1041001

review-article2021
APHXXX10.1177/10105395211041001Asia Pacific Journal of Public HealthArini et al

Review
Asia Pacific Journal of Public Health

Nutrient and Food Intake of Indonesian 2022, Vol. 34(1) 25­–35

© 2021 APJPH
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https://doi.org/10.1177/10105395211041001
DOI: 10.1177/10105395211041001

A Systematic Review journals.sagepub.com/home/aph

Hesti Retno Budi Arini, BSc, MPH1,2 , Veni Hadju, PhD3,

Preetha Thomas, PhD1, and Megan Ferguson, PhD1,4

Abstract
The Indonesian Government’s targets to reduce the prevalence of child malnutrition are unlikely to be met based on current
progress. Adequate dietary intake is key to meeting these targets. This systematic review aimed to provide a comprehensive
overview of the nutrient and food intake of Indonesian children under five years of age. Peer-reviewed and gray literature
published between 2007 and 2019 were collected. Of 1500 records, 38 articles met the study inclusion criteria and a
narrative analysis was conducted. Children under five years were reported to have ranging energy and macronutrient intakes,
some with adequate protein intake. Micronutrient deficiencies, particularly iron, zinc, calcium, and vitamin C, were reported.
Animal-source foods, fruits, and vegetables were consumed by children, but frequency and/or volume of consumption was
low, and it is among the probable causes of micronutrient deficiency among children under five years. The absence of reporting
micronutrient intake in the national survey limited evidence to inform nutrition-related policies. The implementation of a
national micronutrient survey will be beneficial in informing policy and practice aimed at reducing the prevalence of child
malnutrition in line with national targets, through improvement in dietary intake.

Keywords
child nutrition, food, Indonesia, nutrient, under 5 years

What We Already Know
•• Indonesian children are facing the triple burden of
malnutrition.
•• Government targets for child malnutrition are unlikely
to be met based on current progress.
•• Indonesia has conducted several Basic Health
Research surveys, including nutritional status as a
national health survey.
What This Article Adds
•• The reviewed literature indicates inadequate micronu-
trient intake among Indonesian children under 5 years.
•• This review emphasizes the urgency of improving
children’s food intake as a means of achieving ade-
quate nutrient intake and the importance of monitoring
micronutrient intake to inform policy and practice.
rates aims to improve quality of life and productivity of
future populations, in line with the 2030 Agenda for
Sustainable Development.21 Undernutrition in children leads
to a decrease in cognitive development and an elevated risk
of adult health problems, including type 2 diabetes mellitus
and hypertension.8,10 Stunted adults have almost 50% lower
salaries than nonstunted adults and account for 11% loss
of gross domestic product.8 The Indonesian Government’s
target is ≤7% wasting prevalence among children under five
years of age (U5 children) and ≤14% stunting prevalence
among children under two years of age by 2024 through both
nutrition-specific and nutrition-sensitive interventions.3
1
The University of Queensland, Brisbane, Queensland, Australia
2
Research Institute of Socio-Economic Development, Surabaya,
East Java, Indonesia
3
Hasanuddin University, Makassar, South Sulawesi, Indonesia
4
Menzies School of Health Research, Charles Darwin University, Darwin,
Northern Territory, Australia

Corresponding Author:
Introduction Hesti Retno Budi Arini, School of Public Health, The University of
Queensland, 288 Herston Road, Herston, Brisbane, Queensland 4006,
Improving child nutrition has been a priority of the Indonesian Australia.
Government for 15 years.20 Reducing child undernutrition Email: h.arini@uqconnect.edu.au
26
The Indonesian Basic Health Research (BHR) reported a
decline in the national prevalence of child undernutrition in
the 2013 to 2018 period, although it remains higher than
national targets. For U5 children, the prevalence of wasting
reduced from 12.1% in 2013 to 10.2% in 2018, and stunting
declined from 37.2% in 2013 to 30.8% in 2018.14,62 The
Indonesian BHR revealed large regional disparities, ranging
from 4.6% in North Kalimantan to 14.4% in West Nusa
Tenggara (wasting) and from 17.6% in Jakarta to 42.7% in
East Nusa Tenggara (stunting).14,22 This marked gap reflects
the community-level differences of the determinants of child
undernutrition, including poor maternal nutrition status and
child dietary intake.10,17,22
Undernutrition among Indonesian U5 children has been
shown to be related to inadequate macronutrient intake,
particularly energy and protein.23 The average energy con-
sumption of U5 children was lower than the Indonesian
Recommended Dietary Allowance (RDA), where 55.7% of
children consumed less than 80% of the RDA in 2014.24
Protein adequacy among U5 children was also low in 2014
(23.6% of children consumed less than 80% of the RDA for
protein).24 There are no government data relating to micro­
nutrient consumption, so the assessment of micronutrient
intake among U5 children relies on research studies and other
surveys conducted in regional areas.25 Low micronutrient
intake, common in both rural and urban areas, has been
reported to be associated with low stature for age among U5
children.25
Studies of adequate nutrient intake among children exist
for some Indonesian regions; however, there is no review
synthesizing these studies. This review aimed to provide an
overview of the energy and nutrient intake adequacy of
Indonesian U5 children and to report the foods most com-
monly consumed by this age group.
Methods
A systematic review was conducted using a narrative analy-
sis to provide a comprehensive overview of the nutrient and
food intake of Indonesian U5 children. This systematic
review was undertaken using the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA)13
framework.
Selection
Peer-reviewed and gray literature were eligible where they
fulfilled these criteria: (1) cross-sectional studies (survey),
descriptive studies, baseline data of intervention studies, and
other relevant observational studies; (2) published between
2007 and 2019; (3) published in English and Bahasa
Indonesia; (4) study participants were Indonesian U5 chil-
dren without a diagnosed illness, except malnutrition; (5)
employed dietary assessment methods, including 24-hour
food recall, food record, food frequency questionnaire
Asia Pacific Journal of Public Health 34(1)
(FFQ), and diet history; and (6) reported at least one of the
following outcome measures: adequacy of energy and mac-
ronutrient, and/or micronutrient; and food consumption.
Search Strategy
Peer-reviewed literature was searched on February 27, 2019,
across three English-language databases (Scopus, Web of
Science, and PubMed) and four Indonesian-language jour-
nals (Jurnal Gizi dan Pangan, Jurnal Gizi Klinik Indonesia,
Jurnal Gizi Indonesia, and Jurnal Kesehatan Badan
Penelitian dan Pengembangan Kesehatan), chosen as they
have been indexed by the Indonesian Ministry of Research
and Technology using Science and Technology Index.
A search strategy was developed for English-language
databases, incorporating terms for nutrient (eg, protein, vita-
min, zinc) intake (eg, consumption, adequacy), children
under five (eg, child, toddler), and Indonesian regions (eg,
Java, Bali). Zinc, iron, folate, and iodine were included as
key “problem” nutrients in many developing countries.60
Filters were applied for timespan (2007-2019), full-text arti-
cles, and research on humans. Articles were searched across
four Indonesian journals using the term gizi anak (“child
nutrition”), filtered by publication year (2007-2019). Titles
and abstracts were screened, according to the inclusion cri-
teria. A gray literature search informed by Godin et al15 was
conducted searching customized Google search engines,
organizational websites, and through consultation with
experts from March 5 to 10, 2019. First, a Google search was
conducted to identify relevant organizations. The organiza-
tions comprised the Indonesian Government (eg, Ministry of
Health and its agencies), nongovernmental organizations
(eg, Nutrition International and Global Alliance for Improved
Nutrition), and related United Nations agencies (eg, United
Nations Children’s Fund and World Health Organization).
Second, each of the relevant websites was browsed for
potentially relevant reports, briefs, and other documents. In
all, 21 websites were searched. Third, two reports were
obtained via consultation with an Indonesian nutrition expert.
Institutional documents were selected from both the Ministry
of Health Republic of Indonesia and international agencies
based on the most recent publication year.
One author (VH) reviewed the identified list of targeted
websites. The title-abstract screening of all documents was
done, then followed by full-text screening of potentially eli-
gible documents to determine whether those full texts met
the criteria. A total of 15% of excluded and included articles
were independently screened, based on the titles and abstracts
(English, PT; Indonesian, VH). Discrepancies were dis-
cussed and resolved as a team.
Data Collection
Data from included studies were extracted into a template
consisting of the following: (1) author, year; (2) study type;
Arini et al
(3) sample size; (4) health condition (if available); (5) age;
(6) location (eg, district, city); (7) dietary component; (8)
dietary assessment method; (9) main findings; (10) comment
(if available); and (11) type of literature (eg, journal article,
report). A narrative synthesis was used to summarize the out-
comes due to the heterogeneity of studies and outcomes.15
Quality Assessment of Studies
Included studies were assessed for quality and risk of bias
using a 27-item Downs and Black instrument.66 Ten of 27
questions relevant to observational studies (all questions
equally weighted) were used.
Nutrient Adequacy
Energy and nutrient intake >77% of the Indonesian RDA
was determined to be adequate, while intake ≤77% of the
Indonesian RDA was determined to be inadequate.26
Food Consumption
Foods were categorized into the 13 groups used in the
Indonesian BHR report27: (1) rice, noodles, and grains; (2)
roots and tubers; (3) nuts and legumes; (4) vegetables; (5)
fruits; (6) meats and poultry; (7) organ meats; (8) fish and
seafood; (9) eggs; (10) milk and dairy products; (11) oils and
fats; (12) sugar and confectionery; and (13) snacks.
Results
Search Results
The search identified 1455 peer-reviewed articles and 45
gray literature documents (Figure 1). Duplicate removal
resulted in 638 full texts to be screened. A total of 38 arti-
cles/documents (33 peer-reviewed, five gray literature)
were included.
Study Design and Location
Most included studies were cross-sectional studies (n = 29),
with a few randomized controlled trials (n = 3), a quasi-
experimental study (n = 1), and case-control (n = 1), cohort
(n = 3), and longitudinal observational studies (n = 1).
Sample sizes ranged from 23 to 162 922 children. All studies
investigated U5 children in a community setting. The most
frequently used dietary assessment method was a single
24-hour food recall (n = 11; Table 1).
Seven studies were conducted at the national level.
Around half were conducted in Java Island, including
Jakarta, West Java Province, Central Java Province, and East
Java Province (n = 21). Four studies were conducted in the
eastern part of Indonesia (one in Sulawesi Island, two in Nusa
Tenggara Islands, and one in Maluku). Four studies/surveys
27
were conducted in Sumatera Island and 1 each in Kalimantan
Island, Sumatera, and Kalimantan.
The average Downs and Black score of quality was
8.11/10 (range 5-10), indicating the high quality of most
included studies. Most studies had a low score in the accu-
racy of outcome measures (n = 13) and for reporting the
exact probability value (n = 16).
Summary of Findings
Macronutrient Intake. Estimated energy varied across age
groups, ranging from an average of 127 kcal/d (6 months)29
to 1478 kcal/d (36-60 months).33 Protein intake ranged from
an average of 3.70 g/d (6 months)29 to 53.10 g/d (36-60
months).33 Carbohydrate intake varied from an average of
89 g/d (12-36 months)56 to 202 g/d (48-72 months),4 whereas
Hardianti33 reported a fiber intake of 7.90 g/d in children
aged 36 to 60 months. Average fat intake was 7.80 g/d among
children 6 to 11 months54 and 54.6 g/d among children 36 to
60 months.33 Furthermore, Huffman et al59 reported that chil-
dren aged six to 23 months consumed 1.37 g/d of omega-3
fatty acid and 11 g/d of omega-6 fatty acid.
Adequacy of energy and macronutrients varied across
studies. Energy adequacy ranged from 76.10% (1-5 years)2
to 114.00% (3-6 years).57 Protein adequacy ranged from
57.80% (1-5 years)2 to 138.10% (3-6 years).57 Other macro-
nutrients had a similar range of adequacy across age
groups: carbohydrates from 50.60% to 93.50%,57,68 fiber
from 9.10% to 9.30% (reported from one study),57 and fat
from 17.30% to 80.20%.2,58
Quality Assessment
Micronutrient Intake. Average sodium intake of U5 children
was 888 mg/d,27 the average iron intake ranged from 2.40
mg/d29 to 12.80 mg/d,37 and the average zinc intake ranged
from 1.20 mg/d29 to 5.53 mg/d.39 The intake of calcium
ranged from an average of 83 mg/d29 to 707.97 mg/d64 and
phosphorus from an average of 540 mg/d37 to 852 mg/d.64
There were marked differences in consumption of vitamin A,
ranging between 53 and 1335 µg/d,29,34 vitamin B3 (0.60-
3.90 mg/d),29,61 folic acid (34.54-122.60 µg/d),31,39 vitamin C
(2.2-45 mg/d),13,53 and vitamin D (2.75-14.10 µg/d)52,61 but
not for other micronutrients (vitamin B1 0.08-0.63 mg/d,29,39
vitamin B2 0.09-0.93 mg/d,29,39 vitamin B6 0.41-0.85
mg/d,39,52 and vitamin B12 1.59-1.99 µg/d).39,52 Only 1 study
by Mursalim and Mulyani37 reported vitamin E intake
(average of 2.05 mg/d).
There was a marked difference between the lowest and
the highest micronutrient adequacy: vitamin B1 (71.30% to
129.10%),2,68 calcium (14.30% to 96.80%),2,68 and vitamin A
(68.40% to 99.60%).2,68 Other micronutrients also differed in
adequacy across studies, such as iron (41.80% to 74.50%),28,68
vitamin C (44.80% to 92.40%),68 and zinc (27.90% to
57.20%).2,7 Meanwhile, the adequacy of sodium and SFA
28
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.
(saturated fatty acid) was reported in only 1 study (78.70%,
and 40.50% to 41.10%, respectively).57,58 Most studies inves-
tigating nutrient adequacy used the RDA-2013 version in
their calculation, but it is unlikely to skew the real adequacy
because there is no obvious dissimilarity between the RDA-
2013 version and the RDA-2019 version (Table 2).
Food Intake. Rice, noodles, and grains were the most
frequently consumed carbohydrate sources among U5 chil-
dren.11,37,65 Consumption was reported to range from 127.7 to
256.2 g/d27,35 and consumed by most children (94% to 100%),
reported as 1 to 3 times/d and 6.5 d/wk.11,37,65 Meanwhile,
Asia Pacific Journal of Public Health 34(1)
rice-based products (eg, rice flour and vermicelli) had the
lowest volume of consumption,27 corn kernels were con-
sumed by the smallest proportion of children,27 and many
children had not consumed whole wheat bread.11,27 The con-
sumption of roots and tubers was reported to be low.11,27,37,62,65
Where reported, consumption was 12.0 to 13.1 g/d,27,53 and
the proportion of children consuming roots and tubers ranged
from 0.4% to 84%.27,37 Potato was the most commonly con-
sumed root by children (1-3 times/wk).11
Soybean products (eg, tofu and tempeh) were the most
frequently consumed plant-based protein,37 whereas salt-
water fish, processed meats (ie, meatballs and sausages),
 Table 1. Characteristics of Studies.
Nutrient intake Nutrient adequacy
D&B
quality Energy and Energy and Food
Author Study type Language Sample Size Age (months) Specific location Dietary assessment score macronutrients Micronutrients macronutrients Micronutrients intake

Peer-reviewed literature
Ahmad et al20 Cross-sectional English 154 6-23 Aceh Besar district 3 × 24-hour recall 10 — — — ✓ ✓
Ansari et al21 Cross-sectional English 89 6-23 Two villages in East Jakarta 2 × SQ-FFQ and 3 day 10 ✓ — — — —
nonconsecutive 24-hour recall
Asrar et al10 Cross-sectional Indonesian 68 12-59 Nuaulu tribe, Maluku 3 × 24-hour recall 9 ✓ — — — —
Diana et al62 Cohort English 190 6-12 Three districts of Sumedang Weighed food records for 12 days 10 ✓ ✓ ✓ — —
monitored at 6, 9, and 12 months
Elvandari et al23 Cross-sectional Indonesian 140 12-36 Kudus and Grobogan districts 2 × 24-hour recall 9 ✓ ✓ — — —
Ernawati et al24 Cross-sectional English 55 6-8 Several community health centers in Jakarta SQ-FFQ and single 24-hour food 10 ✓ ✓ — — —
recall
Erni and Rialihanto, 200825 Cross-sectional Indonesian 48 24-59 Anak Dalam tribe 3 × 24-hour recall 9 ✓ — — — —
Hardianti et al26 Cross-sectional Indonesian 63 36-60 Playgroups in Banyumanik subdistrict 3 × 24-hour recall 9 ✓ — — — —
Hastuti27 Cross-sectional English 120 12-72, <6 Tengger people in Probolinggo, East Java 2 × 24-hour recall 6 ✓ ✓ — — —
years
Haya et al28 Quasi-experiment with English 48 36-72 Two playgroups in Bengkulu 2× food record form 7 ✓ — ✓ — —
nonrandomized, pre-post
Irwanti et al29 Cross-sectional Indonesian 86 24-60 Two subdistricts in Yogyakarta Single 24-hour recall 8 ✓ — — — —
Jati et al30 Cross-sectional English 118 12-36, 2.47 Betun subdistrict, West Timor Single 24-hour recall 6 ✓ ✓ ✓ ✓ —
± 1.17 years
Kartono et al31 Cross-sectional Indonesian 1462 6-35 One subdistrict in Sragen and 1 subdistrict Single 24-hour recall 8 ✓ ✓ — — —
in Karawang
32
Kusudaryati et al RCT Indonesian 36 24-36 One subdistrict in Surakarta 2 × 24-hour recall 9 ✓ ✓ ✓ ✓ —
Kusumadewi et al33 Cross-sectional English 74 6-8 Kampung Melayu, Jakarta Single 24-hour recall and SQ-FFQ 7 — ✓ — — —
Laurus et al34 Cross-sectional English 70 36-60 Jatinangor subdistrict 3 × 24-hour recall, FFQ 5 ✓ — — — ✓
Martianto et al35 Cross-sectional Indonesian 300 24-60 Two subdistricts in Banjarnegara 2 × 24-hour recall 9 ✓ — — — —
Mulyani et al36 Efficacy cohort study design English 143 12-35 Kudus and Grobogan districts 2 × 24-hour recall 10 ✓ ✓ — — ✓
Mursalim and Mulyani37 RCT Indonesian 386 6-55 Three subdistricts in Jakarta Single 24-hour recall 10 ✓ ✓ — — —
Muslimatun and Longitudinal observational English 227 12-59 Bandung city 2 × 24-hour recall 10 — — — — ✓
Wiradnyani38 study
Nirmala et al39 Case-control English 23 12-59 Southeast Sulawesi Questionnaire 7 ✓ ✓ ✓ — —
Putra et al40 Cross-sectional Indonesian 140 6-59 One village in Pidie 3 × 24-hour recall 6 ✓ — — — —
Riyadi and Anwar41 Cross-sectional English 300 12-60 Two subdistricts in Cianjur Single 24-hour recall 5 ✓ ✓ — — —
Riyadi and Sukandar42 RCT Indonesian 240 6-59 Two subdistricts in Bogor 2 × 24-hour recall 5 ✓ ✓ ✓ ✓ —
Riyadi et al43 Cross-sectional Indonesian 149 6-59 Three villages in Timor Tengah Utara district Single 24-hour recall 5 ✓ ✓ ✓ ✓ —
Sandjaja et al12 Cross-sectional English 4439 out of a 6-59 National Single 24-hour recall 9 ✓ ✓ — — —
total of 7211
Sandjaja et al44 Cross-sectional Indonesian 783 6-59 Ciamis and Tasikmalaya districts 2 × 24-hour recall 9 ✓ ✓ — — —
Santika et al45 Cross-sectional English 100 9-11 Bogor Selatan subdistrict 12-hour weighed food record (6 am 8 — — — — ✓
to 6 pm) and 12-hour food recall
(6 pm to 6 am), 5-day food tally
and questionnaire
Santika et al46 Cross-sectional English 814 12-23 Thirty-three subdistricts in Bandung Two nonconsecutive 24-hour recall 9 ✓ ✓ — — —
Sari et al47 Cross-sectional Indonesian 90 24-59 Pontianak Single 24-hour recall 9 ✓ ✓ — — —
Sudikno and Jus’at48 Cohort English 126 6-59 Ciamis and Tasikmalaya districts Two consecutive days 24-hour 10 ✓ ✓ — — —
recall
Widodo et al49 Cross-sectional English 2391 6-59 National Single 24-hour recall 9 ✓ ✓ — — —
Widodo et al49 Cross-sectional Indonesian 3600 6-71 National Single 24-hour recall 8 ✓ ✓ ✓ ✓ —
Gray literature
Ministry of Health51 Cross-sectional Indonesian 19 775 6-72 National Single 24-hour recall 8 ✓ — — — —
Ministry of Health19 Cross-sectional Indonesian 6093 6-59 National Interview (food intake), single 24- 8 ✓ — ✓ — —
hour recall (nutrient intake)
Ministry of Health52 Cross-sectional Indonesian 162 922 6-59 National Single 24-hour recall 7 ✓ ✓ ✓ ✓ —
National Population and Cross-sectional Indonesian 4999 6-23 National Interview 7 — — — — ✓
Family Planning Agency
et al53
Null et al54 Cross-sectional English 2560 6-36 West Kalimantan, Central Kalimantan, 24-hour recall for past week 8 — — — — ✓
South Sumatera provinces

29
Abbreviations: D&B, Downs and Black score; SQ-FFQ, Semi-Quantitative Food Frequency Questionnaire; RCT, randomized controlled trial.
30 Asia Pacific Journal of Public Health 34(1)

Table 2. The 2019- and 2013-Indonesian RDA for U5 Children.41,63

Age groups
a
0-5 Months 6-11 Months 1-3 Years 4-6 Years

Nutrients 2019 2013 2019 2013 2019 2013 2019 2013

Energy (kcal) 550 550 800 725 1350 1125 1400 1600
Protein (g) 9 12 15 18 20 26 25 35
Fat (g)
Total 31 34 35 36 45 44 50 62
n-6 4.4 4.4 4.4 4.4 7.0 7 10.0 10
n-3 0.5 0.5 0.5 0.5 0.7 0.7 0.9 0.9
Carbohydrate (g) 59 58 105 82 215 155 220 220
Fiber (g) 0 0 11 10 19 16 20 22
Vitamin A (µg) 375 375 400 400 400 400 450 450
Vitamin D (µg) 10 5 10 5 15 15 15 15
Vitamin E (mg) 4 4 5 5 6 6 7 7
Vitamin B1 (mg) 0.2 0.3 0.3 0.4 0.5 0.6 0.6 0.8
Vitamin B2 (mg) 0.3 0.3 0.4 0.4 0.5 0.7 0.6 1
Vitamin B3 (mg) 2 2 4 4 6 6 8 9
Vitamin B6 (mg) 0.1 0.1 0.3 0.3 0.5 0.5 0.6 0.6
Folic acid (µg) 80 65 80 80 160 160 200 200
Vitamin B12 (µg) 0.4 0.4 1.5 0.5 1.5 0.9 1.5 1.2
Vitamin C (mg) 40 40 50 50 40 40 45 45
Calcium (mg) 200 200 270 250 650 650 1000 1000
Phosphor (mg) 100 100 275 250 460 500 500 500
Sodium (mg) 120 120 370 200 800 1000 900 1200
Iron (mg) 0.3 0 11 7 7 8 10 9
Zinc (mg) 1.1 0 3 3 3 4 5 5

Abbreviations: RDA, recommended dietary allowance; U5, children under 5 years of age.
a
The 2019 Indonesian RDA categorized infant age into 0 to 5 and 6 to 11 months old, whereas the 2013 Indonesian RDA used 0 to 6 and 7 to 11
months old.

chicken, chicken eggs, and poultry organ meats were the
most commonly consumed animal protein foods.11,19,27,40,53
Another product categorized as animal product that was
consumed by children was infant formula.27 Goat and
pork products were only consumed by a small proportion
of children.37 The frequency of protein-source consump-
tion varied but was reported to be at least daily.11,27,65
Almost all children consumed vegetables and fruits, with
the average consumption ranging between 18 and 21
g/d.35,54 Carrots, water spinach, and other leafy vegetables
were the most frequently consumed vegetables, whereas
watermelon was the most common fruit in children’s
diet.11,27,28,37,38,53 Despite fruits and vegetables being part
of children’s diets, consumption was reported to be
low.4,5,6,27,37,40,53,61
Palm oil and coconut oil were consumed by about 70%
of children, and the use of other oils (eg, canola oil, olive
oil) was low.27,54 Raw sugar and brown sugar were com-
mon in the children’s diet, whereas syrup was the least fre-
quently consumed confectionery.27,37 Almost all children
consumed snacks daily, particularly crackers (fried, savory,
or sweet) and commercial snack balls.1,27,28,35,37
Discussion
This review aimed to provide an overview of the energy and
nutrient intake adequacy of Indonesian U5 children and the
foods most commonly consumed. The findings indicated both
energy and nutrient deficiencies, though more than half of the
studies reported excessive protein intake. Inadequate micronu-
trient intake was evident for iron, zinc, calcium and vitamin C.
The foods most commonly consumed by Indonesian U5 chil-
dren comprise both carbohydrate and protein food sources,
such as rice, noodles, grains, soybean products, and eggs.
Energy and Macronutrient Intake
U5 children in low-middle-income countries are prone to
several nutrition issues, such as protein-energy malnutrition
and micronutrient deficiencies.43 A low-quality diet, such as
consumption of weaning foods of low energy density, may
contribute to childhood malnutrition and growth faltering.42
There was a large variation between minimum and maxi-
mum energy and macronutrient adequacy of U5 children,
which suggests nutrient intake disparities across Indonesia.
Arini et al
Indonesian children are unlikely to consume adequate
carbohydrate and fat.1,4,11,30,54,56,61 Fat and carbohydrate ade-
quacy in Indonesian children is usually assessed together
with energy and protein consumption, and studies focusing
on adequacy of a specific type of carbohydrate and fat (eg,
fiber and essential fatty acids [EFAs]) are rare. For example,
EFAs consumption can support growth of children under 244;
however, there are only 2 studies included in this review,
which reported on EFAs (adequate) intake and fiber (inade-
quate) intake.21,28
Protein is associated with linear growth, and protein inad-
equacy is correlated with a higher rate of stunting.12 However,
this review found that more than half of the included studies
reported excessive protein intake. Given the likely adequacy
of protein, child malnutrition in Indonesia could be due to
other factors. The mixed reporting of energy and macronutri-
ent intake suggest that undernutrition among Indonesian U5
children is not only caused by inadequate macronutrient
intake, but also likely to be related to micronutrient defi-
ciency, which is not routinely reported.
Micronutrient Intake
Indonesian U5 children were reported to be at risk of micro-
nutrient deficiencies, including iron, zinc, calcium, and vita-
min C. Iron is essential for the growth of children aged six to
24 months, though children in this age group are more likely
to have low iron status.45 The rapid growth occurring in early
childhood leads to increased iron requirement.45 Despite
the national iron fortification of wheat flour, Diana et al22,62
highlighted a high prevalence of iron deficiency among
Indonesian children aged more than 6 months due to the
decline in consumption of iron-fortified infant foods and the
poor availability of iron in wheat flour products consumed
by the children. A similar problem applies to zinc and cal-
cium. The fortification of wheat flour with zinc and volun-
tary fortification of milk with calcium in Indonesia are
unlikely to compensate children’s requirements due to the
late introduction of zinc and calcium food sources and the
poor quality of complementary feeding (eg, phytate-rich
foods, rice-based gruels).29 Meanwhile, vitamin C deficiency
is likely to occur due to low fruit consumption,37 which is in
line with the findings of this review.
Food Intake
Our review highlighted the foods from each food group that
are frequently consumed by U5 children and provided an
indication of food quality. For instance, the frequent con-
sumption of processed meats (eg, meatballs) and unhealthy
snacks may contribute to children’s protein and energy
intake, but provide limited micronutrient intake, and a low
consumption of fruits and vegetables, which are essential
micronutrient sources. However, we did not compare the
intake data with the recommended amount of consumption
31
from the Indonesian Dietary Guidelines due to heterogeneity
in reporting.
Strengths and Limitations
To our knowledge, this is the first study reviewing nutrient
intake among Indonesian U5 children that includes national
and regional studies as well as gray literature. Thus, it is
likely to provide the most comprehensive information on
children’s nutrient and food intake across the nation.
Moreover, we reported on a wide range of intake data, includ-
ing macronutrient and micronutrient intake, and food con-
sumption. Understanding micronutrient intake adequacy, in
addition to macronutrient intake adequacy, may enable the
Indonesian Government to develop nutrition-related initia-
tives to reach the target of wasting and stunting reduction.
Limitations of the Included Studies
Lack of Justification on Sample Representativeness. The national
studies (eg, South East Asian Nutrition Survey [SEA-
NUTS]25 and Indonesian Total Diet Study27) demonstrated
their sample representativeness and provided justification of
sample selection. Unfortunately, many regional studies did
not provide a justification for their sample selection, and it is
unclear whether the sample was representative of the target
population. The studies that used community health care as
their sampling frame were likely to be more representative
than those that only selected particular target groups.
Poor Reporting on the Tool Validity. Most studies used 24-hour
recall or a FFQ. Many studies mentioned the role of trained
enumerators in interviewing participants to ensure the study’s
reliability; however, only a few studies mentioned that they
used a validated 24-hour recall form or FFQ.
Potential for Misreporting. Misreporting of dietary intake is
common among dietary surveys, which may lead to difficul-
ties in estimating adequacy and potential inaccuracy of the
reported nutritional deficiency. Thus, despite the comprehen-
sive overview provided by this review, the potential of mis-
reporting still has to be considered.
Limitations of the Review
This review has two main limitations. First, it was inconsis-
tent age grouping between studies, which limited the ability
to perform a meta-analysis. The difference between the age
grouping in studies and the age group used in the Indonesian
RDA also hindered a single comparison between the studies
and the Indonesian RDA. For example, four studies included
children aged five to six years old, and children aged four to
six years are categorized within the same age group in the
Indonesian RDA. In Indonesia, the RDA for U5 children is
categorized into 4 age groups, and some studies did not use
32
the same age grouping as the RDA. Thus, it is not possible to
assess nutrient adequacy by comparing nutrient intake data
from the included studies with 77% of the RDA.
Second, this review only covered a number of micro­
nutrients, given the included studies assessed a limited range
of micronutrients, which are already known to have a signifi-
cant effect on child growth. Studies investigating micro­
nutrients on children have been conducted in Indonesia, but
most frequently in a clinical setting. Thus, it is important to
conduct more micronutrient studies in addition to the key
“problem” nutrients, particularly in a community setting.
The Importance of a National Micronutrient
Survey: Practical Considerations
This review found that energy and macronutrient intake of
children are widely reported, which are likely to be used as
evidence in developing both nutrition-specific and nutrition-
sensitive interventions.47 Currently, the BHR reports energy
and macronutrient intake only. The absence of national
micronutrient survey data results in reliance on regional
studies and the ASEAN survey (ie, SEANUTS) for micronu-
trient intake data.25 Most of the available micronutrient stud-
ies are conducted in Java Island, which means that evidence
from other regions is still limited. Lack of micronutrient
intake data within a country reflects unidentified micronutri-
ent deficiencies, followed by nonevidence-based policy
formulation.47,48
Currently, for example, the BHR is the only available
national survey to assess nutritional status and biochemical
parameters in evaluation of micronutrient-related programs,
such as vitamin A supplementation, salt iodization, and zinc
supplementation.62 Good-quality studies investigating chil-
dren’s micronutrient intake urgently need to be conducted
across regions of Indonesia. Reflecting on the Malawian
experience in combining the national demographic and
health survey with the national micronutrient survey,9 we
suggest integrating a national micronutrient survey into the
Indonesian BHR.
Details of indicators and methods used in a micronutri-
ent survey have been described by Gorstein et al.66 They
suggested the creation of a national survey planning com-
mittee consisting of relevant government bodies and related
organizations. Reflecting on the experiences of Ghana16
and Iran49 in conducting national micronutrient surveys, at
least four institutions are required for this committee: The
Ministry of Health (including Nutrition Department), an
educational institution (eg, from medical, nutrition, and
public health fields), a clinical laboratory, and a nongovern-
mental organization. Due to the diversity of the Indonesian
population, the contribution of local stakeholders would be
essential. Because a national survey is complex,9 a compre-
hensive understanding of the locality and its population is
key to success. Rhodes et al65 suggested that the planning
stage must commence more than one year prior to the
Asia Pacific Journal of Public Health 34(1)
implementation, and the data collection process may take
three to nine months.16,49
Rhodes et al65 highlighted some advantages and barriers
of an integrated national micronutrient survey, and the plan-
ning committee plays a significant role in minimizing the
potential barriers. First, a national micronutrient survey is
expensive due to its data complexity and the time required
for data collection and analysis.9 Thus, integrating it into the
Indonesian BHR is more time- and cost-effective. Second, a
national micronutrient survey includes many kinds of data in
addition to the biochemical and dietary assessment of respon-
dents; however, experts can provide recommendations on the
prioritized micronutrients and which biologic specimens are
needed.67 Third, the role of national and local governments is
essential in facilitating regular communication and providing
adequate coordination among stakeholders.9
Opportunities for Further Research
This review has highlighted the importance of collecting
national data of children’s micronutrient intake as a means of
addressing micronutrient deficiencies. In addition, there are
two recommendations for future research in the field of child
nutrition. First, more regional studies on children’s nutrient
intake are needed to support the creation of evidence-based
local policies for improving child nutrition. These regional
studies will be beneficial to provide more context, for exam-
ple, nutrient intake of a specific tribe or community, which is
unique and unlikely to be represented in the BHR survey.
Second, future research on other micronutrients is recom-
mended because each micronutrient may have a specific role
in increasing children’s growth.
Conclusion
This is the first systematic review that we are aware of to
focus on nutrient and food intake of Indonesian U5 children,
combining both regional and national studies. This review
highlights inadequate energy and nutrient intake and
unhealthy food consumption among Indonesian U5 children,
which affects child growth. The absence of a national micro-
nutrient survey in Indonesia is noteworthy. We recommend
including a national micronutrient survey to monitor chil-
dren’s nutritional status and inform evidence-based policy
and programs to improve this. Finally, this review can be
used as useful evidence when creating nutrition-related poli-
cies and in informing future research in child nutrition.
Acknowledgments
The authors would like to thank Scott Macintyre for his advice in
conducting this systematic review.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Arini et al
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
project also received funding support from an Australia Awards
Scholarship.
ORCID iD
Hesti Retno Budi Arini https://orcid.org/0000-0003-0652-7754
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