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Jakarta, Indonesia, April 23, 2015 – Indonesia can count many milestones in its development trajectory. A lower rate of mortality for children under-five — from 85 out of 100 births in 1990, dropping to 31 in 2012 — is one of these achievements.

Unfortunately, stunting among children remains a major concern.

Many Indonesians do not know about this problem.  Traditionally, Indonesia has paid more attention to severe underweight as a way to determine the country’s state of nutrition. By this measure alone, nutritional issues appear largely resolved, as the prevalence of severe under weight is just 5.4% in children under five-years.

However, the fact that 8.4 million children or 37.2% of children under five are stunted should be of greater concern, given the lifelong consequences. Between 2010 and 2013, incidences of stunting increased from 35.6 to 37.2 percent.

“One of the main challenges in overcoming stunting in Indonesia is that shortness is often considered normal, due to hereditary reasons,” said Prof. Dr. Endang Achadi, a nutrition expert from the University of Indonesia.

“Shortness is not the real problem,” she added. “When it comes to stunting, other processes in the body are also stunted, such as brain development, which affects intelligence.”

Lifelong consequences of the double burden of malnutrition

Malnutrition among children can start very early in life. When children receive poor nutrition in the womb during the pregnancy stage, their body is “pre-programmed” to cope with minimal intake of nutrition. Due to this pre-programming during the pregnancy phase, these children become prone to obesity as their body – conditioned to cope with less intake – consume more food.  Obesity leaves them more prone to non-communicable diseases, including diabetes and heart disease.

Stunting is a sign of chronic malnutrition. And the most damaging impact of malnutrition is on brain development.  The statistics are staggering:

• Stunting reduces IQ scores by 5-11 points
• Children affected receive lower grades in school
• Children with low birth weight are 2.6 times less likely to go on to higher education or graduate
• Stunted children will earn at least 10 percent less in lifetime earnings

When children are stunted at an early age, they risk reduced productivity over time — poor education results in jobs with low earnings. If followed by accelerated weight gain when older, they risk suffering obesity and other diet-related non-communicable diseases. This is the double burden of malnutrition.

Causes of the double burden of malnutrition in Indonesia

While the causes of the double burden of malnutrition are complex, a World Bank report highlights four main issues for Indonesia. They are:

• Improved life expectancy has contributed to a shift in the burden of disease from infectious diseases to non-communicable diseases.
• Increase in national wealth has been accompanied by an increase in food availability, which has doubled the amount of fat consumed per capita. Processed foods are also being consumed in higher rates, particularly in urban areas.
• Many cities and towns are not pedestrian friendly, do not encourage physical activity, and lack outlets offering healthy foods.  Those traveling to and from school or work have few options other than ready-made foods outside of the home.
• Traditional customs influence maternal and early child nutrition, and social norms dictate that many women marry while still very young. These factors contribute to the high incidence of low-birth rates.

Impact in economic terms

The effects of the double burden of malnutrition are not only felt by people.  The economy suffers too; losses due to stunting and malnutrition are estimated to be 2-3% of Indonesia’s GDP.

“More cases of non-communicable diseases in Indonesia have caused higher expenditure for the government, particularly for the national health insurance,” said Doddy Izwardy, Director of Nutrition at the Ministry of Health. “The highest costs for national health insurance are for treatment of stroke, diabetes, and kidney failure.”

Non-communicable diseases account for around 60% of deaths. The double burden of malnutrition is clearly a concern for Indonesia, and requires urgent attention.

The double burden of malnutrition will also hamper the potential gain from Indonesia’s demographic transition, where the ratio of the non-working age to the working age shrinks.

“What should be a demographic bonus can become a demographic burden”, said Prof. Soekirman, Director of Indonesian Nutrition Foundation for Food Fortification.

Said Prof. Endang Achadi: “In order to get all stakeholders’ collaboration, stunting should be linked to low intelligence and chronic diseases, so that we can improve the quality of our nation.”