International Journals

Background: Pre-pregnancy BMI (PP BMI) and gestational weight gain (GWG) are prominent anthropometric indicators for maternal nutritional status and are related to an increased risk of adverse pregnancy outcomes. This study aimed to determine the factors affecting total GWG, PP BMI and pregnancy outcomes among pregnant women in West Sumatra, Indonesia. Methods: This observational analysis was conducted among healthy women in the Vitamin D Pregnant Mother (VDPM) cohort study. A total of 195 pregnant women and their newborn babies were enrolled, and information regarding their socio-demographic characteristics, obstetric history, dietary intake and anthropometric data were assessed through direct interviews. Furthermore, the Institute of Medicine (IOM) 2009 guidelines were used to obtain the total GWG. Results: PP BMI was used to categorise the 195 pregnant women as overweight/obese (43.1%), normal (46.7%) and underweight (10.2%). There were 53.3%, 34.4% and 12.3% of women who had inadequate, adequate and excessive GWG, respectively. The multinomial logistic regression model indicated that overweight or obese women at the pre-pregnancy stage were 4.09 times more likely to have an excessive rate of GWG (AOR = 4.09, 95% CI: 1.38–12.12, p = 0.011) than those whose weight was normal. Furthermore, women with excessive GWG were 27.11 times more likely to have a baby with macrosomia (AOR = 27.11, 95% CI: 2.99–245.14) (p = 0.001) and those with inadequate GWG were 9.6 times more likely to give birth to a baby with low birth weight (LBW) (AOR = 9.60, 95% CI; 0.88–105.2) (p = 0.002). Conclusions: This study demonstrates that the malnutrition status prior to pregnancy and inadequate or excessive GWG status during pregnancy as significant risk factors for developing adverse pregnancy outcomes. These findings highlight the importance of providing information, preconception counselling and health education on weight management for healthy pregnancies.

Anemia in Indonesia has been of concerning persistence in all age groups for some 75 years since independence. The relationships between anemia and nutrition are complex being evident with compromised general health and nutrition. Increased micronutrient intakes, especially iron and folic acid, has alleviated the problem, but encouraged nutrient-specific micronutrient interventions as attractive policy directions as if anemia were a stand-alone disease irrespective of associated disorder. Concerted action to deal with the fundamental causality has been missing. Much of the pathogenetic pathway may be nutritional, but its multifactoriality is ultimately socioecological. Given the intransigence and progression of societal and ecosystem dysfunction, it can be expected that failure to recognize their causal importance will further entrench endemic anemia. This review deliberates the practical measures taken to recognize anemia by symptomatology, food and nutrition surveys, screening (fingerpick blood), nutrition assessment, and blood loss (menstrual and faecal). It identifies vulnerable groups including premenopausal and pregnant women, children and adolescents, unwell adults, and the dependent aged. Risk settings include food insecurity, infectious disease, non-communicable disease, inheritance and epigenetics, and socioeconomic disadvantage. Underlying socio-ecological problems are livelihood, food systems, cultural habits, belief systems, and social networks and activities. With this framework, policy directions could deal more comprehensively and effectively with the socioecological complexity which underpins and limits progress towards anemia eradication at a time of intense global food and health insecurity. It will require co-operative intersectoral and eco-nutritional approaches which take into account the need for universal, sustainable livelihoods. Recommendations have been made accordingly.

Background and Objectives: Despite enduring efforts in Indonesia to eliminate anemia in pregnancy, it remains a major nutritional problem. Its nutritional contributors were reevaluated. Methods: A meta-analysis of reports on anemia during pregnancy in Indonesia from January 2001 to December 2019 in the PubMed and ProQuest databases was conducted. Pooled ORs were obtained in fixed- and random-effects models. Funnel plots and Egger’s and Begg’s tests were used to evaluate publication bias. Review Manager 5.3 and Stata version 14.2 were used for analysis. Results: A total of 2,474 articles were appraised. Systematic review and meta-analysis were performed on 10 studies including 4,077 participants. Chronic energy deficiency had the highest OR for the risk of anemia (3.81 [95% CI: 2.36–6.14]) followed by greater parity (OR=2.66 [95% CI: 1.20–5.89]), low education level (OR=2.56 [95% CI: 1.04–6.28]), and limited health knowledge (OR=1.70 [95% CI: 1.17–2.49]), whereas older age and inadequate iron supplementation were not apparently associated with maternal anemia (p > 0.05). Conclusion: Future policies and strategic action to reduce nutritional anemia during pregnancy in Indonesia should increase emphasis on local nutritional epidemiology to establish the pathogenesis of anemia and the validity of stand-alone single-nutrient interventions. Attention to chronic energy deficiency as a barrier to preventing anemia in pregnancy may be necessary to enable health workers and women at risk to be better informed in their efforts.

Background: Nutritional anemia in Indonesian children and adolescents is generally regarded and treated as iron-deficient anemia, as it is in individuals in other age groups. Objectives: Yet, it remains a public health threat without comprehensive management or a sustained solution. Methods: This review seeks to improve understanding of impediments to its resolution. Relevant studies reported in the past 5 years were identified in PubMed, Science Direct, Crossreff, Google Scholar, and Directory of Open Access Journals databases. Results: In all, 12 studies in several Indonesian cities provided the basis for the review. Most were conducted in schools, indicating the potential of these institutions as targets for intervention but pointing to serious deficiencies in identification of the problem across the archipelago and in remote and rural areas. No study has evaluated coexistent anemia and malnutrition, which likely would have revealed the multi-factoriality of nutritional anemia. Data regarding nutrition education, food-based innovation, and supplementation, which may alleviate anemia in children and adolescents, are available, although study lengths and sample sizes have limited interpretation and comparison. Conclusions: Broadly, three intervention approaches to nutritional anemia have been undertaken, namely food-based interventions, nutrient supplementation, and nutrition education. Some progress has been made with these approaches, presumably through increases in iron intake. More information is needed regarding the underlying causality and pathogenesis, suboptimal food patterns, and comorbidities, any of which might limit the effectiveness of programs designed to resolve childhood and adolescent anemia in Indonesia.

Anemia affects people worldwide and results in increased morbidity and mortality, particularly in children and reproductive-age women. Anemia is caused by an imbalance between red blood cell (RBC) loss and production (erythropoiesis), which can be caused by not only nutritional factors but also non-nutritional factors, such as inflammation and genetics. Understanding the complex and varied etiology of anemia is crucial for developing effective interventions and monitoring anemia control programs. This review focusses on two interrelated nonnutritional causes of anemia: malaria infection and RBC disorders (thalassemia and G6PD deficiency), as well as tuberculosis. According to the Haldane hypothesis, thalassemia occurs as a protective trait toward malaria infection, whereas G6PDd arises in malaria-endemic regions because of positive selection. Indonesia is a malariaendemic region; thus, the frequency of thalassemia and G6PD deficiency is high, which contributes to a greater risk for non-nutritional anemia. As Indonesia is the second global contributor to the newly diagnosed tuberculosis, and active pulmonary tuberculosis patients are more anemic, tuberculosis is also contributes to the increasing risk of anemia. Therefore, to reduce anemia rates in Indonesia, authorities must consider non-nutritional causes that might influence the local incidence of anemia, and apply co-management of endemic infectious disease such as malaria and tuberculosis, and of genetic disease i.e. thalassemia and G6PDd

Non-nutritional anemia, the second most common type of anemia worldwide after nutritional anemia, includes the anemia of inflammation (AI) and that due to helminthiasis. In this review, we examine the contribution that non-nutritional anemia makes to incidence in Indonesia. Anemia due to helminthiasis is a common problem in Indonesia and contributes to prevalence, particularly in children under 5 years. We conducted a systematic literature review based on Google Scholar and Pubmed for non-nutritional anemia. We supplemented this with hemoglobin and chronic disease data in Makassar where prevalence and type of anemia were available. To effectively reduce anemia prevalence in Indonesia, interventions should address both nutritional and non-nutritional contributing factors, including infection and genetic predisposition.

Background and Objective: Currently, anemia is a severe public health issue in Indonesia. The aim of this review was to examine policy measures and program implementation to reduce anemia attributed to iron deficiency in Indonesia. Methods and Study Design: A literature search was conducted using Google Search, Sciencedirect.com, and PubMed to retrieve relevant studies in the last three decades. Qualitative data were also obtained from service providers. The search yielded 141 articles, of which 32 were excluded, and further screening was conducted based on the type and scale of the intervention program. Results: In the iron–folic acid (IFA) supplementation programs studied, antenatal care and health personnel capacity information were limited. Implementation often did not correspond to standard operating procedures. Analysis, follow-up, and feedback on IFA tablet programs were lacking. Moreover, the IFA tablet supply was inadequate, facilities and infrastructure were insufficient, and counseling guidance, relevant material, and information media were lacking. In the national fortification program, wheat flour was used as a vehicle for anemia prevention. However, evidence from the Total Diet Study indicated that wheat noodles have limited value across the Indonesian archipelago. Conclusion: Programs to reduce the likelihood of anemia will be more successful if they are less dependent on nutrient-specific strategies and focus more on the pathogenetic complexity arising from personal behavior, sociocultural factors, dietary and health patterns, local community, and ecology. Partnerships between the community and government reflected in evidence-based policy will always be of value, but continued research is required to examine the factors contributing to the successful outcomes of such programs.

Purpose Adverse effects of maternal vitamin D deficiency have beenlinked to adverse pregnancy outcomes. We investigated the relationship between maternal vitamin D status and newborn anthropometry measurements using a genetic approach and examined the interaction between genetic variations in involved in vitamin D synthesis and metabolism and maternal vitamin Dconcentrations on newborn anthropometry. Methods The study was conducted in 183 pregnant Indonesian Minangkabau women. Genetic risk scores (GRSs) were created using six vitamin D–related single nucleotide polymorphisms and their association with 25-hydroxyvitamin D [25(OH)D] levels and newborn anthropometry (183 infants) were investigated. Results There was no significant association between maternal 25(OH)D concentrations and newborn anthropometry measurements (P>0.05, for all comparisons). After correction for multiple testing using Bonferroni correction, GRS was significantly associated with 25(OH)D in the third trimester (P = 0.004). There was no association between GRS and newborn anthropometric measurements; however, there wasaninteraction betweenGRSand25(OH)Donheadcircumference(P = 0.030), wheremothers of neonates with head circumference < 35 cm had significantly lower 25(OH)D if they carried ?4 risk alleles compared to those who carried ?3 risk alleles. Conclusion Our findings demonstrate the impact of vitamin D-related GRS on 25(OH)D and provides evidence for the effect of vitamin D-related GRS on newborn anthropometry through the influence of serum 25(OH)D levels among Indonesian pregnant women. Even though our study is a prospective cohort, before the implementation of vitamin D supplementation programs in Indonesia to prevent adverse pregnancy outcomes, further large studies are required to confirm our findings.

Objectives: To analyse the association between maternal physical activity status and birth size outcomes and whether other determinants of confounding variable such as pre-pregnancy BMI (PP BMI) and gestational weight gain (GWG) during pregnancy affect birth size outcomes. Methods: A prospective birth cohort study. Subject’s PAL was measured at the first trimester (T1) and third trimester (T3) during pregnancy. Birth size outcomes were measured immediately after birth. Results: The analyses included 183 mother and infant pairs with a mean newborn birth weight of 3211.75 ± 434.70 g. Pregnant women at T3 had two times lower physical activity than T1 of pregnancy (OR, 2.18; CI, 1.044–4.57; P = 0.045). Maternal PAL at T1 and T3 were in sedentary level (74.30% and 77%, respectively). There was no association between PP BMI and physical activity level during pregnancy. We found no significant association between PAL during pregnancy and birth size outcomes (P > 0.05 for all comparisons). However, we had a significant association with birth weight after our confounder adjustment (P = 0.032). There was a significant interaction between maternal PAL and PP BMI on birth weight and head circumference (Pinteraction < 0.05). Conclusions: Our study provides evidence that neither maternal physical activity status nor pre-pregnancy BMI in the prenatal period are associated with birth size outcomes (birthweight, birth length, and head circumference).

This critical review is intended to analyse the existing studies on the consumption patterns of sweetened condensed milk in the diet of young Indonesian children and its potential nutritional health consequences. Considering its limited nutritional value and high sugar content, sweetened condensed milk (SCM) should not be administered to young children (1-3 years old) with the goal of promoting their growth and development. However, such false practice has been reported in mostly urban studies among the underprivileged population. Conclusive scientific evidence is also still lacking regarding the health risks of long-term SCM consumption by young Indonesian children at early ages, as no study has focused on this specific topic. Nevertheless, inadequate understanding of SCM, its consumption patterns, and its long-term effects on health among young Indonesian children have been implicated in public confusion on the topic. Ongoing disparities that exist between regulation, industrial practices, and product advertisement have led to poor understanding in communities, which, to a considerable extent, has contributed to difficulties in segregating data on the consumption of SCM and its related products. Analogous to sugar-sweetened beverages, limited SCM consumption can be recommended when appropriately implemented with active monitoring and evaluation of product advertisements and product labeling, enforcement of regulations, and provision of effective customer education

Perinatal and maternal mortalities in Java became of concern in the 1980s. Since some 90% of births took place at home, the Tanjungsari (TS) district of West Java was identfied as a locality where community-based risk management strategy might reduce this health burden. In 1987, traditional birth attendants (TBA) were trained to identify risk factors for unfavourable birth outcomes. From January 1st 1988 to December 1989, some 4,000 pregnant women in TS were followed and assigned either a trained or untrained TBA. In the first year, early neonatal, and maternal mortality rates (MMR) (32.9 per 1000 and 170 per 100,000 deliveries respectively) were reduced, but not sustained in the second year. Nationally, MMR was 446 in 2009 and 126 in 2015. Although possible to improve health worker performance, and community engagement, the most likely explanation for benefit attrition is that people and material resources ‘downstream’ of the TBA services were inadequate. Three decades later, Indonesian neonatal and maternal mortality rates of 14 per 1000 and 126 per 100,000 live births in 2015 (globally 16.2 in 2009 and 216 in 2015) according to UNICEF, still demanded improvement, despite more hospital-based births. The original 1988 cohort of women, their children and grandchildren, can now be interrogated for medium to long term health outcomes of nutritional, such as birth weight and growth, and other risk factors. The evolving TS cohort health and nutrition intermediates and endpoints are instructive. Maternal and early life factors predict adult energy metabolism and cognitive function.

Background and Objectives: Intrauterine growth retardation (IUGR) is related to mortality and morbidity. However, defining IUGR by suitable field methods remains a challenge. A maternal-child Risk-ApproachStrategy (during 1988-1989) and follow-on Tanjungsari Cohort Study (TCS) (1989-1990), aimed to generate a practical classification of IUGR and explore its usage in predicting growth, mortality and morbidity of infants in the cohort. Study Design: Some 3892 singleton live-birth infants were followed. IUGR was defined by birth weight (BW) and length (BL) classified as: acute, chronic, non-IUGR or ‘probably preterm’. Growth, mortality, and survival curve were calculated to prove that the classification identified the most vulnerable infants. Fever >3 days and diarrhoea were assessed based on IUGR classification, sex, exclusive breastfeeding, and environmental factors. Results: IUGR infant weight and length did not catch-up with the non-IUGR in the first year. Infant mortality rate was 44.7 per 1000 where some 61% died within 90 days. Using age specific mortality by BW, 23.6% of all deaths occurred when it was <2500 g compared to 66.2% from IUGR and preterm groups. Fever and diarrhoea rates increased over 12 months. Diarrhoea was associated with poor source-of-drinking-water and latrine. Conclusion: The IUGR classification predicted one-year growth curves and survival, besides age and sex. IUGR based on BW and BL identified a larger group of at-risk infants than did low BW. High morbidity rates were partly explained by poor environmental conditions. IUGR inclusive of BL has value in optimizing nutritional status in the first 1000 days of life.

Background and Objectives: Low birth weight leads to growth faltering, attributable inter alia to malnutrition and maternal health and literacy. Risk for growth faltering in rural children under five is studied. Study Design: The Risk Approach Strategy in Tanjungsari, West Java has been analysed for all pregnancies during 1988-1989 and 4,698 singleton infants born between 1 January 1988 and 31 April 1990. Weight and body length/height measurements were repeated over 60 months, and plotted against WHO standards. Weight-for-age and height-forage z-scores were calculated using 2006 WHO growth as reference. The correlation between shortness (so-called stunting) and its presumptive risk factors was determined. A subset underwent DNA analysis for insulin-like growth factor-1 (IGF-1), and insulin receptor substrate-1 (IRS-1) polymorphism. Results: Weight and body length/height follow-ups were followed-up for 3795 infants; 14.2% of the cohort had low birth weight (<2500 g) (LBW) and 85.8% normal birth weight (NBW). LBW infants showed a similar velocity but tended to catch up more slowly (GEE; p<0.001). Relative to WHO references, the differential for stature increased with age, largely offset by reduced weight-for-age so that weight-for-height tracked close to the WHO reference; this contrasts with more divergence internationally. Birth length and weight, along with potable water access were correlated with stunting for children under 2 years. Neither the observed IGF-1, IRS-1 or combined gene polymorphisms were associated with LBW. Conclusions: The prediction by factors operative during pregnancy for early life stature ,with some adaptation for LBW infants, endures to 60 months.

Background and Objectives: Health status during adolescence may predetermine that during adulthood. Being short because of nutritional and health adversity, where stunting is indicative, is a global health concern, possibly in adolescence. This study assessed the prevalence of shortness (defined by HAZ <–2 SD) at age 12 and its determinants. Study Design: This Tanjungsari birth cohort of 1988/1989 was revisited in 2001–2002 with 3093 participating children, their parents and households. The cohort was tracked from birth, to ages 2 and 12 with anthropometry, with birth weight, then weight and height-for-age at 2 and 12, dietary history at age 2, health patterns at age 2 and 12, and environmental exposures. Results: The prevalence of adolescent shortness, presumed ‘stunting’, was 48.8% for which predictor Odds Ratios (OR) were low birth weight 1.64 (95% CI: 1.28-2.09), short height for age at 2-years 1.54 (95% CI: 1.33-1.80), limited maternal education 1.19 (95% CI: 1.01-1.41), unimproved source of drinking water 1.27 (95% CI: 1.08-1.49), unimproved latrine 1.18 (95% CI: 1.01-1.39) and presence of atopic disease at 12 years of age 1.29 (95% CI: 1.01-1.65). Smoking exposure, not breastfed, formula milk consumption and infectious disease at age 2 were not associated with shortness at age 12 on multivariable analysis. Conclusions: Adolescent shortness was found in almost half of this rural Javanese cohort followed from birth. It was associated with birth weight, and several individual, maternal and environmental factors evident at age 2, along with an atopic disposition at age 12. However, stature itself may not constitute a health risk over and above the associated socio-environmental conditions.

Background and Objectives: Resting metabolic rate and cognitive function may be associated with several factors, such as birth weight, growth, and fat-free mass in adulthood. The Tanjungsari Cohort Study (TCS) of 1988, to do with a maternal-child Risk Approach Strategy (RAS), provided the opportunity to determine the associations between birth weight, growth at 2 years, and body composition with adult resting metabolic rate and cognitive function. Methods and Study Design: In 2009 some 197 and, in 2017,144 of these representative participants from the TCS were assessed for energy intake, anthropometry, body composition, indirect calorimetry, and cognitive function in relation to low (ALBW, n=66) or normal (ANBW, n=78) birth weight. Associations were adjusted for basic demographic data. Results: Resting metabolic rate was positively associated with birth weight, body weight at 2 years of age, body mass index and fat free mass in adult life. Time to finish the Trail Making Test-A (TMT-A), a test of attention span, was significantly longer in the ALBW than the ANBW group (41.4±12.8 vs 37.8±15.6, p=0.005). In the ALBW group, weight catch-up improved TMT-A and logical memory test scores (29.5 vs 34.9.41, p=0.004; and 39.3 vs 29.4, p=0.04, respectively). Conclusions: Low birth weight was associated with poorer attention span in adult life; body weight gain at 2 years of age with better attention and memory function in adult life; a greater body mass index in adult life with better memory in adult life.

Background: Vitamin D deficiency (VDD) is a common problem in reproductive-aged women and has become a major public health problem worldwide. The effect of VDD in pregnancy has been associated with several adverse pregnancy outcomes. This study aims to assess the serum levels of 25-hydroxyvitamin D (25(OH)D) in the first trimester and its associated factors (socio-demographics, pregnancy profiles, dietary intake, and maternal anthropometry measurements) for the determination of vitamin D deficiency status in early pregnancy. Methods: A cross-sectional study of 239 pregnant mothers in West Sumatra, Indonesia was conducted. We measured lifestyle, socio-demographics and pregnancy profile through a structured questionnaire and interview process. A semi quantitative-food frequency questionnaire (SQ-FFQ) was used to analyse the dietary intake of the pregnant women. Serum 25(OH)D concentrations were measured at < 13 weeks gestation using ELISA and logistic regression models were employed to identify the predictors of low vitamin D status. Results: The prevalence of first-trimester maternal VDD and sufficiency were 82.8 and 17.2% respectively. The median 25(OH)D was 13.15 ng/mL (3.00–49.29 ng/mL). The significant independent predictors were no working status (OR: 0.029; 0.001–0.708) (p = 0.030); nulliparous parity status (OR: 7.634;1.550–37.608) (p = 0.012); length of outdoor activity status of less than an hour (OR: 9.659;1.883–49.550) (p = 0.007); and no consumption of supplements before pregnancy (OR: 4.49; 1.081–18.563) (p = 0.039). Conclusions: The prevalence of VDD is common in early pregnancy among Minangkabau women. Recommendations and policies to detect and prevent such insufficiency during pregnancy should be developed by considering the associated factors.

Background: The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) in Lombok, Indonesia showedthat maternal multiple micronutrients (MMN), as compared with iron and folic acid (IFA), reduced fetal loss, early infant mortality, and low birth weight. Mitochondria play a key role during pregnancy by providing maternal metabolic energy for fetal development, but the effects of maternal supplementation during pregnancy on mitochondria are not fully understood. Objective: The aim of this study was to assess the impact of MMN supplementation on maternal mitochondrial DNA copy number (mtDNA-CN). Methods: Weusedarchived venous blood specimens from pregnant women enrolled in the SUMMIT study. SUMMIT was a cluster-randomized double-blind controlled trial in which midwives were randomly assigned to distribute MMN or IFA to pregnant women. In this study, we selected 108 sets of paired baseline and postsupplementation samples (MMN=54andIFA=54). Maternal mtDNA-CN was determined by real-time quantitative polymerase chain reaction in baseline and postsupplementation specimens. The association between supplementation type and change in mtDNACN wasperformed using rank-based estimation for linear models. Results: In both groups, maternal mtDNA-CN at postsupplementation was significantly elevated compared with baseline (P < 0.001). The regression revealed that the MMN group had lower postsupplementation mtDNA-CN than the IFA group (? =?4.63,P= 0.003), especially for women with mtDNA-CN levels above the median at baseline (? =?7.49, P = 0.007). This effect was rapid, and observed within 33 d of initiation of supplementation (? =?7.39, P =0.017). Conclusion: Maternal MMN supplementation rapidly stabilized mtDNA-CN in pregnant women who participated in SUMMIT, indicating improved mitochondrial efficiency. The data provide a mechanistic basis for the beneficial effects of MMNonfetal growth and survival, and support the transition from routine IFA to MMN supplementation. This trial was registered at www.isrctn.com as ISRCTN34151616. J Nutr 2019;149:1309–1316.

Background and Objective: There are pros and cons surrounding the relationship between fat mass obesity associated (FTO) rs9939609 variants and the occurrence of obesity with regards to ethnicity and race. The Minangkabau ethnicity is unique compared to other ethnicities in Indonesia regarding its dietary pattern, in that this ethnic diet is high in fat intake and low in fibre intake. This study aimed to investigate the relationship between FTO rs9939609 variants and eating habits and food preferences among adolescent girls of Minangkabau ethnicity. Methodology: This study was a case control study and 275 adolescent girls (130 obese and 145 normal) were included. Tetra-primer amplification refractory mutation system-polymerase chain reaction (tetra-ARMS-PCR) was employed to examine genetic variants of FTO rs9939609. Eating habits were determined using an eating habits questionnaire and body mass index (BMI) was computed using the BMI Z-score (WHO). Results: This study revealed a significant relationship between genetic variants of FTO rs9939609 (TT, TA and AA genotypes) and higher BMI (p = 0.01). Those with the A allele were found to consume more fried food and have a lower intake of fruit (p<0.05) than those with the TT genotype. In the obese group, subjects with the A allele did not have a preference for a fruit-vegetable diet (p<0.05). Based on cooking method, subjects with the A allele preferred to eat less meat curry than those with TA and TT genotypes (p = 0.01). Conclusion: The genetic variants of FTO rs9939609 are associated with obesity, eating behaviour and food preferences in adolescents of Minangkabau ethnicity.

BACKGROUND/OBJECTIVES: The 6-23 months for infants is the longest period in the “first 1,000 days” of life. This period is very important for child development, so complementary feeding (CF) practices should be optimized to maximize children’s potential for growth and development. The aim of this study was to analyze the CF practices and nutritional status of children aged 6-23 months. SUBJECTS/METHODS: For this cross-sectional study, 392 children aged 6-23 months were selected using stratified random sampling. Socio-demographic data were collected through interviews. CF practices, collected by interviews and repeated 24-hour food recall method, were the timely introduction of CF, minimum meal frequency, dietary diversity and minimum acceptable diet, consumption food rich in proteins and vitamin A. Nutritional status was assessed using the indicators of underweight, wasting and stunting. To analyze the association between socio-demographic indicators and CF with nutritional status, the chi-square test with a confidence interval of 95% was used. RESULTS: Results showed that 39% were exclusively breastfed, only 61% received prolonged breastfeeding and 50% received timely introduction of CF. Minimum meal frequency was met by 74% of subjects, but dietary diversity and minimum acceptable diet were only realized in 50% and 40% of the children, respectively. The prevalence of underweight, wasting, and stunting were 26%, 23%, and 28%, respectively. Age of the child, birth order, birth weight, parents’ education level, family size and incidence of fever and diarrhea during the previous two weeks were associated with underweight, while child’s birth order, fathers’ education level, mother’s age, family size, completion of the age-appropriate vaccination and fish consumption frequency were associated with wasting. Age of the child, incidence of fever and acute respiratory infection, and fortified food consumption were associated with stunting. CONCLUSIONS: Suboptimal CF practices and high prevalence of underweight, wasting and stunting were found among children aged 6-23 months old in Aceh. These results highlight the need to improve CF and nutritional status.

Background and Objectives: To evaluate the effect of culturally-relevant food supplementation and psychosocial stimulation on infant growth and development. Methods and Study Design: A community-based randomized controlled trial was conducted in 40 clusters from 5 selected villages in Tanah Datar District of West Sumatera, Indonesia. We assessed 355 infants aged 6 to 9 months at the beginning of the study. The infants were divided into 4 groups: 1) Food Supplementation (FS); 2) Psychosocial Stimulation (PS); 3) Food Supplementation and Psychosocial Stimulation (FS+PS); and 4) Control Group (CG). The formula food supplement was comprised of a variety of local food sources (local MP-ASI) and adjusted for the local habits. The quality of psychosocial stimulation was assessed with the Infant HOME inventory method. Progress at 6 months was assessed by anthropometry and the Bayley scores of cognition, language and motor function. Results: There were improvements in linear growth, cognitive and motor development of children in the FS (p<0.05) and the FS+PS (p<0.01) groups compared to the CG. After six months of intervention, mean length increased to 6.86?2.08 cm and 6.66?2.41 cm for FS and FS+PS respectively (p<0.05). With the combination of food supplementation and psychosocial stimulation (FS+PS), cognitive development increased to 21.4?12.2 points (effect size 0.56) (p<0.01) and motor development increased to 20.7?18.4 points (effect size 0.50) (p<0.001). Conclusion: Combined intervention with local food supplementation and psychosocial stimulation improved infant growth, cognitive and motor development.

Despite progress with the food-associated health agenda in the public health and clinical domains, much remains to be done in Indonesia. There are reasons to be optimistic which include economic development, increasing literacy, progress towards universal health coverage and community organizational arrangements across the archipelago which focus on health through some 10,000 puskesmas. These community health centres are variably staffed with voluntary cadres from the community, bidans (nurses) and general medical practitioners. For more effective prevention and management of nutritionally-related health problems, innovative community and clinical nutrition research and expertise is required. With rapid urbanisation, the growth of the digital economy, increasing socio-economic inequity and climate change, there are imperatives for ecologically sustainable, nonemployment dependent livelihoods which provide energy, food, water, education and health care security. A relevant health care workforce will include those who research and practice clinical nutrition. Here we gather together an account of an extensive body of published and emerging literature which makes a case collectively for a more ecological approach to nutrition and health and how it might revitalise the Indonesian and other health care systems.

Background: Omega-3 fatty acid intake during pregnancy has been confirmed to affect newborn birth outcomes in the developed world. However, the association between maternal omega-3 fatty acid intake and birth size is unknown in developing countries. Objective: To examine the association of maternal omega-3 fatty acid intake with newborn birth size. Methods and Study Design: A cross-sectional study was conducted, involving 282 pregnant women aged 19–40 years who had a gestational age of >32 weeks and received antenatal care at 10 health centres and one referral hospital in East Jakarta, Indonesia. Maternal habitual intake of omega-3 fatty acids, including ?-linolenic acid, docosahexaenoic acid, and eicosapentaenoic acid, was assessed using a semiquantitative food frequency questionnaire. Birth weight and head circumference were measured using a paediatric weighing scale and tape, respectively, and birth length was obtained from medical records. Multiple linear regression analysis was performed to provide adjusted associations. Results: The median total intake of omega-3 fatty acids, docosahexaenoic acid, eicosapentaenoic acid, and ?-linolenic acid was lower than the recommended dietary intake. The newborns of mothers with an ?-linolenic acid intake lower than 0.82 g/d had a significantly lower (?=114, 95% confidence interval=?216, ?13.5; p=0.014) weight compared with those of mothers with high ?-linolenic acid intake, after adjustment for confounding factors. Conclusion: Inadequate maternal intake of ?-linolenic acid, but not omega-3 fatty acids, docosahexaenoic acid, or eicosapentaenoic acid, was associated with lower birth weight. Enhanced promotion of consumption of foods rich in essential fatty acids during pregnancy may facilitate attaining optimal infant weight in urban areas.

Background and Objectives: Infant birth weight might be partly contributed to by maternal nutritional status at birth and maternal nutrition during pregnancy. The objective of this study was to analyze intergenerational maternal birth weight, maternal BMI, weight change during pregnancy, and maternal body composition (FM, FFM, and TBW) changes during pregnancy. Methods and Study Design: We analyzed the associations between the maternal birth weight and body composition of 94 women and infant birth weight by using multiple regression adjusted for socioeconomic and reproductive history. Results: All associations with infant birth weight were positive. The association between infant birth weight and maternal birth weight was 0.28 (95% CI: 0.02–0.54); that for the association between infant birth weight and maternal body weight in the first, second, and third trimesters was 15.1 (95% CI: 4.92–25.3), 13.7 (95% CI: 2.78–24.6), and 16.1 (95% CI: 5.22–27.0), respectively. The association between infant birth weight and fat mass in the second and third trimesters were 18.4 (95% CI: 3.38–33.5) and 16.1 (95% CI: 5.23–27.0), respectively, and those for the association between infant birth weight and fat-free mass in the first and third trimesters were 33.6 (6.38, 60.9) and 34.8 (95% CI: 3.47–66.1), respectively. Conclusions: This study confirms previous findings that maternal birth weight and body composition during pregnancy are associated with infant birth weight.

Background and Objectives: During pregnancy, the body exhibits dynamic changes in fluid composition. More than 50%of women experience nausea and vomiting during the first trimester. Studies of hydration status in pregnant women are limited, and not in tropical countries, like in Indonesia. The objective of this study was to investigate the hydration status and appropriate biomarkers for determination of hydration status in pregnant women in West Jakarta. Methods and Study Design: This study was cross-sectional. A total of 35 pregnant women aged (19-35 years) at the early second trimester of pregnancy was recruited. Urine osmolality, urine specific gravity, and serum osmolality were used to determine hydration status. Subjects then were divided into a hydration group (HG) and a dehydration group (DG). We used independent t tests, chi-square and Spearman rank correlation coefficient to analyse the data. Results: The population was comparably divided between dehydration and hydration groups (57.1% and 42.9%, respectively). The proportions by age, parity, gestational age, height, weight, upper arm circumference, waist circumference, pelvic circumference, body temperature, blood pressure, and fundal height did not differ between groups (p?0.05). There was a relationship between urine colour and hydration status (p<0.05). Differences in hydration biomarker status (urine osmolality and urine specific gravity) were noted between the groups (p<0.05). Conclusions: Dehydration may be common during pregnancy in tropical Indonesia and can be confirmed by the hydration biomarkers of urinary specific gravity and osmolality. Fluid balance is necessary to prevent health problems and intrauterine growth restriction in pregnant women.

Background and Objectives: Exclusive breastfeeding provides many benefits to both infants and mothers. Despite the introduction of laws aimed at protecting the practice of exclusive breastfeeding, the coverage of exclusive breastfeeding remains low, particularly for working mothers. Methods and Study Design: This crosssectional study recruited working mothers employed in medium and large companies in Bantul District, Daerah Istimewa Yogyakarta, Indonesia. The study participants were 158 working mothers whose children were aged 6–12 months, and they were selected using the probability proportional to size technique. The data were analyzed using descriptive statistics, chi-square tests, and multiple logistic regression. Results: Adequate family support for breastfeeding (OR: 2.86; 95% CI: 1.25–6.53) and a high paternal education level (OR: 2.68; 95% CI: 1.11–6.48) were significantly associated with the practice of exclusive breastfeeding among working mothers. However, the infant’s sex and age, parity, and the mother’s age and education level were unassociated with exclusive breastfeeding. Conclusion: Family support and a high paternal education level are crucial in enabling working mothers to practice exclusive breastfeeding. Interventions that promote exclusive breastfeeding should focus on involving the husband and other family members in health care programs related to breastfeeding

Background and Objectives: Recent studies show that maternal obesity is associated with impaired offspring neurodevelopmental outcomes. The mechanism underlying the association is unclear. However, there is evidence to suggest a role for intra-uterine exposure to inflammation and insulin resistance (IR). We aimed to determine if maternal IR and inflammation were associated to fetal neurodevelopment as indicated by fetal heart rate variability (HRV), an index of fetal cardiac autonomic nervous system development. Method and Study Design: A total of 44 healthy maternal-fetal pairs (maternal pre-pregnancy BMI distribution: n=20 normal weight, 8 overweight, 16 obese) were analyzed. We assessed maternal inflammation (plasma IL-6 and TNF-?) and IR (HOMA index). Fetal HRV, a proxy for fetal neurodevelopment, was assessed using fetal magnetocardiogram at the 36th week of pregnancy. The relationships between maternal inflammation and IR with fetal HRV (SD1 and SD2) were estimated individually by Pearson bivariate correlations. Results: No correlations were observed between the fetal HRV components with maternal HOMA-IR and maternal plasma levels of IL-6 and TNF-? (all p<0.05). However, the negative association between maternal TNF-? level and fetal SD2 approached significance (correlation coefficient=-0.29, 95% confidence interval=-0.62,-0.03, p=0.07). Conclusion: Maternal IR and inflammation during pregnancy were not associated with fetal cardiac autonomic nervous system development. Further studies with a larger sample size and more maternal inflammatory indicators are needed to explore these relationships.

Background and Objectives: The sago worm Rhynchophorus ferrugineus is a nutritious food source found in the remaining parts of a sago palm trunk after the removal of sago starch by farmers. The effort to increase sago worm consumption is investigated in an intervention study among children aged < 5 years. Methods and Study Design: Children aged 1–5 years were allocated to a sago worm inclusive diet (n=10) and to a control group eating a usual diet, but without sago worms (n=13). Snacks were served once per day (100 g) for 45 days and designed to contain similar amounts of vegetables (carrots and long beans) and other ingredients including rice, sticky rice, cassava, sweet potato, banana, or tofu with or without sago worms. Food preference was ascertained by interview. Anthropometric measurements were taken at baseline and the endpoint. Results: After mixing all food stuffs into one product for instance nasi gurih, protein and fat content in the intervention group was higher compared to control group (8.8 g and 7.3 g vs 4.7 g and 0.5 g respectively). In the intervention group receiving complementary feeding with sago worms, children’s height changed minimally as did the control group (0.3 vs 0.2 cm); no difference was observed between the groups regarding weight or height. Conclusions: Sago worm consumption can diversify the diet through usage in various dishes, so improving its overall nutritional quality. Worm addition in an intervention program does not compromise, but maintains nutritional value. Local use adds affordability and sustainability to the food and health systems in a sago-consuming culture, so contributing to food security.

Background: Overfatness (overweight and obesity) is associated with an increased risk of cardiovascular disease, including elevated blood pressure, dyslipidaemia, and insulin resistance. Chronic inflammation may play a role in mediating these associations. Objective: To investigate the association between plasma tumour necrosis factor-? and risk factors for cardiovascular disease among overweight and obese adolescents. Methods and Study Design: This study was an observational analysis with a cross-sectional design for high school students in Yogyakarta, Indonesia. One hundred and fifteen overweight and obese adolescents (mean age 16.8 years; 48.3% female) were involved in the study. Overfatness was specified by body mass index z-scores. Anthropometric measurements, blood pressure, lipid profiles, and fasting glucose were obtained. Fasting plasma insulin and plasma tumour necrosis factor-? were quantified using enzyme-linked immunosorbent assay. Insulin resistance was represented as the homeostatic model assessment value. Data were analysed using SPSS for Windows, version 23. Results: Plasma tumour necrosis factor-? was significantly associated with total cholesterol (p=0.046) and diastolic blood pressure (p=0.018) among the overweight and obese adolescents. Results from path analyses showed that there were indirect effects of z-score BMI on systolic and diastolic blood pressures, HDL and fasting plasma glucose mediated by plasma tumour necrosis factor-? concentrations. Meanwhile, there were indirect effects of waist circumference on systolic and diastolic blood pressure by age and height percentile and HDL. There was no significant association between plasma tumour necrosis factor-? and insulin resistance. Conclusion: The study showed that a proinflammatory marker, plasma tumour necrosis factor-?, is associated with blood pressure, HDL and fasting plasma glucose in overweight and obese adolescents. This indicates that inflammation in overweight and obesity may play a role in increasing the risk of cardiovascular disease.

Background: Despite distinct advancements in nutritional therapy, malnutrition and growth retardation remain inevitable consequences of chronic liver disease. The global prevalence of chronic liver disease in children is about 3%, with a quarter undernourished. Malnutrition itself is a negative prognostic indicator of survival. Further research is necessary for delivering adequate nutritional support to reduce morbidity and mortality. Objective: To evaluate the nutritional status and growth of children with chronic liver disease and its contributing factors. Methods and Study Design: Data were gathered about 21 children aged 7 months to 13.3 years diagnosed with chronic liver disease at Harapan Kita Women and Children Hospital between November 2014 and February 2016. Physical growth and nutritional status were evaluated using anthropometric percentiles and z-scores. Laboratory measurements were made on their first visit. Results: The mean age of participants was 43.9±47.4 months. Mean weight was 13.4±9.31 kg, and mean length/height was 88.8±27.7 cm. Ten (47.6%) and 3 (14.3%) patients had moderate or severe undernutrition, respectively, and 38% (8 patients) had growth retardation. Of those with good nutritional status, 62.5% were older than 5 years. Malnutrition was correlated with growth failure, a low serum albumin, and elevated aspartate transaminase (p<0.05 in all cases). Conclusion: Early diagnosis of malnutrition should encourage nutritional support, delay illness progression and increase survival in children with chronic liver disease.

Background and Objectives: Fatigue is a critical occupational health risk among migrant workers. Globally, more than half of migrant workers are women. However, the prevalence rate and risk factors for fatigue in domestically employed migrant women are unknown. Methods and Study Design: In total, 194 Indonesian women migrants aged 20–50 years who were working in Taipei were studied. Self-perceived acculturation, dietary acculturation, BMI and haemoglobin were evaluated. Fatigue and depressive symptoms were assessed using the Brief Fatigue Inventory and Beck Depression Inventory-II, respectively. Results: The prevalence of fatigue was 27.8%. Depressive symptoms (p<0.0001), cooking methods (p=0.027), and self-perceived feelings of sadness and weakness (p=0.003) were associated with fatigue. After adjustment for covariates, the ORs for depressive symptoms (OR: 5.40; 95% CI: 2.32–12.6), deep frying/stir frying (OR: 5.23; 95% CI: 1.27–21.5), and self-perceived feelings of sadness and weakness (OR: 3.41; 95% CI: 1.26–9.25) remained significant. An interactive analysis revealed that women without depressive symptoms who used deep frying/stir frying as a cooking method had a 3.5-fold (1–12.3) higher risk of fatigue than did those who used non-deep frying and stir frying as cooking methods (which served as the reference) for cooking. By contrast, women with depressive symptoms who used non-deep frying and stir frying had a 6.5-fold (2.8–15.3) higher risk of fatigue, and the risk increased sharply to 12.6-fold (1.26–125.8) if they used deep frying and stir frying for cooking. Conclusions: The risk of fatigue among migrant women working domestically is increased when they exhibit depressive symptoms and their cooking technique is frying.

Background and Objective: Serum vitamin D influences cellular immunity against Mycobacterium tuberculosis, particularly in under-five children. Vitamin D insufficiency and deficiency as well as tuberculosis (TB) are highly prevalent in Indonesia. This study described the association of serum vitamin D in the incidence of latent TB in under-five children with a history of close TB contact. Methods and Study Design: This cross-sectional study examined 178 under-five children with a history of close TB contact, with 98 index cases from primary health care facilities in Padang. Latent TB was defined based on a positive tuberculin skin test. Serum vitamin D was determined using ELISA method. General characteristics for age, sex, socioeconomic status, contact score, BCG scars, and nutritional status were also collected. Results: Of 168 eligible subjects, 40.5% had latent TB, however no differences between ‘latent TB’ and ‘without latent TB’ were observed in participant characteristics. Vitamin D deficiency, insufficiency, and sufficiency were observed in 23.3%, 43.5%, and 33.3% of children, respectively. In general, the ‘latent TB’ group had lower serum vitamin D than those in the ‘without latent TB’ group, stratified by age, contact score and nutritional status; however, significant differences were observed in children age<1 years (18.0?2.6 vs 31.2?10.5, respectively, p=0.013). Nevertheless, no associations between the two groups were observed using multivariate analysis. Conclusion: Vitamin D status was not associated with the incidence of latent TB among under-five children with a history of close TB contact, although this may not obtain in children aged <1 year old.

Background and objectives: Energy metabolism may be dysfunctionally integral between host and infective agent in active tuberculosis, mediated by adipocytokines and free fatty acids (FFA) as the products of triglyceride lipolysis in fat, blood or other tissues. Retinol Binding Protein 4 (RBP4) and asymmetric dimethylarginine (ADMA) are candidate adipocytokines. The possibility of a deleterious metabolic nexus in chronic energy deficiency (CED) (BMI <18.5 kg/m²) is explored. Methods and design: Newly diagnosed patients with tuberculosis (n=63) were selected using consecutive random sampling at a Centre for the Care and Treatment of Lung Diseases in Makassar, Indonesia. Diagnosis of pulmonary TB required microscopy with Ziehl-Neelsen stain. Anthropometric measurements were taken. Venesection allowed glomerular filtration rate, FFA, serum glutamic oxaloacetic transaminase and glutamate-pyruvate transaminase to be assessed. Results: CED was evident in 60.3%. For the well and lesser nourished, medians were, respectively, FFA 0.30 and 0.37 mmol/mL (p=0.960); RBP4 199730 ng/mL and 11721 ng/mL (p=0.009); GFR 106 ml/min and 113 ml/min (p=0.673); and ADMA 0.52 ng/mL and 0.51 ng/mL (p=0.172). BMI and serum RBP4 were correlated (?=0.52, p<0.001), with odds ratios (OR) 5.8 (CI 1.68-20.3). RBP4 in CED was lower than in better nourished patients. Serum FFA is not evidently associated with BMI in patients with active TB. Conclusions : RBP4 is some 6-fold lower when active TB patients have CED than when BMI >25 kg/m₂. However, FFA was not associated with CED in these active TB patients which may be a type 2 error or represent an energy impasse where infection and the host’s metabolic needs are in competition.

Background and Objectives: A vicious cycle of infection, malabsorption, and malnutrition has been implicated in the perpetuation of diarrheal disease. This study examined whether persistent diarrhea is associated with changes in selenium status and stool alpha-1 antitrypsin (AAT) concentration. Methods and Study Design: This cross-sectional study included 30 children aged 1–12 years with persistent diarrhea who were hospitalized in Cipto Mangunkusumo Hospital and Fatmawati Hospital, Jakarta, and 30 apparently healthy children who were matched by age and sex and lived in a rural area of Jakarta. Clinical examinations, blood routine tests, erythrocyte glutathione peroxidase (GPX) activity and plasma selenium levels as well as AAT in fresh stool samples were performed in all the subjects. Results: Of 30 children with persistent diarrhea, 17 had moderate malnutrition and 13 had severe malnutrition. The mean plasma selenium was significantly lower in children with persistent diarrhea than in children without diarrhea (86.0 ?g/L [95% CI: 76.1–95.9] vs 110 ?g/L [95% CI: 104–116, p<0.0001). The mean stool AAT concentration was significantly higher in children with persistent diarrhea than in those without diarrhea (115 mg/dL [95% CI: 38.5–191] vs 16 mg/dL [95% CI: 4.0–13.5, p<0.0001]). Selenium correlated with AAT (p=0.05). Fecal fungi were persistently present. Conclusions: Although selenium status in both groups was optimal for the obtained plasma GPX activity, children with persistent diarrhea exhibited lower plasma selenium levels. This study suggests that the decrease in the plasma selenium level may be the consequence of protein loss and that fungi may be involved.

Background: We have recently demonstrated that an obese-years construct is a better predictor of the risk of diabetes than the severity of body weight alone. However, these risk estimates were derived from a population cohort study initiated in 1948 that might not apply to the current population. Objective: To validate an obese-years construct in estimating the risk of type-2 diabetes in a more contemporary cohort study. Design: A total of 5,132 participants of the Framingham Offspring Study, initiated in 1972, were followed up for 45 years. Body mass index (BMI) above 29 kg/m2 was multiplied by the number of years lived with obesity at that BMI to define the number of obese-years. Time-dependent Cox regression was used to explore the association. Results: The risk of type-2 diabetes increased significantly with increase in obese-years. Adjusted hazard ratios increased by 6% (95% CI: 57%) per additional 10 points of obese-years. This ratio was observed to be similar in both men and women, but was 4% higher in current smokers than in never/ex-smokers. The Akaike Information Criterion confirmed that the Cox regression model with the obese-years construct was a stronger predictor of the risk of diabetes than a model including either BMI or the duration of obesity alone. Conclusions: In a contemporary cohort population, it was confirmed that the obese-years construct is strongly associated with an increased risk of type-2 diabetes. This suggests that both severity and the duration of obesity should be considered in future estimations of the burden of disease associated with obesity.

Indonesia, as a major population in the Asia Pacific region, threatened with food and health insecurity through climate change and rapid economic development, faces the challenge to build capacity among its science-based food and health professionals and institutions. The nutrition research agenda is now being more actively set within the region, rather than by external imposition. A series of papers emanating from a new generation of public health and clinical nutrition scientists is reported in this issue of APJCN. It draws attention to the importance of food patterns and background culture as contributors to the failure of the nutrient rather than a food, food system and socio-ecological approach to solve the region’s intransigent nutritionally-related health problems. New understandings of human eco-social biology are providing opportunities to accelerate the resolution of these problems. The challenge is to transform the food-health construct from one which is not sufficiently concerned about the precarious state of ecologically dysfunctional health and its nutrient market drivers to one which strives for more sustainable and affordable solutions. The present reports address a range of options to these ends.

Background and Objectives: Vitamin D deficiency significantly affects cardiovascular disease risk. Cardiovascular disease is epidemic in nature. Because the prevalence of cardiovascular disease has been increasing in children, it has been changing from an adulthood disease to a childhood disease. Therefore, formulating an effective prevention strategy against cardiovascular disease development in children is crucial. Methods and Study Design: From PubMed, we identified and reviewed studies evaluating the association of vitamin D deficiency with cardiovascular disease risk in children. Results: The mechanism through which vitamin D protects against cardiovascular disease has yet to be fully elucidated. Vitamin D deficiency may be associated with various risk factors for cardiovascular disease that are already manifested in childhood, including obesity, hypertension, dyslipidaemia, insulin resistance, and metabolic syndrome. Vitamin D deficiency has been associated with cardiovascular disease because it promotes vascular stiffness and calcification, leading to atherosclerosis. However, studies investigating the effectiveness of vitamin D in preventing cardiovascular disease risk by using an ideal study design are scant. Conclusions: Vitamin D deficiency in children may increase cardiovascular disease risk, which tends to manifest in childhood. Because data on the association of vitamin D deficiency with cardiovascular disease risk among children are limited and inconclusive, additional studies are required to investigate this association in children in general and in a setting with naturally abundant sun exposure

Background and Objective: A balance ratio of dietary omega-3 (n-3) and omega-6 (n-6) fatty acids reduces childhood obesity. However, few studies have focused on validation of semiquantitative food frequency questionnaire (SFFQ) for determining the n-3 and n-6 intakes in children. Therefore, a valid SFFQ for assessing n-3 and n-6 intakes among Indonesian children is required. Methods and Study Design: A cross-sectional study was conducted by selecting 89 healthy children through multistage random sampling. Dietary intakes were assessed using the SFFQ and a 3-day non-consecutive 24-h recall. Randomly selected children (n=35) were assessed for plasma phospholipid fatty acid (PFA). In total, 78 food items in the SFFQ, as in the Thai, Vietnamese, and American food composition databases, were validated using dietary recall and PFA. The SFFQ was readministered after 4 weeks to assess its reproducibility. The validity and reproducibility of the SFFQ were determined by Bland–Altman analysis. Results: Favourable agreement was found between the SFFQ and recall for docosahexanoic acid, eicosapentanoic acid, docosapentanoic acid, and arachidonic acid, but not for total n-3, n-6, ?-linolenic acid, or linoleic acid. Significant correlations were found between the SFFQ estimations and plasma n-6 and LA (r=0.40, p=0.025; and r=0.42, p=0.018, respectively). A 95% limit of Bland–Altman agreement was observed between the first and repeat SFFQ for all fatty acids. Conclusion: The proposed SFFQ is sufficiently valid and reliable for assessment of essential fatty acids intakes in Indonesian children.

Background and Objectives: Vitamin A deficiency is particularly common among children younger than 5 years. In 2011, a study conducted in West Java revealed that the prevalence of vitamin A deficiency in children aged 6–11 months, 12–23 months, and 24–59 months was 18.2%, 15.2%, and 9.9%, respectively. The present study analysed the differences in vitamin A intake and serum retinol in all the preschool children from Grobogan and Kudus, Central Java. Methods and Study Design: The baseline data of vitamin A efficacy were analysed. A total of 143 children aged 1-3 years participants (n=71 from Kudus and n=71 from Grobogan) were recruited and we used independent t-tests to analyse the data. Results: Among the study population, 50.7% and 48.6% were boys and 49.3% and 51.4% were girls from Kudus and Grobogan, respectively. The average intake of energy, carbohydrates, protein, fat, and vitamin A was 698±440 (Kcal), 89±60 (g), 25.9±18.5 (g), 26.1±18.5 (g), and 435.3±554.0 (?g) in Kudus and 868±493 (Kcal), 109±67 (g), 30.9±20.1 (g), 35.1±23.1 (g), and 538.1±622.9 (?g) in Grobogan, respectively. The average serum retinol in Kudus and Grobogan were 26.7±6.4 (µg/dL) and 29.6±5.9 (µg/dL), respectively. Significant differences in energy and fat intake (p<0.05) were also observed between the Kudus and Grobogan districts; however, no differences in protein, carbohydrates, and vitamin A intake (p?0.05) were noted. A significant difference in serum retinol was observed between these two districts (p<0.05). Conclusions: An increase in vitamin A intake through various foods should improve the serum retinol in preschool children.

Background and Objectives: Stunting during childhood is a common public health problem in Indonesia. Complementary food supplementation with a small quantity of lipid-based nutrient supplements (SQ-LNSs) can promote growth and prevent undernutrition. This study investigated the effects of the daily provision of SQ-LNSs and biscuits on linear growth and reduction in the incidence of stunting among infants in rural Indonesia. Methods and Study Design: A 6-month, non-randomised, controlled trial was conducted on 168 infants who received 20 g of SQ-LNSs, 3 pieces of biscuits, or no intervention. The outcome was length gain and incidence of stunting (length-age-z score (LAZ) Results: After the 6-month intervention, the adjusted length gain and change in the LAZ (8.57 cm and ?0.09 z-score unit, respectively) were higher in the SQLNS group than in the control (7.15 cm and ?0.87 z-score unit, respectively) and biscuit groups (7.79 cm and ?0.46 z-score unit, respectively; p<0.01). The rate of length gain was significantly higher in the SQ-LNS group (1.43 cm/month; 95% CI: 1.12–1.26) than in the biscuit (1.29 cm/month, 95% CI: 1.23–1.36) and control groups (1.19 cm/month, 95% CI: 1.12–1.26; p<0.01). At the end study, the incidence of stunting in SQ-LNS group was lower (1.8%) than in the biscuit group (8.5%) and control group (14.6%). In the SQ-LNS group, the relative risk (RR) of stunting was 0.35 and in the biscuit group (0.94). Conclusions: SQ-LNSs improved linear growth and reducing the incidence of stunting over 6-months intervention.

Background and Objectives: Although breastfeeding is recommended by WHO, the breastfeeding rate in Indonesia remains low, because many women fail to maintain their breastfeeding intention during the breastfeeding period. The decision whether to breastfeed or not, like any other nutritional behaviour, may develop over a lifetime and is rooted in many aspects of life; however, many factors may affect a mother’s decision about whether to stop or continue breastfeeding during the breastfeeding period. A critical time point of contact for breastfeeding is a time point when the mother experiences difficulties and encounters influences that may affect breastfeeding continuation. Methods and Study Design: A qualitative approach was used to investigate the factors affecting breastfeeding intention and continuation. A follow-up approach was used to assess actual experiences and problems at each time point of contact. The interviewees in this study were pregnant women who lived and worked in West Jakarta and were in at least Week 36 of their pregnancy. The key interviewees for triangulation were 2 grandmothers and 2 healthcare providers. Results and Conclusions: Knowledge, beliefs, and support were the factors affecting the women’s intentions. Perceived obstacles; common beliefs; stigmas regarding breastfeeding; and support and influences from husbands, mothers, family members, and relatives were the factors influencing breastfeeding continuation within the first month postpartum.

Background and Objectives: Exclusive breastfeeding has been proven to be essential for optimal health, and for reducing infections and mortality in children. However, exclusive breastfeeding coverage both in Indonesia and in globalremains low. This study evaluated the relationship between the timely initiation of breastfeeding and the practice of exclusive breastfeeding in Indonesia. Methods and Study Design: This cross-sectional study used Riskesdas 2013 data. Participants were 7,667 mothers whose children were aged 6–23 months in Indonesia, and were selected based on the completeness of the variables. The data were analysed using descriptive statistics, chisquare tests, and a multiple logistic regression that considered the sampling weight. STATA 13.0 was used for the analyses, and the significance level was set at p<0.05. Results: Timely initiation of breastfeeding within 1 hour of parturition (OR=3.66, 95% CI: 2.14–3.64), timely initiation of breastfeeding at or after 1 hour following parturition (OR=2.79, 95% CI: 3.00–4.46), and neonatal illness (OR=0.69, 95% CI: 0.53–0.91) were significantly associated with an exclusive breastfeeding history among children aged 6–23 months. Other factors, such as the mother’s age, mother’s educational level, child’s birth weight, household economic status, and residential area were not associated with an exclusive breastfeeding history. Conclusion: Timely initiation of breastfeeding and the prevention of neonatal illness should be the main interventions to improve exclusive breastfeeding coverage in Indonesia.

Background and Objectives: Persistent diarrhoea, a serious health problem, is closely related to malnutrition. Children with severe malnutrition have a 9-fold risk of death, and children with severe stunting have a 4-fold risk of death. Prolonged mucosal injury from diarrhoea causes reduced secretin and cholecystokinin secretion, which decreases stimulation to the pancreas, and is indicated by faecal elastase-1 levels. This further aggravates persistent diarrhoea and malnutrition because of the low levels of digestive enzyme production. This study evaluated the exocrine function of the pancreas in children with persistent diarrhoea and malnutrition. Methods and Study Design: This study used a cross-sectional design to compare exocrine pancreatic function among children with persistent diarrhoea, children with malnutrition, and apparently healthy children as reference Children aged 6–60 months were selected from the inpatient and outpatient units of various general hospitals in Jakarta. Faecal elastase-1 levels were used to determine exocrine pancreatic function. Results: The median values of faecal elastase1 in children with persistent diarrhoea, children with malnutrition, and reference children were 743 (1–1503) mcg/g, 861 (17–2909) mcg/g, and 1210 (26–3000) mcg/g, respectively. A significant difference was observed in the faecal elastase-1 levels between reference children and those with persistent diarrhoea (p<0.001). However, no differences in the faecal elastase-1 levels were noted between malnourished and reference children (p>0.05). Children with both persistent diarrhoea and malnutrition showed mean FE-1 392.3+206.9 and median 419 (125-593). Conclusions: Exocrine pancreatic insufficiency is found in children with persistent diarrhoea. Children with combined persistent diarrhoea and malnutrition have the lowest FE-1, to which persistent diarrhea has the most significant contribution.

Background and Objectives: Diets with a specific omega-6/omega-3 fatty acid ratio have been reported to have favourable effects in controlling obesity in adults. However, development a local-based diet by considering the ratio of these fatty acids for improving the nutritional status of overweight and obese children is lacking. Therefore, using linear programming, we developed an affordable optimised diet focusing on the ratio of omega6/omega-3 fatty acid intake for obese children aged 12–23 months. Methods and Study Design: A crosssectional study was conducted in two subdistricts of East Jakarta involving 42 normal-weight and 29 overweight and obese children, grouped on the basis of their body mass index for-age Z scores and selected through multistage random sampling. A 24-h recall was performed for 3-nonconsecutive days to assess the children’s dietary intake levels and food patterns. We conducted group and structured interviews as well as market surveys to identify food availability, accessibility and affordability. Results: Three types of affordable optimised 7-day diet meal plans were developed on the basis of breastfeeding status. The optimised diet plan fulfilled energy and macronutrient intake requirements within the acceptable macronutrient distribution range. The omega-6/omega-3 fatty acid ratio in the children was between 4 and 10. Moreover, the micronutrient intake level was within the range of the recommended daily allowance or estimated average recommendation and tolerable upper intake level. Conclusions: The optimisation model used in this study provides a mathematical solution for economical diet meal plans that approximate the nutrient requirements for overweight and obese children.

Background and Objectives: Plasmodium falciparum infection during pregnancy is characterised by placental inefficiency caused by infected erythrocyte sequestration. Reduced placental efficiency leads to placental intrauterine adaptation for sustaining fetal growth, which is reflected by changes in the expression of placental genes involved in intrauterine growth regulation. Therefore, we aimed to determine whether the placental weight ratio, an indicator of placental efficiency, affects the placental expression of the components of the insulin-like growth factor axis and leptin signalling pathway in P. falciparum-infected pregnant women. >Methods and Study Design: A malaria case-only analysis of 50 P. falciparum-infected pregnant women in Timika, Papua, Indonesia, was conducted. The placental mRNA expression of insulin-like growth factor-I, insulin-like growth factor binding protein-1, leptin, and the long and short isoforms of the leptin receptor was measured through quantitative realtime PCR. Results: The placental weight ratio exerted a positive effect on the placental mRNA expression of insulin-like growth factor-I (coefficient=6.10, p=0.002) and the long isoform of the leptin receptor (coefficient=4.73, p=0.015) in malaria-infected pregnant women without fever or chill symptoms. Conclusion: Our results indicate that placental adaptive responses caused by adverse intrauterine conditions in P. falciparuminfected pregnant women vary depending on the presence or absence of fever and chill symptoms.

Background and Objectives: Social cognitive theory provides the opportunity for program development to enhance healthy personal behvioural characteristics. We devised study to employ social cognitive theory to reduce snacking habits and sedentary activity among overweight adolescents. Methods and Study Design: Eight junior high schools in Makassar city were randomly assigned as intervention and control schools. A total of 238 overweight students aged 11-15 years (BMI z-score ?1 SD, according to a 2007 report from the WHO) were recruited. Adolescents from the intervention schools attended 12 weekly 75-min nutrition education group sessions, which focused on behavioural modification assisted by trained facilitators; furthermore, their parents received weekly nutrition education leaflets. Adolescents from the control schools, but not their parents, received leaflets on evidenced-based nutrition information. The BMI z-scores, waist circumference, snacking habits, sedentary activity, and the adolescents’ self-efficacy data were assessed prior to and after 3 months of intervention. The outcomes were analysed on an intent-to-treat basis. Results: Compared with the control group, the intervention group showed a higher reduction in BMI z-scores (?0.08; p<0.05) and waist circumference (?1.5; p<0.05) at 3 months. Significant between-group differences were also observed for decreased snacking habits, but not for sedentary activity. Additionally, the programme improved self-efficacy for reducing these behaviours. Mean compliance and satisfaction with the programme were 95% and 92%, respectively. Conclusions: These high reduction rates suggest that the programme is promising and may address the problem of overweightness in adolescents. Additional studies are required to develop the programme in community settings.

Background and Objectives: Pro-inflammatory cytokines interleukin 17A (IL-17), leptin, and adiponectin have been associated with obesity and insulin resistance. Moreover, differences in sex and ethnicity as well as plasma concentration of adipocytokines and cytokines have been associated with the risk of insulin resistance. This study was conducted to elucidate whether sex differences exist in the risk of insulin resistance in Indonesian adolescents and to determine how plasma leptin, adiponectin, and IL-17 predict insulin resistance. Methods and Study Design: The study participants were 69 obese–overweight boys, 53 obese–overweight girls, 59 non-obese boys, and 50 non-obese girls aged 15–18 years. Insulin resistance was determined using the homeostatic model assessment of insulin resistance index. Plasma IL-17, leptin, and adiponectin were measured using ELISA. Data were analysed using one-way ANOVA and linear regression analysis. Odd ratios [ORs; 95% confidence intervals (CIs)] were analysed to estimate the risk of insulin resistance; the significance level was set at 95%. Result: The OR (95% CI) for insulin resistance was higher in obese–overweight boys than in obese–overweight girls. The plasma IL-17 was higher in boys, whereas plasma adiponectin and leptin were significantly higher in girls. In all participants, obesity status and plasma leptin were the most efficient predictors of insulin resistance, whereas the IL-17 could not significantly predict insulin resistance. Conclusion: Sexual dimorphism exists in IL17 as well as leptin and adiponectin in adolescents. Plasma IL-17 cannot be used to predict insulin resistance in adolescents of both sex.

Cooling of cooked starch is known to cause starch retrogradation which increases resistant starch content. This study aimed to determine the effect of cooling of cooked white rice on resistant starch content and glycemic response in healthy subjects. Resistant starch contents were analyzed on freshly cooked white rice (control rice), cooked white rice cooled for 10 hours at room temperature (test rice I), and cooked white rice cooled for 24 hours at 4°C then reheated (test rice II). The results showed that resistant starch contents in control rice, test rice I, and test rice II were 0.64 g/100 g, 1.30 g/100 g, and 1.65 g/100 g, respectively. Test rice II had higher resistant starch content than test rice I, hence used in the clinical study along with control rice to characterize glycemic response in 15 healthy adults. The clinical study was a randomized, single-blind crossover study. In the clinical study, test rice II significantly lowered glycemic response compared with control rice (125±50.1 vs 152±48.3 mmol.min/L, respectively; p=0.047). In conclusion, cooling of cooked white rice increased resistant starch content. Cooked white rice cooled for 24 hours at 4°C then reheated lowered glycemic response compared with freshly cooked white rice.

Lactose is the main carbohydrate in infant feeding, but its impact decreases as the child gets older and consumes less milk and dairy products. Congenital lactose intolerance is a very rare condition. However, lactase activity may be low and need to mature during the first weeks of life in many infants. However, the evidence that unabsorbed lactose is causing infantile crying and colic is contradictory. Unabsorbed lactose has a bifidogenic effect and improves calcium absorption. Lactose malabsorption may occur secondary and thus temporally to other etiologies such as infectious gastroenteritis, cow’s milk allergy and celiac disease. One the cause is treated, lactase activity will gradually return to normal. The vast majority of Asian children will develop late onset congenital lactase deficiency. However, this entity only exceptionally causes symptoms before the age of 4-5 years. Symptoms are abdominal cramps, flatulence and watery, acid stools, and decrease the quality of life but lactose intolerance is not associated with “true disease”. The diagnosis is made on clinical grounds and confirmed with a lactose breath test, if needed. These patients need to have a lifetime long reduced lactose intake to improve their quality of life.

The concept of lactose intolerance has become embedded in Western medicine and developing economy medicine. It is based on evidence that intestinal lactase activity persists into later childhood and throughout life in only a minority of the world’s population, notably northern European–derived populations. These people have the T single nucleotide polymorphism (SNP) of the rs49882359 allele (C/T), also known as C/T-13910, the MCM6 gene which positively influences the lactase LCT gene. Other lactase persistent (LP) populations are found in Africa and the Middle East with different genetic variants. These SNPs represent co-evolution with dairying since the agricultural revolution and nutrient-dependent ecological adaptation. That said, gastrointestinal symptoms considered due to small intestinal lactose malabsorption are poorly correlated with lactase non-persistence (LNP), the situation for most people. With LNP, colonic microbiome lactase enables lactose fermentation to occur so that none is found in faeces. Whether the short chain fatty acids (SCFAs) and gases (hydrogen, carbon dioxide and methane) produced cause symptoms is dose-dependent. Up to 25 g of lactose at any one time can usually be consumed by a LNP person, but its food and meal pattern context, the microbiomic characteristics, age and other factors may alter tolerance. Thus, the notion that lactose intolerance is a disorder or disease of LNP people is misplaced and has been one of cultural perspective. What actually matters is whether a particular dairy product as normally consumed give rise to symptoms. It is, therefore, proposed that lactose tolerance tests be replaced with dairy food tolerance tests.

Lactose handling by the human gut by most people, beyond being breast-fed, has been considered a disorder rather than physiological. A non-human mammalian milk source is novel for the majority. During the first 6 months of life, when neonates and infants are best breast-fed, lactose along with other macronutrients, provides energy, but may have other functions as well. At birth, babies are endowed with their mother’s vaginal microbiome, but not if they are born by Caesarean section. How much maternal milk lactose survives the infant’s small intestine and is processed by this unique gut microbiome and to what end is still uncertain, but no lactose or galactose appears in the faeces. Once intestinal lactase activity declines in most infants, lactose may enhance innate immunity through the cathelicidin antimicrobial peptide (CAMP), which is best achieved by lactose synergy with other colonic fermentation metabolites such as butyrate. It is of interest whether this lactose function or a variant of it persists. It might not be evident when lactase is persistent, as it is in most people of northern European ancestry. Population genomics indicate that lactase persistence became prevalent only about 3000-1000 BC, the Bronze Age of Eurasia. Gastrointestinal symptoms (GIS) in lactase nonpersisters who consume dairy foods are partly dose dependent and not usually evident with single lactose intakes ?25 g per day. Spreading intake across the day reduces the risk as can various dietary patterns. Nevertheless, individual differences in GIS lactose sensitivity may merit public health and clinical consideration.

Indonesia is the largest archipelago blessed with one of the richest mega-biodiversities and also home to one of the most diverse cuisines and traditional fermented foods. There are 3 types of traditional dairy foods, namely the butter-like product minyak samin; yogurt-like product dadih; and cheese-like products dali or bagot in horbo, dangke, litsusu, and cologanti, which reflect the culture of dairy product consumption in Indonesia.

“Lactose intolerance (LI)” is considered a common problem in Asians, and in many parts of the world. Its prevalence and age of manifestation varies between by Asian country, for possible genetic or cultural reasons. Studies in Indonesian children 3-15 years old (y) are available within the past two decades, using a pure lactose tolerance test. The prevalences of lactose malabsorption (LM) in pre-elementary (3-5 y), elementary (6-11 y), and junior high (12-14 y) school-children were 21.3%, 57.8%, and 73%, respectively. An increasing trend for LM prevalence was seen within the pre-elementary group, from 9.1% at 3 y to 28.6% at 5 y. The most frequent symptoms of LI in junior high school (JHS) group were abdominal pain (64.1%), abdominal distention (22.6%), nausea (15.1%), flatulence (5.7%), and diarrhea (1.9%), mostly within one hour of lactose ingestion. In children with regular and irregular milk drinking, LM occurred in 81.2% and 69.6%; LI was found in 56.2% and 52.1%, respectively. Most JHS children with dairy-associated recurrent abdominal pain (RAP) symptoms proved to be malabsorbers. Dairy products most related to RAP were milk and yogurt. LI was found in 81% of RAP children with abdominal pain most frequently, followed by nausea, bloating, diarrhea, borborygmi, and flatulence. Symptom onset occurred 30 minutes after lactose ingestion, especially nausea, bloating, and abdominal pain. In RAP children LI symptoms mostly found in breath hydrogen concentration >20 ppm. More LI symptoms were found in lactose malabsorbers, but symptoms were mild and generally disappeared in 7 hours, and in most by 15 hours.

The health relevance of dairy products has mostly been judged by their abundant nutrients (protein, calcium and riboflavin) and recommendations for these derived in lactase-persistent Caucasian populations. Extrapolation to Asians who are generally lactase non-persisters may not be biologically, culturally or environmentally sound. A number of studies, especially among north-east Asians as in Taiwan, provide guidance for their optimal dairy intakes. In Taiwan, the NAHSIT (Nutrition and Health Surveys in Taiwan) linked to the National Health Insurance and Death Registry data bases provide most of the evidence. Cultural and socio-economic barriers create population resistance to increase dairy consumption beyond one serving per day as reflected in food balance sheet and repeat survey trend analyses. For the morbidity and mortality patterns principally seen in Asia, some, but not too much, dairy is to be preferred. This applies to all-cause and cardiovascular, especially stroke, mortality, to the risk of overfatness (by BMI and abdominal circumference) and diabetes and very likely to fracture and its sequelae. In Taiwan, there is no apparent association with total cancer mortality, but among Europeans, there may be protection. Historically, while fermented mammalian milks have been consumed in south Asia and various Asian subgroups and regions, most of the uptake of dairy in Asia after World War 2 has been from imported powdered milk or fresh liquid milk, encouraged further by the use of yogurts and popularization of milk teas and coffee. Asian dietary guidelines and clinical nutrition protocols need to encourage a modest, asymptomatic dairy intake.

The objective of this study was to evaluate the efficacy of multi-micronutrients (MMN) supplementation during preconception period on improving fetal survival and concentration of umbilical cord Insulin-like Growth Factor 1 (IGF-1). A randomized double blind community based trial had been conducted. Study subjects were randomly assigned into two groups (n = 210 in each group), namely multi-micronutrient group (MMN group) and placebo-iron folic acid group (Placebo-IFA group). The MMN group received capsule of multi-micronutrients containing 15 micronutrients every 2 days during preconception period (2-6 months before pregnancy) and to be continued with daily dose during pregnancy. Placebo-IFA group received placebo capsule every 2 days during preconception period (2-6 months before pregnancy) and to be continued with daily dose of iron and folic acid during pregnancy. Four hundred twenty eligible subjects were enrolled to meet approximately 115 babies born. The outcome variables were fetal survival and concentration of serum umbilical cord IGF-1. Data were analyzed using independent t-test to compare mean difference between MMN group and Placebo-IFA group and chi-square was used for dichotomous data to analyzed odd ratio. Results demonstrated significant difference of fetal survival (gestation age >37 weeks) between MMN group and Placebo-IFA group (p = 0.003). Fetuses in MMN group were more likely to survive than those in Placebo-IFA group (OR = 6,099; 95% CI: 0.934-39.847). Despite IGF-1 concentration of umbilical cord of neonates in MMN group was higher (23.6±16.2 ng mLG1) compare to those in Placebo-IFA group (15.8±17.3 ng mLG1) but it was not different significantly (p = 0.070). Furthermore, IGF-1 concentration of umbilical cord of male neonates (18.3±12.2 ng mLG1) was lower than that of female neonates (21.5±19.9 ng mLG1). These findings imply that MMN supplementation prior to pregnancy is very important to support intra uterine environment in early pregnancy for successful complete gestation period.

Current study aimed to determine the potency of germinated-soy milk (GSM) on Superoxide Dismutase (SOD) activity, and Malondialdehyde (MDA) and C-Reactive Protein (C-RP) levels in the blood plasma and skim milk of lactating mothers. Subjects were 50 lactating mothers, 20-35 years old, having newborns up to 6 months old, and willing to sign informed consent. Subjects were divided into two groups consisting of 25 women. Group I was treated with GSM, while group II was given placebo for two consecutive months. Samples of blood plasma and mother’s breast milk were taken 3 times at different times: 0, 1 and 2 months after intervention. Blood samples were taken intravenously using venoject tubes containing EDTA. The blood plasma and skim milk were used as test samples for activities of SOD, as well as the MDA and C-RP levels. Differences were considered significant at P<0.05. Results, GSM increased SOD activity in the blood plasma (P = 0.043), and also in skim milk (P = 0.56). On the other hand, level of MDA decreased in the blood plasma (P = 9.65E-06), and in skim milk (P = 0.047), and also the CRP reduced in the blood plasma (P = 0.0015), and in skim milk (P = 0.77). GSM could be used to reduce oxidative stress and suppress inflammatory levels of lactating mothers