Editorial

Food and Nutrition Bulletin

2021, Vol. 42(1S) S4-S8
ª The Author(s) 2021
The Triple Burden of Article reuse guidelines:
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Malnutrition Among DOI: 10.1177/03795721211007114
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Adolescents in Indonesia

Jee Hyun Rah, MS, PhD1 , Alida Melse-Boonstra, PhD2 ,

Rina Agustina, MD, PhD3,4 , Kesso Gabrielle van Zutphen, MSc2,5 ,
and Klaus Kraemer, PhD5,6

Abstract
Background: Indonesia is a prime example of the triple burden of malnutrition. Indonesian adoles-
cents are among the hardest hit, with approximately one in four adolescent girls suffering from anemia,
while nearly one in seven adolescents is overweight or obese.
Objectives: The present editorial provides a snapshot of the various research papers included in this
Supplement, which calls for increased attention to adolescent nutrition in Indonesia and beyond.
Results: Despite major steps to reduce undernutrition and overweight, including a renewed focus on
anemia among adolescent girls, major gaps remain in our understanding of various nutrition issues
concerning adolescents. These include various drivers and determinants of the triple burden of mal-
nutrition, evidence-based interventions that are supported by large-scale implementation research and
evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents.
Conclusion: The time has come to position adolescent nutrition as central to development, and
mainstream it into health sector plans, strategies, and policies. It is our hope that this issue will sti-
mulate the urgently needed interventions, implementation research and required programs that will
safeguard the nutritional wellbeing of today’s forgotten generation.

Keywords
Indonesia, adolescents, nutrition, health, anemia, overweight

1
UNICEF Indonesia, Jakarta, Indonesia
2
Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands
3
Department of Nutrition, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta,
Indonesia
4
Human Nutrition Research Center, Indonesian Medical Education and Research Center (HNRC-IMERI), Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
5
Sight and Life, Basel, Switzerland
6
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Corresponding Author:
Jee Hyun Rah, UNICEF Indonesia, World Trade Center 2 (22nd Floor), Jalan Jenderal Sudirman Kav. 31, Jakarta 12920,
Indonesia.
Email: jhrah@unicef.org
Rah et al
Indonesia Showcases a Prime
Example of the Triple Burden of
Malnutrition
The Southeast Asia and the Pacific regions con-
tain nearly half of the individuals, worldwide,
having the triple burden of malnutrition, charac-
terized by the coexistence of undernutrition,
overweight, and micronutrient deficiencies. 1
Globally, overweight rates have risen fastest in
this region. 1 The changes in dietary intake
patterns, such as increased consumption of
unhealthy processed foods and a decrease in
physical activity associated with industrialization
and urbanization, are known to have contributed
to an increased prevalence of overweight and
obesity.1 At the same time, the problem of under-
nutrition remains undefeated.
Indonesia is a prime example of the triple bur-
den of malnutrition. About 1 in 3 children aged
under-5 years is stunted, and 1 in ten 10 children
has wasting, while a further 8% are overweight.2
Indonesian adolescents are among the hardest hit,
with approximately 1 in 4 adolescent girls having
anemia, while nearly 1 in 7 adolescents is over-
weight or obese.2
Indonesia’s triple burden of malnutrition is
attributed to improved life expectancy due to a
shift in the burden of disease from infectious to
noncommunicable diseases; rapid economic
development accompanied by increased food
availability, particularly high-fat, processed
foods; and many cities and towns not being
pedestrian-friendly and discouraging physical
activity.3 Notably, until recently, few policies and
programs were targeting to address the triple bur-
den of malnutrition in Indonesia, particularly
among adolescents. Moreover, health care ser-
vices have been poorly equipped to deal with
overweight and obesity, with services to screen,
diagnose, and treat overweight and obesity
largely lacking.
Actions to Address the Triple
Burden of Malnutrition Among
Adolescents Are Underway
Indonesia has begun to take major steps to reduce
undernutrition, and efforts to address overweight
S5
are evolving rapidly. Indonesia joined the Scaling
Up Nutrition movement in 2011, a global multi-
sectoral, multi-stakeholders movement led by
countries to promote action and investment to
improve maternal and child nutrition. Undoubt-
edly, this has helped the country to strengthen the
enabling environment for nutrition in Indonesia
through high-level advocacy to improve legisla-
tive, policy, and regulatory environment and
enhance capacity of national and subnational
authorities, health workers, and community
volunteers to deliver essential nutrition service
with quality and coverage. Specifically, preven-
tion of child stunting has gained traction, with
stunting having been included as a main develop-
ment indicator in the National Medium Term
Development Plan (2020-2024), demonstrating
the government’s commitment to addressing mal-
nutrition and recognizing the need for a multi-
sectoral response.4 Importantly, the Government
of Indonesia has signaled its firm commitment to
address child undernutrition and, in 2017,
launched the National Strategy to Accelerate
Stunting Reduction to be implemented nation-
wide.4 In this context, anemia prevention for ado-
lescent girls has received a renewed focus as part
of an effort to prevent low birth weight—a strong
predictor of child stunting.
Weekly iron-folic acid supplementation has
been a national program in Indonesia since
2016 targeting school-going adolescent girls,
while not yet covering out of school adolescent
girls and boys. While the program has rapidly
expanded its reach, the coverage remains rela-
tively low in many parts of the country, and the
implementation is faced with various challenges
related to supply, monitoring, supportive super-
vision, and communication.5 Other than the ane-
mia prevention program, however, until recently,
few policies were targeted to improve adolescent
nutrition in Indonesia from a more holistic
standpoint.
Accordingly, since 2017, UNICEF and other
stakeholders have been supporting the Govern-
ment of Indonesia in testing public health inter-
ventions and identifying policy options to
improve the nutritional status of adolescents in
the country.6 Efforts have been made to design
an integrated package of nutrition-specific and
S6
nutrition-sensitive interventions to address ado-
lescent nutrition. Notably, for the first time, UNI-
CEF together with the government developed a
gender-responsive social behavior change com-
munication strategy to improve adolescents’ diet-
ary habits and physical activity.6
Nevertheless, major gaps remain in our under-
standing of adolescent nutrition in Indonesia,
especially among the drivers and determinants
of the triple burden of malnutrition, evidence-
based interventions that are supported by large-
scale implementation research and evaluation,
and effective delivery platforms to reach the most
vulnerable groups of adolescents. The time has
come to position adolescent nutrition as central
to development and mainstream it into health sec-
tor plans, strategies, and policies. Thus, the pres-
ent Supplement issue includes research papers
focusing on adolescent nutrition in Indonesia.
Roshita et al7 produced evidence on the diet-
ary and physical activity behaviors of adolescent
girls and boys and the perspectives of adoles-
cents, their families, and communities on factors
influencing these behaviors. The qualitative
inquiry highlights the changing dietary and phys-
ical activity patterns and habits which contribute
to the triple burden of malnutrition among ado-
lescents. These include declining activities both
at and outside the school and rapidly deteriorating
eating habits such as making their own dietary
choices, eating away from home, frequent snack-
ing, and poor dietary diversity. Furthermore,
body image perception, an under researched topic
in Indonesia, might be an important predictor of
eating and physical activity behaviors among
adolescents, with gender and nutritional status
serving as a significant effect modifier. This was
demonstrated in the study by Niswah et al,8 one of
the few which determines the body image percep-
tion of Indonesian adolescents and its association
with their nutritional status, eating, and physical
activity behaviors.
Overweight and obesity are increasing at
alarming rates in Indonesia. Their determinants
are uncovered by Agustina et al,9 who report the
prevalence of adolescent overweight and obesity
from the Indonesian National Health Survey
(INHS) 2013 as well as related psychosocial
and lifestyle risk factors. The 5-year trend of
Food and Nutrition Bulletin 42(1S)
adolescent overweight and obesity from the INHS
2013 to 2018 report was also presented. Findings
from this study call for future effective interven-
tions on dietary and lifestyle changes among
Indonesian adolescents. Other well-known deter-
minants of children’s body weight worldwide
include socioeconomic status and the urban/rural
divide. Inequalities between siblings, however,
such as gender, birth order, and number of sib-
lings, affect body weight variably due to context.
To gain a deeper insight into these associations
and the extent to which they are affected by
maternal education in addition to socioeconomic
status within the Indonesian context, Bras 10
report data from the fifth wave of the Indonesian
Family Life Survey (2014/2015) and investigate
the relationship between intake of high-calorie
foods and body weight. The authors share com-
pelling findings on how maternal education
modifies this relationship.
Anemia among adolescents in Indonesia
remains a paramount public health concern.
Knijff et al11 document the association between
intake of micronutrient-rich foods and anemia
among adolescent girls and boys in 2 selected
districts in Indonesia, stressing the need to
encourage healthy eating behaviors to address the
triple burden of malnutrition among adolescents.
The cross-sectional study by Agustina et al12
involved 335 adolescent girls in West Java prov-
ince. This study assessed the associations
between girls’ knowledge, attitude, and practices
and anemia and nutritional outcomes (ie, anemia
and linear growth failure). The findings empha-
size the need for public health policies to inte-
grate health promotion strategies that contribute
to an improved understanding of anemia and lin-
ear growth among adolescent girls. While knowl-
edge on anemia goes beyond iron deficiency,
etiological factors other than iron have largely
been ignored. Iron deficiency is indeed likely to
explain a large portion of anemia cases among
adolescents; however, a host of other factors may
also contribute to it and must be considered.
Understanding these additional factors would
help to address the problem appropriately. To
unravel this, van Zutphen et al13 searched the
scientific literature for reports on biological fac-
tors brought into connection with anemia in
Rah et al
Indonesian adolescents, including intake and
absorption of nutrients; biochemical markers;
hemoglobinopathies and menorrhagia; infec-
tious diseases; and inflammation. They identify
existing knowledge gaps which must be
addressed when developing intervention pro-
grams aiming to reduce the prevalence of ane-
mia in this age-group.
Following the outstanding knowledge gaps in
adolescent nutrition in Indonesia, an overarching
multidisciplinary research agenda on this topic
is a welcomed and much needed endeavor. In
this issue, Sparrow et al14 take us through the
development of such a research agenda. First, the
investigators identify internationally shared
knowledge gaps regarding nutritional status of
adolescents living in low- and middle-income
countries. They state that nutritional outcomes
in particular during adolescence are determined
by social and economic factors, which cannot be
ignored when designing nutritional intervention
programs. Based on a desk study, the authors
further identify potentially relevant research
topics for the Indonesian context, after which a
well-attended stakeholder meeting was held in
Jakarta in December 2018. During the meeting,
representatives from government, academia, non-
governmental organizations, and private compa-
nies discussed the knowns and unknowns on
adolescent nutrition in Indonesia and expressed
future research needs to address the issue. Finally,
an online survey was conducted among the atten-
dees of the stakeholder meeting, which led to
prioritizing the most pressing research questions.
The resulting research agenda is presented and
will be useful to all those involved in adolescent
nutrition in Indonesia. Moreover, such evidence
will help shape future innovative interventions
aimed at improving healthy dietary habits, a cru-
cial determinant for an optimal second growth
spurt and improved cognition among adolescents
as well as a reduced risk of noncommunicable
diseases later in life.
Today’s largest cohort in human history has
been neglected in worldwide nutrition and health
programs for far too long. In Indonesia, where
adolescents are among the hardest hit by malnu-
trition, scientists and decision-makers are slowly
but surely drawing attention to this forgotten
S7
generation. We hope that this Supplement will
spur the drastically needed interventions, imple-
mentation research, and relevant programs for the
nutritional well-being of adolescents in Indonesia
and beyond.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Jee Hyun Rah https://orcid.org/0000-0002-2524-
4891
Alida Melse-Boonstra https://orcid.org/0000-0001-
8406-7592
Rina Agustina https://orcid.org/0000-0002-8464-
1037
Kesso Gabrielle van Zutphen https://orcid.org/0000-
0001-7623-0847
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