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24 Jan_Gindo_Keynotes Speach.pdf

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24 Jan_Gindo_Keynotes Speach.pdf

  1. 1. Spatial disparity in nutrition challenges in Indonesia Gindo Tampubolon -University of Manchester United Nations University – Helsinki Jakarta, 24 Jan 2023
  2. 2. DOUBLE BURDEN OF MALNUTRITION Some consequences on productivity and health across the life course
  3. 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. 4. Hanandita & Tampubolon 2015. The double burden of malnutrition in Indonesia: social determinants and geographical variations. Soc Sci Med – Population Health
  5. 5. 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)
  6. 6. 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
  7. 7. 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.
  8. 8. THE LIFE COURSE An organizing frame
  9. 9. 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
  10. 10. 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.
  11. 11. CLIMATE CHANGE AND BIRTHWEIGHT
  12. 12. NASA earth observations of daily temperatures and rainfalls throughout the archipelago to estimate climate change and low birth weight
  13. 13. CHILD MALNUTRITION Stunting and underweight across kabupaten & kota (districts)
  14. 14. 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.
  15. 15. Materials • Indonesia Family Life Survey waves 1, 4 & 5 (up to 22 years) • Survei Sosial Ekonomi Nasional 2014 – 2019
  16. 16. 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
  17. 17. Child malnutrition: stunted/underweight on adult depression
  18. 18. Child malnutrition: stunted/underweight on adult depression
  19. 19. Child malnutrition: stunted/underweight on adult IQ (Raven’s)
  20. 20. Child malnutrition: stunted/underweight on adult IQ (Raven’s)
  21. 21. Child malnutrition: stunted/underweight on adult productivity
  22. 22. Child malnutrition on adult productivity
  23. 23. 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?
  24. 24. 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.
  25. 25. CHILD MALNUTRITION 2018 Stunting and underweight across kabupaten & kota (districts)
  26. 26. Children nutrition status: world vs Indonesia Percentile Height Weight (world) Freq. Percent Freq. Percent 90 - 5,618 7.6 5,349 7.2 10 - 90 29,965 40.7 39,104 53.1 1 - 10 19,729 26.8 19,807 26.9 Below 1st 14,562 19.8 8,216 11.2
  27. 27. ADULT UNDERNOURISHMENT New threats from climate change
  28. 28. FAMILY FOOD INSECURITY New threats from climate change
  29. 29. 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.
  30. 30. 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.

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