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Obesity: Forgotten Factor to Control Non-

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Indonesia Hygiea Journal Vol. 1, No. 3

Obesity: Forgotten Factor to Control

Non-Communicable Diseases

__________________________________________________________________
Wulan Sari
Email: wulan.sari71@gmail.com

__________________________________________________________________
Abstract

Obesity is a condition of fat excess that accumulates in adipose tissue caused by

imbalance between food intake and calorie usage. The prevalence of obesity,
especially in the adult population in Indonesia tends to rise, which occurred in the
group of men and women. Along with the increasing prevalence of obesity, it also
followed by increasing of prevalence of non-communicable diseases such as
diabetes mellitus, cardiovascular disease, and cancer. The purpose of this paper is
to evaluate non-communicable disease (NCD) control policies attributed to trend
of incidence of obesity. Writing methodology conducted by literature studies of
three policies control of NCDs in Indonesia, including control policy on Diabetes
Mellitus, Heart and blood vessel disease, and cancer. It is time to develop NCDs
policy based on controlling the risk factors, which are expected to be able to
suppress the incidence of non-communicable disease through a strategy increasing
physical activity and reducing calorie intake. Controlling the risk factors of
obesity is expected to control and decrease the incidence of NCDs in and reduce
the prevalence of overweight or weight control on every individual in the
population. Non-communicable disease control should be carried out
comprehensively by controlling malnutrition. Public Health Center ought to detect
infants and children malnutrition and low birth weight, yet it should also detect
infants and children with overweight and obesity. Thus, Public Health Center has
double role in nutrition control among population.

Keywords: obesity, non communicable disease, policy of control

_________________________________________________________________

Literature Review 1
Indonesia Hygiea Journal Vol. 1, No. 3

Introduction

Population of Indonesia needs of non-food items was

nowadays is around 237.641.326
people. Total estimation population
in 2012, delivering on
assumption that the rate / rate of
population growth in Indonesia every
year was constant. Increase of life
expectancy is characterized by the
soaring number of elder people, both
male and female. The composition of
Indonesian population by age group
proportion, population aged 0-14
years is approximately 28.87%, the
largest proportion is population aged
15-64 years estimated at 66.08%. In
Indonesia, the population aged over
or equal to 65 years, is the smallest
proportion of the population, only
around 5.05% .1
When compared to economic
growth in 2011, the trend
economic growth in Indonesia in
2012 was approximately 6.23%,
which revealed that in all sectors
experienced economic growth. Large
income received by households can
describe the level of welfare in a
society. In 2011, the proportion of
expenditure that was used to meet the
approximately 50.55% and the rest of
49.45% was spending to buy food.
the The biggest food expenses allocation
were for grains, while, non-food
expenditure was greatest for housing,
fuel, lighting and water. Health costs
per capita allocation for every month,
estimated only about 3.04% of the
total expenditure per capita. This
proportion was relatively much
smaller when compared to the need
for housing, fuel, lighting and air.1
In 2012, population of
Indonesia was dominated by
productive age population (15-64
years) with greatest proportion is
about 66.08%. Economic status
increase leads to greater spending on
food particularly on fast foods and
of grains. It coincided with
improvement of nutritional status,
which was mainly found in the group
of the productive adult population.
Nutritional status in the age group of
above 18 years could be seen through
the prevalence of malnutrition based
on indicators of Body Mass Index
(BMI). The nutritional status of the

Literature Review 2
Indonesia Hygiea Journal Vol. 1, No. 3

adult group aged over 18 years was disease, cancer, and

dominated by the problems hiperkolestrolemia.3 Various factors
associated with overweight and including genetic factors,
obesity. Obesity has become public environmental factors, and other
health burden in Indonesia that has risks play an important role for
been faced for long time with the incidence of obesity.
problem of malnutrition and
Body mass index (BMI) is
infectious diseases, which until now
applied to assess overweight
it has still been insurmountable. At
(overweight) and obesity through the
the same time, Indonesia confronts
calculation of weight and height.
with the problem of obesity
Obesity BMI standard set by World
prevalence that increase rapidly
Health Organisation (WHO) is
every years.1
30.4 BMI, this standard is higher
than the standard of Ministry of
Discussion
Health which is 27.5 However,
Obesity is a condition of fat excess BMI has limitation because it cannot
that accumulates in adipose tissue measure body fat or muscle directly.6
which at certain levels caused by an To assess risk metabolic syndrom, it
imbalance between food intake and is necessary to compare BMI. The
use of calories that can adversely ratio of waist circumference to hip
affect the health community.2 circumference is good indicator to
Obesity occurs as a result of an describe the proportion of total fat
imbalance between energy entering within body.7
the body and the energy expended to Increased frequency of
metabolism and routine daily obesity appears very significantly in
activities. It may trigger pathological many urban areas and in rural areas.
condition incidence of various It does not only happen to by the
infectious diseases. Following adults but also children. Such
diseases of obesity are chronic increase was not only deliver the
diseases which include diabetes world's population on public health
mellitus type II, hypertension, heart issues such as those in many

Literature Review
Page 3
Indonesia Hygiea Journal Vol. 1, No. 3

developed countries but also a public
health problem in many developing
countries. Globalization changes in
the global market system, especially
the food and urbanization which
have led on dietary changes at high
risk for obesity and various chronic
diseases. It shifts world's population
in the demographic transition from
population consists of a lot of
children and adolescents to aging
population.8
Global obesity
prevalence is increasing rapidly. This
rise occurred in most parts of the
world both in adult men and women,
and children. The morbidity and
mortality of people with overweight
or obese have been provably higher
than the thin ones.9 In Indonesia,
some data of prevalence of obesity in
adult population, showed an increase
in the prevalence of obesity every
year, both in the group of males and
in women. However, in 2007, 2010
and 2013, female group is more
dominant respectively 23.8, 26.9, and
epidemic
32.9% (See Table 1).

Table 1. Prevalence of obesity in Indonesia and World in 2004

Male (%) Female (%) General
Health Household 24
4
Survey 2004
Basic National
Health Survey
20075 13.9 23.8 10.3
201010 16.3 26.9 11.7
11
2013 19.7 32.9
12
WHO
2002 9.6 20.3
2005 9.7 22.7
2010 9.9 27.1

Risk Factor of Obesity

Research on the adult found that the characteristics of
population in rural areas in Indonesia population, environment, and

Literature Review
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Indonesia Hygiea Journal Vol. 1, No. 3
behavior, significantly associated
with the prevalence of obesity in
Indonesia13 (See Table 2). The risk
factor of obesity that cannot be
modified is age. Adult population at
the age range of 31-65 years are at
higher risk to be obese than the
population aged 19-30.
multivariate, people aged
years have risk of obesity around 1.9
times greater after being controlled
by the variable gender, education,
occupation, marital
consumption of protein, economic
status, and smoking behavior. The
proportion of body fat showed an
increased trend along with modest
improvement of age. Thus, weight
control at the early 30s by increasing
physical activity and maintaining a
diet was one of effective obesity
prevention efforts.
Gender is a risk factor that
cannot be modified, a group of
women at risk for obesity is about
2.1 times larger than male, the
situation can be explained
physical activity levels difference
hormonal factors and physiology15,
or the amount of fat excess that
occurred during the pregnancy16.
Literature Review
Therefore, in order to prevent or
control the risk factor, people at
highr risk, women in particular, must
be prioritized in advance. Women
should be intervention target to
program increasing physical activity
and dietary changes.
In There is strong positive
31-65 relationship between level of
education and obesity in developing
countries, higher education people
have greater risk to be obese
status, compared with low education people.
In contrary, in developed countries,
people with lower level of education
have greater risk for obesity rather
than people with higher level of
education. Higher education has
effect in increasing the opportunity
to get a better job, which has lower
level of activity.
High physical activity is a
factor that prevents the incidence of
obesity in higher education level
group. Occupation such Military
Officer/Police Officer/ Civil Servant
by has greater risk for obesity compared
14
, to the farmer / fisherman / labor.
Low physical activity level based on
increased socio-economic status, diet
change, and lifestyle may explain the
Page 5
Indonesia Hygiea Journal Vol. 1, No. 3

relationship between the levels of compared to the group with low

work with the incidence of obesity. economic level.17
Employment levels are risk factors Consumption of protein
that can be modified through 80%, based on Recommended
behavioral changes like healthy Dietary Allowance (RDA) has
lifestyle that control intake of greater risk for obesity compared to
carbohydrates and fat and increase people who consume less than 80%
physical activity. protein RDA. Eating excessive
Socio-economic status is protein can lead to obesity due to
divided into five levels; they are first deaminated protein. When nitrogen
quintile, second quintiles, third removed from the body, the remains
quintile, fourth quintile and fifth of the carbon is converted into fat
quintile. Economic status is a risk and stored in body.18 Another
factor that cannot be modified but possibility causing obesity is excess
has biggest risk to be obese of food, lack of physical activity, the
compared to variable of age, sex, ease in life, technological
education, occupation, marital status, advances, psychological
and consumption of protein, as well genetic factor16 and urbanization.
as smoking habit. Various literatures Every movement of people from
have made it clear that in developing rural to urban area or transformation
countries, including Indonesia, the of rural area into urban area will
economic status variables are always be followed by increase in the
positively related to the incidence of prevalence of obesity. Various
obesity. Across the world there are studies show that urbanization or
strong assocation between high alteration status from rural areas into
income and eating behavior. It has an urban areas, followed by an increase
impact on high dietary intake of in income is always followed by
calories and protein when it was dietary changes then leads to
increase in the prevalence of obesity.

Literature Review
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Indonesia Hygiea Journal Vol. 1, No. 3

Table 2. Risk Factor of Obesity among Adults in Rural Area in Indonesia

Variabel OR 95% CI Nilai p

Age 1.940 1.801-2.089 0.0005

Sex 2.132 1.952-2.329 0.0005
Education 0.0005
Higher Education 1.429 1.300-1.571
Occupation 0.0005
Military Service/Police Officer/
1.853 1.617-2.124
Civil Servant
Married Status 0.0005
Married 2.356 2.061-2.692
Protein Consumption 1.132 1.066-1.202 0.0005
Economu Status 0.0005
th
(Quintile 5 ) 2.607 2.354-2.887
Smokin Habit 1.573 1.429-1.732 0.0005

Obesity and Chronic Disease Control

WHO (2005) reported that Diabetes Mellitus is a disease

about 70% of deaths worldwide were caused by metabolic disorders which
caused by non-communicable is characterized by blood glucose
diseases, heart disease and blood levels that exceed normal limits and
vessels (30%), cancer (13%), chronic is one of the main causes of death.
disease (9%), respiratory diseases The disease is caused by diet /
chronic (7%), accidents (7%), as nutrition, unhealthy behaviors,
well as 2% by diabetes mellitus. In physical activity and stress that occur
Indonesia, at this time, the type of from childhood and persist into
non-communicable diseases that adulthood. Basic National Health
show rising trend include Survey in 2013 showed that there
hypertension, arthritis, traffic had been an increase in the
accidents, heart disease, diabetes prevalence of diabetes mellitus
mellitus, tumors / cancer, asthma, approximately 2.1% based on
and stroke.19 diagnostic criteria and symptoms

Literature Review
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Indonesia Hygiea Journal Vol. 1, No. 3

compared to Basic National Health incidence of heart disease, especially

Survey in 2007, about 1.1%. coronary heart disease.20
Based on health profile, in Across the world, cancer is
2012, the prevalence of heart disease the second cause of death after
in Indonesia was about 7.2%. cardiovascular disease. In Indonesia,
However, referring to diagnosis Basic National Health Survey in
record made by health professional 2007 found that the prevalence of
worker, the frequency of heart tumors was approximately 4.3 per
disease was found only about 0.9%. 1000 people. Meanwhile, the
Coverage of heart disease cases prevalence of cancer was 1.4 per
detection by health personnel was 1,000 people. Hospital statistical data
approximately 12.5% of all for 2006 showed breast cancer was at
respondents who had subjective first rank, followed by cervical
symptoms similar to the symptoms cancer, liver cancer and intra-hepatic
of heart disease. Meanwhile, the data bile duct cancer, non-Hodgkin's
of Basic National Health Survey in lymphoma, and leukemia. Obesity
2013 showed an increase of heart and lack of physical activity increase
disease prevalence was about 1.5%, the risk of cancer in children and
which was confirmed by interviews adults.21 Research conducted by the
of health workers in diagnosis Center for Health San Francisco
history. Research about obesity with concluded that obesity was proven to
heart disease has been carried on trigger the risk of breast cancer.
various studies using a cross Advance stages of breast cancer risk
sectional study design or longitudinal in women who are obese are about
study. There is empirical evidence 56% -82% higher than women with
that a strong relationship between normal weight. In the body of obese
obesity and heart disease that can be women contained higher estrogen
explained by Body Mass Index and levels is a trigger the growth of
fat tissue distribution that is tumor.22
generally used to predict the Obesity is a risk factor that is
closely related to the incidence of

Literature Review
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Indonesia Hygiea Journal Vol. 1, No. 3

chronic non-communicable diseases diseases cannot be separated from

such as hypertension, diabetes the important role of obesity which
mellitus and metabolic diseases, contribute greatly to the incidence of
cardiovascular disease, stoke, non-communicable diseases than
chronic obstructive pulmonary other risk factors of non
disease (COPD), infertility in communicable disease.
women, and osteoarthritis.2,20
frequency increase of chronic

Table 3. Primary Risk Factor of Non Communicable Disease

No. Risk Factor Cardiovaskuler Stroke Diabetes Certain COPD

mellitus Cancer
1. Lack of Physical
Activity
2. Unhealthy Diet
3. Obesity
4. Hiperglicemia
5. Hipertensi
6. Hipercolesterol
7. Smoking Habit
8. Alcohol

To prevent the rise of control of heart disease and blood

frequency of non communicable vessels. It was developed with the
disease, Indonesian government aim of becoming a reference for
gives serious attention to the governments and communities in
incidence of NCDs, including heart tackling heart disease and blood
and vascular disease, diabetes vessels in an integrated, efficient,
mellitus, and cancer. This is effective and equitable, to create an
performed through the establishment independent society and aware in
of policies on the control of chronic control of primordial factor and risk.
diseases such as guidelines for It is expected to have a major impact

Literature Review
Page 9
Indonesia Hygiea Journal Vol. 1, No. 3

on the reduction in morbidity, as cancer, which places obesity as a

disability, and premature deaths of risk factor that plays an important
non-communicable diseases.23 role in the enhancement of NCD. It is
Guidelines Control of time to control non-communicable
diabetes mellitus and metabolic diseases with focusing on the control
diseases can be a guidance book for of various risk factors. Regarding to
program organizers of disease morbidity control will be more
control on diabetes and metabolic effective if it is carried out at the
disease across programs and good level of the early infants and
sector to the central government or children. Control policy risk factor
the technical implementation unit for many chronic non-communicable
(UPT), provincial / district / diseases that should have been done
municipal, universities, professional since infants and children.
organizations, NGOs, the general
public and communities at risk. Suggestion
Manual control of diabetes mellitus
and the metabolic disease was set in Community Health Center manages
2008. The cancer control guidelines to detect groups of infants and
in Indonesia established through the children who are malnourished and
Minister of Health Decree No. 430 / low weight should also perform to
Menkes / SK / IV / 20 in 2007. The detect infants and children with
policy aims to reduce morbidity and overweight and obesity. Thus
mortality from cancer, extend life Community Health Center can have
expectancy and improve quality of double role, to detect groups of
life penderita.24 infants and children with
It is a dilemma, when the malnutrition status and
policy on controlling NCD has been simultaneously detect groups of
established, it is still an increase in infants and children with overweight
the prevalence of NCD include and obesity. Non communicable
diabetes mellitus, heart disease and disease control is implemented
other cardio vascular disease, as well comprehensively with controlling

Literature Review 10
Indonesia Hygiea Journal Vol. 1, No. 3

disease and malnutrition. It is 7. Haslam D, Sattar N, Lean M.

Obesity : Time to Wake Up. In:
expected to control and decrease the Sattar N, Lean M, editors. ABC
incidence of NCDs in Indonesia Obes. United Kingdom:
Blackwell Publishing [Internet]
through a strategy of early detection 2007. p 6402. Available from:
www.abcbookseries.com
and control of obesity by increasing
physical activity and reducing calorie 8. Sun Hye Kim, et al. Dietary Factors
Related To Body Weight In Adult
intake. Vietnamese In The Rural Area Of
Haiphong, Vietnam: The Korean
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