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

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          Abstract

          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.

          Highlights

          • 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.

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          Most cited references41

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          The medical care costs of obesity: an instrumental variables approach.

          This paper is the first to use the method of instrumental variables (IV) to estimate the impact of obesity on medical costs in order to address the endogeneity of weight and to reduce the bias from reporting error in weight. Models are estimated using restricted-use data from the Medical Expenditure Panel Survey for 2000-2005. The IV model, which exploits genetic variation in weight as a natural experiment, yields estimates of the impact of obesity on medical costs that are considerably higher than the estimates reported in the previous literature. For example, obesity is associated with $656 higher annual medical care costs, but the IV results indicate that obesity raises annual medical costs by $2741 (in 2005 dollars). These results imply that the previous literature has underestimated the medical costs of obesity, resulting in underestimates of the economic rationale for government intervention to reduce obesity-related externalities. Copyright © 2011 Elsevier B.V. All rights reserved.
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            Urbanization in developing countries: Current trends, future projections, and key challenges for sustainability

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                Author and article information

                Contributors
                Journal
                SSM Popul Health
                SSM Popul Health
                SSM - Population Health
                Elsevier
                2352-8273
                18 November 2015
                December 2015
                18 November 2015
                : 1
                : 16-25
                Affiliations
                [0005]Cathie Marsh Institute for Social Research, University of Manchester, Humanities Bridgeford Street Building 2F, Oxford Road, Manchester M13 9PL, United Kingdom
                Author notes
                Article
                S2352-8273(15)00005-1
                10.1016/j.ssmph.2015.10.002
                5757754
                29349117
                bd8cfac5-bb05-4918-bf36-6635b457e3e2
                © 2015 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 3 June 2015
                : 17 October 2015
                : 19 October 2015
                Categories
                Article

                double burden malnutrition,underweight,overweight,indonesia,social determinants,multilevel model,quantile regression

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