Plant protein consumption is associated with body mass index among women of reproductive age in Indonesia.

Introduction: One of the known determinants of obesity in Southeast Asia countries, including Indonesia, is the nutritional transition, which is indicated by fast changes in food production, dietary habits, and physical activity. With rising incomes, plant protein from grains, tubers, and legumes is gradually being replaced by animal protein from poultry, eggs, dairy, and red meat. This change is identified as a protein transition. Different choices of protein sources in the diet have varying health effects. However, there is limited information on the Asian population on the role of protein consumption on the increasing obesity prevalence. Therefore, this study aimed to investigate the association of protein sources consumption with body mass index (BMI) among women of reproductive age in Indonesia. Methods: This study used secondary data from the 2018 Indonesia Food Barometer (IFB) conducted using a quantitative cross-sectional survey. A total of 467 Indonesian reproductive-aged women (20-49 years) were included in this study. Dietary intake, including protein consumption, was obtained using 24-h dietary recall. Multiple linear regression was applied to find the association of protein consumption with BMI with a p-value <0.05 considered as a significant outcome variable. Results: The Mean BMI was 25.02 kg/m2, median of animal and plant protein was 28.01 g/day and 25.37 g/day, respectively. Consumption of plant protein was significantly associated with BMI after adjusting for marital status and age (p-value = 0.043; R2 = 0.080). The quality of plant protein should be considered to prevent obesity problems among women of reproductive age.

Breakfast Consumption and Quality of Macro- and Micronutrient Intake in Indonesia: A Study from the Indonesian Food Barometer.

Breakfast is an important meal that has been shown to have a positive effect on health. The current study aimed to assess the patterns of breakfast consumption among adult Indonesians and to estimate the contribution of breakfast to their nutrient intake and dietary quality. The study used 24-h recall data from the 2018 Indonesian Food Barometer study to assess breakfast intake among 1333 adults aged 18 and above from six provinces in Indonesia. Diet quality was measured using the Nutrient Rich Food index (NRF) 9.3, and the nutritional profile of breakfast was compared across tertiles of NRF 9.3. In total, 5.2% of adults in Indonesia skipped breakfast. Breakfast contributed 26% to daily energy intakes and 22-28% to intakes of all reported nutrients, except for total sugar (12%), vitamin C (8%) and vitamin D (7%). With respect to daily requirements, breakfast contributed approximately 20% to energy, protein, fat and sodium requirements, 26% to saturated fat but <15% to the requirements for most micronutrients and only 5% for fiber. Among breakfast consumers, a higher NRF score was associated with higher daily intakes of protein, dietary fiber and micronutrients and lower intakes of sodium from breakfast. This study suggests that a balanced breakfast in Indonesia should aim to lower fat and saturated fat intake while increasing fiber, potassium, calcium and vitamin C and D intake. These findings could inform the development of nutrient-based guidelines for breakfast consumption in Indonesia.

Diversity of protein food sources, protein adequacy and amino acid profiles in Indonesia diets: Socio-Cultural Research in Protein Transition (SCRiPT).

The ongoing nutrition transition in lower- and middle-income countries (LMIC) in South East Asia may have a positive impact on protein nutrition. This study assessed the diversity of plant and animal protein food sources in relation to essential amino acid (EAA) adequacy in a population-based sample (N 1665) in Indonesia. Dietary intakes from in-person 24 h recalls provided data on energy and protein intakes (in g/d) from plants (grains, legumes), meat, poultry and fish, and eggs and dairy. Protein diversity scores were based on the number of protein food sources over 24 h. EAA scores were the ratio of amino acid intakes to recommended values. Protein diversity and EAA scores were then compared across multiple socio-demographic indices. Analysis of variance and χ 2 tests were used to test for differences among groups. Energy intakes were 1678 kcal/d for men and 1435 kcal/d for women. Average protein intakes (and prevalence of inadequacy) were 59⋅4 g/d (41⋅7 %) for men and 51⋅5 g/d (51⋅1 %) for women. In regression analyses, higher protein diversity scores were associated with higher protein intakes, more animal protein and less plant protein and with higher EAA scores. Lower protein diversity scores were associated with lower intakes of lysine, leucine and valine relative to requirements, as well as with lower EAA, rural settings, less wealth and less modernisation. Greater diversity of animal protein food sources, observed among groups of higher socio-economic status, was linked to better amino acid adequacy and protein nutrition.

Prevalence of multiple non-communicable diseases risk factors among adolescents in 140 countries: A population-based study.

Background: Modifiable non-communicable disease (NCD) risk factors are becoming increasingly common among adolescents, with clustering of these risk factors in individuals of particular concern. The aim of this study was to assess global status of clustering of common modifiable NCD risk factors among adolescents. Methods: We used latest available data from nationally representative survey for 140 countries, namely the Global School-based Student Health Survey, the Health Behaviour in School-Aged Children and the longitudinal study of Australian Children. Weighted mean estimates of prevalence with corresponding 95% confidence intervals of nine NCD risk factors - physical inactivity, sedentary behaviour, insufficient fruits and vegetable consumption, carbonated soft drink consumption, fast food consumption, tobacco use, alcohol consumption and overweight/obesity - were calculated by country, region and sex. Findings: Over 487,565 adolescents, aged 11-17 years, were included in this study. According to trend analysis, prevalence of four or more NCD risk factors increased gradually over time. Prevalence of four or more NCD risk factors was 14.8% in 2003-2007 and increased to 44% in 2013-2017, an approximately three-fold increase (44.0%). Similar trends were also observed for three and two risk factors. Large variation between countries in the prevalence of adolescents with four or more risk factors was found in all regions. The country level range was higher in the South-East Asia Region (minimum Sri Lanka = 8%, maximum Myanmar = 84%) than Western Pacific Region (minimum China = 3%, maximum Niue = 72%), European Region (minimum Sweden = 13.9%, maximum Ireland = 66.0%), African Region (minimum Senegal = 0.8%, maximum Uganda = 82.1%) and Eastern Mediterranean Region (minimum Libya = 0.2%, maximum Lebanon = 80.2%). Insufficient vegetable consumption, insufficient fruit consumption and physically inactivity were three of the four most prevalent risk factors in all regions. Interpretation: Our results suggest a high prevalence of four or more NCD risk factors in adolescents globally, although variation was found between countries. Results from our study indicate that efforts to reduce adolescent NCD risk factors and the associated health burden need to be improved. These findings can assist policy makers to target the rollout of country- specific interventions. Funding: None.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta.

BACKGROUND: Childhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia. METHODS: A qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students. RESULTS: Among the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited. CONCLUSIONS: This study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

Animal and Plant Protein Food Sources in Indonesia Differ Across Socio-Demographic Groups: Socio-Cultural Research in Protein Transition in Indonesia and Malaysia.

BACKGROUND: Plant-based diets in lower-income countries are often associated with inadequate protein nutrition and adverse health outcomes. OBJECTIVE: To examine the diversity of protein food sources, in both animal and plant, across diverse socio-demographic groups in Indonesia as compared to Malaysia. DESIGN: The SCRiPT (Socio Cultural Research in Protein Transition) study was based on population-based samples recruited in Indonesia (N = 1665) and in Malaysia (N = 1604). Data from 24-h in-person dietary recalls in each country were used to construct the frequency counts of protein sources by food group. Protein sources were defined as fish, poultry, red meat (beef, pork, and mutton), eggs, dairy, and plants (cereals, pulses, and tubers). The percent reported frequencies for animal and plant proteins were compared across socio-demographic strata and by country. Analyses were based on one-way Anovas and general linear model regressions adjusting for covariates. RESULTS: Animal protein frequency counts were 34% of total in Indonesia, but 50% in Malaysia's. Higher reported consumption frequencies for poultry and red meat in both countries were associated with urban living, greater modernization, and higher socioeconomic status, with stronger social gradients observed in Indonesia. Reported fish consumption was higher in Indonesia than in Malaysia. Fish was more likely to be listed by rural island populations in Indonesia and was associated with lower education and incomes. Consumption frequencies for plant-based proteins were associated with lower socio-economic status in Indonesia and in Malaysia. CONCLUSIONS: More affluent groups in both countries reported higher frequencies for meat, eggs, and dairy as opposed to fish. Greater economic development in Southeast (SE) Asia is associated with more animal protein, particularly from poultry, which may displace fish, the traditional source of high quality protein for the region.

Socio-Cultural and Economic Drivers of Plant and Animal Protein Consumption in Malaysia: The SCRiPT Study.

Countries in South East Asia are undergoing a nutrition transition, which typically involves a dietary shift from plant to animal proteins. To explore the main drivers of protein consumption, the SCRiPT (Socio Cultural Research in Protein Transition) study recruited a population sample in Malaysia (N = 1604). Participants completed in-person 24 h dietary recalls and socio-demographic surveys. Energy and nutrient intakes were estimated using Nutritionist Pro. A novel recipe-based frequency count coded protein sources as meat (chicken, beef, pork, and mutton), fish, eggs, dairy, and plants (cereals, pulses, tubers). Dietary intakes and frequencies were examined by gender, age, income, education, ethnicity, religion, and family status, using ANOVAs and general linear models. Energy intakes were 1869 kcal/d for men and 1699 kcal/d for women. Protein intakes were 78.5 g/d for men and 72.5 g/d for women. Higher energy and protein intakes were associated with Chinese ethnicity, higher education and incomes. Frequency counts identified plant proteins in 50% of foods, followed by meat (19%), fish (12%), eggs (12%), and dairy (7%). Most frequent source of meat was chicken (16%) rather than pork or beef (1.5% each). In bivariate analyses, animal protein counts were associated with younger age, higher education and incomes. In mutually adjusted multivariate regression models, animal proteins were associated with education and ethnicity; plant proteins were associated with ethnicity and religion. Protein choices in Malaysia involve socio-cultural as well as economic variables.

Inadequate dietary α-linolenic acid intake among Indonesian pregnant women is associated with lower newborn weights in urban Jakarta.

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 α-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 α-linolenic acid was lower than the recommended dietary intake. The newborns of mothers with an α-linolenic acid intake lower than 0.82 g/d had a significantly lower (ß=114, 95% confidence interval=-216, -13.5; p=0.014) weight compared with those of mothers with high α-linolenic acid intake, after adjustment for confounding factors. CONCLUSION: Inadequate maternal intake of α-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.

Development and evaluation of a semiquantitative food frequency questionnaire for estimating omega-3 and omega-6 fatty acid intakes in Indonesian children.

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, α-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.

A social cognitive theory-based programme for eating patterns and sedentary activity among overweight adolescents in Makassar, South Sulawesi : a cluster randomised controlled trial.

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.

Food Store Choice Among Urban Slum Women Is Associated With Consumption of Energy-Dense Food.

The aim of this study was to examine the associations of food store choice with food consumption among urban slum women. A cross-sectional survey was carried out among 188 urban slum women (19-50 years old) in Jakarta, Indonesia. A semiquantitative food frequency questionnaire was used to assess food consumption. Associations between food consumption and food store choice were tested by linear regression. This study found that frequencies of buying food from small shops (warung), street food vendors, and modern food stores were significantly associated with consumption of snacks, mixed dishes, and fruit respectively. In addition, buying food from traditional markets and small cafes (warung makan) was not significantly associated with particular types of food consumption. As modern food stores are rarely utilized by these women, small shops (warung) and street food vendors are likely to be important channels to improve slum dwellers' diet.

Role of family support and women's knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in Indonesia.

OBJECTIVE: To examine whether women's knowledge of pregnancy-related risks and family support received during pregnancy are associated with adherence to maternal iron-folic acid (IFA) supplementation. DESIGN: Secondary data analysis of the 2002-03, 2007 and 2012 Indonesia Demographic and Health Survey. Analysis of the association between factors associated with adherence (consuming ≥90 IFA tablets), including the women's knowledge and family support, was performed using multivariate logistic regression. SETTING: National household survey. SUBJECTS: Women (n 19 133) who had given birth within 2 years prior to the interview date. RESULTS: Knowledge of pregnancy-related risks was associated with increased adherence to IFA supplementation (adjusted OR=1·8; 95 % CI 1·6, 2·0), as was full family (particularly husband's) support (adjusted OR=1·9; 95 % CI 1·6, 2·3). Adequate antenatal care (ANC) visits (i.e. four or more) was associated with increased adherence (adjusted OR=2·2; 95 % CI 2·0, 2·4). However, ANC providers missed opportunities to distribute tablets and information, as among women with adequate ANC visits, 15 % reported never having received/bought any IFA tablets and 30 % had no knowledge of pregnancy-related risks. A significant interaction was observed between family support and the women's educational level in predicting adherence. Family support significantly increased the adherence among women with <9 years of education. CONCLUSIONS: Improving women's knowledge of pregnancy-related risks and involving family members, particularly the husband and importantly for less-educated women, improved adherence to IFA supplementation. ANC visit opportunities must be optimized to provide women with sufficient numbers of IFA tablets along with health information (especially on pregnancy-related risks) and partner support counselling.

Dietary patterns of obese and normal-weight women of reproductive age in urban slum areas in Central Jakarta.

Developing countries including Indonesia imperatively require an understanding of factors leading to the emerging problem of obesity, especially within low socio-economic groups, whose dietary pattern may contribute to obesity. In this cross-sectional study, we compared the dietary patterns and food consumption of 103 obese and 104 normal-weight women of reproductive age (19-49 years) in urban slum areas in Central Jakarta. A single 24-h food recall was used to assess energy and macronutrient intakes (carbohydrate, protein and fat) and calculate energy density. A principal component analysis was used to define the dietary patterns from the FFQ. Obese women had significantly higher intakes of energy (8436·6 (sd 2358·1) v. 7504·4 (sd 1887·8) kJ (2016·4 (sd 563·6) v. 1793·6 (sd 451·2) kcal)), carbohydrate (263·9 (sd 77·0) v. 237·6 (sd 63·0) g) and fat (83·11 (sd 31·3) v. 70·2 (sd 26·1) g) compared with normal-weight women; however, their protein intake (59·4 (sd 19·1) v. 55·9 (sd 18·5) g) and energy density (8·911 (sd 2·30) v. 8·58 (sd 1·88) kJ/g (2·13 (sd 0·55) v. 2·05 (sd 0·45) kcal/g)) did not differ significantly. Two dietary patterns were revealed and subjectively named 'more healthy' and 'less healthy'. The 'less healthy' pattern was characterised by the consumption of fried foods (snacks, soyabean and roots and tubers) and meat and poultry products, whereas the more healthy pattern was characterised by the consumption of seafood, vegetables, eggs, milk and milk products and non-fried snacks. Subjects with a high score for the more healthy pattern had a lower obesity risk compared with those with a low score. Thus, obesity is associated with high energy intake and unhealthy dietary patterns characterised by consumption of oils and fats through fried foods and snacks.

Will iron supplementation given during menstruation improve iron status better than weekly supplementation?

To investigate the efficacy of two different iron supplements administered either on a weekly basis or during menstruation, a 16-week community experimental study was carried out among postmenarcheal female adolescent students in Kupang, East Nusa Tenggara, Indonesia. Forty eight students received a placebo tablet weekly, 48 other students got an iron tablet weekly and 41 students took an iron tablet for four consecutive days during their menstruation cycle. All subjects were given deworming tablets before supplementation. Haemoglobin, serum ferritin, height, weight, mid-upper arm circumference and dietary intake were assessed before and after intervention. The supplementation contributed to a significant improvement in the iron status of the intervention groups compared to the placebo group (P < 0.05). In the menstruation group, the haemoglobin concentrations of the anaemic subjects improved significantly (P < 0.05) while for the non-anaemic subjects, serum ferritin concentrations also increased significantly (P < 0.05). In the weekly group for anaemic and nonanaemic subjects, there was a significant increase in both haemoglobin and serum ferritin concentrations (P < 0.05). This study revealed that weekly supplementation of iron tablets continued for 16 weeks contributed a higher improvement to haemoglobin concentration, compared with supplementing iron tablets for four consecutive days during menstruation for four menstrual cycles. This suggests that weekly iron supplementation is preferable.