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Past trends in nutritional status of urban children in southeast asia, and present changes in indonesia related to the socio-economic crisis
Werner Schultink, PhD
Deutsche Gesellschaft für Technische Zusammenarbeit, Eschborn, Germany
Peter Pritasari, MSc, Dwi Susilowati, PhD, Erica Wasito, MSc
The Regional SEAMEO-TROPMED Centre for Community Nutrition, University of Indonesia, Jakarta, Indonesia

S A J Clin Nutr 2000 February Vol. 13 No 1.

Past trends in nutritional status in urban areas
In recent years economic growth has been very rapid in many Southeast Asian countries. For example, in Indonesia and the Philippines the average gross national product per capita has approximately doubled in the past decade, and is now above US$ 1 000. 1 Vietnam is still at a lower level, but recently economic growth has been substantial. In association with this economic progress many changes have occurred. For example, life expectancy is increasing owing to improved health care and household food availability.

Another important change is progressing urbanisation; in many countries 30 - 50% of the population lives in urban areas. Compared with life in rural areas, life in the cities has advantages, such as better availability of health care and social services, and greater employment possibilities. On the other hand urbanisation is often characterised by pollution, crowding, infrastructure problems, and a disruption of traditional support and value systems.

In spite of the disadvantages of urban life, the average growth performance of urban children is better than that of most rural populations, indicating a better quality of life. The prevalence of stunting among a group of low-middle socio-economic class preschool children from Jakarta was 23%, whereas the prevalence among rural children from different locations in Indonesia varied between 33% (East-Java) and 69% (West-Kalimantan).2 This improved growth performance was probably related to economic growth over the past years, which is clearly associated with a secular trend in growth of urban children. Yap et al.3 showed that preschool boys in Singapore experienced significantly improved growth performance between 1973 and 1987. In 1987 Singapore boys grew almost the same as the NCHS reference population. A secular trend in growth was also observed in Hanoi, Vietnam.4 Although in 1995 boys from Hanoi still showed a significant difference in growth performance compared with the NCHS reference population, they grew about 15 - 20 cm taller at 9 years of age compared with boys in 1975. One may question whether growth performance of Southeast Asian children can be compared with the NCHS reference population. Droomers et al.5 reported that the height of a group of high socio-economic class preschool children from Jakarta was similar to the NCHS population. Average height-for-age z-score of these children (N = 168) was 0.24, indicating that preschool children of the elite in Jakarta grew as well as the NCHS reference children, and that the existing prevalence of stunting in urban areas was caused largely by environmental factors.

In spite of improvement in growth performance, micronutrient status of many urban preschoolers remains inadequate, as indicated by several studies. The prevalence of anaemia (haemoglobin < 11 g/dl) among a group of 575 preschoolers from Jakarta was about 27%, anaemia being most common among children younger than 2 years of age.6 With regard to urban preschool children, it can be concluded that in many Southeast Asian countries a positive secular trend was occurring, and that children from high socio-economic class families probably had a growth performance similar to that of the NCHS reference population. However, although the growth performance of urban children was better than that of their rural peers, the micronutrient status of a considerable part of the urban population remained inadequate.

Current situation in indonesia – the influence of the crisis
The positive trends in development have changed since 1998 in several Southeast Asian countries, not least Indonesia. Since the beginning of 1998 the Asian economic crisis has badly affected Indonesia. It developed into a wider political and social crisis, which led to the resignation of president Suharto in May 1998 after he had been in power for about 30 years. As a consequence of the crisis many factories closed down, leading to a decrease in job opportunities, and the prices of basic commodities increased steeply. By the beginning of 1999 the crisis had still not abated. One of the concerns is that the nutrition and health status of the lower income groups, especially in the large cities, may be seriously affected, and that the progress made over the past decades in improving nutrition and health will be negated. Therefore, an attempt has been made to assist the poor through the initiation of social safety net programmes, which include distribution of infant foods, provision of free medical services, initiation of food-for-work and other labour intensive employment programmes. However, data to objectively quantify the impact of the crisis on nutrition and health status remain scarce.S6

We report on repeated cross-sectional assessments of the nutrition situation of households with children under 5 years of age living in the eastern part of Jakarta. Since the measurements were taken before and after the start of the crisis the data give a good impression of the crisis impact.

Methodology of impact measurement
East Jakarta has approximately 1.7 million inhabitants and consists of 10 sub-districts which are divided into 65 village units. Cross-sectional surveys were carried out in April 1993, April 1998, and December 1998. Children under 5 and their mothers (Table I) were the main subjects of the surveys. For each survey, multi-staged random sampling was used to select households with children under the age of 60 months in each of the 10 sub-districts, and from 16 village units. Data on socio-economic status, food intake, environmental situation and nutritional status were collected using a pre-coded questionnaire and anthropometrical measurements. Data collection was carried out by MSc students enrolled in a postgraduate training programme on community nutrition. In each survey the same sampling and data collection methodology was used in the same village units.7 Anthropometric indicators for the preschoolers were calculated using the growth reference data of the National Centre for Health Statistics.8

Table I. Selected characteristics of parents

Influence of the crisis on nutritional status of jakarta preschoolers
In 1998 the percentage of mothers who had less than 3 years official education was reduced compared with 1993, and therefore the illiteracy rate in 1998 was lower than in 1993. In 1998 the percentage of surveyed fathers who were employed as civil servants or in the army was reduced compared with 1993. At the end of 1998 the percentage of fathers without occupation was still less than 5%, but tended to be slightly higher than in 1993 (4.4 % v. 2.0%). In December 1998 the number of fathers employed as lower-level industrial workers was reduced compared with April 1998.

In 1993, 14.4% of the non-pregnant women had a body mass index (BMI) below 18.5, which may indicate a chronic energy deficiency. This prevalence was similar in April 1998 at 13.2%, and 14.5% in December 1998.

The average age of the children was similar in the three surveys (Table II). The prevalence of stunting (growth retardation) tended to be lower in April 1998 than in 1993, whereas the prevalence of wasting and underweight was similar (Table III). In December 1998 the stunting rate was again similar to April 1993. The prevalence of wasting tended to be lower in December 1998 compared with the other two occasions. In all three surveys the prevalence of stunting and wasting was similar in boys and girls.

The stunting rate was lowest among children younger than 1 year of age (Table III). This can be expected because the nutritional requirements of a child can be covered by breastmilk milk until the age of 4 - 6 months, and breast-milk continues to play an important role afterwards since the majority of mothers breast-feed for at least 12 months (69% in both 1993 and 1998). The stunting rate generally increases sharply among children aged 12 - 24 months, which indicates the inadequate feeding of these younger children. After reaching 1 year of age children still need to be fed more than three times per day, and although the relative requirements are less than those of a child aged 6 -12 months, inadequate food in terms of quality and/or quantity will lead to growth retardation. It is likely that the process of growth retardation already starts after the children reach the age of 6 months, since from that age onwards other food besides breast-milk is needed to cover nutritional requirements.

Table IV indicates that the prevalence of diarrhoea in 1998 was higher than in 1993. The occurrrence of respiratory infections among the surveyed children did not vary between the surveys.

Food intake changed during the crisis, as shown in Table V. Rice remained the main staple food, but the consumption of other staple foods such as bread and noodles became less frequent.

Compared with the results of April 1993 and 1998, in December 1998 the percentage of households consuming eggs, milk, and green leafy vegetables at least once a day was markedly reduced. In April 1998, for example, 44.1% of households stated to consume eggs at least once a day, wheras in December 1998 daily egg consumption occurred in 22.2% if the questioned households. In 1993, 27.6% of households consumed milk less than once a month, whereas in December 1998 this percentage had increased to 56.4%. Poultry was also less frequently consumed by the end of 1998. In April 1993 about 60% of the questioned households started to consume poultry at least once per week, whereas this rate was reduced to 43.0% in April 1998 and dropped further to 31.9% in December 1998. More than 70% of the households consumed tahu and/or tempeh on a daily basis in December 1998. Vegetable consumption became less varied and was more restricted to green leafy vegetables.

Table II. Prevalence of stunting, wasting and underweigh preschoolers*

Table III. Prevalence of stunting (%) among preschoolers according to age categories

Table IV. Prevalence (%) of diarrhoea and respiratory infections among preschoolers

Table V. Distribution of the frequency with which households* consumed selected foodstuffs (%)

Conclusion
The percentage of fathers without occupation at the end of 1998 was less than 5%; not a significant increase compared with 1993. This could have been because fathers were successful in keeping or finding some form of employment in spite of the crisis. It should, however, be realised that the answers may not have been completely truthful and that in fact more fathers may have been unemployed or only partially employed. Furthermore, their income may have been relatively low, especially those who worked as unskilled labourers or small scale vendors.

The crisis was associated with a clear negative shift in food consumption. The intake of foods providing minerals and vitamins of high quality which can be well absorbed by the body such as milk, eggs, and poultry decreased markedly. The daily diet of the surveyed population appears to have become less varied and more monotonous. The frequent consumption of tahu and/or tempeh is encouraging because it is a good source of high quality protein.

The percentage of growth retarded children (stunting) was similar in 1993 and December 1998. Growth retardation is a result of combined chronic inadequate food intake and/or frequent episodes of infectious diseases which can be considered an indicator of poor living conditions. The fact that in December 1998 the percentage of growth retarded children was similar to 1993 suggests that during the past 5 years no real improvement in living conditions had occurred, or that eventual improvements were only small and already negated by the crisis. The relatively high percentage of stunted children in December 1998 in the age category 24 - 60 months is in line with the data on the food intake of the households. For adequate growth children need good quality foods such as eggs, milk, poultry and vegetables, and the consumption of these foods in particular has decreased.

It can be concluded that food intake of less well-to-do urban Jakarta households has deteriorated during the crisis, which will most probably (as suggested by the presented data) negatively affect nutrition and health status of the population as a whole, but especially that of young children.

Improvements in nutritional status that occurred during the years of economic growth may be completely reversed if the crisis continues.

References

1. United Nations Development Programme. Human Development Report 1994. Delhi, India: Oxford University Press, 1994. Gross R, Schultink W, Sastroamidjojo S. Stunting as an indicator for health and wealth: an Indonesian application. Nutrition Research 1996; 12: 1829-1837.
2. Yap MA, Lun KC, Lyen KR, Lam SL. Secular trend of growth in preschool children in Singapore. Asian Pacific Journal of Clinical Nutrition 1994; 3: 61-64.
3. Hop LT, Gross R, Giay T, Schultink W, Thuan BTN, Sastroamidjojo S. Longitudinal observation of growth of Vietnamese children in Hanoi, Vietnam from birth to 10 years of age. Eur J Clin Nutr 1997; 51:164-171.
4. Droomers M, Gross R, Schultink W, Sastroamidjojo S. High socioeconomic class preschool children from Jakarta, Indonesia are taller and heavier than NCHS reference population. Eur J Clin Nutr 1995; 49: 740-744.
5. Gross R, Kielmann A, Korte R, Schoeneberger H, Schultink W. Handbook on Nutritional Baseline Surveys. Bangkok: SEAMEO/GTZ,1997.
6. Gross R, Kielmann A, Korte R, Schoeneberger H, Schultink W. Guidelines for Nutrition Baseline Surveys in Communities. Bangkok: SEAMEO-GTZ, 1997.
7. National Center for Health Statistics. NCHS growth curves for children, birth - 18 years, United States. Washington, DC: US Department of Health, Education and Welfare, 1977.