Indonesia : facing up to the double burden of malnutrition

 December 2012 74768 THE WORLD BANK Indonesia Health Sector Review Indonesia: Facing up to the Double Burden of Malnutrition The Double Burden of Malnutrition be affected by the DBM, with overweight increasing faster than underweight is decreasing in most of them. and Its Consequences While obesity has doubled globally in the last three de- A concept first presented just over a decade ago, the cades, it has tripled in LMICs in just two decades. DBM is the coexistence of undernutrition and overnutri- tion of macronutrients and micronutrients across the life The consequences of the DBM are grave and manifesta- course in the same population, community, family and cross the life course. Overall country development, im- even individual. Of particular concern is the life-course proved water and sanitation practices, and increased dimension of the DBM, or the link between maternal vaccine coverage mean that more children are likely to and fetal undernutrition and increased susceptibility to survive their first two years of life, even if they have suf- overnutrition and diet related non-communicable dis- fered undernutrition. For those that survive this critical eases (NCD) later in life. period, however, the damage done by this early inter- val of undernutrition is seen throughout the life course. The DBM is a global problem that affects rich and poor When this stunted length growth is followed by acceler- countries alike: 25% of the world’s population is over- ated weight growth later in life, there is an increased risk weight, while 17% of pre-school children are under- for obesity and other diet-related NCDs, such as Type 2 weight and 28.5% are stunted, 40% of women of repro- diabetes and cardiovascular disease, later in life. NCDs ductive age have anaemia, and one-third of the global are responsible for the majority of deaths worldwide, population still suffers from iodine deficiency. Most low- and are disproportionately high in LMICs, where nearly er-middle-income countries (LMICs) are considered to 80% of all NCD deaths occur. This knowledge brief summarizes findings and policy recommendations from a recent technical assessment of the DBM problem in Indonesia by Roger Shrimp- ton (International Nutrition Expert/Consultant) and Claudia Rokx (Lead Health Specialist, World Bank) with contributions from the Indonesian SUN working group, Leslie Elder (Senior Nutrition Specialist, World Bank), Puti Marzoeki (Senior Health Specialist, World Bank), Darren Dorkin (Senior Operations Officer, World Bank), Rebekah Pinto (Human Development Specialist, World Bank) and Eko Pambudi (Research Analyst, World bank). Based on interviews with key actors in Ja- karta and Yogyakarta in late 2011, the assessment builds on the Government of Indonesia’s Landscape Analysis Country Assessment (LACA) Report completed in 2010 to examine the Indonesia situation and offer policy actions to help prevent and mitigate the DBM problems across the life course. The report was reviewed by Indonesian stakeholders (policy makers and academics) in March 2012. Special thanks are due to UNICEF for valuable technical inputs, to Dana DeRuiter (Health Policy Consultant) for expertly summarizing the technical assessment into this brief and to Megha Kapoor (Research Analyst, World Bank) for providing oversight during the production process. Funding for this note was made available by the Millennium Challenge Corporation. Additional technical papers, including the one summarized here as well as a more general assessment of DBM, are available at www.worldbank.org. Another related additional paper on multisectoral approaches for DBM, is forthcoming. For further information, please contact Darren Dorkin at ddorkin@worldbank.org.  KEY MESSAGES • The DBM already exists at the population level in Indonesia and is growing rapidly • Undernutrition is well understood, but many policy makers and health providers still assume it is the only malnutrition issue in Indonesia. In fact, child undernutrition is declining, but child stunting is not, which is part of the cause for child overweight increasing. • Addressing DBM in early life will save many lives and substantial resources in later life Indonesia’s DBM problem is is just 5.4% in children under-five. That 36% of children under five are stunted is of greater concern given the urgent lifelong consequences (see Table 1). There is evidence of overweight and underweight The Indonesian Family Life Surveys, representative of among young children, indicating that the DBM is al- 85% of the population, indicate that over a fifteen year ready a concern in Indonesia. Stunting is the principal period, the proportion of thin men and women de- nutrition concern, a fact made more troubling given the creased considerably while the proportion of “gemuk