Indonesia, as a major population in the Asia Pacific region, threatened with food and health insecurity through climate change and rapid economic development, faces the challenge to build capacity among its science-based food and health professionals and institutions. The nutrition research agenda is now being more actively set with-in the region, rather than by external imposition. A series of papers emanating from a new generation of public health and clinical nutrition scientists is reported in this issue of APJCN. It draws attention to the importance of food patterns and background culture as contributors to the failure of the nutrient rather than a food, food system and socio-ecological approach to solve the region’s intransigent nutritionally-related health problems. New un-derstandings of human eco-social biology are providing opportunities to accelerate the resolution of these prob-lems. The challenge is to transform the food-health construct from one which is not sufficiently concerned about the precarious state of ecologically dysfunctional health and its nutrient market drivers to one which strives for more sustainable and affordable solutions. The present reports address a range of options to these ends.

Background and Objectives: Vitamin D deficiency significantly affects cardiovascular disease risk. Cardiovascular disease is epidemic in nature. Because the prevalence of cardiovascular disease has been increasing in children, it has been changing from an adulthood disease to a childhood disease. Therefore, formulating an effective prevention strategy against cardiovascular disease development in children is crucial. Methods and Study Design: From PubMed, we identified and reviewed studies evaluating the association of vitamin D deficiency with cardiovascular disease risk in children. Results: The mechanism through which vitamin D protects against cardiovascular disease has yet to be fully elucidated. Vitamin D deficiency may be associated with various risk factors for cardiovascular disease that are already manifested in childhood, including obesity, hypertension, dyslipidaemia, insulin resistance, and metabolic syndrome. Vitamin D deficiency has been associated with cardiovascular disease because it promotes vascular stiffness and calcification, leading to atherosclerosis. However, studies investigating the effectiveness of vitamin D in preventing cardiovascular disease risk by using an ideal study design are scant. Conclusions: Vitamin D deficiency in children may increase cardiovascular disease risk, which tends to manifest in childhood. Because data on the association of vitamin D deficiency with cardiovascular disease risk among children are limited and inconclusive, additional studies are required to investigate this association in children in general and in a setting with naturally abundant sun exposure.

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.

Background and Objectives: Vitamin A deficiency is particularly common among children younger than 5 years. In 2011, a study conducted in West Java revealed that the prevalence of vitamin A deficiency in children aged 6–11 months, 12–23 months, and 24–59 months was 18.2%, 15.2%, and 9.9%, respectively. The present study analysed the differences in vitamin A intake and serum retinol in all the preschool children from Grobogan and Kudus, Central Java. Methods and Study Design: The baseline data of vitamin A efficacy were analysed. A total of 143 children aged 1-3 years participants (n=71 from Kudus and n=71 from Grobogan) were recruited and we used independent t-tests to analyse the data. Results: Among the study population, 50.7% and 48.6% were boys and 49.3% and 51.4% were girls from Kudus and Grobogan, respectively. The average intake of energy, carbohydrates, protein, fat, and vitamin A was 698±440 (Kcal), 89±60 (g), 25.9±18.5 (g), 26.1±18.5 (g), and 435.3±554.0 (μg) in Kudus and 868±493 (Kcal), 109±67 (g), 30.9±20.1 (g), 35.1±23.1 (g), and 538.1±622.9 (μg) in Grobogan, respectively. The average serum retinol in Kudus and Grobogan were 26.7±6.4 (μg/dL) and 29.6±5.9 (μg/dL), respectively. Significant differences in energy and fat intake (p<0.05) were also observed between the Kudus and Grobogan districts; however, no differences in protein, carbohydrates, and vitamin A intake (p≥0.05) were noted. A significant difference in serum retinol was observed between these two districts (p<0.05). Conclusions: An increase in vitamin A intake through various foods should improve the serum retinol in preschool children.

Background and Objectives: Stunting during childhood is a common public health problem in Indonesia. Complementary food supplementation with a small quantity of lipid-based nutrient supplements (SQ-LNSs) can promote growth and prevent undernutrition. This study investigated the effects of the daily provision of SQ-LNSs and biscuits on linear growth and reduction in the incidence of stunting among infants in rural Indonesia. Methods and Study Design: A 6-month, non-randomised, controlled trial was conducted on 168 infants who received 20 g of SQ-LNSs, 3 pieces of biscuits, or no intervention. The outcome was length gain and incidence of stunting (length-age-z score (LAZ) <−2SD) during a 6-month follow-up. Results: After the 6-month intervention, the adjusted length gain and change in the LAZ (8.57 cm and −0.09 z-score unit, respectively) were higher in the SQLNS group than in the control (7.15 cm and −0.87 z-score unit, respectively) and biscuit groups (7.79 cm and −0.46 z-score unit, respectively; p<0.01). The rate of length gain was significantly higher in the SQ-LNS group (1.43 cm/month; 95% CI: 1.12–1.26) than in the biscuit (1.29 cm/month, 95% CI: 1.23–1.36) and control groups (1.19 cm/month, 95% CI: 1.12–1.26; p<0.01). At the end study, the incidence of stunting in SQ-LNS group was lower (1.8%) than in the biscuit group (8.5%) and control group (14.6%). In the SQ-LNS group, the relative risk (RR) of stunting was 0.35 and in the biscuit group (0.94). Conclusions: SQ-LNSs improved linear growth and reducing the incidence of stunting over 6-months intervention.

Background and Objectives: Although breastfeeding is recommended by WHO, the breastfeeding rate in Indonesia remains low, because many women fail to maintain their breastfeeding intention during the breastfeeding period. The decision whether to breastfeed or not, like any other nutritional behaviour, may develop over a lifetime and is rooted in many aspects of life; however, many factors may affect a mother’s decision about whether to stop or continue breastfeeding during the breastfeeding period. A critical time point of contact for breastfeeding is a time point when the mother experiences difficulties and encounters influences that may affect breastfeeding continuation. Method and Study Design: A qualitative approach was used to investigate the factors affecting breastfeeding intention and continuation. A follow-up approach was used to assess actual experiences and problems at each time point of contact. The interviewees in this study were pregnant women who lived and worked in West Jakarta and were in at least Week 36 of their pregnancy. The key interviewees for triangulation were 2 grandmothers and 2 healthcare providers. Results and Conclusions: Knowledge, beliefs, and support were the factors affecting the women’s intentions. Perceived obstacles; common beliefs; stigmas regarding breastfeeding; and support and influences from husbands, mothers, family members, and relatives were the factors influencing breastfeeding continuation within the first month postpartum.

Background and Objectives: Exclusive breastfeeding has been proven to be essential for optimal health, and for reducing infections and mortality in children. However, exclusive breastfeeding coverage both in Indonesia and in globalremains low. This study evaluated the relationship between the timely initiation of breastfeeding and the practice of exclusive breastfeeding in Indonesia. Methods and Study Design: This cross-sectional study used Riskesdas 2013 data. Participants were 7,667 mothers whose children were aged 6–23 months in Indonesia, and were selected based on the completeness of the variables. The data were analysed using descriptive statistics, chisquare tests, and a multiple logistic regression that considered the sampling weight. STATA 13.0 was used for the analyses, and the significance level was set at p<0.05. Results: Timely initiation of breastfeeding within 1 hour of parturition (OR=3.66, 95% CI: 2.14–3.64), timely initiation of breastfeeding at or after 1 hour following parturition (OR=2.79, 95% CI: 3.00–4.46), and neonatal illness (OR=0.69, 95% CI: 0.53–0.91) were significantly associated with an exclusive breastfeeding history among children aged 6–23 months. Other factors, such as the mother’s age, mother’s educational level, child’s birth weight, household economic status, and residential area were not associated with an exclusive breastfeeding history. Conclusion: Timely initiation of breastfeeding and the prevention of neonatal illness should be the main interventions to improve exclusive breastfeeding coverage in Indonesia.

Background and Objectives: Persistent diarrhoea, a serious health problem, is closely related to malnutrition. Children with severe malnutrition have a 9-fold risk of death, and children with severe stunting have a 4-fold risk of death. Prolonged mucosal injury from diarrhoea causes reduced secretin and cholecystokinin secretion, which decreases stimulation to the pancreas, and is indicated by faecal elastase-1 levels. This further aggravates persistent diarrhoea and malnutrition because of the low levels of digestive enzyme production. This study evaluated the exocrine function of the pancreas in children with persistent diarrhoea and malnutrition. Methods and Study Design: This study used a cross-sectional design to compare exocrine pancreatic function among children with persistent diarrhoea, children with malnutrition, and apparently healthy children as reference Children aged 6–60 months were selected from the inpatient and outpatient units of various general hospitals in Jakarta. Faecal elastase-1 levels were used to determine exocrine pancreatic function. Results: The median values of faecal elastase-1 in children with persistent diarrhoea, children with malnutrition, and reference children were 743 (1–1503) mcg/g, 861 (17–2909) mcg/g, and 1210 (26–3000) mcg/g, respectively. A significant difference was observed in the faecal elastase-1 levels between reference children and those with persistent diarrhoea (p<0.001). However, no differences in the faecal elastase-1 levels were noted between malnourished and reference children (p>0.05). Children with both persistent diarrhoea and malnutrition showed mean FE-1 392.3+206.9 and median 419 (125-593). Conclusions: Exocrine pancreatic insufficiency is found in children with persistent diarrhoea. Children with combined persistent diarrhoea and malnutrition have the lowest FE-1, to which persistent diarrhea has the most significant contribution.

Background and Objectives: Diets with a specific omega-6/omega-3 fatty acid ratio have been reported to have favourable effects in controlling obesity in adults. However, development a local-based diet by considering the ratio of these fatty acids for improving the nutritional status of overweight and obese children is lacking. Therefore, using linear programming, we developed an affordable optimised diet focusing on the ratio of omega- 6/omega-3 fatty acid intake for obese children aged 12–23 months. Methods and Study Design: A crosssectional study was conducted in two subdistricts of East Jakarta involving 42 normal-weight and 29 overweight and obese children, grouped on the basis of their body mass index for-age Z scores and selected through multistage random sampling. A 24-h recall was performed for 3-nonconsecutive days to assess the children’s dietary intake levels and food patterns. We conducted group and structured interviews as well as market surveys to identify food availability, accessibility and affordability. Results: Three types of affordable optimised 7-day diet meal plans were developed on the basis of breastfeeding status. The optimised diet plan fulfilled energy and macronutrient intake requirements within the acceptable macronutrient distribution range. The omega-6/omega-3 fatty acid ratio in the children was between 4 and 10. Moreover, the micronutrient intake level was within the range of the recommended daily allowance or estimated average recommendation and tolerable upper intake level. Conclusions: The optimisation model used in this study provides a mathematical solution for economical diet meal plans that approximate the nutrient requirements for overweight and obese children.

Background and Objectives: Plasmodium falciparum infection during pregnancy is characterised by placental inefficiency caused by infected erythrocyte sequestration. Reduced placental efficiency leads to placental intrauterine adaptation for sustaining fetal growth, which is reflected by changes in the expression of placental genes involved in intrauterine growth regulation. Therefore, we aimed to determine whether the placental weight ratio, an indicator of placental efficiency, affects the placental expression of the components of the insulin-like growth factor axis and leptin signalling pathway in P. falciparum-infected pregnant women. Methods and Study Design: A malaria case-only analysis of 50 P. falciparum-infected pregnant women in Timika, Papua, Indonesia, was conducted. The placental mRNA expression of insulin-like growth factor-I, insulin-like growth factor binding protein-1, leptin, and the long and short isoforms of the leptin receptor was measured through quantitative realtime PCR. Results: The placental weight ratio exerted a positive effect on the placental mRNA expression of insulin-like growth factor-I (coefficient=6.10, p=0.002) and the long isoform of the leptin receptor (coefficient=4.73, p=0.015) in malaria-infected pregnant women without fever or chill symptoms. Conclusion: Our results indicate that placental adaptive responses caused by adverse intrauterine conditions in P. falciparuminfected pregnant women vary depending on the presence or absence of fever and chill symptoms.

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.

Background and Objectives: Pro-inflammatory cytokines interleukin 17A (IL-17), leptin, and adiponectin have been associated with obesity and insulin resistance. Moreover, differences in sex and ethnicity as well as plasma concentration of adipocytokines and cytokines have been associated with the risk of insulin resistance. This study was conducted to elucidate whether sex differences exist in the risk of insulin resistance in Indonesian adolescents and to determine how plasma leptin, adiponectin, and IL-17 predict insulin resistance. Methods and Study Design: The study participants were 69 obese–overweight boys, 53 obese–overweight girls, 59 non-obese boys, and 50 non-obese girls aged 15–18 years. Insulin resistance was determined using the homeostatic model assessment of insulin resistance index. Plasma IL-17, leptin, and adiponectin were measured using ELISA. Data were analysed using one-way ANOVA and linear regression analysis. Odd ratios [ORs; 95% confidence intervals (CIs)] were analysed to estimate the risk of insulin resistance; the significance level was set at 95%. Result: The OR (95% CI) for insulin resistance was higher in obese–overweight boys than in obese–overweight girls. The plasma IL-17 was higher in boys, whereas plasma adiponectin and leptin were significantly higher in girls. In all participants, obesity status and plasma leptin were the most efficient predictors of insulin resistance, whereas the IL-17 could not significantly predict insulin resistance. Conclusion: Sexual dimorphism exists in IL17 as well as leptin and adiponectin in adolescents. Plasma IL-17 cannot be used to predict insulin resistance in adolescents of both sex.

Background and Objectives: Maternal nutrition affects fetal growth and development. This study evaluates the effects of milk powder fortified with micronutrients, docosahexaenoic acid (DHA), a prebiotic, and probiotic Bifidobacterium animalis subsp. lactis HN019 DR10TM on the micronutrient status, as well as the presence of faecal probiotic and immune markers in pregnant women. Methods and Study Design: This randomised, double-blind, placebo-controlled trial was conducted at Budi Kemuliaan and Cipto Mangunkusumo Hospital in Jakarta from 2013 to 2014. A total of 104 participants were randomly allocated to receive either completely enriched milk powder (intervention group) or iron- and vitamin folic-acid-enriched milk powder (control group). Data were collected using standardised measures and were statistically analysed using the independent t or Mann–Whitney test. Results: At the baseline, the micronutrient status of the participants was acceptable, except for 25-OH-vitamin D, in both the intervention and control groups. Vitamin B-1, zinc, total free fatty acid, linoleic acid, arachidonic acid, and DHA were significantly higher in the intervention group in the second trimester (p=0.014, 0.028, 0.023, 0.014, 0.001, and 0.032, respectively). Interleukin-6 and tumor necrosis factor-α levels did not significantly vary during pregnancy. B. animalis subsp. lactis DR10TM was present in the faeces of the intervention group but not the control group (61.1% vs 0%). Conclusion: Milk fortified with a prebiotic, probiotic, DHA and micronutrients increases the faecal concentration of the organism used for fortification in Indonesian pregnant women. This may represent an improvement in intra-partum maternal gut health.