Reading Time: 7 minutes

Between 1990 and 2010, there was an increase in cases of double burden of malnutrition (DBM) in 15 low and middle-income countries, including Indonesia (Popkin et al., 2020). Indonesia has the highest prevalence of severe DBM in the world. DBM occurs when one household member is overweight or obese, and another is undernourished, such as micronutrient deficiencies, underweight, stunting, or wasting (Biswas et al., 2021; Guevara-Romero et al., 2021). Four combinations within a family lead to DBM: both children being stunted and overweight, the mother being overweight and the child being wasted, the mother being overweight and the child being stunted, and the mother being thin and the child being overweight. The overweight mother and stunted child combination is prevalent in every country (Popkin et al., 2020).

Stunting negatively affects children’s cognitive development and increases the risk of non-communicable diseases like diabetes type 2, hypertension, and cardiovascular diseases (Black et al., 2013). Being overweight negatively impacts a mother’s health, leading to chronic diseases and lower economic output (Black et al., 2013). According to the Indonesia Demographic and Health Survey (IDHS), 30.8% of Indonesian children were stunted, and 35.4% of Indonesian adults were overweight or obese, with more prevalence among women (Diana, 2020). However, within families, 28% experience DBM (Rachmah et al., 2021).

Several factors contribute to Indonesia’s high DBM prevalence, including biological factors (age, height), health-related behaviours (feeding, food intake, lifestyle), socioeconomic factors (mother’s education, occupation, and household income), healthcare access and area of residence (Guevara-Romero, 2021). DBM might increase in the future, and limited studies on this phenomenon make it more challenging to address than standalone malnutrition (Guevara-Romero, 2021; Khaliq et al., 2022). This article explores the family health approach to overcoming the DBM issue at the household level in Indonesia.

Promoting breastfeeding and encouraging exercise among mothers is essential

Breastfeeding is essential for both mothers and children. It can protect mothers from obesity and reduce the risk of stunting in children (WHO, 2017). However, only about 45.4% of infants in Indonesia are breastfed exclusively (Diana, 2020). Supporting mothers in breastfeeding is crucial, as it helps children meet their nutritional needs and lowers their chances of becoming overweight. This support from family members can prevent the double burden of malnutrition (DBM) at the household level (Hong, 2021).

Obesity is linked to reduced physical activity, often influenced by modern technology, home production, and transportation systems (Popkin et al., 2020). To combat obesity, household members should encourage mothers to engage in physical activity (Menon & Penalvo, 2020). By doing so, we can promote better health for both mothers and children.

Providing information on daily nutrition for mothers and babies and recommending good dietary habits are necessary

Children of mothers with lower levels of education tend to have higher rates of stunting (Rachmah et al., 2021). This is because maternal education protects against the double burden of malnutrition (DBM) (Kroker-Lobos, 2014). Mothers play a crucial role in providing food for their families, and those with less formal education may lack the knowledge to encourage healthy eating habits, leading to unhealthy food choices for their families (Gea-Horta et al., 2016). Fathers’ education is also linked to DBM at home, with homes where the father has completed postsecondary education having lower odds of having a child with DBM (Yasmin et al., 2019).

Health professionals need to emphasize the importance of meeting nutritional needs to prevent stunting in children and overweight issues in mothers. They should encourage families to choose foods high in fibre, vitamins, minerals, and other nutrients, such as fruits and vegetables while reducing saturated fat and sugar intake (Hoque et al., 2017). Increasing the consumption of high-quality protein and micronutrients found in animal-based foods like zinc, iron, calcium, and vitamin B12 is essential to combat DBM at the individual level (Kulkarni, 2018). Data shows that children in Indonesia consume high rates of sugary, salty, and fatty/fried foods but need more fruits and vegetables (Diana, 2020). Limiting the intake of high-energy, high-sugar, high-fat foods and drinks is crucial because they are linked to childhood stunting and maternal obesity (Hawkes et al., 2020).

Health professionals should also encourage and support breastfeeding initiation while informing mothers about the risks of using breastmilk substitutes like formula milk (Wong et al., 2015). Regular check-ups at clinics, community health centres, or hospitals to monitor DBM at the household level are also vital (Hawkes et al., 2020). By addressing dietary habits, providing nutritional education, promoting breastfeeding, and ensuring regular health check-ups, we can make strides in preventing DBM in Indonesia.

The World Health Organization (WHO)’s Double Duty Actions (DDAs) to address DBM must be supported by programs, policies, and interventions

The ability of households to provide enough nutrition for mothers and children is affected by household income (Black et al., 2020). Low household income increases the likelihood of DBM by 5% (Rachmah et al., 2021). DBM is more common in rural areas, where people often lack running water and nutritious food (Guevara-Romero, 2021). To address this, government initiatives should target low-income families and rural residents. Behavioural education interventions can be used to educate family members on dealing with DBM (Menon & Penalvo, 2020). A randomized controlled trial can test the program’s effectiveness, providing nutrition education through home visits or printed materials for 12 weeks. Food-based dietary guidelines can help households with DBM meet their nutritional needs, considering different age groups and DBM levels (Chavasit et al., 2013).

The highest concentration of DBM cases occurs in households with the lowest quartiles of Gross Regional Domestic Product (GRDP) (Popkin et al., 2020; Sahanggamu et al., 2017). To tackle this, the government should establish a food supplementation program at Integrated Health Posts (Posyandu). The program can provide nutrient-dense foods to reduce DBM incidence (Nykänen et al., 2018). Eligibility for the program is determined by various minimum income thresholds, with lower-income households receiving more aid in rural and urban areas. Foods like rice, maize, millet, sweet potatoes, chickpeas, and fish can be promoted to ensure balanced nutrition. Encouraging people to eat locally grown foods, as seen in the “Go Local Awareness” campaign in the Federated States of Micronesia, can benefit Indonesia, given its abundant farm and sea-caught goods (Englberger et al., 2011).

In addition to nutrition-focused interventions, access to primary healthcare, safe drinking water, and environmental sanitation must be prioritized, especially in low-income and marginalized communities (Buonomo, 2020). The government should ensure an adequate and continuous food supply and establish a system to evaluate and track progress toward meeting DBM’s micronutrient targets (Hawkes et al., 2020). By addressing these aspects, we can progress in reducing DBM in Indonesia.

Writer: Yulinda Nurul Aini

Editor: Inayah Hidayati

References:

Biswas, T., Townsend, N., Magalhaes, R. J. S., Hasan, M., & Mamun, A. (2021). Patterns and determinants of the double burden of malnutrition at the household level in South and Southeast Asia. European Journal of Clinical Nutrition, 75(2), 385–391. https://doi.org/10.1038/s41430-020-00726-z\

Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., De Onis, M., Ezzati, M., Grantham-Mcgregor, S., Katz, J., Martorell, R., & Uauy, R. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, 382(9890), 427–451. https://doi.org/10.1016/S0140-6736(13)60937-X

Buonomo, E., Moramarco, S., Tappa, A., Palmieri, S., Di Michele, S., Biondi, G., Agosti, G., Alessandroni, C., Caredda, E., & Palombi, L. (2020). Access to health care, nutrition and dietary habits among school-age children living in socio-economic inequality contexts: results from the “ForGood: Sport is Well-Being” programme. International Journal of Food Sciences and Nutrition, 71(3), 352–361. https://doi.org/10.1080/09637486.2019.1655714

Chavasit, V., Kasemsup, V., & Tontisirin, K. (2013). Thailand conquered under-nutrition very successfully but has not slowed obesity. Obesity Reviews, 14(S2), 96–105. https://doi.org/10.1111/obr.12091

Diana, R. (2020). Double-Duty Actions to Reduce the Double Burden of Malnutrition in Indonesia. Amerta Nutrition, 4(4), 326. https://doi.org/10.20473/amnt.v4i4.2020.326-334

Englberger, L., Lorens, A., Pretrick, M., Tara, M. J., & Johnson, E. (2011). Local food policies can help promote local foods and improve health: a case study from the Federated States of Micronesia. Hawaii Medical Journal, 70(11 Suppl 2), 31–34.

Géa-Horta, T., Silva, R. D. C. R., Fiaccone, R. L., Barreto, M. L., & Velásquez-Meléndez, G. (2016). Factors associated with nutritional outcomes in the mother-child dyad: A population-based cross-sectional study. Public Health Nutrition, 19(15), 2725–2733. https://doi.org/10.1017/S136898001600080X

Guevara-Romero, E., Flórez-García, V., Egede, L. E., & Yan, A. (2021). Factors associated with the double burden of malnutrition at the household level: A scoping review. Critical Reviews in Food Science and Nutrition, 0(0), 1–12. https://doi.org/10.1080/10408398.2021.1908954

Hawkes, C., Ruel, M. T., Salm, L., Sinclair, B., & Branca, F. (2020). Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. The Lancet, 395(10218), 142–155. https://doi.org/10.1016/S0140-6736(19)32506-1

Hong, S. A. (2021). Prevalence and regional variations of coexistence of child stunting and maternal overweight or obesity in Myanmar. Public Health Nutrition, 24(8), 2248–2258. https://doi.org/10.1017/S136898002000186X

Hoque, M. E., Hasan, M. T., Rahman, M., Long, K. Z., & Al Mamun, A. (2017). Double burden of underweight and overweight among Bangladeshi adults differs between men and women: Evidence from a nationally representative survey. Public Health Nutrition, 20(12), 2183–2191. https://doi.org/10.1017/S1368980017000957

Khaliq, A., Wraith, D., Nambiar, S., & Miller, Y. (2022). A review of the prevalence, trends, and determinants of coexisting forms of malnutrition in neonates, infants, and children. BMC Public Health, 22(1), 879. https://doi.org/10.1186/s12889-022-13098-9

Kroker-Lobos, M. F., Pedroza-Tobias, A., Pedraza, L. S., & Rivera, J. A. (2014). The double burden of undernutrition and excess body weight in Mexico. American Journal of Clinical Nutrition, 100(6), 1652S-1658S. https://doi.org/10.3945/ajcn.114.083832

Kulkarni, B. (2018). Addressing the Double Burden of Malnutrition in Developing Countries: Need for Strategies to Improve the Lean Body Mass. Food and Nutrition Bulletin, 39(2_suppl), S69–S76. https://doi.org/10.1177/0379572118768572

Menon, S., & Peñalvo, J. L. (2020). Actions targeting the double burden of malnutrition: A scoping review. Nutrients, 12(1), 1–14. https://doi.org/10.3390/nu12010081

Nykänen, E. P. A., Dunning, H. E., Aryeetey, R. N. O., Robertson, A., & Parlesak, A. (2018). Nutritionally optimized, culturally acceptable, cost-minimized diets for low income Ghanaian families using linear programming. Nutrients, 10(4). https://doi.org/10.3390/nu10040461

Popkin, B. M., Corvalan, C., & Grummer-Strawn, L. M. (2020). Dynamics of the double burden of malnutrition and the changing nutrition reality. The Lancet, 395(10217), 65–74. https://doi.org/10.1016/S0140-6736(19)32497-3

Rachmah, Q., Mahmudiono, T., & Loh, S. P. (2021). Predictor of Obese Mothers and Stunted Children in the Same Roof: A Population-Based Study in the Urban Poor Setting Indonesia. Frontiers in Nutrition, 8(December), 1–9. https://doi.org/10.3389/fnut.2021.710588

Sahanggamu, P. D., Purnomosari, L., & Dillon, D. (2017). Information exposure and growth monitoring favour child nutrition in rural Indonesia. Asia Pacific Journal of Clinical Nutrition, 26(2), 313–316. https://doi.org/10.6133/apjcn.012016.09

WHO. (2017). Double-duty actions for nutrition Policy Brief. Who/Nmh/Nhd/17.2, 5, 10. https://apps.who.int/iris/bitstream/handle/10665/255414/WHO-NMH-NHD-17.2-eng.pdf?ua=1

Wong, K. L., Tarrant, M., & Lok, K. Y. W. (2015). Group versus individual professional antenatal breastfeeding education for extending breastfeeding duration and exclusivity. Journal of Human Lactation, 31(3), 354–366. https://doi.org/10.1177/0890334415583294

Yasmin, G., Kustiyah, L., & Dwiriani, C. M. (2019). Stunted Children Has Higher Risk of Overweight: A Study on Children Aged 6-12 Years in Eight Provinces in Indonesia. Pakistan Journal of Nutrition, 18(5), 455–463. https://doi.org/10.3923/pjn.2019.455.463