Maternal contributors to intergenerational nutrition, health, and well-being: revisiting the Tanjungsari Cohort Study for effective policy and action in Indonesia.

Perinatal and maternal mortalities in Java became of concern in the 1980s. Since some 90% of births took place at home, the Tanjungsari (TS) district of West Java was identfied as a locality where community-based risk management strategy might reduce this health burden. In 1987, traditional birth attendants (TBA) were trained to identify risk factors for unfavourable birth outcomes. From January 1st 1988 to December 1989, some 4,000 pregnant women in TS were followed and assigned either a trained or untrained TBA. In the first year, early neonatal, and maternal mortality rates (MMR) (32.9 per 1000 and 170 per 100,000 deliveries respectively) were reduced, but not sustained in the second year. Nationally, MMR was 446 in 2009 and 126 in 2015. Although possible to improve health worker performance, and community engagement, the most likely explanation for benefit attrition is that people and material resources 'downstream' of the TBA services were inadequate. Three decades later, Indonesian neonatal and maternal mortality rates of 14 per 1000 and 126 per 100,000 live births in 2015 (globally 16.2 in 2009 and 216 in 2015) according to UNICEF, still demanded improvement, despite more hospital-based births. The original 1988 cohort of women, their children and grandchildren, can now be interrogated for medium to long term health outcomes of nutritional, such as birth weight and growth, and other risk factors. The evolving TS cohort health and nutrition intermediates and endpoints are instructive. Maternal and early life factors predict adult energy metabolism and cognitive function.

The Clinical Nutrition Research Agenda in Indonesia and beyond: ecological strategy for food in health care delivery.

Despite progress with the food-associated health agenda in the public health and clinical domains, much remains to be done in Indonesia. There are reasons to be optimistic which include economic development, increasing literacy, progress towards universal health coverage and community organizational arrangements across the archipelago which focus on health through some 10,000 puskesmas. These community health centres are variably staffed with voluntary cadres from the community, bidans (nurses) and general medical practitioners. For more effective prevention and management of nutritionally-related health problems, innovative community and clinical nutrition research and expertise is required. With rapid urbanisation, the growth of the digital economy, increasing socio-economic inequity and climate change, there are imperatives for ecologically sustainable, nonemployment dependent livelihoods which provide energy, food, water, education and health care security. A relevant health care workforce will include those who research and practice clinical nutrition. Here we gather together an account of an extensive body of published and emerging literature which makes a case collectively for a more ecological approach to nutrition and health and how it might revitalise the Indonesian and other health care systems.

Developments in clinical food and nutrition science in Indonesia.

Indonesia, as a major population in the Asia Pacific region, threatened with food and health insecurity through climate change and rapid economic development, faces the challenge to build capacity among its science-based food and health professionals and institutions. The nutrition research agenda is now being more actively set within the region, rather than by external imposition. A series of papers emanating from a new generation of public health and clinical nutrition scientists is reported in this issue of APJCN. It draws attention to the importance of food patterns and background culture as contributors to the failure of the nutrient rather than a food, food system and socio-ecological approach to solve the region's intransigent nutritionally-related health problems. New understandings of human eco-social biology are providing opportunities to accelerate the resolution of these problems. The challenge is to transform the food-health construct from one which is not sufficiently concerned about the precarious state of ecologically dysfunctional health and its nutrient market drivers to one which strives for more sustainable and affordable solutions. The present reports address a range of options to these ends.

Determinants of child malnutrition during the 1999 economic crisis in selected poor areas of Indonesia.

There is empirical evidence at the national level that suggests the 1999 Indonesian economic crisis impact was very heterogeneous both between urban and rural areas and across regions. A cross sectional study of the nutritional status of children and its determinants was performed in urban poor areas of Jakarta, and rural areas of Banggai in Central Sulawesi, and Alor-Rote in East Nusa Tenggara. Two-stage cluster sampling was used to obtain 1078 households with under-five children in the urban poor area of Jakarta, and 262 and 631 households with under-five children each for the rural areas of Banggai and Alor-Rote, respectively. Data collection for both studies was performed from January 1999 to June 2001. The study shows that wasting affected more children in the urban poor areas of Jakarta than in the other study areas. On the other hand, stunting and anemia were significantly more severe among children 6-59 months of age in the rural area of Alor-Rote compared to the other study areas. The high prevalence of infectious diseases was significantly related to the higher prevalence of wasting in the study areas of Jakarta and Banggai, and also significantly related to the higher prevalence of stunting and anemia in the study area of Alor-Rote. To avert this kind of health impact of a economic downturn, there is a need to improve the nutritional and health status of under-five children and their mothers through the existing health care system, provide basic health services and improve the capacity of health staff across Indonesia as part of the decentralization process.

Weight management in transitional economies: the " double burden of disease" dilemma.

The nature of nutritionally-related disease (NRD) in transitional economies is such that deficiency can frequently co-exist with excess. This is most usually represented by the combination of diets of low nutritional quality (low and little food component density and diversity, FCDD) and decreased levels of physical activity, predicated, in part, on limited affordability of alternatives. Moreover, these changes are not simply inter-generational, as the pace of socio-environmental change is great enough for them to be intra-generational as well. The most troublesome situation is that of maternal undernutrition, with intra-uterine growth retardation, compromised lactation and infant feeding, leading to stunting in early life and to abdominal obesity and its consequences later in life. Weight management in these situations requires pre-conceptional interventions, effective maternal-child health programmes and life-long approaches to avoid inappropriate gene programming and body compositional disorders. It is unlikely that narrow strategies, located solely around energy balance, will do more than attenuate this growing burden of disease for most of the world's populations. The pluralistic approaches to health required are likely to build on more effective lifestyle, behavioural and pharmacotherapeutic strategies to weight management, and do so at all ages, from conception to later life.