Zahra and Zohra are 32-month-old twin girls living in the central Javan village of Pandes, Indonesia. The girls were born prematurely, weighing just 1.6 and 2.1 kg respectively. Since birth, they have struggled to achieve a healthy weight. Living close by is Bintang, a 15-month-old boy. Since he was six months old, his weight has soared and he is considered overweight for his age.
Bintang’s story is a familiar one. His father, Budianto, and his grandmother, Desi, care for him while his mother works at a local clothes store. While his father considers Bintang to be healthy, his growth chart shows that his weight is far too high.
Bintang was breastfed until he was two months old but, when his mother had to return to work, his father fed him with formula milk during the day. Now that Bintang is older, he is given a variety of foods, including many processed, high-sugar and high-fat snacks.
“For snacks, Bintang has bread, biscuits, jelly and wafer biscuits,” explains his father Budianto. “He eats so easily. Sometimes before meal time, he’s already asking for food.”
Bintang’s grandmother takes him for his regular health checks at the local clinic. He is weighed and measured and, like all children in the village, receives a vitamin A supplement every six months. Although she is aware that health and nutrition counselling is available, she has chosen not to take part in these sessions.
“I don’t need to go to these classes,” she says. “I feed him the same things that I ate growing up.”
Changing face of malnutrition
These young children show the changing nature of malnutrition in many countries in Southeast Asia. Several countries, including Indonesia, are facing a double crisis; high levels of wasting, where children are too thin for their height, as well as a large and rapidly growing percentage of overweight children.
According to a new report by UNICEF, ASEAN and WHO, 12 per cent of children in Indonesia suffer from wasting while a further 12 per cent are overweight. Known as the ‘double burden of malnutrition’, this trend cuts across social groups and is increasingly common in middle-income countries such as Indonesia, Malaysia, the Philippines and Thailand.
Double burden means the coexistence of undernutrition and overnutrition in the same country, district, community and household. This presents a severe public health challenge. While undernutrition is a major contributing factor to child illness, disability and death, overnutrition in childhood can lead to diet-related non-communicable diseases such as diabetes and cardiovascular disease in later life.
Changing lifestyles owing to urbanization, a higher participation of women in the workforce and increasing consumption of energy dense processed foods are some factors that have led to a rapid rise in overweight children.
“Many countries in South East Asia have seen impressive economic gains in the last decade, lifting thousands of children out of poverty,” said Christiane Rudert, Regional Nutrition Adviser for UNICEF East Asia and Pacific. “However, at the same time we have seen the rise of conditions like obesity, previously associated with high income countries. Asian children are now at risk of malnutrition from both ends of the spectrum.”
UNICEF and the EU recently completed a five-year partnership to tackle nutrition issues in five Asian countries, including Indonesia, Lao PDR and the Philippines. “The objective of the partnership was to help governments develop a holistic approach to nutrition, looking beyond just the health sector,” UNICEF’s Christiane added.
According to local health workers, Bintang’s rapid weight gain can be attributed to two major factors: traditional, out-dated practices and the marketing and convenience of high-sugar and high-fat processed foods. In older children, the problem is also due to low levels of physical activity and a sedentary lifestyle.
Although grandparents can be a great help for parents who work, Pandes village chief, Heru Purnomo, says they need to be open to new ideas. “The role of grandparents is the most difficult in changing attitudes towards nutrition,” he says. “They have old-fashioned and out-of-date patterns of thinking, and this is hard to change. They still think the best things were done during their years.”
It’s a problem echoed by the village nutritionist, Dessy Sandra Dewi. She says that grandparents’ traditional feeding practices and their desire to “spoil” their grandchildren can result in them feeding their grandchildren a poor diet.
“Often both parents are working so the grandparents are left with the children, Dewi says. “But many grandparents don’t have the knowledge to feed the children a balanced diet. They are also attracted by the advertising of processed foods that make these foods seem desirable.”
It’s a problem that cuts across social classes, as Dewi explains. “The highly educated and those with a higher income often have worse nutrition due the perceived higher status of processed foods. To try to change this, we’ve formed discussion groups amongst the parents to compare different types of food so that mothers can choose what is best for their children.”
Importance of breastfeeding
Other factors can contribute to children suffering from poor nutrition, such as the case of the 32 month-old twin girls, Zahra and Zohra. When the girls were four months old, their father had a serious motorcycle accident and was hospitalised for more than a month. He was unable to work for a further six months.
Burdened with the care of her prematurely born twin girls, an additional child and the nursing of her husband, Asri Setyouati stopped breastfeeding her babies. Grandparents and neighbours bought sachets of formula milk to feed the babies. The girls, now almost three years old, have consistently failed to meet weight expectations for their age and remain underweight.
“They are really picky eaters”, explains Asri. “They don’t like to eat much solid food. They still prefer to drink formula milk rather than eat food.”
Supporting optimal breastfeeding and complementary feeding practices is a critical component of efforts to address all forms of malnutrition, protecting children from undernutrition as well as from becoming overweight. UNICEF recommends exclusive breastfeeding up the age of six months. From six months, a range of proteins (such as beans, meat, fish, and eggs), fruits and vegetables should be added to the infant diet, alongside continued breastfeeding.
UNICEF is teaching local health workers how to tackle issues that result in the double burden of malnutrition. Together with local government, UNICEF trains midwives and nutritionists at health centres to counsel mothers on infant feeding, who in turn train large groups of village midwives and community volunteers.
This network of committed counsellors teaches mothers, fathers and grandparents about the benefits of breastfeeding and nutrient-rich complementary feeding practices and helps them to address problems that they face in feeding their children.
With the right support, the double burden of malnutrition can be addressed, and the UNICEF programme has seen strong results. In central Java, the village of Pandes now has far fewer overweight and underweight children than the national average in Indonesia.