September 7, 2022
JAKARTA – The government has committed to reducing the prevalence of stunting in children to below 14 percent by 2024. This is a welcome focus of the government’s health agenda given the official data that found one in four children aged below five is stunted.
Stunting is recognised as impacting physical, health and developmental capacities and remains a significant public health problem in developing countries such as Indonesia. Nutrition-specific interventions are key to reducing the risks, including a diversified diet.
But the reality is that many Indonesian children are falling behind on this measure, with the problem magnified among disadvantaged families.
The World Health Organization (WHO) suggests all infants and young children meet minimum dietary diversity (MDD) targets which include the daily consumption of at least five out of the eight food groups: grains, roots and tubers, legumes and nuts, dairy products, flesh foods such as meat or fish, eggs, vitamin A-rich fruits and vegetables, other fruits and vegetables and breastmilk.
In Indonesia, however, data suggests that only half of infants and young children eat a diversified diet. Based on a review of Indonesia Demographic and Health Surveys between 2007 and 2017, which I led, infants aged up to six months only consumed two to three types of food groups per day.
Dietary diversity appeared to increase with age; on average, children ate four food groups after nine months and five food groups after 18 months. However, the overall food intake is dominated by grains, roots and tubers and less than 60 percent of children consumed flesh foods and eggs. This is concerning, as animal-source foods are critical to reducing the risk of undernutrition, particularly among children in poorer households.
Dietary diversity is also impacted by inequality, with children from socioeconomically disadvantaged backgrounds in Indonesia more likely to eat a less varied diet. Mothers in these households often have a low level of education, including inadequate dietary knowledge, health literacy or nutrition information-seeking behavior, which impacts dietary diversity outcomes.
More affluent families, by contrast, tend to have more resources to obtain more varied and nutritious foods. This group also typically has better access to health care and information, which can encourage optimal child feeding practices and a more diversified diet.
The COVID-19 pandemic and the war in Ukraine have disrupted food systems globally and triggered a surge in food prices. In Indonesia, the price of goods such as red chili, cooking oil and eggs have risen and driven inflation. The impact of these price surges and related food security concerns will invariably hit hardest on the poor. This may include a change in dietary practices, which adversely affects their nutrition and health status.
This is a concern for Indonesia and the world. As of the end of 2021, it was estimated that 50 million children were suffering from wasting – the most life-threatening form of malnutrition. This may be exacerbated by current global developments.
So what can Indonesia do to support diverse and healthy diets among children?
The government’s Guide for Balanced Nutrition recommends the population consume nutritious staples from across different food groups, encouraging people to “be grateful and enjoy various foods”. However, some of its messaging is not practical and difficult to follow. It is also less socialized and implemented compared to the old “Healthy Four, Perfect Five”’ which is still being used by some industries and communities. A more straightforward approach would be to follow the internationally accepted dietary diversity indicators set out by the WHO.
Further, child nutrition cannot be enhanced without addressing fundamental issues of inequality, which will require multi sectoral approaches.
In the health system, mothers should receive quality counseling sessions about appropriate feeding practices during prenatal and postnatal care. Although 96 percent of pregnant women had access to antenatal services in 2018, only 74 percent had at least four antenatal care visits, ranging from 44 percent in Papua to 90 percent in Yogyakarta. This suggests the need to boost health access for marginalized communities.
Other aspects of care should also be addressed, including ensuring counseling sessions are of adequate duration, stemming the use of unstandardised nutrition guidelines and increasing knowledge and training among general health workers on dietary diversity.
As with the health system, Indonesia’s education system shows disparities across geographic regions, gender and economic status, particularly at the secondary and tertiary levels. Governments should encourage greater school participation among girls and address key reasons for dropping out, such as insufficient funds, distance, labor force participation, marriage and household chores.
A more decentralized education system could be considered and the development of alternative learning opportunities, such as non-formal education. With more equitable participation in education, school-based food and dietary education can more effectively address gaps in nutrition knowledge.
Finally, more diverse income-generating strategies would help reduce the economic barriers to accessing a varied diet. This could include initiatives such as homestead food production, which is a small-scale plant or animal production system around the household or community using simple technology and low capital inputs. The activities may include but are not limited to backyard chicken-raising, small fish ponds and vegetable gardens.
Increasing women’s participation in the labor force would boost household incomes and could be encouraged by better national policies for working mothers, such as sufficient maternity leave and national health insurance. Women should also be empowered to lead income allocation within households, which may help boost child nutrition outcomes.
We must recognize the multifaceted challenge of child dietary and nutrition issues, which requires a solid commitment and multisectoral approach to scale up nutrition-specific interventions, such as enhancing dietary diversity. Adequate support from the updated research and evidence-based programmes and policies will hopefully guide us towards healthier and more nutritious future generations.
***
The writer is a researcher at the Department of Nutrition, Faculty of Health Sciences, Alma Ata University, Yogyakarta, and a PhD candidate in the University of Sydney’s School of Public Health.