The double burden of malnutrition in Indonesia: Social determinants and geographical variations

• We study the double burden of malnutrition in Indonesia using multilevel model.
• Education and income protect Indonesians from being undernourished.
• At the same time, they also increase the likelihood of being overweight.
• Income inequality increases the odds of being both under- and overweight.
• The risk of dual malnutrition is spatially clustered within the islands of Indonesia.

The presence of simultaneous under- and over-nutrition has been widely documented in low- and middle-income countries, but global nutritional research has seen only a few large-scale population studies from Indonesia. We investigate the social determinants as well as the geographical variations of under- and over-nutrition in Indonesia using the largest public health study ever conducted in the country, the National Basic Health Research 2007 (N=645,032). Multilevel multinomial logistic regression and quantile regression models are fitted to estimate the association between nutritional status and a number of socio-economic indicators at both the individual and district levels. We find that: (1) education and income reduce the odds of being underweight by 10–30% but at the same time increase those of overweight by 10–40%; (2) independent from the compositional effect of poverty, income inequality is detrimental to population health: a 0.1 increase in the Gini coefficient is associated with an 8–12% increase in the odds of an individual׳s being both under- and overweight; and (3) the effects that these determinants have upon nutritional status are not necessarily homogeneous along the continuum of body mass index. Equally important, our analysis reveals that there is substantial spatial clustering of areas with elevated risk of under- or over-nutrition across the 17,000-island archipelago. As of 2007, under-nutrition in Indonesia remains a ‘disease of poverty’, while over-nutrition is one of affluence. The income inequality accompanying Indonesia׳s economic growth may aggravate the dual burden of under- and over-nutrition. A more equitable economic policy and a policy that improves living standards may be effective for addressing the double burden.