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24 Jan_Gindo_Keynotes Speach.pdf
1. Spatial disparity in nutrition challenges in Indonesia
Gindo Tampubolon -University of Manchester
United Nations University – Helsinki
Jakarta, 24 Jan 2023
2. DOUBLE BURDEN OF MALNUTRITION
Some consequences on productivity and health across the life course
3. Double burden of
malnutrition in
Indonesia (World
Bank 2015)
Stunting in childhood can
reduce a person’s
productivity as an adult, and
increase risks of non-
communicable diseases at
older age
4.
5. Hanandita &
Tampubolon 2015.
The double burden of
malnutrition in
Indonesia: social
determinants and
geographical
variations. Soc Sci
Med – Population
Health
6. Biological consequences of malnutrition
“Shortness is not the real problem, other processes in the body
are also stunted, such as brain development which affects
intelligence.”
– Prof. Dr. Endang Achadi (Nutrition, University of Indonesia)
7. Manifest consequences of malnutrition
• Stunting reduces IQ scores by 5-11 points
• Stunting children receive lower grades in school
• Stunting reduces earning ten percent in a lifetime
• Children born with low weight are 2.6 times less
likely to attend higher education or graduate
8. Consequences of malnutrition (continued)
• Losses due to malnutrition are estimated to be 3% of Indonesia’s
gross domestic products (World Bank)
– Using Indonesia Family Life Survey of 22 yrs, my estimate is lower though
still considerable.
• “More cases of non-communicable diseases in Indonesia have
caused higher expenditure for the national health insurance. The
highest costs are for treatment of cardiovascular diseases.” Doddy
Izwardy, Ministry of Health.
• Non-communicable diseases, not infectious diseases, account for
60% of deaths.
11. The life course
• Stages in life are connected and consequential
• Gestation, childhood, adulthood and elderhood (old
age)
• Stunting in childhood is a famous case of life course
structuring of health
• Investigated using longitudinal or panel surveys
• Emerging evidence is the long arm of childhood
condition
• On episodic memory, sarcopenia and depression
• America, Britain plus 26 European countries
12. Tampubolon 2023. Childhood poverty,
epigenetic ageing, and late-life health in
America, Britain, and Europe. In Rasmus
Hoffmann (ed). Handbook of Health
Inequalities across the Life Course.
19. Mechanism
1. Under-nourished mother giving birth to malnourished,
low weight babies
2. Low weight babies grow up to be malnourished
(stunted or underweight) children up to ten years
3. Malnourished, stunted or underweight children,
become adults with lower IQ, less education, more
depression, less earnings
4. Summarised in GDP effect.
20. Materials
• Indonesia Family Life Survey waves 1, 4 & 5 (up to 22
years)
• Survei Sosial Ekonomi Nasional 2014 – 2019
21. Variable Mean Min Max Label
agemonth 60 1 120 Age in month
she .5 0 1 Sex, Female
expcat 1 5 Quint consumption per person 1993
stunted .15 0 1 Severely stunted, at -3SD
underwt .09 0 1 Severely underweight, at -3SD
coll .3 0 1 University
lbljorg 13.7 11.8 16.7 log consumption per person 2015
CESD 6.6 0 24 Depression scale
depress .26 0 1 Depression case, CESD>10
IQ 7.6 0 13 Intelligence, Raven
28. The cost of stunting in GDP
≡ the lives saved in a pandemic
• Stunting in 1993 alone costs at least 1.4% GDP in 2015
• Equivalent to 1,053 type C 100-beds hospitals with ICU
• Or 3 new hospitals (each 100 beds plus ICU) for each
district outside Java-Bali.
• Had you eliminated stunting, how many covid-19
patients could have been saved with these new
hospitals?
29. Odds ratios of spatial disparity in nutrition
challenges – summary of what is to come
Median odds ratio Lower Upper
Stunting 1.49 1.43 1.55
Underweight 1.43 1.34 1.52
Adult under-nourishment 2.13 2.03 2.23
Family food insecurity 2.30 2.17 2.44
Median Odds Ratio translates the kabupaten variance to the widely used
odds ratio scale. This makes the MOR comparable with the odds ratios of
individual and kabupaten covariates.
MOR can be interpreted as the median increased odds of stunting if an
under-five
moves to another kabupaten with higher risk. Therefore, the higher the
MOR the
greater the contextual or spatial effect. Merlo et al 2016.
50. Summary of spatial disparity in nutrition
challenges – recap
Median odds ratio Lower Upper
Stunting 1.49 1.43 1.55
Underweight 1.43 1.34 1.52
Adult under-nourishment 2.13 2.03 2.23
Family food insecurity 2.30 2.17 2.44
Median Odds Ratios are comparable with the odds ratios of other
covariates. MOR can be interpreted as the median increased odds of worse
nutrition if one
moves to another kabupaten with higher risk. Therefore, the higher the
MOR the
greater the contextual or spatial effect.
51. Key notes
• Indonesia doesn’t have a stunting problem; it has a nutrition
problem throughout the whole distribution.
• Children in the healthiest decile is way below their peers
• Children in the poorest decile is way too many
• Improving nutrition of all children is the key.
• Otherwise, their adults’ nutrition and productivity will likely
suffer.
• Spatial distribution of adult nutrition is worse than that of
children – a consequence of previous decades’ unmet
challenge
• Some kabupaten/kota are worse. Identification and regular
tracking are needed.
