Overweight in Indonesia: an observational study of trends and risk factors among adults and children

Association between ultra-processed food consumption, sociodemographic characteristics, malnutrition and obesity among urban school-aged children in Lilongwe, Malawi: a cross-sectional study

INTRODUCTION

The escalating consumption of ultra-processed foods (UPFs) among school-aged children in developing countries poses a significant threat to public health, contributing to the dual burden of malnutrition. In Malawi, where undernutrition coexists with a burgeoning obesity epidemic, understanding the determinants of UPF consumption and its impact on children's nutritional status is imperative. This study, conducted in Lilongwe, Malawi, aimed to investigate the association between UPF consumption, sociodemographic factors and the nutritional status of school-aged children.

MATERIALS AND METHODS

511 children aged 7-14 were recruited from 2 densely populated townships using systematic random sampling. Data on sociodemographic factors, UPF consumption and nutritional status were collected through face-to-face interviews and anthropometric measurements. UPF consumption was assessed using a validated Food Frequency Questionnaire while multinomial logistic regression was employed to analyse associations.

RESULTS

Results revealed alarmingly high UPF consumption among children, particularly those high in sugar. Multinomial logistic regression identified significant predictors of malnutrition outcomes. Notably, children consuming UPFs more than three times a week were more likely to be malnourished. Overweight status was positively associated with sausage intake (β=0.226, adjusted OR 1.254, 95% CI 1.004 to 1.566, p=0.046) and age (β=0.020, adjusted OR=0.257, 95% CI 0.156 to 0.28, p=0.003). Conversely, underweight status was linked with residential location (β=4.507, adjusted OR 0.01, 95% CI 0.000 to 0.281, p=0.006) and fizzy drinks (β=1.071, adjusted OR 2.919, 95% CI 1.413 to 6.028, p=0.004).

CONCLUSION

The high prevalence of UPF consumption among school-aged children is significantly associated with malnutrition. Moreover, sociodemographic factors influence UPF consumption, highlighting the need for targeted interventions to reduce malnutrition. These findings may inform public health policies to mitigate malnutrition among children in Malawi's urban communities.

Associations between food consumption/dietary habits and the risks of obesity, type 2 diabetes, and hypertension: a cross-sectional study in Jakarta, Indonesia

BACKGROUND/OBJECTIVES

This study aimed to assess the current mean daily intake of 10 food groups, analyze the sociodemographic factors associated with food consumption, and determine the associations between food consumption/dietary intake and the prevalence rates of obesity, type 2 diabetes (T2D), and hypertension (HTN) in Jakarta, Indonesia.

SUBJECTS/METHODS

A total of 600 participants aged 20-85 yrs were included in this cross-sectional study. Food consumption and dietary habits were assessed using a food frequency questionnaire. To determine the association between food consumption/dietary habits and the abovementioned diseases, logistic regression analysis was performed.

RESULTS

The average vegetable and fruit intake was lower, while sugar and salt consumption were higher than that recommended by Indonesia's national dietary guidelines. A high intake of ultra-processed foods (UPFs) was associated with young age, men, "single" status, a high education level, and employment with a high monthly income. Obesity and T2D were positively correlated with high intakes of cereals and tubers, UPFs, sugars, fats, and oils. Conversely, an inverse association was found between legume, vegetable, and fruit consumption and obesity risk. An inverse correlation was also observed between vegetable consumption and T2D risk. Moreover, a high salt intake was inversely correlated with fruit consumption in terms of HTN risk. Non-indulgence in habitual late-night snacking and refrainment from consuming more than one dish at each meal were also negatively related to the prevalence of obesity, T2D, and HTN. Inverse correlations were also observed between the prevalence rates of T2D and HTN and abstaining from adding sugar to beverages.

CONCLUSION

Foods high in fat, sugar, and sodium were strongly associated with the risks of obesity, T2D, and HTN. Additionally, poor eating habits were also associated with disease development.

Body Mass Index Asian populations category and stroke and heart disease in the adult population: a longitudinal study of the Indonesia Family Life Survey (IFLS) 2007 and 2014

BACKGROUND

A substantially elevated Body Mass Index (BMI) is one of the largest global modifiable risk factors for stroke and heart diseases. Most studies classify BMI according to the WHO BMI cut-off point in stroke and heart disease studies. However, there is a limited understanding of the association between the BMI cut-off point in the Asian population category and stroke and heart disease. This study aimed to investigate the incidence rate ratio of stroke and heart disease by BMI categories for the Asian population.

METHODS

A 7-year prospective longitudinal study (2007-2014) was conducted on 6,688 adult Indonesian individuals (≥ 35 years) residing across 13 different provinces in Indonesia during the survey periods. Data on BMI were collected in 2007. Information on stroke and heart disease was obtained in both 2007 and in 2014. A multivariate-adjusted Poisson regression model was used to estimate the incidence rate ratio (IRR) and 95% confidence intervals (CIs) of either stroke or heart disease or both stroke and heart disease by BMI.

RESULTS

Among the 6,688 eligible participants, 334 (5%) were judged as stroke and heart disease in 2014. The IRR (95% CI) of stroke and heart disease for participants with obesity was 2.57 (1.64-4.04) compared with those within normal weight. This incidence rate ratio was more pronounced among middle-aged adults (< 55 years) rather than the older adults (≥55 years).The IRR of stroke and heart disease among obese middle-aged adults was 4.18 (95% CI 2.10-8.31).

CONCLUSIONS

An association was observed between obesity and the risk of stroke and heart disease, especially in middle-aged adults. These findings suggest that lowering BMI through the adoption of healthy dietary habits and increasing physical activity, particularly among middle-aged adults with high education, occupational employment, and residence in either urban or rural areas, may be beneficial for preventing stroke and heart disease.

Factors associated with overweight/obesity of children aged 6-12 years in Indonesia

BACKGROUND

Globally, the prevalence of childhood obesity has increased considerably, including in Indonesia. Obesity results from multifactorial interactions at the personal, familial, and environmental levels. However, little is known about the factors associated with overweight/obesity among children in Indonesia. This study is intended to identify personal, familial, and environmental factors associated with overweight/obesity in children aged 6-12 years in Indonesia.

METHODS

Study design was a secondary data analysis using the Indonesia Family Life Survey in 2014/2015, focusing on 6,090 children aged 6-12 years. The questions covered the child's body mass index and potential personal, familial, and environmental factors. Logistic regression analysis was performed to identify the personal, familial, and environmental factors.

RESULTS

The mean age of participants was 8.9 years (SD = 2.0); 51.0% were boys; 9.4% were overweight; and 8.1% were obese. Overweight and obesity were associated with age [AOR 1.09 (95% CI 1.04-1.14)], having an overweight [AOR 1.93 (95% CI 1.58-2.36)] or obese [AOR 3.36 (95% CI 2.43-4.61)] father compared with a normal father, being of Chinese [AOR 9.51 (95% CI 1.43-79.43)] or Javanese [AOR 1.60 (95% CI 1.16-2.24)] ethnicity compared with Sundanese ethnicity, and residing in an urban area [AOR 1.36 (95% CI 1.10-1.70)]. A lower risk of child overweight/obesity was associated with the father's perception [AOR 0.56 (95% CI 0.38-0.80)] and mother's perception [AOR 0.66 (95% CI 0.43-0.98)] of the child's food consumption as being less than adequate compared with adequate.

CONCLUSIONS

Risk factors in children for overweight/obesity were older age, having an overweight/obese father, membership of certain ethnic groups, and urban residence. The main protective factor was parents' perception that a child's food consumption was less than adequate. Health promotion programs focused on these factors could help control or prevent childhood obesity in Indonesia.

Does urbanisation lead to unhealthy diets? Longitudinal evidence from Indonesia

Urbanization is generally believed to contribute to dietary patterns that increase the risk of non-communicable disease (NCD). However, empirical evidence using nuanced measures of urbanization and longitudinal data is limited. This study examines the link between urbanization and dietary patterns in Indonesia, the largest country in Southeast Asia, between 2000 and 2015. Results show that urbanisation is associated with dietary patterns conducive to increased NCD risk-for example, high in soft drinks and ultra-processed foods-but also with higher consumption of healthier foods such as vegetables and fish. Results highlight important non-linearities and draw attention to the need to refrain from generalizations about the effect of urbanization on nutritional health.

Behavioural and environmental risk factors associated with primary schoolchildren's overweight and obesity in urban Indonesia

OBJECTIVES

To aid the design of nutrition interventions in low- and middle-income countries undergoing a nutrition transition, this study examined behavioural and environmental risk factors associated with childhood overweight and obesity in urban Indonesia.

DESIGN

Body height and weight of children were measured to determine BMI-for-age Z-scores and childhood overweight and obesity status. A self-administered parental survey measured socio-economic background, children's diet, physical activity, screen time and parental practices. Logistic and quantile regression models were used to assess the association between risk factors and the BMI-for-age Z-score distribution.

SETTING

Public primary schools in Central Jakarta, sampled at random.

PARTICIPANTS

Children (n 1674) aged 6-13 years from 18 public primary schools.

RESULTS

Among the children, 31·0 % were overweight or obese. The prevalence of obesity was higher in boys (21·0 %) than in girls (12·0 %). Male sex and height (aOR = 1·67; 95 % CI 1·30, 2·14 and aOR = 1·16; 95 % CI 1·14, 1·18, respectively) increased the odds of being overweight or obese, while the odds reduced with every year of age (aOR = 0·43; 95 % CI 0·37, 0·50). Maternal education was positively associated with children's BMI at the median of the Z-score distribution (P = 0·026). Dietary and physical activity risk scores were not associated with children's BMI at any quantile. The obesogenic home food environment score was significantly and positively associated with the BMI-for-age Z-score at the 75th and 90th percentiles (P = 0·022 and 0·023, respectively).

CONCLUSIONS

This study illustrated the demographic, behavioural and environmental risk factors for overweight and obesity among primary schoolchildren in a middle-income country. To foster healthy behaviours in primary schoolchildren, parents need to ensure a positive home food environment. Future sex-responsive interventions should involve both parents and children, promote healthy diets and physical activity and improve food environments in homes and schools.

Trends in BMI of Indonesian adults between 1993 and 2014: a longitudinal population-based study

OBJECTIVE

To examine the trajectories of BMI in Indonesian adults from 1993 to 2014, investigating different patterns by sex and birth cohort.

DESIGN

Longitudinal study: secondary data analysis of the Indonesian Family Life Survey, a large-scale population-based longitudinal study, had their height and weight measured up to five times throughout the 21-year study period (1993-2014). The change in BMI across time was estimated using group-based trajectory models, then differences by sex and birth cohort were investigated using random effect (mixed) models.

SETTING

Thirteen out of twenty-seven provinces in Indonesia.

PARTICIPANTS

Indonesian adults aged 19 years and older (n 42 537) were included in the analysis.

RESULTS

Mean BMI in adults increased between 1993 (21·4 kg/m2) and 2014 (23·5 kg/m2). The group-based trajectory model found three distinct groups with mean BMI increasing more rapidly in the most recent time periods. The first group (56·7 % of participants) had a mean BMI entirely within the normal weight range; the second group (34·7 %) started in the normal weight category and were obese, on average by the end of the study period; and the third group (8·6 %) were always in the obese category, on average. The shape of these three trajectories differed by gender (P < 0·001) and birth cohort (P < 0·001).

CONCLUSIONS

The mean BMI among Indonesian adults has increased between 1993 and 2014, driven by those in the most recent birth cohorts. Our findings support the urgent need for targeted overweight and obesity prevention and intervention programmes in Indonesia.

Maternal and Child Health handbook and under-6 child overweight in greater Jakarta, Indonesia: a cross-sectional web-based survey

BACKGROUND

In Indonesia, the double burden of child overnutrition and undernutrition is a public health concern. The nationally distributed Maternal and Child Health (MCH) handbook provides child nutrition information to caregivers. We aimed to find mothers' information sources regarding child nutrition, including the internet and the MCH handbook, and to explore the association between overweight and use of the MCH handbook.

METHOD

A cross-sectional web-based survey was conducted among mothers with children under 6 years old in Greater Jakarta during 2019. Bivariate and multivariate logistic regression examined the association between child nutrition status and use of the MCH handbook.

RESULTS

Data were collected from 233 children. Overweight, underweight, wasting, and stunting were identified in 36.4%, 22.6%, 26.8%, and 37.6%, respectively. 62.5% of mothers used the MCH handbook, and 88.2% used the internet via a mobile phone. Significantly more cases of overweight were observed among children whose mothers used the MCH handbook (adjusted OR [aOR]: 5.829; 95% Confidential Interval [CI]: 1.618-20.999) whereas no relationship was observed between MCH handbook use and child undernutrition. Significant associations with child overweight were found for mother's education (tertiary) (aOR: 0.294; 95%CI: 0.098-0.885), employment type (fulltime) (aOR: 0.185; 95%CI: 0.061-0.562), watching television (more than 1 h) (aOR: 4.387; 95%CI: 1.648-11.678) and recognition of child overweight by mother (yes) (aOR: 3.405; 95%CI: 1.05-11.03).

CONCLUSION

These results indicate the need to support mothers of children exhibiting overnutrition and undernutrition. The MCH handbook should be modified to address this issue.

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study

Aims

To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia.

Methods

In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40-80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables.

Results

The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51-2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07-1.96) and inpatient care (AOR 1.45, 95% CI: 1.07-1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21-2.28), and have lower labor participation (AOR: 0.24, 95% 0.20-0.28).

Conclusions

Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

The urgency in proposing the optimal obesity cutoff value in Indonesian population: A narrative review

In developing nations such as Indonesia, obesity and central obesity have emerged as major public health issues. Many studies have revealed that morbidity and death from obesity-related diseases are already significant in some "Asian" communities at low body mass index (BMI) levels. A recent study showed that the obesity prevalence in Indonesia is underestimated when using the current BMI cutoff (obese ≥ 27.0). Indonesia faced an increase in obesity-related chronic diseases despite having a lower obesity prevalence than developed countries, which may be explained by the underestimation of obesity levels in Indonesia. This creates a huge global health problem, as well as an economic burden. Another recent study on the Indonesian population depicted the new proposed cutoff of waist circumference (WC), which is lower than the World Health Organization (WHO) standard for detecting the early detection of type 2 diabetes mellitus (T2DM), one of the comorbidities and a strong correlation with obesity. An analysis of 58 studies in 2021 that included Indonesian adult subjects revealed enormous differences and ambiguities in defining obesity cutoffs values among Indonesian researchers. Additionally, we advocate adding the Edmonton Obesity Staging System (EOSS) staging to the anthropometric classification for a better clinical evaluation of obesity. Considering the urgency of obesity determination in Indonesia for clinical application and study purposes, this review highlights the need to revise the optimal cutoff value for obesity to warrant early prevention and control of diabetes complications.

IoT Framework for a Decision-Making System of Obesity and Overweight Extrapolation among Children, Youths, and Adults

Approximately 30% of the global population is suffering from obesity and being overweight, which is approximately 2.1 billion people worldwide. The ratio is expected to surpass 40% by 2030 if the current balance continues to grow. The global pandemic due to COVID-19 will also impact the predicted obesity rates. It will cause a significant increase in morbidity and mortality worldwide. Multiple chronic diseases are associated with obesity and several threat elements are associated with obesity. Various challenges are involved in the understanding of risk factors and the ratio of obesity. Therefore, diagnosing obesity in its initial stages might significantly increase the patient’s chances of effective treatment. The Internet of Things (IoT) has attained an evolving stage in the development of the contemporary environment of healthcare thanks to advancements in information and communication technologies. Therefore, in this paper, we thoroughly investigated machine learning techniques for making an IoT-enabled system. In the first phase, the proposed system analyzed the performances of random forest (RF), K-nearest neighbor (KNN), support vector machine (SVM), decision tree (DT), logistic regression (LR), and naïve Bayes (NB) algorithms on the obesity dataset. The second phase, on the other hand, introduced an IoT-based framework that adopts a multi-user request system by uploading the data to the cloud for the early diagnosis of obesity. The IoT framework makes the system available to anyone (and everywhere) for precise obesity categorization. This research will help the reader understand the relationships among risk factors with weight changes and their visualizations. Furthermore, it also focuses on how existing datasets can help one study the obesity nature and which classification and regression models perform well in correspondence to others.

Analysing 11 years of incidence trends, clinicopathological characteristics, and forecasts of colorectal cancer in young and old patients: a retrospective cross-sectional study in an Indonesian national referral hospital

OBJECTIVE

To obtain annual incidence trends, understand clinicopathological characteristics, and forecast the future burden of colorectal cancer (CRC) in Indonesia.

DESIGN

11-year retrospective cross-sectional study.

SETTING

A national referral hospital in Jakarta, Indonesia.

PARTICIPANTS

Data from 1584 eligible cases were recorded for trends and forecasting analyses; 433 samples were analysed to determine clinicopathological differences between young (<50 years) and old (≥50 years) patients.

METHODS

Trend analyses were done using Joinpoint software, expressed in annual percentage change (APC), and a regression analysis was executed to generate a forecasting model. Patients' characteristics were compared using χ2 or non-parametric tests.

MAIN OUTCOMES

Analysis of trends, forecasting model, and clinicopathological features between the age groups.

RESULTS

A significant increase in APC was observed among old patients (+2.38%) for CRC cases. Colon cancer increased remarkably (+9.24%) among young patients; rectal cancer trends were either stable or declining. The trend for right-sided CRC increased in the general population (+6.52%) and old patients (+6.57%), while the trend for left-sided CRC was stable. These cases are expected to be a significant health burden within the next 10 years. Patients had a mean age of 53.17±13.94, 38.1% were young, and the sex ratio was 1.21. Prominent characteristics were left-sided CRC, tumour size ≥5 cm, exophytic growth, adenocarcinoma, histologically low grade, pT3, pN0, inadequately dissected lymph nodes (LNs), LN ratio <0.05, no distant metastasis, early-stage cancer, no lymphovascular invasion, and no perineural invasion (PNI). Distinct features between young and old patients were found in the histological subtype, number of dissected LN, and PNI of the tumour.

CONCLUSIONS

Epidemiological trends and forecasting analyses of CRC cases in Indonesian patients showed an enormous increase in colon cancer in young patients, a particularly concerning trend. Additionally, young patients exhibited particular clinicopathological characteristics that contributed to disease severity.

Complementary Feeding Practices among Young Children in China, India, and Indonesia: A Narrative Review

Under- and overnutrition are co-existing health issues in several countries across Asia. Poor complementary feeding (CF) is a significant determinant of malnutrition in children and a major cause of morbidity and mortality. The purpose of this narrative review is to summarize the most recent evidence regarding the CF practices in 3 countries with a high prevalence of stunting and overweight, and currently undergoing rapid economic and nutritional transition: China, India, and Indonesia. We focused particularly on the adequacy of CF, based on the WHO feeding indicators (2021) regarding timing, frequency, diversity, as well as the consumption of specific food groups. According to the findings, the majority of infants in the 3 countries are introduced to CF at an inappropriate time: either too early (particularly in urban/rural areas of China and Indonesia) or too late (India) compared with the WHO recommendation. Furthermore, in all countries, diets are characterized by a low variety and frequency of CF and consist mainly of staple foods with poor nutritional quality, such as rice, cereals, or noodles. Nutrient-dense and protein-rich foods, such as foods of animal origin, are either inadequately consumed (rural areas of China and India) or introduced too late (urban areas of China and Indonesia) in the diets of children. In all countries, the consumption of fruit and vegetables, especially during the early CF period, is poor. In contrast, a significant proportion of both urban and rural children, particularly in Indonesia and India, are consuming energy-dense/nutrient-poor snacks and sugary drinks during the CF period. The described practices may pose a significant risk for the development of energy and/or nutrient gaps, magnifying the double and triple burden of malnutrition present in these countries. Further research is warranted to understand the significance of the observed practices for stunting and/or overweight/obesity risk.

Shifting educational gradients in body mass index trajectories of Indonesians: an age period cohort analysis

Background

Globally, the number of obese adults has increased rapidly in many developing countries. The links between increased educational attainment and lower risks of overweight/obesity have been studied in a number of high-income contexts. However, educational attainment can have a different association with obesity at different levels of economic development and different stages of the nutritional transition, and these associations may vary by period and cohort. This study aims to provide evidence on the shifting of educational gradients in overweight/obesity in Indonesia, a low middle income country.

Methods

Using five waves of Indonesian Family Life Survey (IFLS), this study examines the Body Mass Index (BMI) trajectories of 14,810 individuals from 1993 to 2014. This study analyses how educational gradients in BMI have shifted over time and across cohorts using a hierarchical age-period-cohort (HAPC) model to account for the effects of age and the changes in historical periods (social and environmental contexts).

Results

In older generations, higher educational attainment is associated with higher BMI, but the gap between educational groups shrinks in more recently-born cohorts. The BMI of lower educational groups is catching up with that of the tertiary educated, leading to an increased risk of overweight/obesity among low educated individuals. Having tertiary education lowers the risk of weight gain (-0.04 point) among recently-born cohort of women, but it still increases the risk (+ 0.04 point) for men.

Conclusion

Changes in access to education and the ongoing nutritional transition in Indonesia are leading to a shifting of educational gradients in overweight/obesity over time. The rising trends in BMI among low-educated and younger individuals are of substantial concern for Indonesian public health due to their implications for the risk of communicable and non-communicable diseases in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13379-3.

Prevalence and associated factors of overweight and obesity among primary school children: a cross-sectional study in Thanhhoa City, Vietnam

OBJECTIVE

To determine the prevalence and associated factors of overweight and obesity among primary school children (6-11 years old) in Thanhhoa city in 2021.

DESIGN

Cross-sectional study.

SETTING

Seven primary schools in Thanhhoa city, Vietnam.

PARTICIPANTS

782 children (and their parents).

PRIMARY AND SECONDARY OUTCOME MEASURES

Two-stage cluster random sampling was used for selecting children and data were collected from January to February 2021. A self-administrated questionnaire was designed for children and their parents. Children's height and weight were measured and body mass index (BMI)-for-age z-scores were computed using the WHO Anthro software V.1.0.4. Data were analysed using R software V.4.1.2. The associations between potential factors and childhood overweight/obesity were analysed through univariate and multivariate logistic regression analyses. Variables were selected using the Bayesian Model Averaging method.

RESULTS

The prevalence of overweight/obesity among primary school children in Thanhhoa city was 35.93% (overweight 21.61% and obesity 14.32%). The proportion of overweight girls was nearly equal to that of boys (20.78% and 22.52%, respectively, p=0.6152) while the proportion of boys with obesity was four times as many as that of girls (23.86% and 5.62%, respectively, p<0.0001). Child's sex was the factor significantly associated with childhood overweight/obesity. Boys had double the risk of being overweight/obese than girls (adjusted OR: aOR=2.48, p<0.0001). Other potential factors which may be associated with childhood overweight/obesity included mode of transport to school, the people living with the child, mother's occupation, father's education, eating confectionery, the total time of doing sports, and sedentary activities.

CONCLUSION

One in every three primary school children in Thanhhoa city were either overweight or obese. Parents, teachers and policy-makers can implement interventions in the aforementioned factors to reduce the rate of childhood obesity. In forthcoming years, longitudinal studies should be conducted to determine the causal relationships between potential factors and childhood overweight/obesity.

Evidence-Based Nutrition Interventions Improved Adolescents' Knowledge and Behaviors in Indonesia

Adolescence is a nutritionally vulnerable and critical life stage. However, few programs and policies focus on improving adolescent nutrition in Indonesia. To address this gap, we implemented a gender-responsive package of interventions: (1) breakfast and weekly iron-folic acid supplementation (WIFS), (2) a school-based nutrition education program, and (3) a social behavior change communication strategy. We surveyed 514 adolescents at baseline (2019) and endline (2020) in Klaten and Lombok Barat districts in Indonesia. The survey included a knowledge assessment on nutrition, as well as indicators of attitudes and behaviors on diet, physical activity, and WIFS. We employed multivariable linear and logistic regression to test for pre–post intervention differences. Overall knowledge was significantly higher post-intervention (β: 3.3; 95% confidence interval [CI]: 2.6, 3.9). Diet diversity was high at both timepoints, however, at post-intervention there was significantly higher odds of consuming vitamin A-rich fruits and vegetables (Odds Ratio [OR]: 1.5; 95% CI: 1.1, 2.0) and lower odds of consuming sugar-sweetened beverages (OR: 0.4; 95% CI: 0.3, 0.5). Post-intervention, there was higher odds of reporting 60 min of daily physical activity (OR: 2.3; 95% CI: 1.7, 3.2) and WIFS among girls (OR: 6.7; 95% CI: 1.5, 30.9). The package of interventions may be a promising first step to improving adolescent nutrition in Indonesia.

Toward a Sustainable Food System in West Papua, Indonesia: Exploring the Links Between Dietary Transition, Food Security, and Forests

Natural tropical forests cover 89% of the land area of West Papua Province, Indonesia. Forests have traditionally been an important part of local food systems for Indigenous Papuans. Despite the contribution of forests to food security, West Papua has been ranked as one of the most food-insecure provinces in Indonesia, with high rates of both under-and-overnutrition. This paper aims to discuss the dietary transition taking place in West Papua and uses local perspectives to explore the link between changes in diets, food security, and forests. We used mixed methods with a triangulation design to corroborate the quantitative data that we present from two rounds of the National Socioeconomic Survey (SUSENAS) on food consumption for West Papua from 2008 and 2017, with information from four focus group discussions with institutional and local stakeholders. The quantitative analysis showed that West Papua is experiencing a dietary transition, moving away from the consumption of traditional foods, such as sago, tubers, wild meat, and fresh legumes, toward diets with more rice, chicken, tofu, and tempeh. The consumption of processed and ultra-processed food (UPF) has increased while the consumption of fresh food has decreased. The qualitative analysis confirmed these findings. The institutional stakeholders expressed a desire for Papuans to return to eating traditional diets for better food security, whereas the local stakeholders worried about their children's high consumption of UPFs. We also found a disconnect between how food security is measured by the national Food Security Index (FSI) and the point of view of the institutional stakeholders. While the FSI indicators are more infrastructure-related measures, the institutional stakeholders link food security with the availability, accessibility, stability, and sustainability of the food sources in their surrounding environment, especially the forests. The institutional stakeholders support the commitment of the provincial government to maintain at least 70% of the forest cover in West Papua, as stated in the Manokwari Declaration although they expressed the need for more clarity on how this will impact their food security. The Indonesian government and the international community should support this initiative and carry it out with substantial input from local Papuan stakeholders.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta

BACKGROUND

Childhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia.

METHODS

A qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students.

RESULTS

Among the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited.

CONCLUSIONS

This study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

Gender Differences in Comorbidities and Attitudes Regarding Weight Control among Young Adults with Obesity in Korea

INTRODUCTION

Obesity in young adulthood increases the risk for premature death, and the prevalence of obesity rapidly increasing among young adults, particularly in young men. We evaluated the gender differences in accompanying comorbidities and attitudes regarding weight control among young Korean adults with obesity.

MATERIALS AND METHODS

We analyzed 2,050 young adults with obesity (1,325 men and 725 women) in the 7th KNHANES (2016-2018) aged 19-44 years, with body mass indexes (BMIs) ≥25.0 kg/m2. The odds ratios (ORs) and 95% confidence intervals (CIs) for poor lifestyle factors and accompanying illnesses as well as self-perceived weight status, weight control efforts, and weight control strategies in men compared to those in women were calculated by multivariate logistic regression analysis.

RESULTS

The mean BMIs and waist circumferences were 28.2 ± 0.1 kg/m2 and 93.6 ± 0.2 cm and 28.6 ± 0.1 kg/m2 and 88.7 ± 0.4 cm, in men and women, respectively. The ORs and 95% CIs for abdominal obesity (1.52, 1.11-2.07), hypertension (3.11, 2.20-4.40), hypercholesterolemia (1.45, 1.09-1.93), hypertriglyceridemia (3.37, 2.38-4.78), and elevated alanine transaminase concentration (6.53, 4.56-9.36) were higher in young men compared to those in young women. Despite the higher prevalences of comorbid conditions, the odds of inappropriate weight perception (8.13, 4.17-15.86), lack of weight control efforts (2.20, 1.71-2.84), lack of diet therapy (1.56, 1.13-2.16), lack of pharmacotherapy (13.27, 6.82-25.79), heavy drinking (1.32, 1.02-1.72), current smoking (6.92, 5.00-9.59), and frequent eating out (4.38, 3.35-5.71) were higher among men. However, the odds of not engaging in exercise (0.48, 0.35-0.64) were lower among men compared to that in women.

DISCUSSION

Despite their higher prevalences of comorbidities, appropriate weight perception and weight control efforts are insufficient in young men with obesity. These gender differences should be considered to provide tailored programs for weight reduction in young adults with obesity.

Built environment as a risk factor for adult overweight and obesity: Evidence from a longitudinal geospatial analysis in Indonesia

Indonesia has nearly doubled its urban population in the past three decades. In this period, the prevalence of overweight and obesity in Indonesia has also nearly doubled. We examined 1993-2014 panel data from the Indonesian Family Life Survey (IFLS) to determine the extent to which the increase in one's built environment contributed to a corresponding increase in adult overweight and obesity during this period. We estimated longitudinal regression models for body mass index (BMI) and being overweight or obese using novel matched geospatial measures of built-up land area. Living in a more built-up area was associated with greater BMI and risk of being overweight or obese. The contribution of the built environment was estimated to be small but statistically significant even after accounting for individuals' initial BMI. We discuss the findings considering the evidence on nutritional and technological transitions affecting food consumption patterns and physical activity levels in urban and rural areas.

Crisis of the Asian gut: associations among diet, microbiota, and metabolic diseases

The increase of lifestyle-related diseases in Asia has recently become remarkably serious. This has been associated with a change in dietary habits that may alter the complex gut microbiota and its metabolic function in Asian people. Notably, the penetration of modern Western diets into Asia, which has been accompanied by an increase in fat content and decrease in plant-derived dietary fiber, is restructuring the Asian gut microbiome. In this review, we introduce the current status of obesity and diabetes in Asia and discuss the links of changes in dietary style with gut microbiota alterations which may predispose Asian people to metabolic diseases.

Balancing a sustained pursuit of nutrition, health, affordability and climate goals: exploring the case of Indonesia

BACKGROUND

To guide the transformation of food systems to provide for healthy and sustainable diets, countries need to assess their current diet and food supply in comparison to nutrition, health, affordability, and environmental goals.

OBJECTIVES

We sought to compare Indonesia's food utilization to diets optimized for nutritional value and cost and to diets that are increasingly plant-based in order to meet further health and environmental goals, including the EAT-Lancet planetary health diet, to explore whether multiple goals could be achieved simultaneously.

METHODS

We compared 13 dietary scenarios (2 current, 7 optimized, 3 increasingly plant-based, 1 EAT-Lancet) for nutrient content, cost, greenhouse gas emissions (GHGe), and water footprints, using the FAO food balance sheet, Indonesia Household Income and Expenditure Survey household food expenditure, food composition, life cycle assessment, food losses, and trade data.

RESULTS

The diversity of modeled scenarios was higher than that of current consumption, reflecting nutritional deficiencies underlying Indonesia's burden of different forms of malnutrition. Nutrient intake targets were met best by nutrient- and cost-optimized diets, followed by the EAT-Lancet diet. Those diets also had high GHGe, although less than 40% of a scenario in which Indonesia would adopt a typical high-income country's diet. Only the low food chain diet had a GHGe below the 2050 target set by the EAT-Lancet commission. Its nutrient content was comparable to that of a no-dairy diet, slightly above those of fish-and-poultry and current diets, and somewhat below those of the EAT-Lancet diets. To meet nutrient needs, some animal-source foods had to be included. Costs of all except the optimized diets were above the current national average food expenditure. No scenario met all goals simultaneously.

CONCLUSIONS

Indonesia's consumption of rice and unhealthy foods should decrease; food production, trade, and processing should prioritize diversification, (bio)fortification, and limiting environmental impacts; and consumer and institutional demands for healthy, nutritious, and sustainable foods should be stimulated. More granular data and tools are required to develop and assess more detailed scenarios to achieve multiple goals simultaneously.

The double burden of malnutrition and dietary patterns in rural Central Java, Indonesia

Background

Indonesia is undergoing a nutrition transition (NT) comprised of rising rates of overweight/obesity and consumption of high fat food/snacks but is still struck by undernutrition, causing a double burden of malnutrition. Little research pertains to the double burden of malnutrition and its associations with diet in rural Indonesia using primary village level data.

Methods

We conducted a 24-hour food recall and food frequency questionnaire and assessed anthropometric status of rural villagers from four villages in Central Java, Indonesia. Exploratory principal component analysis was used to identify dietary patterns and multi-level modeling was performed to identify variables associated with dietary pattern indicative of the NT.

Findings

1,521 participants were included in analysis. Double burden of malnutrition was prevalent whereby 32.3% of children were stunted, 68.8% of women 35–49 years-old were overweight, and 39% of homes were classified as double burden. The NT was evident in a dietary pattern associated with soft drink, snacks, and animal products. There was small but significant correlation between undernutrition and stunting status among children (r = −0.139, p < 0.01). The NT was associated with young age (B = 1.696, 95% CI = 1.508–1.885) but not with overweight (B = −0.099, 95% CI = −0.184–−0.013).

Interpretation

Our findings suggest that whilst the typical pattern of the double burden of malnutrition (stunted child/overweight adult) exists in rural Central Java, dietary patterns indicative of the NT are predominant among children, not adults. Overweight among adults may not be necessarily due to a diet indicative of the NT, and nutrition interventions in rural Central Java should focus on educating parents of young children about the health-risks of a diet associated with a NT.

Funding

Funding was obtained from the UBS-Optimus Foundation and the National Health and Medical Research Council.

Sugar content and nutrient content claims of growing-up milks in Indonesia

'Growing-up milks' (GUMs)-breast-milk substitutes targeted for young children (aged 12-36 months)-are commonly consumed in Indonesia. The World Health Assembly has stated that GUMs are not necessary for proper growth and development, and recently, the American Academy of Pediatrics declared that such products are not recommended for young children due to their common use of sweeteners. To contribute to the evidence base on the composition of GUMs and their appropriateness for young child diets, this cross-sectional study documented the declared sugar content and presence of nutrient content claims of 99 GUMs newly launched in Indonesia between January 2017 and May 2019. Sugar content was evaluated against the draft 2018 Codex Alimentarius Standard for Follow-Up Formula guidance on sugar content and the United Kingdom Food Standard Agency's front-of-pack (UK FSA FOP) colour coding system for sugar. Almost all (97%) GUMs contained one or more added sugars. None of the products were fully compliant with all three sugar content recommendations in the draft Codex standard. Seventy-one per cent of GUMs were determined to have high sugar content according to the UK FSA FOP system. Nutrient content claims were found on 97% of GUMs. Median total sugar content was 7.3 g per 100 ml, similar to sugar content levels in sugar-sweetened beverages. Many GUMs available in Indonesia claim to offer nutritional benefits; however, the current levels of sugar content in GUMs are a serious concern and are inappropriate for inclusion in the diets of young children.

Snacks, nudges and asymmetric peer influence: Evidence from food choice experiments with children in Indonesia

Many children in low- and middle-income countries are growing up during a rapid nutrition transition. Experimental evidence on food choice in developing countries is scarce, while it is unclear to what extent evidence from high-income countries can be generalized. Children participated in a snack choice experiment. We expose some children to emoji labels encouraging healthy snacks, while others observe healthy or unhealthy snacking by peers. While emoji labels moderately promote healthy snacking, the adverse effect of observing a peer eating the unhealthy snack is very large. The effect associated with observing a healthy peer is insignificant. Additionally, cross-randomized blocks of children watched a nutrition video to study the interaction of information provision and nudging. The video independently improves healthy choices but does not aid the emoji nudge and cannot counter the strong negative peer effect. We compare our findings to studies conducted in developed countries and discuss policy implications.

Association between television viewing and overweight and obesity among women of reproductive age in Timor-Leste: evidence from the demographic health survey 2016

OBJECTIVE

This study aimed to assess the possible relationship between television viewing and overweight and obesity among Timorese women of reproductive age.

METHODS

This cross-sectional study analysed the Timor-Leste Demographic and Health Survey 2016 dataset. A weighted sample of 11 398 Timorese women aged 15-49 years was chosen using a two-stage stratified random sampling technique. Asian criteria-based body mass index (BMI) cut-offs were used to define overweight (BMI 23.0 to <27.5 kg/m²) and obesity (BMI ≥27.5 kg/m²). Frequency of TV viewing was categorised into three groups: (1) not at all, (2) less than once a week and (3) at least once a week. Multilevel ordered logistic regression was performed to identify the correlates of overweight and obesity. Both crude and adjusted odds ratios (AOR) along with a 95% CI were calculated to show the strength of association.

RESULTS

Among 11 398 respondents, 19.4% were overweight or obese (overweight: 15.7% and obese: 3.8%). Although about half of the respondents reportedly did not watch TV at all, just over two-thirds watched TV at least once a week. Women who watched TV at least once a week were found to have 1.3 times the odds of being overweight or obese compared with those who never watched TV (AOR: 1.3, 95% CI: 1.1 to 1.5; p<0.001). However, when stratified by settlement type, the statistical significance stood for the rural women only (AOR: 1.5, 95% CI: 1.2 to 1.8; p<0.001), after adjusting for the covariates.

CONCLUSION

Watching TV at least once a week was found to be a significant correlate of overweight and obesity in rural Timorese women of reproductive age. Further studies need to be undertaken to assess physical activity, sedentary and dietary patterns to clarify the possible mechanism through which TV viewing may influence BMI in those groups.

Predicting Obesity in Adults Using Machine Learning Techniques: An Analysis of Indonesian Basic Health Research 2018

Obesity is strongly associated with multiple risk factors. It is significantly contributing to an increased risk of chronic disease morbidity and mortality worldwide. There are various challenges to better understand the association between risk factors and the occurrence of obesity. The traditional regression approach limits analysis to a small number of predictors and imposes assumptions of independence and linearity. Machine Learning (ML) methods are an alternative that provide information with a unique approach to the application stage of data analysis on obesity. This study aims to assess the ability of ML methods, namely Logistic Regression, Classification and Regression Trees (CART), and Naïve Bayes to identify the presence of obesity using publicly available health data, using a novel approach with sophisticated ML methods to predict obesity as an attempt to go beyond traditional prediction models, and to compare the performance of three different methods. Meanwhile, the main objective of this study is to establish a set of risk factors for obesity in adults among the available study variables. Furthermore, we address data imbalance using Synthetic Minority Oversampling Technique (SMOTE) to predict obesity status based on risk factors available in the dataset. This study indicates that the Logistic Regression method shows the highest performance. Nevertheless, kappa coefficients show only moderate concordance between predicted and measured obesity. Location, marital status, age groups, education, sweet drinks, fatty/oily foods, grilled foods, preserved foods, seasoning powders, soft/carbonated drinks, alcoholic drinks, mental emotional disorders, diagnosed hypertension, physical activity, smoking, and fruit and vegetables consumptions are significant in predicting obesity status in adults. Identifying these risk factors could inform health authorities in designing or modifying existing policies for better controlling chronic diseases especially in relation to risk factors associated with obesity. Moreover, applying ML methods on publicly available health data, such as Indonesian Basic Health Research (RISKESDAS) is a promising strategy to fill the gap for a more robust understanding of the associations of multiple risk factors in predicting health outcomes.

Faculty Service-Learning Students as Home-Visitors: Outcomes of a Lifestyle Modification Program for Vulnerable Families With Residents in Rural Indonesian Communities

Background: Risks attributed to chronic diseases, cancer, musculoskeletal discomfort, and infectious diseases among Indonesians were found to be associated with lifestyle behaviors, particularly in rural areas. The aim of this study was to examine the outcomes of a home-visiting lifestyle modification program on improving health risk behaviors among Indonesians living in rural areas. Methods: A total of 160 Indonesians living in rural hamlets in the Yogyakarta Region of Indonesia participated in the program in the period of June 21 to July 21, 2019. In the pre-intervention home interview, learning needs of diet, exercise, hand hygiene, and substance use were identified by using structured assessment tools. In the next home visit, the visitors provided health education and facilitated lifestyle planning based on the related affective and cognitive domains of learning. Subsequent follow-up interviews were conducted 3 weeks after intervention. Results: The results showed that the self-reported intake of vegetables, fruits, meat and salt, cooking with less oil, hand hygiene before eating, number of cigarettes smoked, and symptoms of muscle stiffness significantly improved after the intervention. The lifestyle modification program consisted of the affective and cognitive domains of learning, and could lead to the target behavioral changes in self-reported and observable measures over 1 month. Conclusions: The findings contributed to the framework of community-based health education for health risk reduction and behavioral modification in developing rural communities where health care resources were limited. Further studies with control groups and vigorous objective measures were recommended to elucidate its long-term impacts. The factors leading to its sustainability concerning collaborative care partnerships between community residents and faculty resources are worthy of continued exploration.

Gut Microbiome of Indonesian Adults Associated with Obesity and Type 2 Diabetes: A Cross-Sectional Study in an Asian City, Yogyakarta

Indonesia is a developing country facing the national problem of the growing obesity and diabetes in its population due to recent drastic dietary and lifestyle changes. To understand the link between the gut microbiome, diet, and health of Indonesian people, fecal microbiomes and metabolomes of 75 Indonesian adults in Yogyakarta City, including obese people (n = 21), type 2 diabetes (T2D) patients (n = 25), and the controls (n = 29) were characterized together with their dietary and medical records. Variations of microbiomes showed a triangular distribution in the principal component analysis, driven by three dominant bacterial genera, namely Bacteroides, Prevotella, and Romboutsia. The Romboutsia-driven microbiome, characterized by low bacterial diversity and high primary bile acids, was associated with fat-driven obesity. The Bacteroides-driven microbiome, which counteracted Prevotella but was associated with Ruminococcaceae concomitantly increased with high-carbohydrate diets, showed positive correlation with T2D indices but negative correlation with body mass index. Notably, Bacteroides fragilis was increased in T2D patients with a decrease in fecal conjugated bile acids, particularly tauroursodeoxycholic acid (TUDCA), a farnesoid X receptor (FXR) antagonist with anti-diabetic activity, while these features disappeared in patients administered metformin. These results indicate that the gut microbiome status of Indonesian adults is differently associated with obesity and T2D under their varied dietary habits.

The relationship between malnutrition and TH 2 immune markers: a study in school-aged children of different socio-economic backgrounds in Makassar, Indonesia

OBJECTIVE

The burden of underweight remains a major problem in Indonesia, and at the same time, the prevalence of overweight is increasing. Malnutrition is a major determinant of health and has been linked to allergic disorders in children. We examined the relationship between malnutrition and TH 2 immune markers in school-aged children in Makassar, Indonesia.

METHODS

A cross-sectional study was performed in five schools where socio-demographic characteristics were recorded. Children's standardised z-scores of body mass index (z-BMI) and age-standardised z-scores of height (z-HA) were assessed using WHO child growth standards. Skin prick test (SPT) reactivity was determined to house dust mite allergens. Helminth infection status, (growth) hormones including insulin-like growth factor (IGF-1) and TH 2 immune markers were measured.

RESULTS

In total, 954 children were included of whom 21.6% were underweight and 14.8% overweight. After controlling for confounders, overweight was positively associated with leptin (GMR 3.55, 95% CI: 2.99-4.23) and IGF-1 (GMR 1.45, 95% CI: 1.15-1.82), whereas underweight was negatively associated (respectively GMR 0.57, 95% CI: 0.49-0.66 and GMR 0.78, 95% CI: 0.63-0.97). Underweight was associated with a lower eosinophil count (GMR 0.79, 95% CI: 0.64-0.97) but not with total IgE levels or SPT reactivity. Overweight was positively associated with SPT reactivity (adjusted OR 2.68, 95% CI: 1.50-4.78) but no relationship was found with the other TH 2 immune markers.

CONCLUSION

Malnutrition is prominent in school-aged children in Makassar, with overweight associated with increased SPT reactivity. Therefore, interventions should focus on undernutrition, but also on overweight to prevent the increase of allergic disorders in Indonesia.

Burden of metabolic diseases in Indonesia: an even more critical issue during COVID-19 pandemic

[No abstract available]

Obstetrical care is associated with child's dietary diversity in Indonesia: analysis from Demographic and Health Survey 2017

OBJECTIVE

To explore the influence of obstetrical care factors on dietary diversity and individual food group consumption in Indonesia.

DESIGN

Cross-sectional study to assess the association between pregnancy care factors and dietary diversity score, minimum dietary diversity (MDD) and consumption of seven food groups.

SETTING

Data from the Indonesia Demographic and Health Survey 2017.

PARTICIPANTS

A total of 5113 children aged 6-23 months.

RESULTS

Dietary diversity score was significantly higher for children whose mothers received four or more prenatal care visits, were delivered at a health facility, had a professionally trained delivery assistant and were delivered by C-section. Children born at a health facility and delivered by a health professional had higher odds of meeting MDD (adjusted OR (AOR) 1·45, 95 % CI 1·18, 1·79 and OR 2·10, 95 % CI 1·54, 2·87, respectively). Four or more antenatal visits, delivering at a health facility and having a professional delivery attendant were associated with higher odds of consumption of lentils (AOR 1·66, 95 % CI 1·23, 2·25, AOR 1·30, 95 % CI 1·02, 1·65 and AOR 1·79, 95 % CI 1·19, 2·69). Four or more antenatal visits, delivering at a health facility and having a professional delivery attendant had higher odds of consumption of other fruits and vegetables (AOR 1·70, 95 % CI 1·23, 2·35, OR 1·23, 95 % CI 1·03, 1·61 and OR 1·90, 95 % CI 1·29, 2·79).

CONCLUSIONS

Efforts focusing on providing nutritional education during antenatal care and delivery should be encouraged, especially for mothers seeking care outside of a health facility.

Consumer preference for dried mango attributes: A conjoint study among Dutch, Chinese, and Indonesian consumers

Abstract

One way to add value to tropical fruit and increase its availability in the global market is to develop new, less perishable, products from fresh fruit. The purpose of this study is to compare the perception of key quality attributes and preferences of dried mango between consumers with different familiarity and health consciousness. This study surveyed respondents from China, Indonesia, and the Netherlands via an adaptive choice‐based conjoint method (n = 483) to evaluate intrinsic quality attributes that influenced consumer preference for dried mango. Consumers in different countries have different texture, taste, and color preferences for dried mango. The most important attribute for the Dutch and Chinese was “free from extra ingredients”, while for Indonesians, it was the texture. Familiarity with dried mango and health consciousness do not influence consumer preference of intrinsic attributes of dried mango. Different preferences of intrinsic attributes of dried mango between countries are related to cultural differences. This study provides useful insights for food manufacturers into the significance of key intrinsic quality attributes in developing dried mango.

Practical Application

Intrinsic quality parameters of dried mango are not perceived in the same way by every consumer and this is related to cultural differences. Crispy texture is important only for Indonesian consumers, while “free from extra ingredients” is the most important for Dutch and Chinese consumers. This information is relevant when developing dried mango products for the respective markets.