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Nutrition transition and the double burden of malnutrition in Indonesia: a mixed method approach exploring social and contextual determinants of malnutrition
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction

Nutrition transition concerns the broad changes in the human diet that have occurred over time and space. In low- to middle-income countries such as Indonesia, nutrient transition describes shifts from traditional diets high in cereal and fibre towards Western pattern diets high in sugars, fat, and animal-source foods. This causes a swift increase in the prevalence of overweight and obesity while undernutrition remains a great public health concern. Thus a double burden of malnutrition occurs in the population. The main aim of this investigation was to explore social and contextual determinants of malnutrition in Indonesia. The specific objectives were: (i) to examine body mass index (BMI) changes at the population level, and between and within socioeconomic groups; (ii) to estimate which context (i.e., household or district) has a greater effect on the variation of BMI; (iii) to assess the prevalence of double burden households (defined as the coexistence of underweight and overweight individuals residing in the same household) and its variation among communities as well as its determining factors; and (iv) to explore and understand what contributes to a double burden of malnutrition within a household by focusing on gender relations.

Methods

A mixed method approach was adopted in this study. For the quantitative analyses, nationally representative repeated cross-sectional survey data from four Indonesian Family Life Surveys (IFLS; 1993, 1997, 2000, 2007) were used. The IFLS contains information about individual-level, household-level and area-level characteristics. The analyses covered single and multilevel regressions. Data for the qualitative component were collected from sixteen focus group discussions conducted in Central Java and in the capital city Jakarta among 123 rural and urban men and women. Connell’s relational theory of gender and Charmaz’s constructive grounded theory were used to analyse the qualitative data.

Results

Greater increases in BMI were observed at higher percentiles compared to the segment of the population at lower percentiles. While inequalities in mean BMI decreased between socioeconomic groups, within group dispersion increased over time. Households were identified as an important social context in which the variation of BMI increased over time. Ignoring the household level did not change the relative variance contribution of districts on BMI in the contextual analysis. Approximately one-fifth of all households exhibited a double burden of malnutrition. Living in households with a higher socioeconomic status resulted in higher odds of double burden of malnutrition with the exception of women-headed households and communities with high social capital. The qualitative analysis resulted in the construction of three categories: capturing the significance of gendered power relations, the emerging obesogenic environment, and generational relations for child malnutrition.

Conclusion

At the population level, greater increases in within-group inequalities imply that growing inequalities in BMI were not merely driven by socioeconomic factors. This suggests that other under-recognised social and contextual factors may have a greater effect on the variation in BMI. At the contextual level, recognition of increased variation among households is important for creating strategies that respond to the differential needs of individuals within the same household. At the household level, women’s empowerment and community social capital should be promoted to reduce inequalities in the double burden of malnutrition across different socioeconomic groups. Ultimately community health and nutrition programmes will need to address gender empowerment and engage men in the fight against the emerging obesogenic environment and increased malnutrition that is evident within households, especially overweight and obesity among children.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2017. , 100 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1873
Keyword [en]
Double burden of malnutrition, Child obesity, Body Mass Index, Gender relations, Social capital, Multilevel modelling, Grounded theory, Indonesian Family Life Surveys, Indonesia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-130552ISBN: 978-91-7601-637-4 (print)OAI: oai:DiVA.org:umu-130552DiVA: diva2:1067919
Public defence
2017-02-17, Sal 135 Allmänmedicin, Byggnad 9A, ingång X5, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2017-01-27 Created: 2017-01-23 Last updated: 2017-02-01Bibliographically approved
List of papers
1. The effect of gender and social capital on the dual burden of malnutrition: a multilevel study in indonesia
Open this publication in new window or tab >>The effect of gender and social capital on the dual burden of malnutrition: a multilevel study in indonesia
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2014 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 8, e103849- p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: The paradoxical phenomenon of the coexistence of overweight and underweight individuals in the same household, referred to as the "dual burden of malnutrition", is a growing nutrition dilemma in low- and middle-income countries (LMICs).

AIMS: The objectives of this study were (i) to examine the extent of the dual burden of malnutrition across different provinces in Indonesia and (ii) to determine how gender, community social capital, place of residency and other socio-economic factors affect the prevalence of the dual burden of malnutrition.

METHODS: The current study utilized data from the fourth wave of the Indonesian Family Life Survey (IFLS) conducted between November 2007 and April 2008. The dataset contains information from 12,048 households and 45,306 individuals of all ages. This study focused on households with individuals over two years old. To account for the multilevel nature of the data, a multilevel multiple logistic regression was conducted.

RESULTS: Approximately one-fifth of all households in Indonesia exhibited the dual burden of malnutrition, which was more prevalent among male-headed households, households with a high Socio-economic status (SES), and households in urban areas. Minimal variation in the dual burden of malnutrition was explained by the community level differences (<4%). Living in households with a higher SES resulted in higher odds of the dual burden of malnutrition but not among female-headed households and communities with the highest social capital.

CONCLUSION: To improve household health and reduce the inequality across different SES groups, this study emphasizes the inclusion of women's empowerment and community social capital into intervention programs addressing the dual burden of malnutrition.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-92535 (URN)10.1371/journal.pone.0103849 (DOI)000340952200010 ()25153321 (PubMedID)
Available from: 2014-08-27 Created: 2014-08-27 Last updated: 2017-01-24Bibliographically approved
2. Households, the omitted level in contextual analysis: disentangling the relative influence of households and districts on the variation of BMI about two decades in Indonesia
Open this publication in new window or tab >>Households, the omitted level in contextual analysis: disentangling the relative influence of households and districts on the variation of BMI about two decades in Indonesia
2016 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 15, 102Article in journal (Refereed) Published
Abstract [en]

Background: Most of the research investigating the effect of social context on individual health outcomes has interpreted context in terms of the residential environment. In these studies, individuals are nested within their neighbourhoods or communities, disregarding the intermediate household level that lies between individuals and their residential environment. Households are an important determinant of health yet they are rarely included at the contextual level in research examining association between body mass index (BMI) and the social determinants of health. In this study, our main aim was to provide a methodological demonstration of multilevel analysis, which disentangles the simultaneous effects of households and districts as well as their associated predictors on BMI over time.

Methods: Using both two- and three-level multilevel analysis, we utilized data from all four cross-sections of the Indonesian Family life Survey (IFLS) 1993 to 2007-8.

Results: We found that: (i) the variation in BMI attributable to districts decreased from 4.3 % in 1993 to 1.5 % in 1997-98, and remained constant until 2007-08, while there was an alarming increase in the variation of BMI attributable to households, from 10 % in 2000 to 15 % in 2007-08; (ii) ignoring the household level did not change the relative variance contribution of districts on BMI, but ignoring the district level resulted in overestimation of household effects, and (iii) households' characteristics (socioeconomic status, size, and place of residence) did not attenuate the variation of BMI at the household-level.

Conclusions: Estimating the relative importance of multiple social settings allows us to better understand and unpack the variation in clustered or hieratical data in order to make valid and robust inferences. Our findings will help direct investment of limited public health resources to the appropriate context in order to reduce health risk (variation in BMI) and promote population health.

Keyword
Body mass index, Multilevel modelling, Omitted level, Contextual effect, Households, Indonesian family life survey
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-124508 (URN)10.1186/s12939-016-0388-7 (DOI)000380105800001 ()27388459 (PubMedID)
Available from: 2016-08-22 Created: 2016-08-15 Last updated: 2017-01-24Bibliographically approved
3. Inter-individual inequality in BMI: an analysis of Indonesian Family LifeSurveys (1993–2007)
Open this publication in new window or tab >>Inter-individual inequality in BMI: an analysis of Indonesian Family LifeSurveys (1993–2007)
2016 (English)In: SSM - Population Health, ISSN 2352-8273, Vol. 2, 876-888 p.Article in journal (Refereed) Published
Abstract [en]

Widening inequalities in mean Body Mass Index (BMI) between social and economic groups are well documented. However, whether changes in mean BMI are followed by changes in dispersion (or variance) and whether these inequalities are also occurring within social groups or across individuals remain understudied. In addition, a substantial body of literature exists on the global increase in mean BMI and prevalence of overweight and obesity. However, whether this weight gain is shared proportionately across the whole spectrum of BMI distribution, also remains understudied. We examined changes in the distribution of BMI at the population level over time to understand how changes in the dispersion reflect between-group compared to within-group inequalities in weight gain. Moreover, we investigated the entire distribution of BMI to determine in which percentiles the most weight gain is occurring over time. Utilizing four waves (from 1993 to 2007) of Indonesian Family Life Surveys (IFLS), we estimated changes in the mean and the variance of BMI over time and across various socioeconomic groups based on education and households’ expenditure per capita in 53,648 men and women aged 20–50 years. An increase in mean and standard deviation was observed among men (by 4.3% and 25%, respectively) and women (by 7.3% and 20%, respectively) over time. Quantile-Quantile plots showed that higher percentiles had greater increases in BMI compared to the segment of the population at lower percentiles. While between socioeconomic group differences decreased over time, within-group differences increased and were more prominent among individuals with poor education and lower per capita expenditures. Population changes in BMI cannot be fully described by average trends or single parameters such as the mean BMI. Moreover, greater increases in within-group dispersion compared with between-group differences imply that growing inequalities are not merely driven by these socioeconomic factors at the population level.

Place, publisher, year, edition, pages
Elsevier, 2016
Keyword
Body mass index, Distributional change, Health inequalities Obesity, Socioeconomic status, Indonesian Family Life Survey
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-130558 (URN)10.1016/j.ssmph.2016.09.013 (DOI)
Available from: 2017-01-23 Created: 2017-01-23 Last updated: 2017-01-24Bibliographically approved
4. Concerned and conscious, but defenceless: the intersection of gender and generation in child malnutrition in Indonesia: A qualitative grounded theory study
Open this publication in new window or tab >>Concerned and conscious, but defenceless: the intersection of gender and generation in child malnutrition in Indonesia: A qualitative grounded theory study
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(English)Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-130559 (URN)
Available from: 2017-01-23 Created: 2017-01-23 Last updated: 2017-01-26

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