchased, and/or microwaved and/ or eaten after reheating. They are most suited to snacking, which when coupled with their higher energy densities and high glycemic indexes, can become a problem. Processed foods are also most suited to fortification, and as such can be an important source of micronutrients, as is the case with iodized salt and instant noodles in Indonesia that are fortified with iodine and iron and zinc respectively. High glycemic index foods are those that cause a high and prolonged postprandial glucose level in the blood stream. Numerous observational, experimental and epidemiological studies suggest that postprandial hyperglycemia plays a pivotal role in the pathogenesis of CVD'17. Furthermore, the metabolic cost of assimilating the energy in processed foods appears to be half that of whole-foods'". Over time these small differences in energy balance can gradually cause a person to gain weight. A small extra amount of energy, as little as 150 kcal if consumed every day, can lead to the gradual accumulation of fat, which eventually becomes overweight and then obesity'". All over the world Group 1 and Group 2 foods are being displaced by Group 3 ultra-processed products. In Brazil ultra-processed foods were already contributing around a third of dietary energy in 200319". In the UK eight ultra-processed products - bread, cakes, pastries, confectionery, biscuits, processed meats, cheeses and soft drinks - together supply almost half of total household purchased calories'91. Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition In the US the five most commonly consumed foods are "regular" sugared soft drinks, cakes and pastries, burgers, pizzas, and potato chips'92. Furthermore, Americans' tax dollars are directly subsidizing junk food ingredients'. In the last fifteen years US$16.9 billion went into subsidizing just four common food additives: corn syrup, high fructose corn syrup, corn starch, and soy oils, helping to make processed foods cheaper. Outside of commodity crops, other agricultural products receive very little in federal subsidies, with only US$262 million spent since 1995 subsidizing apples, which is the only significant federal subsidy of fresh fruits or vegetables. While the price of vegetables and fruits increased 40% in the US in last 20 years, the price of sodas decreased 30%194. Swinburn and colleagues' postulate that an energy balance flipping point has occurred during the last century in most high-income countries. Furthermore, there are two distinct phases with the so- called "move less, stay lean"phase (1910-60), characterised by decreasing physical activity levels and energy intake, and a population that remained lean, and the subsequent so-called "eat more, gain weight" phase from 1960 onwards, characterised by increasing energy intake and a concomitant rise in population weight. Food supply data from the US lends support to this flipping point hypothesis, as well as a recent study which found that the dietary factors showing the strongest positive association with the average 1.5kg weight gain over a four year period in US adults included the intake of potato chips, potatoes, sugar-sweetened beverages, and negatively with the intake of vegetables, whole grain, fruits and nuts'6. How current increases in the price of food occurring globally will affect the dietary component of the nutrition transition in LMICs, and in Indonesia in particular, is difficult to predict. Most likely it will mean that consumption of cheaper ultra-processed foods (many of which benefit from EU and US subsidies to keep their prices low) will increase even more than before. Group 1 foods especially are likely to become increasingly expensive, while the mass produced Group 3 foods, made from food supply chains that benefit from subsidies in the EU and US, will become comparatively cheaper. Unless measures are taken to avoid this, Group 3 ultra-processed foods will become even more attractive to the poorest segments of the LMIC population. Energy dense foods composed of refined grains, added sugars, or fats are well recognized to represent the lowest cost option to the consumer"'. That obesity is paradoxically more common in the poorer segments of the developed countries is most likely because high energy dense "fast foods" are cheaper to buy and/or easier to prepare than the more healthy foods such a fruits and vegetables'. 4.3 The physical/built environment The physical/built environment includes factors that influence individual activity behaviour, including the type, frequency and intensity of physical activity, as well as access to "healthy" food. Many changes in lifestyle occur together with urbanization, including people becoming increasingly sedentary'99. With people moving from rural to urban areas comes a shift of the workforce away from agriculture towards manufacturing and service employment, and a concomitant reduction in the energy expenditure of work. Increased mechanisation and motor-driven transport means less physical effort is needed to carry out daily life. Access to healthy foods is also often limited in urban environments, when the population has to travel from home to school and to work, so that increasing amounts of food are purchased readymade and eaten outside of the home. Energy balance depends on regulating intake and expenditure of calories, and the key variable of energy output is the degree of physical activity. This can be seen by the following comparison: In sedentary adults the basal metabolic rate (BMR) is 60% and the thermic effect of food (TEF) is 10% and physical activity (PA) is 30% of total energy expenditure; in very active adults BMR is 40%,TEF is 10% and PA is 50% of total energy expenditure. For any individual, BMR and TEF are constant and so modifying PA is an essential component of energy expenditure in order to achieve energy balance, and/or lose weight209. This is especially true in an environment where the food available is predominantly energy dense. The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition 4.3.1 Activity environment Urban planning can play an important role in increasing opportunities for exercise, and local governments have an important role to play, through creating parks and open spaces for exercise as well as bike lanes and pavements to encourage pedestrians201. The availability, accessibility and convenience of destinations and facilities, as well as the general functionality of the neighbourhood (e.g., the presence of sidewalks, traffic conditions) and aesthetics have been shown to be positively associated with various levels of physical activity202. Indonesian cities are slow in adjusting to the needs of pedestrians and bicyclists, with automobiles still tending to hold sway. An Indonesian non-governmental organization (NGO) called Bike2Work reports that many provincial capitals including Balikpapan, Yogyakarta, Surabaya, Denpasar, Bandung and Palembang have begun to introduce bike lanes. The first (and only) 1.5 km bike lane, introduced in Jakarta in May 2011, was developed with funds raised by an NGO (Komite Sepeda Indonesia) rather than by the city authorities. The capacity of schools as a setting for preventing child obesity in Indonesia is not clear, especially since decentralization. With public awareness of the DBM problem largely absent, it seems unlikely to be covered adequately in the school curriculum. There was once a school meal system, but that seems to have been largely disbanded, and/or is left up to district authorities to organize. It seems that sales of food from vending machine in Indonesia remained negligible up to 2011, with the concept of automated vending machines remaining a foreign concept in the country203. On the streets, mobile vendors have a strong presence, as they do not have to rent any space, and can also avoid taxes. There is also normally a high density of independent traditional kiosks or convenience stores, which makes vending redundant as a retail channel. Where children get their food is unclear, but it seems that approximately 35% of food comes from street sellers and local stores204. Regulating this and trying to ensure that children eat healthy food is challenging. Indonesia will more tightly supervise the sale of food products sold in and around schools, if a government agency-backed effort to reduce the impact of unhealthy snacks on the country's fifty million 6-18 year-olds is approved. Worksite interventions, by offering education, screening for risk factors, offering incentives to walk or ride a bike to work and facilities for exercise during breaks, as well as healthy foods in cafeterias, can reduce staff sick days and health costs to the benefit of both employers and employees. Whether Indonesia has any initiatives of this sort was not readily apparent at the time of this research. 4.3.2 Activity behaviour The WHO Report 916 recommended a goal for physical activity which focuses on maintaining healthy body weight. The recommendation is for a total of one hour per day of moderate-intensity activity, such as brisk walking, on most days of the week. This is different from the widely recognized public health recommendation of half an hour a day of moderate physical activity, which reduces the riskof cardiovascular risk, although it does not reduce riskfor all of the other NCDs. High levels of fitness protects against mortality from cardiovascular disease and diabetes at all levels of BMI (i.e. even in those that are overweight/obesity). Regular exercise increases the capacity of muscles to use fat rather than sugar during physical activity. Preventing weight gain after weight loss requires 60-90 minutes of moderate physical activity a day. Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition Figure 7. Prevalence of insufficient activity in the The majority of the Indonesian population is Indonesian population above ten years of age in inactive. Riskesdas 2007 reported the amount 2007, by age group of physical activity among the population aged 90 -ten years and older, as shown in Figure 7. 80 I10-14y Inadequate physical activity was considered to 70 - be that less than 30 minutes a day of moderate -5 60 * 25-34y activity (brisk walking) during at least five days a a 2 50 - 35-44y week. Even the most active age groups (45-54 o 40 -45-54y years of age) still had over a third getting 30 *55-64y insufficient exercise. The most inactive were those aged 75 years or more, with three-quarters 10 s 7 having insufficient activity, which is perhaps not 0 Isurprising. But the next most inactive age group were children 10-14 years of age, with 67% not Source: Riskesclas 2007 achieving the required level of exercise. That 10-14 year old children in Indonesia get so little exercise is surprising, as they are nearly all in school, and presumably should be getting exercise there. It is therefore important to investigate how Indonesian schools are performing in this regard. A recent analysis205 concluded that school health and nutrition has not figured significantly in efforts to improve the quality and equity of education, through the setting of standards for district authorities that are responsible for delivering primary and secondary education. It would seem that the potential in this area still remains to be exploited. 4.4 The socio-cultural environment The socio-cultural environment includes the influence of media, education, peer pressure or culture and how these impact an individual's drive for particular foods and consumption patterns, or physical activity patterns or preferences. 4.4.1 Socio-cultural influences (societal norms and customs) The culture of Indonesian society has been shaped by long interaction between original indigenous customs and multiple foreign influences over many centuries.The many indigenous cultures have been influenced by a multitude of religions, including Hinduism, Buddhism, Confucianism and Islam. When Indonesians talk about their cultural differences with one another, one of the first words they use is "adat" (custom or tradition). This is different from the word "budaya" which concerns the artistic dimensions of culture, including music, dance, painting, and the ancient legends transmitted through puppet shows, for example. The meaning of "adat" has undergone a number of transformations over time, and in some circumstances has assumed a kind of legal status; certain adat laws (hukum adat) are recognized by the government as legitimate. These ancestral customs may pertain to a wide range of activities: agricultural production, religious practices, marriage arrangements, legal practices, political succession, or artistic expressions. The status of women in Bali is subject to adat law, for example. The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition In Indonesia, as in many LMICs and in the rural areas especially, certain traditional customs continue to contribute to maternal and early child undernutrition. Gender-related issues are especially relevant in rural areas where women often still do a lot of the hard physical work but are not favoured in terms of food access. Hard physical labour and an excessive workload during pregnancy contribute to constrained fetal growth, as does the stress associated with marital violence during pregnancy. Early timing of pregnancy, including teenage pregnancy, is likely to be a factor contributing to the high child malnutrition rates in Indonesia. A quarter of all women of reproductive age in Indonesia are married before 18 years of age06 and 10% before 16 years of age. A strong correlation is known to exist between age of first marriage and age of first birth207. The higher rates of chronic energy deficiency (CED) seen in adolescent women of reproductive age in Indonesia are most probably because they are still growing and they have not yet reached maturity. In the US it has been observed that for pregnancy during adolescence (<18y), the growth of the mother (who is still a child) takes priority over the growth of her fetus, which is born on average 200g lighter208. As a consequence, the mother gains more weight than she would if she was mature, and maternal height growth is cut short. The development of maternal obesity in mothers over twenty years of age has been shown to be related to teenage pregnancy and parity in Brazil209. The increased completion of schooling by girls, especially at the secondary level, will gradually contribute to the reduction of child marriages and of teenage pregnancies in Indonesia. Schools should also be offering in their curriculum healthy life skills in this regard, in addition to those relating to eating a healthy diet and taking sufficient exercise. Cigarette smoking, still so widespread among Indonesian men, is fortunately not practised by women. Riskesdas 2007 reported that while 46% of men smoked every day, just 3% of women did so. Most men had started smoking while still at school, suggesting that once again much could be done in school to prevent this habit being formed so early in boys. Indonesia is modernizing rapidly, and modern media permeates everywhere. Nearly universal education in "Bahasa Indonesia', the one common language, allows universal coverage of the same media channels and formats. Television dominates the media landscape in Indonesia. More than 90% of Indonesian households have at least one TV set. Most of the adult population in the country watches the news on television at least once a week210. There are more than ten private national television networks that operate in competition with the publicly owned Televisi Republik Indonesia (TVRI), which until 1989 was the only television station in the country. Research by the Indonesian Children's Welfare Institute (YKAI) in 2000 found that Indonesian children are heavy viewers of television, glued to the screen more than 26 hours a week, or nearly four hours a day211. On Sundays, children watched TV more than seven hours. The number of hours spent watching television has been shown to be related to the prevalence of overweight/obesity in children in the US212 213. A cross-sectional study among adolescents in three Indonesian cities found that there was a greater likelihood of obesity in those who spent greater amounts of time using a computer or Play Station214. Among junior high school students in Yogyakarta, obese adolescents spent more time in sedentary activity than non-obese adolescents, and the relationship was independent of calorie intake, or parental obesity215. The advertising of processed foods can be seen everywhere in Indonesia from billboards, to newspapers to TV spots. A multi-country survey of the influence of television advertisements on children216, which included Indonesia, reported that advertising to children was widespread across the countries surveyed, and that while all six countries had common core food-based messages in national nutrition guidelines, the diet actively being promoted on television in all countries goes in the opposite direction. The report found that 16% of children in Indonesia watched over eight hours of television a day, and that for each hour of children's programming there was fifteen minutes of advertising, of which food advertising was dominant. The majority of children in Indonesia loved watching TV advertisements (61%), which they thought informed them about product quality/features (75%) and updated them about new products (91 %). Multinational and domestic food companies, which promote energy-dense foods and drinks, use highly effective marketing techniques to encourage regular consumption, repeat purchases, and Indonesia Health Sector Review Chapter4 Assessing the Causes of the Double Burden of Malnutrition brand loyalty, especially among children. While 75% of parents in Indonesia based their buying decisions on their own judgement, and only 33% said these were influenced by advertisements, 58% said they were influenced by their children. In all six countries, piecemeal legislation exists alongside self-regulation codes, and punitive measures could be taken against those that violate such codes, but only in the Philippines was there provision for suspension/retraction of licences to advertise. Indonesian advertising control was said to be solely based on a "complaint feedback" mechanism. Two subsequent reviews carried out under the remit of WHO confirmed that the findings of the Consumers International survey are largely applicable and relevant for most countries across the globe217 218. 4.4.2 Individual psychology There is no evidence that the capacity to make rational decisions is reached at any different age in Indonesia than elsewhere in the world. That the human brain is not fully mature until 25 years of age, i.e. the end of adolescence, has only recently been fully recognized. The maturing brain goes from straight processing of facts before the age of 12 years, into a slow progression to abstract thinking starting between 12 and 14 years, and maturity is only fully achieved by around 25 years of age219. Before maturity is reached, adolescents are not yet fully able to make "rational" decisions, and are much more influenced by "emotional context" This argues for limiting advertising of food especially to children22. The Double Burden of Malnutrition in Indonesia Chapter 4 Assessing the Causes of the Double Burden of Malnutrition Indonesia Health Sector Review Chapter 5 Nutrition Capacity and Governance Chapter 5 Nutrition Capacity and Governance When considering how to tackle the double burden of malnutrition (DBM) in low- and middle-income countries (LMICs), the renewed momentum to act on nutrition that is gathering pace across the globe could, should and must be built upon. A process of dialogue called the SUN (Scaling up Nutrition) Global Movement22' developed over the last few years has been widely endorsed by over a hundred international development institutions in recognition that development funding for nutrition interventions to reduce maternal and child undernutrition has been far too small222, especially considering the magnitude of the consequences these bring in terms of mortality, morbidity, and human capital development. The SUN movement recognizes that taking to scale a package of evidence-based high impact nutrition interventions such as those proposed in the Lancet Nutrition Series223 will not only prove to be cost-effective over the long run, but will also make a big contribution to achieving most of the Millennium Development Goals (MDGs). Although the SUN movement is focused on maternal and child undernutrition, it is important to recognise that this is one of the most important first steps LMICs should be taking to prevent the DBM in the future. Conversely, much of the capacity development needed for scaling up nutrition should be designed with consideration of the DBM. The SUN Movement agreed to a Framework224 which calls on all partners to scale up efforts against maternal and child undernutrition by, among other things: * Developing a coordinated, multi-stakeholder approach; * Using the Paris Accra Principles of Aid Effectiveness; * Mobilizing key stakeholders in an inclusive approach to country ownership; * Using the "Three Ones" (i.e. One agreed overarching policy framework that provides the basis for coordinating the work of all partners, One national coordinating authority, One agreed national monitoring and evaluation system); * Developing strong prioritized country nutrition strategies that, while grounded in country specificity, take particular account of the "window of opportunity"from conception to two years of age; * Ensuring efforts are multi-sectoral, linking agriculture and food security, social protection and public health; and * Including elements of capacity development and monitoring and evaluation. Figure 8. The four essential functions of the nutrition The LACA report found that coordination for system improving nutrition across sectors, within sectors, at all levels of government, and in Nutrition I B ding a Healthy Foundation for theFtue the UN, is lacking in Indonesia. National level Four Functions of a Nutrition System coordination is needed for strategy and policy development, while at sub-national levels Ntwri (district and sub-district), coordination is needed efor implementation. A recent analysis of the Setn standrds, international nutrition system published in the udniling tprate)s rLancet Nutrition Series considered the system to be fragmented and dysfunctional, and recommended thecreation ofanewgovernance structure2'. Perhaps more importantly, S however, the Lancet Nutrition Series called for a more functional international nutrition system r which is connected to and serves the needs of a a the national nutrition systems, which should be unwilin tooperte)R&Dits building blocks2'. While the Lancet Nutrition w-wGlobalNutritionSeri-sLorg Series article only considered maternal and child Source: Lancet 2008 undernutrition, the concept of the essential functions of a nutrition system that was proposed is equally valid for the DBM. S Indonesia Health Sector Review Chapter 5 Nutrition Capacity and Governance Helping to build commitment to and the capacity of the nutrition system requires that the four functions shown in Figure 8 are strengthened. Commitment is measured by the level of stewardship and resources made available, and is largely a central function.The capacity of the nutrition system relates to the service delivery mechanisms and the installed capacity to ensure that nutrition interventions are delivered, which are more field level functions. Efforts to build capacity and commitment for improved nutrition outcomes are strengthened when both undernutrition and overnutrition are considered together, especially in Indonesia. As shown in Table 7, a programme framework has been proposed for the DBM which includes interventions that can contribute to prevention and treatment of the DBM across the life course. This builds on the table developed by Gillespie and Haddad 227 in 2001 for reducing the DBM in Asia, draws upon the more recent Lancet Nutrition Series evidence-base for interventions for tackling maternal and child undernutrition22, as well as recent reviews of evidence on interventions for tackling overweight and obesity229 230. The table includes both direct and indirect nutrition interventions, and is organized by the stages of the life course. Such a programme framework could be used to guide the development of future National Plan for Development (RPJMN) and National Action Plan for Food and Nutrition (RANPG). Direct interventions are those targeted at the individual level, and have also been termed "nutrition specific" interventions in the SUN Framework. These include nutrient supplements, food supplements, nutrition education, and food fortification. Indirect interventions are those delivered at the level of the household or community, and include cash transfers, and fiscal policy instruments as well as codes of practice concerning marketing of foods. The implementation of direct interventions during the early part of the life course in Indonesia still requires considerable improvement, especially with regard to breastfeeding. In addition to the well-recognized benefits of breastfeeding in reducing mortality in infants and young children, there is increasing recognition of its benefits for preventing overweight/obesity later in the life course. Recent research suggests that exclusive breastfeeding during early months is central to the mechanism by which breastfeeding protects against later obesity231. Future growth seems to be programmed during the first six months of life, when normal growth in exclusively breastfed babies is much slower than in bottle-fed ones. Furthermore, there is a dose-response effect for the prevention of obesity, with longer duration of breastfeeding being associated with lower tendency to later obesity. The risk of being overweight is 20% greater if exclusively bottle-fed than exclusively breast milk-fed during the first six months of life. The International Code of Marketing of Breast-milk Substitutes (The Code) was adopted by the World Health Assembly (WHA) in 1981 as a"minimum requirement"to be enacted in its entirety in all countries. The Code aims to promote safe and adequate nutrition for infants by protecting breastfeeding and ensuring appropriate marketing of breast-milk substitutes. The Code bans all advertising of breast- milk substitutes, as well as the provision of samples and gifts to mothers and health workers, and the use of healthcare systems to promote breast-milk substitutes. Indonesia ratified parts of the Code in a 1997 decree of the Minister of Health, which only covered infants 0 to 11 months, did not properly differentiate between breast-milk substitutes and complementary foods, had four months as the limit for exclusive breastfeeding, and did not specify any legal penalties for those that perform infractions232. A new regulation is supposed to come into force this year that will include penalties of fines and even jail for those promoting the use of breast-milk substitutes for infants. Anaemia during pregnancy also needs continued attention, as the 2010 Riskesdas found that although 80% of mothers of infants reported taking iron pills during their last pregnancy, only 18% of mothers reported having taken the full 90 tablets as recommended by the GOI. Considering that the WHO recommendation is 180 tablets, there is still a long way to go here. But there is also a need to consider giving a multiple micronutrient supplement, especially given the extent of vitamin A and zinc deficiency that is known to occur in the same populations. It is well recognized that preventing zinc deficiency at The Double Burden of Malnutrition in Indonesia Chapter 5 Nutrition Capacity and Governance Table 7. Programme interventions for tackling the DBM across the life course Conception to 1. Micronutrient (Iron/folate 1. Salt lodization 1. Prevent child 1. Fiscal food birth or multiple micronutrient) 2. Flour marriage policies supplements fortification and teenage a. Food 2. Balanced protein energy 3. Oil fortification pregnancies subsidies supplements* 2. Conditional b. Fat/sugar 3. Deworming cash transfer taxes 4. Reduction of household/ programmes (with c. Levies cigarette smoke nutrition education) 5. Presumptive radical treatment 2. Urban planning for malaria* a. Bike lanes 6. Insecticide-treated bed nets* b. Parks Young 1. Exclusive breastfeeding 1. Code of marketing c. Pedestrian Children promotion, of breast milk precincts (0-5 years) 2. Appropriate complementary substitute d. Sanitation feeding promotion 2. Conditional e. Smoke free 3. Hand washing and hygiene cash transfer houses interventions programmes (with 4. Young child supplementation nutrition education) with vitamin A and zinc, and other micronutrients as appropriate 5. Deworming 6. Management of severe acute malnutrition Children 1. School based 1.No vending (5-18 years) 2. Providing healthy meals machines or junk 3. Promotion and provision of food sales in schools daily physical exercise 2.No advertising 4. Weekly iron supplements/ of food aimed at deworming children Adulthood 1. Medical service provider 3.Food labelling (18+ years) counseling on healthy diet a. Nutrition 2. Worksite encouragement to signposting exercise and eat healthy foods b. Control food 3. Taking regular exercise claims the population level is best achieved through multiple micronutrient approaches, be they fortification or supplementation233. Since the Lancet Nutrition Series, more recent reviews of multiple micronutrient supplements during pregnancy have shown considerable impact on birth weight, for example234. Trials of multiple micronutrient supplementation (MMS) during pregnancy have shown considerable impact in Indonesia. A trial of MMS compared to iron iron folic acid supplements in Java found that the mean birth weight was 40 g higher in the MMS group and that among those who consumed 90 or more iron supplements during pregnancy, there was a 50% reduction rate of miscarriage, stillbirth, or neonatal death235. A considerably larger trial in Lombok showed that MMS as compared with regular iron folic acid supplements reduced post-natal infant mortality between one and three months of age by 18% overall, by 25% in mothers who were undernourished at enrolment, and 38% in mothers who were anaemic at enrolment236 . Interestingly the effect of MMS on birth weight was found to be an increase of 50g, but only in non-wasted mothers237. Perhaps more importantly, the use of community facilitators in the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) led to significant increases in the use of birth attendants at delivery, resulting in a 30% reduction in early infant mortality independent of the impact of micronutrient supplementation238. Therefore, if women were to consume multiple micronutrients on a regular basis and to use a trained birth attendant at delivery, the risk of early infant mortality could be Indonesia Health Sector Review Chapter 5 Nutrition Capacity and Governance reduced by nearly 50%. Ensuring high coverage of micronutrient supplements through the local midwife, and ensuring that all births are covered by the midwife could be achieved through the Posyandu. Such changes have not yet been adopted, however, and even deworming during pregnancy, as recommended by INACG, WHO and UNICEF239 240 241, is not implemented. The Lancet Nutrition Series242 recommended maternal food supplements that are balanced in energy and protein in food insecure areas, and used a cut-off of 10% for excessive thinness (i.e. BMI less than 18.5) in women of reproductive age, in order to model the effects of the intervention. Programme guidance on when and how to provide balanced energy-protein supplements to mothers during pregnancy is not readily available, however, and improving maternal nutrition status to improve fetal development is not simply a matter of improving dietary intake as has been reported by several technical consultations243 244 Indonesia has established legislation regarding the fortification of certain staple foods with micronutrients, and plans to do more. All salt has been required to be fortified with iodine since 1994 and all wheat flour with iron, zinc, folic acid, vitamin 1 and vitamin B2 since 2001245. As mentioned above, the salt iodization programme is still far from achieving its goal of eliminating iodine deficiency. So far there does not seem to be any evaluation or monitoring of flour fortification to assess its effectiveness, although the improvement in anaemia levels noted earlier in this report may well be due to this. There are reports that the consumption of fortified instant noodles is contributing to reducing iron deficiency anaemia in young children246. Cooking oil fortified with vitamin A has been tested in one province and is being initiated with the expectation that it become mandatory in 2012. Rice fortification is also being tested in two provinces, using rice from the Rice for the Poor Family (RASKIN) programme described below. It is important to carry out national surveys to measure the current situation of micronutrient deficiencies in order to gain a better understanding of how effective the various micronutrient supplementation and fortification efforts have been. Among the indirect interventions for tackling maternal and child undernutrition, the principle programme is a food subsidy policy called RASKIN, which began during the economic crisis in 1997/8 and has been implemented as part of a larger social safety net package from 1999 onwards. The RASKIN program is one of the GOI's key programs for improving food security, and in 2005 aimed to supply 20 kg of rice per month to 9 million poor families. The programme has had administrative difficulties, and part of the subsidy never reached households at all, going instead into the Indonesian Bureau of Logistics (BULOG's) operating costs. A review of the cost structure of RASKIN found that the cost of the food subsidy as a percentage of GDP tended to increase from 0.18% in 2006 to 0.23% in 2009, and that the efficiency of the subsidy also deteriorated in the period studied, with distribution costs of almost 20% of total cost in 2009247. An evaluation of RASKIN found a positive impact of the programme with beneficiaries increasing expenditures on nutrient rich animal source foods, as well as health expenditures248. However, extra income due to the programme was also spent on adult goods such as alcohol and tobacco, which had an even greater impact than on the expenditures on animal source foods. There was also considerable"leakage"with ten per cent of the highest income quintile households being beneficiaries. The gender-related aspects of economic and social risks have also been overlooked by RASKIN, and could be better addressed by dealing specifically with the vulnerabilities of mothers and young children from conception to toddlerhood249. The GOI introduced a second generation of social assistance programs following the partial removal of regressive fuel subsidies in 2005. A portion of the savings from the fuel subsidy cuts were reallocated to four programs: operational aid to schools (Bantuan Operasional Sekolah, BOS), health insurance for the poor (Asuransi Kesehatan Miskin, Askeskin), village infrastructure (Infrastruktur Pedesaan, IP) and rice for the poor (Beras Miskin, RASKIN). These programs are the basis of an emerging, permanent social safety net, providing income support for poor and near-poor households. Askeskin, re-named Jamkesmas (Jaminan Kesehatan Masyarakat), now covers around 76 million beneficiaries, making it the largest social assistance program in Indonesia. RASKIN continues to distribute rice to millions of families across the country. These programs joined the array of small social welfare programs already implemented by the Department of Social Affairs (DepSos), targeting especially vulnerable groups, such as orphans or the disabled. The Double Burden of Malnutrition in Indonesia Chapter 5 Nutrition Capacity and Governance More recently, the government has begun introducing and re-defining social assistance programs to break the generational transmission of poverty. In 2007 the GOI piloted a conditional cash transfer program (Program Keluarga Harapan, PKH) executed by DepSos. PKH assistance is transferred only when families obtain preventive basic health and nutrition services, and send their children to school.To date, the program has reached around 700,000 poor households and is preparing for further expansion. Block grants for community development are also being used to promote social development through the National Program for Community Empowerment (Program Nasional Pemberdayaan Masyarakat Mandiri, PNPM). Mandiri is the main government community-driven development program. As part of its commitment to improve the health of its population, the GOI has piloted two programs aimed at improving access to basic health and education services since 2007. Nasional Pemberdayaan Masyarakat Generasi Sehat dan Cerdas (PNPM Generasi) is an incentivized community block grant program that aims to enable communities to address both demand and small-scale supply-side problems that restrict access to services and hamper their ability to improve health and education performance as part of PNPM Rural. PNPM Generasi supports community efforts to improve a core set of health and education outcomes. PNPM Rural is based on the assumption that communities are best placed to identify the needs and actions required to achieve outcomes. As part of the Generasi project, communities receive assistance from trained facilitators to diagnose problems and identify ways to use funding provided by village-level block grants to achieve twelve health and education indicators. An evaluation of the PNPM Generasi programme has shown significant reduction of malnutrition by 2.2 percentage points (weight-for-age). Yet the results of the evaluation have showed that impact can be enhanced by increasing the demand for quality health and nutrition services. As such, strengthening the capacity of health providers in nutrition counselling and knowledge sharing will improve the quality of maternal and child health services, and most likely increase the demand thereof. In addition, improving the capacity of PNPM Generasi facilitators to identify the causes of health and nutrition problems is essential as they in turn assist communities to assess problems and to use the funds to solve them. Ensuring that these social assistance programmes not only contribute to reducing poverty, and to reducing maternal and child undernutrition, but are also consistent with the reduction of the DBM across the life course is necessary, albeit challenging. Making all such programmes effectively into conditional cash transfer programmes is one possibility to consider. Another is linking the provision of such cash transfers to the promotion/production of highly nutritional cash crops such as fruits and vegetables, which could/should be sold by small-scale local farmers through local farmers markets250 251. Animal source foods and fortified foods are also important for mothers and young children in order to prevent stunting. Food stamps can be linked to the purchase of these foods, as well as of fruit and vegetables in local farmers markets as is done in the US, for example, where the USDA Federal nutrition assistance programs provided approximately US$10 billion in support of fruit and vegetable consumption in Fiscal Year 2005. These funds support:the purchase and distribution offruitsand vegetables by the USDAto schools,food banks,and other program providers; the purchase and use by program providers through the Child Nutrition Programs; and participants' purchases in the marketplace through Food Stamps, Women, Infants and Children (WIC) and the farmer's market nutrition programs252. A result of these programs for agricultural and food production policies is increased support for the production of high value crops, such as fruit and vegetables through small-scale farmers rather than to rice self-sufficiency through industrial agriculture. Schools have been found to be the critical setting for preventing child obesity253, as well as for reducing other chronic disease risk factors and improving fitness254. School-based programmes should cover the role of both nutrition and physical activity in maintaining physical and mental health, with school food services providing healthy meals and the promotion and provision of daily physical exercise as part of the curriculum. The excessive consumption of sugar-sweetened beverages is an important driver of the current obesity epidemic in the US255, and is associated with a significantly elevated riskof type 2 diabetes256. Most US states have recently adopted laws that regulate the availability of sugar-sweetened beverages in school settings257, and in France and the UK vending machines have either been banned in schools or are no longer filled with sugar-sweetened beverages or Group 3 processed snackfoods. Indonesia should consider Indonesia Health Sector Review Chapter 5 Nutrition Capacity and Governance promoting the WHO-led Nutrition Friendly Schools Initiative (NFSI)58, which aims to increase access and availability of healthy foods as well as opportunities to be physically active, and to decrease access to and availability of unhealthy or "junk" foods as well as to support healthy lifestyles. A successful Indonesian model upon which to build and adapt as needed is the community-based school feeding program which was implemented through block grants to schools in "left behind villages"during the economic crisis in the 1990s259, as well as through PMTAS which is currently being implemented. Another promising arena for intervention in Indonesia is the workplace, which offers the potential for public private partnerships to be developed. An example is provided by Johnson & Johnson in the US which introduced Live for Life in 1979; by the end of the third year of the program, savings to the company were more than US$400 per year per employee265. A recent systematic review of worksite nutrition interventions for controlling overweight and obesity provides further support to these findings261. Training medical staff to address overnutrition, and prioritizing obesity as a disease among the NCDs is particularly important to consider. The Department of Noncommunicable Diseases plans to train health staff in health centres to address NCDs, including overweight/obesity. Hopefully, this will draw on experience from the US, which has shown that interventions by healthcare providers can be effective, especially if the professionals are trained to measure BMI and/or waist circumference (WC) to detect patients who are either overweight and/or gaining weight. Even brief messages from health professionals about nutrition through diet counseling can influence behavior, and the magnitude of the effect is related to the intensity of the intervention262 263 The GOI, like many national governments, has developed policies with dietary recommendations for their population, PUGS, which are largely based on the recommended nutrient intakes in the WHO Report 916. The objective of these is to help develop dietary guidelines for the public to be incorporated as part of nutrition education efforts. These recommendations are often depicted graphically, such as in PUGS and the'the Food Guide Pyramid'that originated in the US in 1992 by the USDA and now have been adopted or adapted in many countries, including Indonesia. Healthy diets based on the food group and pyramid approach have been much criticized, however, not least because during the thirty years of the food pyramid in the US, obesity rates soared. In Indonesia, as in most countries, dietary guidelines seem to have been little assimilated by the general public, in part because the messages were too complicated, but also because they were drowned out by food industry advertising264. One of the problems with the US food pyramid based dietary guidelines was that it focused more on"what to eat"than on "how much to eat" The original food pyramid aimed at limiting fat intake, and in general seems to have had an effect, with low-fat diets and special "light" foods becoming popular. But with no differentiation between types of fats, the benefits of"good"unsaturated fats were forgone265. Also, guidelines recommended increased consumption of starchy foods, and in particular grains (cereals) and cereal products, with little or no consideration given to the benefits of eating reduced carbohydrate diets266. Recommendations often give preference to "minimally processed" or "high-fibre" or "wholegrain" versions. However, the cereal part of the food pyramid does not differentiate between the type of processing that the cereal and/or starches have been subject to, such that Group 3 processed foods are considered acceptable267. Although dietary guidelines are important, efforts of the food industry promote the consumption of products that are, usually, not aligned with dietary guidelines. Globally, the food industry spends US$40 billion a year on advertising food, most of which promotes the consumption of ultra-processed foods268. Transnational soft drink and fast food companies market their products extensively worldwide, especially to children and youth269. As revealed by a consumers union report in the US, the US$11.26 billion spent on advertising by the food, beverage, and restaurant industries in 2004 dwarfed the mere US$9.55 million spent on communications by federal and state of California "5 A Day" programs to encourage eating five or more servings of fruit and vegetables each day270. In consequence, the majority of the American public still remains unaware that eating at least five servings of varied vegetable and fruits each day can improve health outcomes and help manage weight gain. The Double Burden of Malnutrition in Indonesia Chapter 5 Nutrition Capacity and Governance Based on evidence provided to it, the sixty-third World Health Assembly in May 2010 endorsed resolution WHA63.14, which called for national and international action to reduce the impact on children of marketing of foods high in saturated fats, trans fatty acids, free sugars, or salt. Advertising to children of any kind is banned in several Scandinavian countries, for example, and Brazil has outlawed all TV advertisements aimed at children. Hopefully Indonesia will follow suit, although it may take some time as Indonesia has yet neither signed the Framework Convention on Tobacco Control nor adopted all provisions of the International Code of Marketing of Breast-milk Substitutes. There is a growing consensus that a framework convention for obesity control is needed, similar to the one developed for tobacco control271. Transport policy and environmental design have fundamental effects on the determinants of physical activity and therefore influence the risk of obesity and other chronic diseases. Limiting the role of automobiles is one important area for intervention and can be achieved through a variety of channels, including making private car ownership and use more expensive, through higher taxes on cars and fuel, and introducing road tolls and congestion charges, as well as parking fees. The fees collected can be used to improve the provision of public transportation. Walking and biking can also be encouraged by creating special bike lanes, as well as by making town centers pedestrian-only precincts. Increasing the space available for leisure activities such as playing fields, parks, and public gardens, will also encourage more walking, running and sports. By law, all foods that are processed or imported in Indonesia must have a label. Labels which describe the nutrition content of foods can, in theory, permit the more discerning consumer to make more informed purchases. Evidence for the effectiveness of "front of pack" labelling is still weak, however272. Nutrition labels on pre-packaged foods, which are among the most prominent sources of nutrition information, are perceived as highly credible sources and many consumers use nutrition labels to guide their selection of food products. Evidence also shows a consistent link between the use of nutrition labels and healthier diets. However, the use of labels varies considerably across subgroups, with lower use among children, adolescents and older adults who are obese. Labels are most used by educated and wealthier segments of the population. Standards and guidelines related to texts for food products have been developed by Codex Alimentarius, but as described in the recent review of the global regulatory environment, there is considerable variation of approaches and regulations in countries around the world273. In all countries of Southeast Asia except Malaysia, nutrition labelling is voluntary unless nutritional claims are made274. WHO provides guidance on developing or adapting nutrient profile models275. The aim of this work is to harmonize nutrient profile model development in order to produce consistent and coherent public health nutrition messages for the consumer, and ultimately to improve nutrition and public health. Based on these nutrient profiles, claims such as "low fat" or "healthy choice" on food labels and in marketing can be regulated by national food standards authorities. The food industry has also pledged to self-regulate, but stringent standards are needed if self-regulation is to be effective. Voluntary nutrition-labelling adopted by the food industry in the US is considered far from ideal in many ways276. Fiscal policies such as subsidies and taxes can either stimulate or reduce consumption of products, including foods. Capitalist economics has been considered to have a central role in the global obesity epidemic, and economic policies are arguably the optimal target for intervention. Heavy taxes on cigarettes helped reduce their consumption in many countries, for example. Poland provides an example for food, where reduced subsidies on lard and butter soon after the transition to a democratic government resulted in a rapid increase in the consumption of cheaper non-hydrogenated vegetable fat. In consequence the ratio of dietary polyunsaturated to saturated fat increased from 0.33 in 1990 to 0.56 in 1999 and mortality from coronary artery disease dropped 28%. A tax on sugar-sweetened beverages has many proponents, and if the tax is sufficiently large (20%) has great potential to reduce obesity as well as to raise revenues. A useful guide on ways to develop fiscal policies in the Asian region has been developed by WHO, which provides guidance in relation to free market issues and the WTO, for example277. Indonesia Health Sector Review Chapter 5 Nutrition Capacity and Governance There is currently no overarching coordinating mechanism for nutrition in Indonesia and this gap was identified as a need in the LACA. The resource function depicted in Figure 7 ensures that necessary funds are provided to reach national goals and achieve national targets. The stewardship function sets goals and targets, regulates them, and govern what activities should be done, by whom and with what priority. In Indonesia, the stewardship and resource functions are divided between the various line ministries including Health and Agriculture as well as the National Development Planning Agency (BAPPENAS). With the emerging and escalating problem of the DBM, many more sectors are involved and consideration is needed for how to provide the necessary oversight going forward. Improved coordination and functionality for nutrition is essential for developing more coherent national nutrition policies and programmes tackling the DBM, and creating national nutritional councils has been recommended278. Implementation experience from the National Plans of Action for Nutrition (NPAN), which stemmed from the International Conference on Nutrition (ICN) also suggests that some central coordination mechanism was essential. The ICN efforts to implement national nutrition programmes, which were for both overnutrition and undernutrition, showed that strategies from different sectors could be best grouped into the four pillars depicted in Table 8. This overarching DBM policy framework was found to facilitate the delegation of service delivery within the Ministry of Health as well as across other sectors, and to assign responsibility for setting goals and strategies to achieve them279. It is presented as an illustrative example of how such a high-level coordinating body might be organized to help facilitate the full range of programmes involved in tackling the DBM across the life course. Table 8. The Four Overarching Pillars of DBM Nutrition Policy Framework Sector Nutrition Policy Pillars Sustainable Food Food Safety Healthy Lifestyle Nutrition Security Health 1. Food safety 1. Promotion of 1. Micronutrient and hygiene healthy eating supplementation regulations 2. Promotion of 2. Nutrition education 2. Food Inspections exercise 3. Dietary Guidelines 3. Food standards 3. Infection Control 4. Nutritional 4. Family Planning surveillance Public Works 1.Rural roads 1. Water and 1. Urban bike lanes and urban 2.Irrigation Sanitation 2. Pedestrian planning walkways Agriculture 1. Food availability 1. Food standards (Food production) Education 1. School gardens 1. Hygiene education 1. Physical exercise 1. Nutrition education 2. School meals 2. Life skills and sex 2. Anemia control education Social Welfare/ 1. Food Access (cash Security transfers) Industry and 1. Food availability 1. Food Standards 1. Food fortification Trade (manufacture and marketing) Public 1. Marketing of food 1. Code of marketing Information to children of breast-milk substitutes Finance/ 1.Food Subsidies 1. Food Taxes economy 2.Import/export restrictions Source: Authors The Double Burden of Malnutrition in Indonesia Chapter 5 Nutrition Capacity and Governance While global experience to date with creating national nutrition councils has not been entirely positive and there are not many good examples to draw upon, this may well be because past efforts were largely focused solely on undernutrition. The challenges posed by the burgeoning problems of the DBM in LMICs are much more multi-sectoral and far-reaching than undernutrition alone, which may well justify creating such high-level coordination mechanisms. The one example of a successful high-level coordination mechanism for nutrition comes from Brazil, where during the last few decades there has been a spectacular fall in child undernutrition, as measured by stunting in particular280 . Brazil has a high-level coordinating body called CONSEA (National Food and Nutrition Council) for oversight and broad policy setting, as well as a coordination mechanism for implementation. As noted in the LACA report281, the capacity to act for nutrition in Indonesia needs to be strengthened. Service provision has primarily revolved around child growth monitoring and is largely misdirected to the under-five year olds rather than focused on children under two and their mothers. Less priority is given to preventive activities related to counselling of mothers on infant and young child feeding than to the curative function of detecting and treating wasting, and when counselling is done it is mostly done by minimally trained community-based posyandu cadres. Attention to maternal nutrition is limited to iron/folate tablet distribution with little prioritization or promotion. Although a sufficient number of nutritionists are being trained, the training curriculum is outdated and incomplete; it hardly recognizes the DBM problem, for example. Nutritionists are under-employed, especially in the implementation of service delivery, and there is little or no in-service training in nutrition. A recent study of the capacity of the nutrition workforce in Indonesia concluded that it was inadequate to meet the challenges that Indonesia faces, especially because current diet-related NCD problems are not widely recognized as being due to poor nutrition across the life course"'. The report further recommended that workforce capacity be strengthened by improving the quality of nutrition education in Indonesia by: 1. Establishing nutrition service standards; 2. Developing consensus on nomenclature, scope, and the practice of different practitioners; 3. Enumerating current workforce attributes; 4. Projecting workforce needs; 5. Developing shared competency standards for the spectrum of modes of practice (clinical dietetics through community nutrition, to research and teaching). Any capacity development efforts in Indonesia need to be linked to and guided by the policy and programme components of a national nutrition plan. As noted in the Indonesian LACA, the National Plan for Development 2010-2014 (RPJMN) is focused on stunting and the Essential Nutrition Intervention package from the Lancet Nutrition Series. Although provinces and districts plans (RPJMD) are supposed to refer to the RPJMN when defining their own plans, there is often a disconnect between the planning processes at central and sub-national levels.The National Action Plan for Food and Nutrition (RANPG) for the five year period 2011-2015 is based on the RPJMN at both national and provincial level. Its main objective is to reduce stunting by five per cent in five years (from 37% to 32%). The RANPG is only concerned with maternal and child undernutrition, however. The problems of overnutrition and of overweight/obesity are part of the national NCD policy and strategy, aimed at controlling risk factors and prevention of NCDs, early detection, and health promotion measures. The NCD unit of the Ministry of Health was only created in 2005 and so activities in this area are relatively new. The current RPJMN and RANPG do not address the DBM problem as a whole, and so the main objective should be to ensure that the next RPJMN and RANPG are developed in a more harmonious way and cover both aspects of the nutrition problem. Indonesia Health Sector Review Chapter 6 Conclusions Chapter 6 Conclusions Indonesia has a big double burden of malnutrition (DBM) problem and needs to take urgent steps to both prevent it as well as to mitigate its effects across the life course. In Indonesia, undernutrition is still given more priority because overweight and obesity is believed to be a problem of the wealthy and an issue of personal choice. However this is not the case as gemukness is already a serious problem across all income levels, and is conditioned by increasingly obesogenic environments, especially among the poorest adults who are the most stunted. Furthermore, consequences of the DBM are increasingly likely to be greatest among the poorest that are least capable of accessing treatment for the cardiovascular diseases that are increasingly pervasive. A challenge of addressing gemukness is that it is a hidden problem. Asians have a higher proportion of body fat than Caucasians, and therefore greater risk of diet-related noncommunicable diseases (NCDs) such as cardiovascular disease. Among Asians, Indonesians are at greater risk of NCDs at the same level of gemukness than Chinese or Vietnamese, for example. Gemukness affects twice as many women as men, and tends to increase with age, peaking at 45-54 years. Of greatest concern is that the prevalence of gemukness has doubled in the last two decades and seems to be accelerating, while the rate of stunting, which reflects inadequate growth during the period from conception to two years of age and is itself associated with a greater risk of NCDs including gemukness, has remained static around 30% over the same period. It is the combination of increased weight gain across the life course coupled with constrained fetal and young child growth that is known to potentiate the risks of diet-related NCDs in adulthood. This problem is supported by the fact that the levels of gemukness in adults are greatest in the Outer Islands where maternal and child undernutrition rates are highest. One likely cause of constrained fetal and young child growth is the on-going problem of micronutrient deficiencies, likely to still be affecting at least a quarter of young mothers, as well as teenage pregnancies. Assessing the health and biological causes of the DBM reveals that the problem is related, in part, to an ageing population. Because of the demographic and epidemiological transition that Indonesia has experienced, largely due to family planning and health service coverage, NCDs and especially cardiovascular diseases are now the main causes of death. Unfortunately sanitation coverage is still far from universal and gastro-intestinal parasite infections are still exceedingly common, which contributes to the on-going problem of maternal anaemia. The health system in Indonesia is not well-equipped to deal with the new disease reality, however, largely because of a lackof awareness of the overnutrition problem and insufficient capacity to deal with its consequences. Increased cardiovascular diseases are also reflected in population-based blood analysis. Hypertension affected 46% of men and 53% of women over 45 years of age in 2007, reaching to 75% of women aged 75 years and over. Perhaps worse is that only a third knew of their condition and over ninety per cent were not receiving any treatment. Blood lipid levels worsen with age, and of those aged 45 years and older, 22% of women and 11% of men had high cholesterol levels, while 67% of men and 40% of women had low levels of HDL cholesterol, which is protective against cardiovascular diseases. These differences probably reflect the higher rates of smoking in men and of overweight/obesity in women. Diabetes is already affecting at least 6% of the population and 10% is pre-diabetic. There is no evidence in Indonesia that genetics plays any part in the growing obesity problem. The mechanisms that are likely to be in play are epigenetic not genetic, and are caused by the constrained fetal growth, as reflected in stunting, coupled with increasing wealth and increased weight growth during childhood. Among the epigenetic changes associated with constrained fetal growth and stunting is the creation of visceral adipose cells, as an insurance against the bleak times expected after birth. Diabetes, increased blood pressure, and dyslipidaemia affecting a large percentage of the population are consequences of the inflammatory state associated with being overweight, and especially of Indonesia Health Sector Review Chapter 6 Conclusions abdominal obesity. Adipose cells in the visceral fat deposits produce hormones and inflammatory markers as part of the body's energy balancing mechanisms. In the absence of food and energy sources coming into the blood, the adipose cells in the fat gland produce leptin which stimulates hunger centres in the brain. If too much energy is consumed and subcutaneous fat cells get full then energy gets diverted to the visceral fat gland by the inflammatory markers, and over time this leads to diabetes. Appetite mechanisms that evolved during hunter-gatherer existence are not able to cope with continuous snacking on energy- dense foods, such that as little as a 150 extra calories a day over the course of a year can lead to an average weight gain of a kilogram and a half a year. Once these fat reserves are created they are difficult to lose and easy to put back on again, thanks to the efficiency of the fat gland's energy conservation mechanisms. The inflammatory state ofobesity is also a potential cause of anaemia, and may be associated with the persistence of anaemia in Indonesia. Assessing the economic and food environments associated with the DBM reveals that the steady increase in national wealth has been accompanied by impressive reductions in poverty. In parallel, food availability as energy per capita has grown by 40% (20% from fat) in the last three decades while the population has doubled. While rice availability per capita remained the same, the availability of fish and meat doubled, milk tripled, and wheat increased sevenfold. These production increases achieved due to the Green Revolution were largely made possible by using oil-based inputs, so that while oil was cheap food was cheap. But that is changing fast: with oil prices high and increasing commodity speculation, global food prices are at all-time highs and are likely to remain so. With the increased global trading in foods, and opening up of borders to trade, increasing amounts of processed food are being imported and distributed through growing supermarket chains. Many of these commodities are artificially cheap because of subsidies given to farmers in the EU and US. All wheat in Indonesia is imported and largely used to make instant noodles. Food consumption patterns, although difficult to evaluate from the data available, also suggest increased food intake. Consumption estimates based on food expenditures are 16% higher, and show a five per cent increase in energy per capita purchased by households across the last decade. The greatest increase to this total came from meat, fish, and eggs, and in prepared foods, both of which nearly doubled. So not only has food consumption increased quantitatively in the last decade, but this growth has been in the more expensive items such as animal protein and food consumed outside the home. Vegetable and fruit consumption has remained stable and low at 4% of total energy purchased, with 94% of the population reporting not to have consumed the recommended five portions a day. There does not seem to be any information available to evaluate the quality of the diet, including the type of fat and the type of carbohydrates being consumed, and more research is needed here. It seems likely, however, that the increase in "prepared foods" from outside the home consists of processed foods such as instant noodles that are made from wheat and other wheat-based products, all of which are energy dense. The increased consumption of these "Group 3" processed foods is likely to be contributing to the increases in adiposity. The increasing price of foods is likely to promote consumption of the cheaper processed foods, made from imported commodities that continue to be subsidized in the country of origin. Inadequate breastfeeding is another poor food consumption pattern, and that continues to deteriorate despite GOI efforts to protect it. Only a third of babies are put to the breast within an hour of birth, and only 15% are exclusively breasted for six months. Seventy per cent of babies are fed formula milk at birth. Exclusive breastfeeding not only protects against young child growth failure and mortality, but also protects against future obesity. In addition, child feeding practices in older children aged 6-24 months are far from adequate, contributing to young child stunting and increasing the risks of NCDs later in the life course. Assessing the physical and built environments of the DBM in Indonesia reveals an urban environment that discourages exercise. There are few if any bike lanes, sidewalks or pedestrian precincts, and parks are a rarity. Access to processed foods in the street is almost the only option when commuting. In consequence, The Double Burden of Malnutrition in Indonesia Chapter 6 Conclusions the majority of school children, for example, purchase snack food from street vendors and local shops. Perhaps not surprisingly, the majority of the population do not get sufficient exercise to protect them from the risks of cardiovascular disease and weight gain. One of the most inactive age groups is school children. Assessing the socio-cultural environment of the DBM in Indonesia reveals a culture that retains much of its traditional customs while being totally immersed in all forms of modern media. Social customs drive child marriage, and a third of women do indeed get married while still children. This custom is likely to be contributing to elevated low birth weight rates seen in the Outer Islands especially. The reach of television is almost universal, however, and most adults watch the news at least once a week. Children watch around four hours of TV a day, more time than is spent in classrooms. The advertising of processed foods especially dominates the media, and is targeted at children. The majority of parents report that their purchases are more informed by their children's choice than the influence of advertisements. It is now well-recognized that the capacity of adolescents to make rational choices only reaches maturity at around twenty-five years of age. The capacity to deliver nutrition actions and the governance mechanisms that control these need strengthening, and actions are underway under the umbrella of the SUN (Scaling-Up Nutrition) Movement. The SUN Movement aims to develop a coordinated multi-stakeholder approach with one agreed overarching policy framework, one national coordinating authority, and one monitoring and evaluation system. While the SUN Movement targets maternal and child undernutrition and not the DBM, it should develop with the DBM in mind and recognize overnutrition as an equally important problem as undernutrition, with many overlapping interventions. The first priority for tackling the DBM is to address maternal and child undernutrition. A programme framework for the DBM is proposed, with evidence-based interventions organized by phase of the life course, and by direct and indirect interventions similar to the nutrition specific and nutrition sensitive language of the SUN framework. Many of the interventions in the DBM programme framework are already being implemented in Indonesia, although not organized under such a framework. An assessment of the coverage of the various interventions reveals a mixed picture with many advances and many gaps that still need to be filled. Non-implementation of the Code of Marketing of Breast-milk Substitutes is one example of such a gap, now existing for two decades or more. Policies, programmes and legislation exist but enforcement is lacking. Many advances have been achieved though food fortification with micronutrients, such as through iodized salt, but maternal anaemia in particular is still a problem. Social welfare programmes have done well in ensuring food security even among the poorest of the poor, but the emphasis to date has been more on food quantity than quality, and targeting has often been poor. Schools are critically important for fostering healthy lifestyles that will mitigate the effects of the DBM, but very little yet seems to have been done in this regard. Health systems and medical professionals can also be effective in tackling the DBM, but the lack of awareness of overweight/obesity and stunting as problems among health staff will need to be rectified. Little or no mechanisms exist for controlling the advertising of food to children, and food labelling and nutrition profiling seem still to be incipient. In addition, there are challenges posed by decentralization and the lack of adequate nutrition guidelines for districts to follow in preparing local development plans, as well as the lack of capacity in nutrition, especially at the district level. The lack of an overarching coordinating mechanism for nutrition in Indonesia has already been recognized. In constructing such mechanisms it is essential to envisage programmes for the DBM, and not just maternal and child undernutrition. Indeed the financial implications of the DBM are massive, with effects way beyond the Ministry of Health. A policy framework for such a coordinating body is proposed to organize the various programme interventions by the ministry under four pillars, namely: food security, food safety, healthy lifestyles, and nutrition. The capacity to act in nutrition has already been recognized as in need of strengthening, and actions are already underway to do this. Indonesia Health Sector Review Chapter 7 Suggested Policy Actions for Consideration Chapter 7 Suggested Policy Actions for Consideration In order to tackle the double burden of malnutrition (DBM) in Indonesia the following policy actions are suggested. These are grouped into various functional areas, both by stage of the life course as well as type of activity. Nutrition Policies and Plans 1. Ensure from the earliest, practical moment possible that nutrition programmes in Indonesia become oriented towards tackling the DBM, recognizing that the first priority for doing this is to tackle the problem of stunting by improving maternal and child nutrition, largely by implementing the Lancet Nutrition Series package of direct nutrition interventions 2. Ensure that the currently evolving high-level national nutrition council/forum for coordination and oversight for nutrition programmes and policies includes plans to tackle the DBM, building on current initiatives to follow through on the SUN Movement. 3. Consider ways to ensure that future RPJMN and RANPG adequately address the DBM. Maternal, Infant and Young Child Nutrition 1. Strengthen the mechanisms already in place and ensure their enforcement so that the Code of Marketing of Breast-milk Substitutes becomes a reality and infants are no longer given breast milk substitutes by health professionals, especially at the time of birth. 2. Strengthen efforts to improve diets of young children, be it through home-fortification, fortification of complementary foods and/or the use of local animal source foods as appropriate. 3. Further strengthen all efforts to control the multiple micronutrient deficiencies that continue to assail mothers and young children especially, through fortification and/or supplementation. Furthermore, in order to control maternal anaemia, introduce deworming during pregnancy, as recommended by WHO, as a short term measure until sanitation levels improve. Food and Nutrition Security 1. Strengthen aspects of agricultural policy in order to promote vegetable and fruit production through small-scale local farmers, not only to improve quality of food availability but also to improve incomes among the rural poor, so that both food security and nutrition security are ensured. 2. Strengthen all social welfare programmes for mothers and young children by ensuring conditionality of cash transfers as well as linkages to the promotion of highly nutritional cash crops such as fruits and vegetables, which could/should be provided by small-scale local farmers through local farmers markets. Nutrition Education and Healthy Lifestyles 1. A first priority is for dealing with the stunting/obesity/NCDs problem is to develop extensive and effective nutrition education throughout the country starting with students, academicians, government officials, politicians, the food industry as well as the general public. In order to do, this some short term awareness-raising effort aimed initially at policy-makers may be needed. 2. Develop plans to make all schools "nutrition friendly" schools which promote the use of healthy foods and physical activity, starting in 2013 with pilot initiatives in at least five provinces, building on PMTAS. 3. Ensure that all capacity-building efforts to strengthen nutrition professionals and health service staff fully address the DBM. 4. Put into national law regulations to reduce the impact on children of marketing of foods high in saturated fats, trans fatty acids, free sugars, or salt, as recommended by the World Health Assembly resolution WHA63.14. Advertising of any food to children through any media should be banned and infractions punished. 5. Take measures to ensure that future urban planning initiatives are "exercise friendly" by including more bike lanes, pavements, pedestrian precincts and parks. Indonesia Health Sector Review Chapter 7 Suggested Policy Actions for Consideration Research 1. Develop models to estimate the economic and fiscal impacts of the DBM across the life course. 2. Explore the potential for and possibilities of introducing taxes on imported food commodities that benefit from subsidies in the country of origin, as well as taxes on selected fast foods such as high sugar drinks that are particularly obesogenic. 3. Investigate the fat content of the national diet including: the quality of the fat, the proportion that is saturated verses poly-unsaturated, and the amounts and sources of trans fats being consumed. 4. Conduct national level nutrition surveys to ascertain what the situation is with regard to micronutrient status, especially for iron deficiency anaemia, iodine, vitamin A and zinc deficiencies. The Double Burden of Malnutrition in Indonesia References 1 GOI. 2010. Landscape Analysis 2 Hadi H. 2005. 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