Malnutrition Prevalence and Nutrient Intakes of Indonesian Older Adults in Institutionalized Care Setting: A Systematic Review of Observational Studies.

INTRODUCTION: Data on the prevalence of malnutrition and nutrient intakes among Indonesian older aduls in institutionalized care setting are scattered and scarce. Thus, we conducted a systematic review of published and grey literature to estimate (1) the prevalence of malnutrition, (2) the level and distribution of habitual energy and nutrient intakes, and (3) the prevalence of inadequacy of energy and nutrient intakes among hospitalized and institutionalized older adults in Indonesia. METHODS: This systematic review was written following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The population of this review was Indonesian older adults in institutionalized care settings, including hospital ward, orphanages, nursing homes, residential facilities, and rehabilitation centers . Malnutrition was assessed using body mass index, the mini nutritional assessment (MNA) score, or the subjective global assessment (SGA) score. The dietary intakes (from food recalls, food records, or food frequency questionnaire) were compared with the Indonesian recommended daily allowances (RDAs) for people aged 65 to 80. The prevalence of inadequacy was calculated using two-thirds of the RDA as a proxy for the estimated average requirement (EAR). RESULTS: The search yielded 330 studies from electronic databases, resulting in fifteen eligible studies. One report was obtained from an unpublished study. Based on the JBI criteria, most studies had low risk of bias and represented the target population. The prevalence of malnutrition in hospital, nursing home, and other institutionalized care ranged from 6.5%-48.3% in hospitals and 3.2%-61.0% in other institutionalized care units. In the hospital setting, there was a high prevalence of inadequacies for all nutrients, particularly protein (20%), calcium (more than 90%), and vitamin D intakes (more than 50%). In nursing homes, these proportions were exceptionally high for protein (66%) and calcium and vitamin D intakes (almost 100%). CONCLUSION: The high risk of malnutrition Indonesian older adults in institutionalized care setting is pronounced, along with poor intakes of macronutrients and micronutrients in both settings.

Cooking behavior among mothers of children aged 2-5 years old in Kendari, Southeast Sulawesi, Indonesia.

BACKGROUND: Cooking at home was associated with parental feeding practices. This study aimed to explore the interplay of components in cooking behavior of mothers with young children aged 2-5 years old in Kendari city of Southeast Sulawesi, Indonesia. METHODS: This qualitative study involved 33 mothers from Kendari city, which was represented by each two sub-districts in coastal and mainland areas that were randomlyselected. Six focus group discussions (FGDs) were carried out using 20-item guide questions. The guide questions were developed following the Model of Goal-Directed Behavior (MGDB) theory approach exploring the components of cooking behavior i.e., skill, intention, desire, confidence, and attitude in cooking. Data analysis was performed in the field to assist decision on data saturation, followed by data analysis at desk through multilevel coding from the verbatim transcripts using NVivo R1 software. The data was analyzed thematically using pre-determined themes according to the MGDB theory. Emerging topics on enabling factors and constraints were captured to enhance our understanding of the complexity of cooking behavior. RESULTS: The mothers' mean age was about 30 years old with a comparable representation of younger and older mothers. Most mothers were housewives and accomplished secondary school level. The mothers' intention was shown as they frequently cooked at home and allocated time for cooking. The enabling factors included their knowledge about food and nutrition, food source availability, their confidence in cooking meals and following recipes, and their motivation to keep their children healthy representing some intrinsic factors. The main constraint was the lack of skill to make snacks. The other extrinsic barriers were dependence on mobile food sellers and the availability of food kiosks that facilitated children's snack preferences. CONCLUSION: The study obtained some insights that mothers had favorable cooking intention and desire, were supported with a confidence in some basic cooking skills. However, the existing constraints that encouraged the development of unfavorable children's snacking habit were beyond the mothers' control. A cookbook specifically for snack recipes that utilizes local ingredients may assist mother in preparing more healthier options for the children.

Behavioural and environmental risk factors associated with primary schoolchildren's overweight and obesity in urban Indonesia.

OBJECTIVES: To aid the design of nutrition interventions in low- and middle-income countries undergoing a nutrition transition, this study examined behavioural and environmental risk factors associated with childhood overweight and obesity in urban Indonesia. DESIGN: Body height and weight of children were measured to determine BMI-for-age Z-scores and childhood overweight and obesity status. A self-administered parental survey measured socio-economic background, children's diet, physical activity, screen time and parental practices. Logistic and quantile regression models were used to assess the association between risk factors and the BMI-for-age Z-score distribution. SETTING: Public primary schools in Central Jakarta, sampled at random. PARTICIPANTS: Children (n 1674) aged 6-13 years from 18 public primary schools. RESULTS: Among the children, 31·0 % were overweight or obese. The prevalence of obesity was higher in boys (21·0 %) than in girls (12·0 %). Male sex and height (aOR = 1·67; 95 % CI 1·30, 2·14 and aOR = 1·16; 95 % CI 1·14, 1·18, respectively) increased the odds of being overweight or obese, while the odds reduced with every year of age (aOR = 0·43; 95 % CI 0·37, 0·50). Maternal education was positively associated with children's BMI at the median of the Z-score distribution (P = 0·026). Dietary and physical activity risk scores were not associated with children's BMI at any quantile. The obesogenic home food environment score was significantly and positively associated with the BMI-for-age Z-score at the 75th and 90th percentiles (P = 0·022 and 0·023, respectively). CONCLUSIONS: This study illustrated the demographic, behavioural and environmental risk factors for overweight and obesity among primary schoolchildren in a middle-income country. To foster healthy behaviours in primary schoolchildren, parents need to ensure a positive home food environment. Future sex-responsive interventions should involve both parents and children, promote healthy diets and physical activity and improve food environments in homes and schools.

Nutrient intakes of pregnant and lactating women in Indonesia and Malaysia: Systematic review and meta-analysis.

Introduction: Optimizing dietary intake during pregnancy and lactation is crucial to the growth and development of children and their lifelong health. We performed a systematic review and meta-analysis to describe the nutrient intakes of pregnant and lactating women in Indonesia and Malaysia, countries that are experiencing rapid nutrition transition in Southeast Asia. Methods: We screened 2,258 studies published between January 1980 and March 2021. The nutrient intakes of pregnant and lactating women were quantitatively analyzed to calculate the percentage of adequacy using national recommended daily allowances or nutrient intakes (RDA/RNI) and estimated average requirements (EAR) for micronutrients. Standardized mean differences (SMD) between dietary intake and RDA/RNI were determined for selected nutrients. Results: Fifty-three studies were included and showed that energy and macronutrient intakes among pregnant and lactating women in both countries were below the RDA/RNI. In addition, most studies reported that women failed to meet the EAR for vitamin D (<70% EAR), vitamin E (<50% EAR), and water-soluble vitamins (<80% EAR) except for vitamin C and A among Malaysians. Moreover, calcium, potassium, and iron intakes of pregnant women were <60% EAR in Indonesia and <80% EAR in Malaysia. Phosphorus intake among pregnant women in both countries and sodium intake among Malaysian pregnant women exceeded 100% EAR. Indonesian lactating women had <60% EAR for calcium and potassium intakes, while Malaysian women had more than 100% EAR. For 21 studies reporting overall protein intakes, the standard mean difference (SMD) was -2.26 (95% CI; -2.98, -1.54) below the RDA/RNI for pregnant women and -0.67 SMD (95% CI -15.7, -11.5) for lactating women. When the four studies from Malaysia were analyzed separately, protein intakes of pregnant women were above the RNI. Moreover, low intakes of vitamin D, vitamin C, calcium, and iron, but sufficient intakes in vitamin A, zinc, and phosphorus were observed in pregnant women in both countries. Conclusion: Dietary intakes of energy, macronutrients, and micronutrients (vitamin D, vitamin E, water-soluble vitamins, calcium, and iron) of pregnant and lactating women in Indonesia and Malaysia were below the recommendations. Important heterogeneities were observed even between these two countries for specific essential nutrient intakes. Innovative research and targeted programs to address specific deficiencies should be prioritized. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021252204, identifier: CRD42021252204.

The impact of government pandemic policies on the vulnerability of healthcare workers to SARS-CoV-2 infection and mortality in Jakarta Province, Indonesia.

INTRODUCTION: Healthcare workers (HCWs) are on the frontlines of the COVID-19 pandemic, putting them at a higher risk of infection and disease than non-HCWs. We analysed the effects of government policies for the public and for HCWs on the likelihood of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality among HCWs during the first 8 months of the pandemic in Jakarta province, the capital city and COVID-19 hotspot in Indonesia. METHODS: We conducted a retrospective cohort study using secondary data from the Jakarta provincial government from March to October 2020, which included sociodemographic characteristics, symptoms, comorbidities and COVID-19 diagnosis history for all cases. A generalized linear mixed-effect regression model was used to determine the effect of each month on the odds ratio (OR) of COVID-19 cases and deaths for HCW compared with non-HCW, assuming that monthly trends were influenced by varying government policies. RESULTS: A total of 894,487 suspected and confirmed COVID-19 cases in health facilities in Jakarta province were analysed. The OR of confirmed cases for HCW was 2.04 (95% CI 2.00-2.08; p < .001) compared to non-HCW. Despite this higher OR for infection, the case fatality rate (2.32 per 100) and OR (1.02, 95% CI 0.93-1.11; p = .65) of COVID-19 deaths for HCW were similar to those of non-HCW. We observed a trend towards a lower number of COVID-19 patients in hospitals and lower odds of COVID-19 cases among HCWs during the April-to-July 2020 phase compared to the August-to-October phase. This chronologically aligned with more extensive policies to support hospital-based, community-based and well-being-related actions to protect HCW. CONCLUSIONS: HCW had higher odds of having SARS-CoV-2 infection, yet similar odds of death from COVID-19, as compared to non-HCW. Government policies with collective efforts to prevent hospital overcapacity during high transmission and burden periods of the pandemic should be prioritized.

Healthcare workers (HCWs) had higher exposure and odds of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection than non-HCWs but a similar risk of death, consistent with previous studies.Government policies favouring reduced workloads of HCW and interventions to promote resilience can be achieved through combined hospital-based, community-based and well-being-related approaches.Studies to identify the patterns and trends of COVID-19 cases and deaths, hospital admissions and policy dynamics are important to promote evidence-based decision-making by the government.

Comparisons of Characteristics and Nutritional Inadequacies in Indonesian Older Adults Consuming or Refraining from Dairy Products.

BACKGROUND: Milk consumption in the Indonesian elderly population is among the lowest in the world, and two-thirds of the population are lactose intolerant. This might have an impact on energy and nutrient intakes. However, data on the prevalence of nutrient intake inadequacies in dairy users versus non-dairy users, as well as population characteristics, are lacking. Therefore we obtained data comparing nutritional inadequacies and characteristics of Indonesian older adults consuming or refraining from dairy products. METHODS: A cross-sectional study was conducted in 2021 as a part of the INA LACTASE study, involving 194 community-dwelling older adults in the outpatient geriatric clinic at Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia. We collected data on demographic and clinical characteristics as part of a routinely performed comprehensive geriatric assessment. A structured questionnaire was developed to categorize participants as dairy-or non-dairy users based on habitual dairy intake. Food records were collected to assess nutrient intakes. The prevalence of inadequacies of energy, macronutrients, and a selection of micronutrients (calcium, vitamin D, and vitamin B12) was calculated by comparing the reported mean intakes to the recommended dietary intakes of the Indonesian population (Indonesian RDA). Prevalence ratios were calculated to measure the association between dairy product consumption and the prevalence of nutrient inadequacies. RESULTS: We recruited 194 eligible participants. This study found that dairy users had a higher proportion of women, a higher monthly income, but a lower proportion of hypertension, diabetes mellitus, and dyslipidaemia in older adults consuming dairy products. We observed wide variability in energy and nutrient intakes, as well as a high prevalence of inadequacies for all dietary intake parameters, particularly micronutrients. Dairy users had a lower prevalence of micronutrient inadequacies than non-dairy users. The prevalence of vitamin D inadequacies in dairy users versus non-dairy users was 91.6% vs. 99.3% in men and 71.9% vs. 98.0% in women, respectively. Inadequate vitamin B12 intake was found in 60.6% of dairy users vs. 89.4% of non-dairy users in men and 65.5% vs.. 68.4% of women, respectively. The most pronounced difference was found in the prevalence of calcium intake inadequacies in dairy users vs. non-dairy users, which was 64.8% vs. 99.5% in men and 89.9% vs. 99.8% in women. We found statistically significant differences in the prevalence of calcium, vitamin D, and vitamin B inadequacies between dairy and non-dairy users. CONCLUSION: This study identified that dairy users had a higher monthly income and had a lower proportion of hypertension, diabetes mellitus, and dyslipidemia. In addition, we discovered a high prevalence of nutrient intakes inadequacies in Indonesian older adults, particularly among non-dairy users. Micronutrient inadequacies are major sources of concern, with statistically significant difference in calcium, vitamin D, and vitamin B12 prevalence of inadequacies.

Development and preliminary validity of an Indonesian mobile application for a balanced and sustainable diet for obesity management.

BACKGROUND: Mobile applications such as personalized tracking tools and food choice aids may enhance weight loss programs. We developed and assessed client preferences for the content, user interface, graphics, and logic flow of a mobile application, and evaluated its validity for tracking compliance with weight control and making healthy and sustainable food choices. METHODS: Our four-stage study comprised formative research, application development, acceptance assessment, and validity. The formative research included literature reviews and six focus groups with 39 respondents aged 19-64 years at high risk for obesity. The development stage included programmer selection, defining application specifications, design, and user interface. Prototype acceptability was assessed with 53 respondents who graded 17 features of content, graphic design, and application flow (ranked as good, moderate, and poor). A feature was considered to have "good" acceptance if its mean response was higher than the mean of overall responses. The validity was assessed in 30 obese women using Bland-Altman plots to compare results from dietary intake assessment from the application to conventional paper-based methods. RESULTS: The application was named as EatsUp®. The focus group participants defined the key requirements of this app as being informative, easy, and exciting to use. The EatsUp® core features consisted of simple menu recommendations, health news, notifications, a food database, estimated portion sizes, and food pictures. The prototype had a "good" overall acceptance regarding content, graphics, and flow. Fourteen out of 17 parameters were graded as "good" from > 70% of respondents. There was no significant difference between the rated proportions for content, graphics, and app flow (Kolmogorov-Smirnov Z-test, p > .05). The agreement using the Bland-Altman plots between EatsUp® and the paper-based method of measuring food intake was good, with a mean difference of energy intake of only 2.63 ± 28.4 kcal/day (p > 0.05), well within the 95% confidence interval for agreement. CONCLUSIONS: The EatsUp® mobile application had good acceptance for graphics and app flow. This application can support the monitoring of balanced and sustainable dietary practice by providing nutritional data, and is comparable with conventional dietary assessment tools, and performed well in tracking energy, macronutrient, and selected micronutrients intakes. TRIAL REGISTRATION: NCT03469869 . The registration date was March 19, 2018.

Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose.

OBJECTIVE: Antenatal multiple micronutrient supplements (MMS) are a cost-effective intervention to reduce adverse pregnancy and birth outcomes. However, the current WHO recommendation on the use of antenatal MMS is conditional, partly due to concerns about the effect on neonatal mortality in a subgroup of studies comparing MMS with iron and folic acid supplements (IFA) containing 60 mg of iron. We aimed to assess the effect of MMS vs IFA on neonatal mortality stratified by iron dose in each supplement. METHODS: We updated the neonatal mortality analysis of the 2020 WHO guidelines using the generic inverse variance method and applied the random effects model to calculate the effect estimates of MMS vs. IFA on neonatal mortality in subgroups of trials (n=13) providing the same or different amounts of iron, i.e. MMS with 60 mg of iron vs IFA with 60 mg of iron; MMS with 30 mg of iron vs IFA with 30 mg of iron; MMS with 30 mg of iron vs IFA with 60 mg of iron; and MMS with 20 mg of iron vs IFA with 60 mg of iron. RESULTS: There were no statistically significant differences in neonatal mortality between MMS and IFA within any of the subgroups of trials. Analysis of MMS with 30 mg vs IFA with 60 mg of iron (7 trials, 14,114 participants), yielded a nonsignificant Risk Ratio (RR) of 1.12 (95% CI 0.83 to 1.50). CONCLUSION: Neonatal mortality did not differ between MMS and IFA regardless of iron dose in either supplement.

Malnutrition Prevalence and Nutrient Intakes of Indonesian Community-Dwelling Older Adults: A Systematic Review of Observational Studies.

Background: Malnutrition and inadequate nutrient intake are associated with functional decline, frailty, and bad clinical outcomes among community-dwelling older adults. Despite the growing proportion of the elderly population in Indonesia, data on the prevalence of malnutrition and adequacy of macronutrient and micronutrient intakes among Indonesian older adults are scattered and vary between studies. Therefore, our study aims to obtain data on malnutrition prevalence, level and distribution of nutrient intakes, and prevalence of macronutrient and micronutrient inadequacies in Indonesian community-dwelling older adults. Methods: We carried out a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in PROSPERO. A systematic electronic database search of MEDLINE, CENTRAL, EMBASE, ProQuest, HINARI, IMSEAR, GARUDA, and Indonesian Publication Index was undertaken. Additional searches were conducted in gray literature sources, hand-searching, retrospective searching, and personal communication with authors of the relevant publication. Observational studies presenting the malnutrition prevalence of habitual dietary intakes of older adults (60 years or older) were included. The risk of bias of studies was assessed using the Joanna Briggs Institute critical appraisal form. Sex-specific mean (and standard deviation) habitual macronutrient and a selection of micronutrients (calcium, vitamin D, and vitamin B12) intakes were extracted from each article to calculate the percentage of older people who were at risk for inadequate micronutrient intakes using a proxy of estimated average requirement (EAR) cut-point method, which is calculated from the national guideline of recommended dietary allowance (RDA). Prevalence of malnutrition, based on body mass index (BMI) categories and mini-nutritional assessment (MNA) criteria. and the population at risk of malnutrition were presented descriptively. Results: Nine studies retrieved from electronic databases and gray literature were included in the pooled systematic analysis. According to BMI criteria, the underweight prevalence ranged from 8.0 to 26.6%. According to the MNA, the prevalence of malnutrition ranged from 2.1 to 14.6%, whereby the prevalence of at risk of malnutrition amounted to 18-78%. Our systematic review identified a high prevalence of nutrient inadequacies, most markedly for protein, calcium, vitamin D, and vitamin B12. Conclusion: We signal a high risk of malnutrition along with poor macronutrients and micronutrients intakes among Indonesian community-dwelling older adults. These findings provide important and robust evidence on the magnitude of malnutrition and nutrient inadequacy concerns that call for appropriate nutrition, as well as public health policies and prompt intervention. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018102268.

Multiple micronutrient supplements versus iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis.

Antenatal multiple micronutrient supplements (MMS) are more effective than iron and folic acid (IFA) supplements in reducing adverse pregnancy outcomes. Questions remain, however, about the ability of MMS to prevent anemia as effectively as IFA, especially at a lower dose of daily iron and in areas of high anemia prevalence. Analyzing data from 11 trials from a recent Cochrane review, we compared MMS to IFA, delivering either 30 or 60 mg of iron, in sustaining hemoglobin and preventing third trimester anemia and iron deficiency anemia (IDA), accounting for daily iron dose, total supplemental iron intake, and baseline prevalence of anemia. There were no differences between MMS and IFA in third trimester hemoglobin concentration or risks of anemia or IDA by iron dose or total supplemental iron consumed. MMS providing 30 mg of iron was comparable to IFA with 60 mg of iron: mean hemoglobin difference of -0.26 g/L (95% CI: -1.41 to 0.89), risk ratios of 0.99 (95% CI: 0.92-1.07) for anemia, and 1.31 (95% CI: 0.66-2.60) for IDA. Baseline prevalence of anemia did not explain heterogeneity in findings. Compared to IFA, MMS results in comparable hemoglobin concentration and protection against anemia during pregnancy, independently of iron dose.

Relationships of Child-, Parents-, and Environment-Associated Determinants with Diet Quality, Physical Activity, and Smoking Habits Among Indonesian Urban Adolescents.

BACKGROUND: The trend of unhealthy lifestyles is increasing among adolescents and has been associated with the rising burden of noncommunicable diseases (NCDs). However, specific determinants of unhealthy lifestyles among adolescents in low- and middle-income countries remain limited. OBJECTIVE: To investigate the relationships of child-, parents-, and environment-associated determinants with diet quality, physical activity, and smoking habits among low-socioeconomic urban adolescents. METHODS: A cross-sectional study involving 238 adolescents aged 11 to 17 years was conducted in Jakarta, Indonesia. Adolescents and their parents were interviewed to assess the determinants of healthy lifestyles that included diet quality, physical activity, and smoking habits. Diet and physical activity were quantified using the Diet Quality Index for Adolescents (DQI-A) and Physical Activity Questionnaire for Older Children (PAQ-C), respectively. Multiple regression was used to determine the ß coefficients and odds ratios predictive of healthy lifestyles. RESULTS: Mean scores of DQI-A and PAQ-C were considered low (33.5% ± 8.9% and 2.1 ± 0.5, respectively). Overall, 17.6% of adolescents were smokers, with 88% of these being males. Predictors of diet quality were child- (age, gender) and environment-associated (house size, access to a computer) determinants with ß coefficients of -6.52 to 3.26. The PAQ-C score was associated with child- (female) and environment-associated (living area) determinants with ß coefficients of -0.45 and 0.14, respectively. Younger adolescents and females were protective factors for smoking. Parents-associated determinants were not associated with any lifestyle indicators. CONCLUSIONS: Child- and environment-associated determinants were predictors of healthy lifestyles among adolescents. Thus, personal empowerment and environment transformation are needed to facilitate a healthy lifestyle and reduce the burden of NCDs among adolescents.

Human Milk Oligosaccharides as a Missing Piece in Combating Nutritional Issues during Exclusive Breastfeeding.

Extensive studies have shown that breast milk is the best source of nutrition for infants, especially during the first six months, because it fulfills almost all of their nutritional needs. Among the many functional building blocks in breast milk, human milk oligosaccharides (HMOs) have been receiving more attention recently. Furthermore, it is the third most common group of compounds in human milk, and studies have demonstrated the health benefits it provides for infants, including improved nutritional status. HMOs were previously known as the 'bifidus factor' due to their 'bifidogenic' or prebiotic effects, which enabled the nourishment of the gastrointestinal microbiota. Healthy gastrointestinal microbiota are intestinal health substrates that increase nutrient absorption and reduce the incidence of diarrhea. In addition, HMOs, directly and indirectly, protect infants against infections and strengthen their immune system, leading to a positive energy balance and promoting normal growth. Non-modifiable factors, such as genetics, and modifiable factors (e.g., maternal health, diet, nutritional status, environment) can influence the HMO profile. This review provides an overview of the current understanding of how HMOs can contribute to the prevention and treatment of nutritional issues during exclusive breastfeeding.

The psychological distress of parents is associated with reduced linear growth of children: Evidence from a nationwide population survey.

BACKGROUND: Stunting, an indicator of restricted linear growth, has become a primary measure of childhood undernutrition due to its persistent high prevalence globally, and importance for health and development. Although the etiology is recognized as complex, most analyses have focused on social and biomedical determinants, with limited attention on psychological factors affecting care and nurturing in the home. We assessed whether the psychological distress of parents is related to child linear growth and stunting, and documented the associated risk factors, and examined the relationship between parental distress and behavioral and other risk factors for stunting. METHODS: We used data from the Indonesia National Health Survey 2013, including 46,315 children 6-59 months of age. Multivariate linear, logistic, and multilevel multinomial logistic regression, using survey weights, were used to assess the relationship between parental distress, as assessed by the WHO Self Reporting Questionnaire (SRQ20), with height-for-age z score (HAZ), stunting, and behavioral and other risk factors for stunting. RESULTS: Maternal, paternal and parental distress (i.e. both maternal and paternal distress) were associated with reduced linear growth of the children by 0.086 (95% CI -0.17, -0.00), 0.11 (95% CI -0.24, -0.02) and 0.19 (95% CI -0.37, -0.00) HAZ-scores, respectively. Maternal and paternal distress increased the risk of mild stunting (HAZ <-1) by 33% (95% CI 1.17,1.50) and 37% (95% CI 1.18,1.60), and the risk of moderate stunting (HAZ <-2) by 25% (95% CI 1.10,1.43) and 28% (95% CI 1.08,1.51]), respectively. Parental stress increased the risk of moderate stunting by 40% (95% CI 1.06,1.85). Amongst specific groups of risk factors, the proportion of HAZ-score lost was associated with socioeconomic factors (30.3%) including, low wealth, low maternal occupational status, low maternal education, rural residence, and low paternal occupational status; physiological factors (15.5%) including low maternal height, low maternal mid-upper arm circumference, being male, low paternal height; behavioral factors (8.9%) including open garbage disposal, paternal smoking, not using iodized salt; and experiencing at least one infectious diseases episode (1.1%). CONCLUSIONS: Maternal, paternal and parental stress were associated with reduced linear growth of children. These findings highlight the complex etiology of stunting and suggest nutritional and other biomedical interventions are insufficient, and that promotion of mental and behavioral health programs for parents must be pursued as part of a comprehensive strategy to enhance child growth and development, i.e. improved caretaker capacity, integrated community development, improved parenting skills, as well as reduced gender discrimination, and domestic violence.

Integration of symptomatic, demographical and diet-related comorbidities data with SARS-CoV-2 antibody rapid diagnostic tests during epidemiological surveillance: a cross-sectional study in Jakarta, Indonesia.

OBJECTIVES: Affordable options for COVID-19 epidemiological surveillance are needed. Virus detection by reverse transcription-PCR (RT-PCR) is sensitive but costly, and antigen-based rapid diagnostic tests (RDTs) are cheap but with reduced sensitivity; both detect current infection but not exposure. RDT-IgM/IgG antibodies to SARS-CoV-2 detect exposure but have poor sensitivity for current infection. We investigated if the integration of symptomatic, demographical and diet-related comorbidities data with antibody RDTs improves their potential to assess infection rates in addition to exposure, thereby broadening their utility for surveillance. DESIGN: We conducted a cross-sectional study using data from community surveillance for SARS-CoV-2. Health workers collected nasopharyngeal swabs for RT-PCR and RDT antigen assessments and venous blood for RDT-IgM/IgG from symptomatic and asymptomatic persons. Data on age, gender, contact history, symptoms (ie, fever, cough, runny nose, sore throat, headache, dyspnoea and diarrhoea), diet-related comorbidities (ie, diabetes and hypertension) and chest radiology were collected. SETTING: High-risk communities in Jakarta, Indonesia, in May 2020. PARTICIPANTS: 343 community members' data were included. OUTCOME MEASURES: RDT-IgM/IgG sensitivity, specificity and predictive values and area under receiver operating characteristic curve for RT-PCR positivity using RDT results alone and in combination with other predictors, including symptom components derived from principal component analysis. RESULTS: There were 24 PCR-confirmed infections. RDT-IgM/IgG-positive tests were associated with infection (OR 10.8, 95% CI 4.43 to 26.4, p<0.001) with an area under the curve (AUC) of 0.708% and 50% sensitivity, 91.5% specificity, 30.8% positive predictive value (PPV) and 96.1% negative predictive value (NPV). RDT results combined with age, gender, contact history, symptoms and comorbidities increased the AUC to 0.787 and yielded 62.5% sensitivity, 87.0% specificity, 26.6% PPV and 96.9% NPV. CONCLUSIONS: SARS-CoV-2 RDT-IgM/IgG results integrated with other predictors may be an affordable tool for epidemiological surveillance for population-based COVID-19 exposure and current infection, especially in groups with outbreaks or high transmission.

Snacks, nudges and asymmetric peer influence: Evidence from food choice experiments with children in Indonesia.

Many children in low- and middle-income countries are growing up during a rapid nutrition transition. Experimental evidence on food choice in developing countries is scarce, while it is unclear to what extent evidence from high-income countries can be generalized. Children participated in a snack choice experiment. We expose some children to emoji labels encouraging healthy snacks, while others observe healthy or unhealthy snacking by peers. While emoji labels moderately promote healthy snacking, the adverse effect of observing a peer eating the unhealthy snack is very large. The effect associated with observing a healthy peer is insignificant. Additionally, cross-randomized blocks of children watched a nutrition video to study the interaction of information provision and nudging. The video independently improves healthy choices but does not aid the emoji nudge and cannot counter the strong negative peer effect. We compare our findings to studies conducted in developed countries and discuss policy implications.

Identification of Food-Derived Isoflavone Sulfates as Inhibition Markers for Intestinal Breast Cancer Resistance Proteins.

Potential inhibition of the breast cancer resistance protein (BCRP), a drug efflux transporter, is a key issue during drug development, and the use of its physiologic substrates as biomarkers can be advantageous to assess inhibition. In this study, we aimed to identify BCRP substrates by an untargeted metabolomic approach. Mice were orally administered lapatinib to inhibit BCRP in vivo, and plasma samples were assessed by liquid chromatography/time of flight/mass spectrometry with all-ion fragmentation acquisition and quantified by liquid chromatography with tandem mass spectrometry. A differential metabolomic analysis was also performed for plasma from Bcrp -/- and wild-type mice. Plasma peaks of food-derived isoflavone metabolites, daidzein sulfate (DS), and genistein sulfate (GS) increased after lapatinib administration and in Bcrp -/- mice. Administration of lapatinib and another BCRP inhibitor febuxostat increased the area under the plasma concentration-time curve (AUC) of DS, GS, and equol sulfate (ES) by 3.6- and 1.8-, 5.6- and 4.1-, and 1.6- and 4.8-fold, respectively. BCRP inhibitors also increased the AUC and maximum plasma concentration of DS and ES after coadministration with each parent compound. After adding parent compounds to the apical side of induced pluripotent stem cell-derived small intestinal epithelial-like cells, DS, GS, and ES in the basal compartment significantly increased in the presence of lapatinib and febuxostat, suggesting the inhibition of intestinal BCRP. ATP-dependent uptake of DS and ES in BCRP-expressing membrane vesicles was reduced by both inhibitors, indicating inhibition of BCRP-mediated DS and ES transport. Thus, we propose the first evidence of surrogate markers for BCRP inhibition. SIGNIFICANCE STATEMENT: This study performed untargeted metabolomics to identify substrates of BCRP/ABCG2 to assess changes in its transport activity in vivo by BCRP/ABCG2 inhibitors. Food-derived isoflavone sulfates were identified as useful markers for evaluating changes in BCRP-mediated transport in the small intestine by its inhibitors.

Adolescent Nutrition-Developing a Research Agenda for the Second Window of Opportunity in Indonesia.

BACKGROUND: Recently, adolescence has been identified as a second window of opportunity for the correction of nutritional inadequacies. However, there is a lack of knowledge on evidence-based integrated nutrition strategies for adolescents in Indonesia. OBJECTIVE: To provide a research agenda and the prioritization of research actions to tackle outstanding knowledge gaps on adolescent nutrition in Indonesia. METHODS: A preliminary set of research topics was listed based on a desk study of the academic literature and policy documents. Second, a stakeholder meeting was held to further identify and discuss research topics related to adolescent nutrition in Indonesia. Third, an online survey was conducted in which respondents were asked to indicate priority research themes for the next 3 to 5 years and to rank a total of 23 research questions. RESULTS: Most (52%) of the respondents who returned the survey (n = 27) prioritize research on implementation and program evaluation, while 30% prefer descriptive and explanatory research, and 19% place priority with intervention and discovery research. However, when we followed up with specific topics for each of these broad research areas, a more nuanced picture emerged, with intervention and discovery research taking a more prominent standing. CONCLUSIONS: In order to support the design, implementation, and effectiveness of integrated nutrition programs for Indonesian adolescents, in-depth studies should question the best intervention strategies, modes of delivery, and long-term outcomes, while nationwide and disaggregated data should investigate associations and trends over time and identify vulnerable groups.

The Triple Burden of Malnutrition Among Adolescents in Indonesia.

BACKGROUND: Indonesia is a prime example of the triple burden of malnutrition. Indonesian adolescents are among the hardest hit, with approximately one in four adolescent girls suffering from anemia, while nearly one in seven adolescents is overweight or obese. OBJECTIVES: The present editorial provides a snapshot of the various research papers included in this Supplement, which calls for increased attention to adolescent nutrition in Indonesia and beyond. RESULTS: Despite major steps to reduce undernutrition and overweight, including a renewed focus on anemia among adolescent girls, major gaps remain in our understanding of various nutrition issues concerning adolescents. These include various drivers and determinants of the triple burden of malnutrition, evidence-based interventions that are supported by large-scale implementation research and evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents. CONCLUSION: The time has come to position adolescent nutrition as central to development, and mainstream it into health sector plans, strategies, and policies. It is our hope that this issue will stimulate the urgently needed interventions, implementation research and required programs that will safeguard the nutritional wellbeing of today's forgotten generation.

Associations of Knowledge, Attitude, and Practices toward Anemia with Anemia Prevalence and Height-for-Age Z-Score among Indonesian Adolescent Girls.

BACKGROUND: Crucial gaps persist in knowledge, attitude, and practice (KAP) of adolescent girls that affect anemia and linear growth failure. OBJECTIVE: To understand the role of KAP as a risk factor of anemia and linear growth problem in adolescent girls. METHODS: We conducted a cross-sectional survey of 335 adolescent girls selected by clustered random sampling. The KAP questionnaire had 18 variables consisting of 9 knowledge, 3 attitude, and 6 practice components. Twelve variables addressed nutrition, dietary diversity, and health environments related to both anemia and stunting. The questionnaire was adapted from the 2014 Food and Agriculture Organization nutrition-related KAP guidelines for anemia. Dietary practice was evaluated from 2-day 24-hour recalls and a semi-quantitative food-frequency questionnaire. Associations between KAP and anemia, and height-for-age z-score (HAZ), were analyzed using multivariate logistic and linear regression models, respectively. RESULTS: The mean hemoglobin (Hb) level was 119.7 g/L, with 44% of the adolescent girls being anemic (Hb < 120 g/L) and mean height was 151.0 cm with 25% being stunted (HAZ < -2 standard deviation [SD]). The median KAP score was 7 and ranged from 3 to 10. Low to moderate KAP scores were not significantly associated with being anemic (adjusted odds ratio [AOR] = 1.26; P = .43), however 1-point KAP score increment was associated with an increase of HAZ by 0.037 SD (P = .012). CONCLUSIONS: The KAP related to diet and healthy environments was not associated with anemia prevalence, but was positively associated with increased HAZ among adolescent girls. Strategy to reduce anemia risk in this population should combine KAP improvement with other known effective nutrition interventions.

Psychosocial, Eating Behavior, and Lifestyle Factors Influencing Overweight and Obesity in Adolescents.

BACKGROUND: Adolescent overweight and obesity (AOO) is a global public health problem and risk for noncommunicable diseases. Understanding context-specific risks is crucial for interventions. OBJECTIVE: Determine the prevalence of AOO in the Indonesian National Health Survey (INHS) 2013, assess the 5-year trend from 2013 to 2018, and identify risks. METHODS: We selected adolescents aged 10 to 19 years (n = 174 290) from the INHS 2013 and used hierarchical logistic regression to identify gender-specific risks for those aged 15 to 19 years (n = 77 534). Change in AOO was assessed by comparison to INHS 2018 reports. RESULTS: The national AOO prevalence increased over 5 years by 48% in young adolescents (13-15 years) and 85% in older ones (16-18 years). High prevalence areas included the urban location of Jakarta (20.9%) and the remote rural region of Papua (19.4%). Overall, AOO risks were being sedentary, male, lower education, married, younger adolescent, and school enrollment, with urban residence and higher wealth being persistent risks for all analyses. Data for depressive symptoms were available for older adolescents whose additional risks were being sedentary, depressive symptoms, and high-fat diet. Male risks were being sedentary and lower education, and female risks were being married, depressive symptoms, high-fat intake, and lower education. Higher intake of fruits and vegetables and fewer sweets did not protect against AOO if a high-fat diet was consumed. CONCLUSIONS: Adolescent overweight and obesity in Indonesia is rapidly increasing, especially in older adolescents and males, and with gender-specific risks. Customized multisectoral interventions to identify strategies for lifestyle change are urgently needed.