Prevalence of, and factors associated with anaemia in children aged 1-3 years in Aceh, Indonesia: A cross-sectional study.

Background: Child anaemia continues to represent a major public health challenge in lower-and-middle income countries. It has serious long-term consequences for child growth and development. In Indonesia, there was a 10% increase in the national prevalence of child anaemia between 2013 and 2018. Aim: This study aims to assess the prevalence of, and factors associated with anaemia among children aged one to three years in eight districts in Aceh Province, Indonesia. Methods: A cross-sectional study was conducted on a sample of 1148 mother-child dyads aged one to three years between November and December 2018. The sampling process involved a three-stage cluster sampling design using the probability proportionate to size methodology. Anaemia status was determined using haemoglobin level (Hb < 11.0 g/dL). Data were analysed using multivariable logistic regression to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (95% CI) for associated factors. Results: The overall prevalence of anaemia was 76.1% (869/1142). 44.7% (510/1142) and 28.6% (327/1142) had moderate and mild anaemia, respectively. Child aged 12-24 months (aOR: 2.00, 95% CI: 1.26-3.17), not receiving routine immunisation (aOR: 2.62, 95% CI: 1.34-5.10), and maternal anaemia (aOR: 2.15, 95% CI: 1.59-2.90) were significantly associated with anaemia. Conclusion: The prevalence of anaemia among the children in this study was high, and was associated with child age, immunisation status, and maternal anaemia. These findings provide further insight into anaemia as a public health issue at a sub-national level in Indonesia and for development of targeted programmes to address associated risk factors of child anaemia.

Consumption patterns of sweetened condensed milk in the diet of young Indonesian children and its potential nutritional health consequences.

This critical review is intended to analyse the existing studies on the consumption patterns of sweetened condensed milk in the diet of young Indonesian children and its potential nutritional health consequences. Considering its limited nutritional value and high sugar content, sweetened condensed milk (SCM) should not be administered to young children (1-3 years old) with the goal of promoting their growth and development. However, such false practice has been reported in mostly urban studies among the underprivileged population. Conclusive scientific evidence is also still lacking regarding the health risks of long-term SCM consumption by young Indonesian children at early ages, as no study has focused on this specific topic. Nevertheless, inadequate understanding of SCM, its consumption patterns, and its long-term effects on health among young Indonesian children have been implicated in public confusion on the topic. Ongoing disparities that exist between regulation, industrial practices, and product advertisement have led to poor understanding in communities, which, to a considerable extent, has contributed to difficulties in segregating data on the consumption of SCM and its related products. Analogous to sugar-sweetened beverages, limited SCM consumption can be recommended when appropriately implemented with active monitoring and evaluation of product advertisements and product labeling, enforcement of regulations, and provision of effective customer education.

Interpersonal communication campaign promoting knowledge, attitude, intention, and consumption of iron folic acid tablets and iron rich foods among pregnant Indonesian women.

BACKGROUND AND OBJECTIVES: Indonesia's community health delivery system offers services such as prenatal care and supplementation. Despite accessibility to these services, compliance with supplementation is low, and childhood stunting rates remain high. To address undernutrition, a National Nutrition Communication Campaign (NNCC) - using interpersonal communication (IPC) strategies - was implemented to promote consumption of iron-folic acid (IFA) supplements and iron-rich foods (ATIKA). The purpose of this study was to understand how participation in IPC activities influenced knowledge, attitude/intention, and consumption of IFA supplements and ATIKA among pregnant Indonesian women. METHODS AND STUDY DESIGN: Cross-sectional data came from 766 pregnant women that participated in a survey that was based on the constructs from the Theory of Planned Behavior and Health Belief Model. Adjusted linear and logistic regression models were conducted to analyze the differences between self-reported IPC participants and non-IPC participants. Approximately 20% of women were exposed to the IFA portion of the IPC campaign, and 18% were exposed to the ATIKA portion. RESULTS: Women that were exposed to the campaign reported significantly higher knowledge of IFA tablets and ATIKA, and improved attitudes/intentions towards IFA, compared to non-exposed women. Exposure was not associated with actual consumption behaviors. CONCLUSIONS: These findings suggest that exposure to a low-intensity intervention can increase knowledge but may not be sufficient to impact behavior. As such, future efforts to reduce stunting through improved maternal nutrition should seek to increase exposure, address barriers, understand perceived susceptibility, and improve self-efficacy in order to expand intervention reach in Indonesia.

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.

Efficacy of daily and weekly multiple micronutrient food-like tablets for the correction of iodine deficiency in Indonesian males aged 6-12 mo.

BACKGROUND: Infants are highly vulnerable to iodine deficiency, and little data exist on the effect of multiple micronutrient supplementation on their iodine status. OBJECTIVE: We aimed to compare the efficacy of daily and weekly multiple micronutrient food-like tablets (foodLETs) on increasing iodine status among infants. DESIGN: In a double-blind, placebo-controlled trial, 133 Indonesian males aged 6-12 mo were randomly assigned to 1 of 4 groups: a daily multiple-micronutrient foodLET providing the Recommended Nutrient Intake (RNI)(DMM), a weekly multiple-micronutrient foodLET providing twice the RNI (WMM), a daily 10-mg Fe foodLET (DI), or placebo. Urinary iodine (UI) concentrations were measured at baseline and at 23 wk. RESULTS: At baseline, the average UI concentration (1.37 micromol/L) was within the normal range, and 30.8% of subjects had iodine deficiency (UI < 0.79 micromol/L). At 23 wk, the DMM group had the highest increment in UI; however, after adjustment for initial UI, the changes in UI were not significantly different between the 4 groups (P = 0.39). Initial UI correlated inversely with the changes in UI (P < 0.001). The DMM group had the greatest reduction and increment in the proportion of iodine-deficient infants and in infants with iodine excess, respectively; however, no significant difference was found in these proportions (P = 0.13 and P = 0.42) between the 4 groups. CONCLUSION: Daily consumption of a multiple-micronutrient foodLET providing the RNI during infancy may be one strategy to improve iodine status.

Effect of daily or weekly multiple-micronutrient and iron foodlike tablets on body iron stores of Indonesian infants aged 6-12 mo: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: There is still uncertainty about the best procedure to alleviate iron deficiency. Additionally more reliable methods are needed to assess the effect of iron intervention. OBJECTIVE: We examined the efficacy of daily iron (10 mg), daily and weekly multiple-micronutrient supplementation (10 and 20 mg Fe, respectively) in improving body iron stores of Indonesian infants. DESIGN: Infants aged 6-12 mo were randomly allocated to 1 of 4 groups: daily multiple-micronutrients (DMM) foodlike tablets (foodLETs), weekly multiple-micronutrient (WMM) foodLETs, daily iron (DI) foodLETs, or daily placebo. Hemoglobin, ferritin, transferrin receptors, and C-reactive protein data were obtained at baseline and 23 wk. RESULTS: Body iron estimated from the ratio of transferrin receptors to ferritin was analyzed for 244 infants. At baseline, mean iron stores (0.5 +/- 4.1 mg/kg) did not differ among the groups, and 45.5% infants had deficits in tissue iron (body iron < 0). At week 23, the group DI had the highest increment in mean body iron (4.0 mg/kg), followed by the DMM group (2.3 mg/kg; P < 0.001 for both). The iron stores in the WMM group did not change, whereas the mean body iron declined in the daily placebo group (-2.2 mg/kg; P < 0.001). Compared with the daily placebo group, the DMM group gained 4.55 mg Fe/kg, the DI group gained 6.23 mg Fe/kg (both P < 0.001), and the WMM group gained 2.54 mg Fe/kg (P = 0.001). CONCLUSIONS: When compliance can be ensured, DI and DMM foodLETs are efficacious in improving and WMM is efficacious in maintaining iron stores among Indonesian infants.

Food-poverty status and food insecurity in rural West Lombok based on mothers' food expenditure equivalency.

BACKGROUND: When the Central Bureau for Statistics (CBS) developed a national food-poverty line for Indonesia, some aspects, such as food availability,food beliefs, and food habits, were not considered. In addition, the reference population was determined on the basis of their nonfood expenditures. OBJECTIVE: To develop and use a method applicable in any given sociocultural setting, as well as to determine food-poverty status in rural West Lombok, Indonesia, using mothers'food expenditure equivalency (FEE). METHOD: Mothers' actual food intake determined by a modified 24-hour recall served to establish FEE. The results were verified with household food-security measures based on the US Household Food Security/Hunger Measurement (US HFSSM), and the mothers' nutritional status was assessed by the body-mass index (BMI). RESULTS: Most mothers (72%) were food-poor and 79% were also food-insecure. Food poverty has a positive correlation with household food insecurity. The severely food poor also had the highest risk of household food insecurity. The nutritional status of mothers showed no correlation with food-poverty status and therefore was not found to be an appropriate indicator of food poverty in this cultural setting. CONCLUSIONS: Because most food consumed by mothers was purchased, financial security plays a key role in determining family food sufficiency, in terms of both quantity and variety. Mothers' BMI status differed between the food-poor and non-food-poor groups, but the difference was not statistically significant, suggesting that in our setting the food-poverty line cannot be used to identify physiological need but is rather more of a social and economic indicator. We suggest the use of US HFSSM questionnaires as a simple alternative means to assess both food-poverty and food-security status, mainly because the method is simple to apply and corroborates our findings using area-specific FEEs. Finally, our study results suggest a number of follow-up investigations.

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.

Multiple micronutrient supplements improve micronutrient status and anemia but not growth and morbidity of Indonesian infants: a randomized, double-blind, placebo-controlled trial.

Multiple micronutrient deficiencies are highly prevalent in Indonesia, but the interventions are still focused on single micronutrients. This study aimed to investigate the efficacy of multiple micronutrient supplements for improving micronutrient status, anemia, growth, and morbidity of Indonesian infants. In this double-blind, placebo-controlled trial, 284 infants aged 6-12 mo were randomly allocated to 4 treatment groups for 23 wk; 260 (92%) infants completed the study. Group 1 (DMM) received one adequate intake of multiple micronutrient supplements daily (n = 66); group 2 (WMM) received 2 adequate intakes of multiple micronutrient on 1d plus 6 d of placebo (n = 60); group 3 (DI) received 10 mg of iron supplement daily (n = 69); group 4 received a placebo supplement daily (n = 65). Blood samples were collected at baseline and at posttreatment to assess anemia and micronutrient status. Anthropometric measurements were taken monthly, and morbidity was recorded daily. At baseline, 58.1% of infants were anemic, 34.2% were iron deficient, 21.3% were vitamin A deficient, and 11% were zinc deficient. The DMM and DI supplements both corrected iron deficiency, but DMM supplements were more efficacious in improving hemoglobin levels of anemic infants than the other supplements. However, anemia still persisted in one-third of DMM infants posttreatment. The DMM supplement was more efficacious than WMM or DI supplementation in improving infant status of other micronutrients, including zinc, tocopherol, and riboflavin, whereas DI exacerbated zinc deficiency. There were no significant differences in growth and morbidity among treatment groups, and growth faltering was not prevented.