Malnutrition in Indonesia (click di sini untuk Bahasa Indonesia)

In the ‘developed world’ huge proportions of people suffer from ill health caused by overweight and obesity.  Meanwhile, in poorer parts of the world, malnutrition is still a huge problem. 

Malnutrition not only affects the health of an individual, but reduces the ability of communities to pull themselves out of poverty.  Malnutrition reduces a person’s ability to work and a child’s ability to learn at school - through having days off for ill-health and being too fatigued to work and to learn well.  It is estimated that malnutrition can cost a country 2-3% of its gross domestic product (“Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action,” published by the World Bank in 2006). 

Women and children are often the most commonly and severely affected – with pregnant women facing an increased risk of losing their baby, of the woman or child dying during child-birth, or the baby being born with learning or physical disabilities.  Malnutrition contributes to 56% of the deaths of the 11 million children die worldwide from preventable causes before reaching their fifth birthday. 

In the South-East Asian country Indonesia, despite poverty levels dropping in terms of average earnings, there are still areas where malnutrition is a huge problem.  Protein-energy malnutrition – causing children to be underweight, slow growing and more susceptible to infections affects nearly 2 in 5 children under five, and iron, iodine and vitamin A deficiency are also problems. Read more>

Tropical diseases such as malaria, dengue fever, tuberculosis and gut infections are also common – particularly in poorer areas.

The reasons for high levels of malnutrition in Indonesia are complex.  Sometimes the problem is a lack of access to sufficient food, but often it is access to, or not choosing to eat an adequate variety of foods for a nutritious diet. Many people in poorer areas have a low level of education and some have a lack of awareness of the importance of a varied diet, particularly for children.

Rice is the national staple and in poorer areas is often overly relied-on, leading to families feeling full, but diets lacking in the variety needed for good nutrition.  In other areas even rice is scarce – climate change, unpredictable weather and natural disasters affect crop growth, and many families cannot afford to buy enough food if their own crops – their only source of income - fail.  Poor sanitation is common in communities where water supplies are scarce, and this contributes to gut infections and malnutrition-causing diarrhoea.  

The Indonesian healthcare system is a good one and includes well trained nutritionists based in local health centres and a system where there should be trained midwives in every village, conducting monthly clinics to monitor the weight of children and mothers, carrying out immunisations and giving out nutritional supplements and nutrition advice. However, Indonesia is a country with over 200 million people spread over more than 16 000 islands, and in some areas the health service is less adequate than others. 

In some areas of Indonesia, the roads are in poor repair, or non-existent, making it difficult for remote villages to access hospitals and health centres when needed, and when there are roads, transport is expensive and erratic. In some areas other problems lie in traditional beliefs – trust in traditional medicine, and gender issues making it difficult for women to make health choices without permission of their husbands.

nutritionnutrition’s Zoe Connor spent 9 months in Indonesia in 2007 as a volunteer nutrition advisor working with a local-run organisation Yayasan Ayo Indonesia (www.ayoindonesia.org) in a mountain town called Ruteng, in Flores island in the poor province of NTT in Eastern Indonesia.


Zoe Connor and Jeany Vianey walking back from a visit to a
women's agricultural group near Cancar, Flores, February 2007

Ayo Indonesia’s excellent work includes health, agriculture, road building, installing water access, and improving the work of local groups.  They work through training local people and empowering the local communities throughout the Manggarai and Eastern Manggarai districts. 

The health component of their programme involves training local women’s groups in growing their own healthy vegetables, training on healthy living, and managing their finances, and working together with the local health staff to improve the health of women and children.  In 2007 they were also involved in an international research project into the effect of poor road access into health with the IFTRD link>   


Women's group making organic fertiliser, Rentung village, Flores, February 2007


Memik, Ayo Indonesia's health field worker, proudly showing off produce
from a successful village garden, Cole, Flores, December 2006

Health promotion by Zoe and local workers focussed on basic nutrition and health methods. This key basic advice for improving nutrition in rural areas in Indonesia was:
  1. Eating 3 meals – with food from each of the three main food groups every day  - Energy foods such as rice, taro, cakes, sweet potato, cassava, corn, sago, flour, bread or potatoes, with butter or oil; Growth foods such as tempe (fermented soya beans), tofu, fish, eggs, milk, seafood and beans; and Helper foods – a variety of fruit and vegetables

  2. Adding iodised salt to food

  3. Washing hands with soap before eating

  4. Giving babies only breast milk until 6 months old

  5. Giving babies from 6 months old regular small meals containing foods from each of the 3 food groups, with breast feeding continuing until up to 2 years

  6. Giving every child immunisations

  7. Children and pregnant women should attend the local health clinics regularly for growth monitoring

  8. Vitamin A, iron and iodine supplements should be taken by women and children from the health clinics as advised. 

Cole village, Flores, March 2007, after a demonstration
of making a nutritious flour mix to add to baby foods.

For links to some useful resources about nutrition in Indonesia and other 'developing' countries, click here> 

Fact sheets written by Zoe with her colleagues in Bahasa Indonesia can be downloaded from the links at the bottom of page 26.

Information if you want to visit Flores island, Indonesia

A road trip from one end of Flores to the other will take a couple of days, and take you through some of the most beautiful and untouched scenery in the world. Flores has something for everyone - hiking, diving, beautiful deserted islands, and visits to villages whose unique cultures have been unspoilt by mass tourism and modern living.

Highlights on a visit to Flores include drinking local palm wine (arak or sopi), the famous mysterious three coloured lakes of Kelimutu, breathtaking mountainous scenery, some of the best diving and snorkelling in the world, and the amazing sight of the Komodo dragons. You can read more about Komodo National Park - the UNESCO world heritage site hosting some of the most beautiful islands and corals in the world, and home to the dragons here>. Our friend's site has lots of useful information and photos if you are interested in finding out more about road trips and camping trips www.flores-outdoor.com.  We can also recommend the friendly 3-8 day boat trips from Lombok to Flores and back, via Komodo national park, run by the socially-responsible locally-owned tourism company PeramaTour.     

More about the main nutrition problems in Indonesia:
 
Undernutrition – protein-energy malnutrition  

Causes

Acute undernutrition is caused by a short period of not eating enough food, or the right foods to gain enough calories and protein, diarrhea and vomiting, and other infections.  

Chronic undernutrition is caused by a longer period of not eating enough food, or the right foods to gain enough calories and protein, or by recurring diarrhea, vomiting or other chronic illnesses    

Symptoms and consequences

Acute undernutrition is usually easy to identify as a child would be underweight and thin – they would have a low ‘weight-for-age’ on child growth chart, and would be at an increased risk of infections.  

Chronic undernutrition is harder for a community to identify – a child would be growing slower than expected – in both weight and height, and so not necessarily appear too thin, but a weight and height check would show that they have low ‘height-for-age’ on child growth chart – i.e. they are stunted.    Chronic malnutrition can affect a child’s brain and physical development, and increase their risk of infections. 

Undernourished women are more likely to give birth to low birth weight children, who have a higher risk of infections.

Prevention

Eating a varied and adequate diet with enough calories and protein – so including staple foods such as rice, cassava and sweet potato daily, and protein foods such as meat, fish, eggs, beans or milk at least every other day.  Extra oil, coconut or butter can be added to foods to increase the calorie intake, particularly in a child or adult who doesn’t feel like eating much. 

Giving babies only breastmilk until they are 6 months old reduces their risk of getting diarrhea and vomiting, and provides balanced adequate nutrition.  If the mother can’t or doesn’t want to breast feed, it is important for the baby to have regular feeds of infant formula milk made with clean, safe water – normal cow’s milk is not adequate. 

From 6 months it is best to continue breastfeeding but give 3 to 6 small meals a day of a variety of foods including protein foods.     

Undernutrition can also be partly prevented by the prevention of worms, infections, diarrhoea and vomiting by better sanitation and treatment of illnesses, particularly deworming.  

Indonesia statistics

In 2004 37% of under-5s were underweight (28% moderately underweight, and 9% severely underweight) and 38% were too short (source Susenas 2004 - National Socio-Economic Survey – Survei Sosial Ekonomi Nasional).   The government have a supplementary feeding programme so that children and pregnant women who are identified as underweight are given extra food and advice when they are seen at their local health clinic for growth monitoring.  


Iron deficiency

Causes  

Not eating enough foods high in iron, and also women having too frequent and too many pregnancies, malaria, hookworm and menstruation increase the risks of being iron deficient.

Symptoms and consequences  

Iron deficiency is the most widespread deficiency in the world, and is particularly dangerous for pregnant women – increasing their risk of bleeding and death in childbirth. Iron deficiency is reported as the main cause of 20% of maternal deaths and a contributing factor in up to 50% maternal deaths.    Iron deficiency also affects children’s brain and physical development, and makes a person lethargic and more likely to get infections.  

Prevention

Eating a diet containing iron-rich foods such as meat, fish, eggs, green vegetables, beans, peanuts, tofu and tempe (fermented soya beans).  These foods are particularly important for pregnant women and children from 6 months.   Other important strategies to combat iron deficiency are the prevention and treatment of malaria - particularly in pregnancy, family planning education to encourage families to space out and reduce pregnancies, and the prevention of intestinal worms and provision of regular deworming treatment

Indonesia statistics  

WHO report that 6.4% of pregnant women were iron deficient in Indonesia in 2000.  Iron rich foods are often difficult for poor families to afford, and malaria and worms are problems in many areas of the country. In poorer areas it is common for families to have over 10 children, although family planning education does occur.  The government recommend that pregnant women and children under 5 should receive daily iron supplements from their local health clinic.


Iodine deficiency  

Causes

Not eating enough iodine-rich foods

Symptoms and consequences  

Iodine deficiency in pregnant women causes still-birth, and increased risk of miscarriage and children born with low-weight, and in severe deficiencies, children born with the irreversible disability cretinism, and children born with lower intelligence and movement abilities than usual. Deficiency can also cause lethargy and enlargement of the thyroid gland in the throat – goiter. 

Prevention

Eating foods rich in iodine naturally such as fish, seafood and seaweed, and plants grown in areas where the soil contains iodine; iodised salt; and iodine supplements.

Statistics in Indonesia  

Iodine deficiency is a problem in many inland areas of the poorer parts of Indonesia, where seafood is expensive or not available, and soils are poor in iodine due to leaching out by rains. Iodised salt is available, but many people choose to use un-iodised salt as it is cheaper. WHO reported in 2000 that 46% of households in Indonesia still don’t regularly used iodised salt, and that 10% of school children had iodine deficiency.  The Indonesian government recommends that all women of childbearing age in areas of iodine deficiency should receive iodine supplements every 6 months from their local health clinic. 


Vitamin A deficiency

Causes  

Not eating enough vitamin A-rich foods.  Deficiency is also exacerbated by infections, particularly measles.

Symptoms and consequences  

Vitamin A deficiency is a major cause of blindness and eye problems – xeropthalmia - and also reduces resistance to other infections.

Prevention  

Eating a diet with vitamin A-rich foods such as dark green leaves, tomatoes, carrots, mango, fish, liver, egg, citrus fruit, papaya, pumpkin, sweet potatoes and red palm oil. 

Indonesia statistics  

Government health campaigns that vitamin A capsules should be taken by  women in the first 40 days after birth, and every 6 months for children from 6 m to 5yr, have been successful, and in 1999 WHO reported that 64% of children under 5 had received supplements, and that in 1995 only 0.3% of children suffered from deficiency.


Page first published: January 20th 2008.  If you think amendments need to be made, please contact us.