CHAPTER I

INTRODUCTION

A. Background
One of the main health problems in developing countries including
Indonesia is a disruption to public health problems caused by lack of
nutrition. Currently in the era of globalization where there is a change in
lifestyle and diet, Indonesia faces of malnutrition are generally caused by
poverty, lack of food supplies, lack of good quality of the environment, and
the lack of public knowledge about nutrition.
Approximately 37.3 million people live below the poverty line, half of
the total households consume less food than daily necessities, five million
children under age status of undernourished, and more than 100 million
people at risk of malnutrition problems.
According to the MOH (2006) issue of malnutrition is still a problem
public health and can be the cause of death, especially in high-risk groups
(infants and toddlers).
According to Alan Berg (1986), the less nutrition lead to its impact
on mental development, physical development, and human productivity
because it affects the economic potential of human beings.
Nutritional problem is essentially overcome health problems that
can not be done with the approach of medical and health services alone.
The cause of malnutrition is multifactorial, therefore mitigation approach
should involve a wide range of related sectors. Although it has a lot to do
counseling aboutmalnutrition but there are still many people who have
problems of nutrition, therefore, the author is trying to find out various
things about the problem of malnutrition in Indonesia as well as what will
be discussed in this paper.

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B. problem Formulation
1. What is the sense of malnutrition?
2. Any factors that cause the occurrence of malnutrition?
3. Any problem of malnutrition that frequently occur in Indonesia?
4. How the impact caused by the lack of nutrition?
5. How to prevent and tackle the problem of malnutrition?

C. This paper Aims to

1. To know the meaning of malnutrition.

2. To determine the factors that cause the occurrence of malnutrition.
3. To find out the problem of malnutrition that frequently occur in Indonesia.
4. To determine the impact caused by undernutrition.
5. To find out how to prevent and tackle the problem of malnutrition.

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 CHAPTER II
DISCUSSION

A. Understanding of malnutrition
Malnutrition are health problems caused by deficiency or imbalance
of nutrients needed for growth, the activity of thinking and all the things
associated with life. Dietary deficiencies are mild to severe. Malnutrition
illustrates the lack of food required to meet nutritional standards.
Of malnutrition can occur for a person experiencing a shortage of
one nutrient or in the body (Almatsier, 2005). Also mean less nutrition, a
condition that occurs when a person experiences a shortage of certain
essential nutrients, failed to meet the demands of the body that cause an
effect on growth, physical health, mood, behavior and other functions of
the body. It thus becomes malnutrition does not necessarily mean that the
person is underweight.
This lack of nutrition experienced by many children since I was in
the womb and fatal, the problem is sometimes very difficult to overcome
even, can not be repaired when the children before adulthood. Segments
of society that are vulnerable to undernutrition are children under five,
pregnant and lactating women.

B. Factors Why of Nutrition Less

Factors that cause the occurrence of malnutrition, among others:

1. Diet or nutrition is lacking and life styles.
2. Socio-cultural factors
What is meant here is the lack of public awareness of the
importance of nutritious food for growing children. Thus, many children
who were fed "minimally" or origin of satiety when poor nutrition. Other
problems also in the form of restrictions on use of certain foods that may
have a high nutritional value however, not be consumed because it is a

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 tradition passed down through generations that may affect the incidence of
undernourishment.
3. educational factors
Lack of knowledge about the importance of nutrition among people
whose education is relatively low such, knowledge of parents about the
importance of food intake enough nutrition.
4. Economic factors and population density
Poverty and low income families who can not meet the needs of
children result in nutritional balance is not met. The low income of the
people and the rate of population increase is not matched by
bertambahnyaketersediaan foodstuffs would lead to a food crisis. It also
can be a cause of malnutrition.
5. Factors infections and other diseases
Any grade infection may worsen the nutritional effect on the body.
Other factors also influence disease such as tuberculosis, HIV / AIDS,
respiratory and diarrhea.
6. Environment sanitation
The state of environmental sanitation is not good and healthy to
allow various kinds of diseases such as diarrhea, intestinal worms, and
gastrointestinal infections. If the child is suffering from a gastrointestinal
infection, absorption of nutrients will be disrupted which leads to
malnutrition.
7. Parenting, such as maternal behavior or other caregivers in terms of
feeding, caring for, cleaning giving love and so on. All are related to
maternal health (physical and mental), nutritional status, education,
knowledge, work, customs and so on from the mother and other
caregivers.
8. Natural disasters, war, political expediency and economic burden of the
people. Floods, landslides, tsunamis, volcanic eruptions and other natural
disasters will hamper nutrition in Indonesia. Natural disasters could

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 potentially stymie the process of distribution of food so that food that is not
properly distributed.
9. Environmental health services and inadequate.
The difficulties of clean water and access to health care facilities led
to the lack of guarantees for the family. The principal problem is the lack of
nutrition in the community of family empowerment and lack of utilization of
community resources associated with various factors directly or indirectly.
This can be overcome by the various activities in the community such as
neighborhood health center, health post, etc.

C. Much Less Nutrition problems which occurred in Indonesia

Global situation, for the extraordinary incident, the high price of food
will increase the number of malnourished children, especially in the WHO
reported the discovery of cases of malnutrition. The world population in
2008 is expected at risk of malnutrition reached 44 967 million people
living in urban and rural areas, which is the main cause of death (WHO,
2008).
While in Indonesia, Susenas the data show that the prevalence of
malnutrition has always demonstrated risen from 12.66% (2001), 14.28%
and 14.33% (2004) (Health Affairs, 2004). Examples of problems of
malnutrition that frequently occur in Indonesia, among others:

1. KEP (Protein Energy Deficiency) / PEM (Protein Energy Malnutrition)

Protein-energy malnutrition malnutrition is caused by low
consumption of energy and protein in the daily diet so it does not meet the
nutritional adequacy rate (AKG). According Supariasa (2000) Protein
Energy Malnutrition (PEM) is someone who malnutrition caused by low
consumption of energy and protein in the daily diet and certain diseases or
disorders.
The toddler is the group that shows the rapid growth of the body, so
it requires nutrients that high every kilogram of body weight. The toddler is

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precisely the age group that most often suffer from malnutrition. In children
KEP can inhibit the growth of, susceptible to infectious diseases and
resulted in a low level of intelligence (Almatsier, 2003).

The immediate cause of PEM is protein-calorie deficiency.

(Sediaoetomo, 1999), Put less food and a disease or disorder that affects
children, such as infectious disease, and other malabsorption. Indirect
causes of KEP very much, so it is also known as a disease with
multifactorial causes (Sediaoetomo, 1999).

It can also be due to impaired absorption of protein, such as in a

state of chronic diarrhea, loss of abnormal protein in proteinuria
(nephrosis), infection bleeding or burns, and failed to synthesize proteins,
such as in a state of chronic liver disease (Nelson, 1999).

Form of Protein Energy Malnutrition (PEM) in adults divided into

two forms: Undernutrition (less nutrients) and Starvation (famine) whereas,
in children in the form of PEM (Protein Energy Malnutrition) by Jelliffe
cover all age groups of children, grouped into: PEM light, PEM medium
and PEM weight consisting of marasmus, kwashiorkor and marasmus-
kwashiorkor.
High prevalence occurs in young children, pregnant women
(pregnant women) and nursing mothers. PEM on mild and moderate only
show symptoms of malnutrition like, growth and less weight, body
condition looked thin, size arm circumference decreased, activity and less
attention however, is not commonly found abnormalities such as skin and
hair disorders. Meanwhile, PEM on severity (malnutrition) were divided
into three types: kwashiorkor, marasmus-kwashiorkor and marasmus are
impaired growth, emerging clinical symptoms and biochemical
abnormalities characteristic.

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a. marasmus

marasmusis the lack of energy (calories) to the foods that cause the
body's protein reserves used so that children become "thin" and
"emotional". Often occurs in babies who are not getting enough food and
not given a replacement, or occur in infants who are often diarrhea.

Clinical symptoms of marasmus, among others:

Face as a parent

Whiny and Fussy

The eye is not glowing

Often accompanied by infectious diseases (diarrhea, mostly chronic

recurrent, TBC)

Looks very thin (bones wrapped in skin)

Wrinkled skin, subcutaneous fat tissue is very little to no (baggy pants)

a concave stomach

Xylophone ribs (ribs protruding).

b. kwashiorkor

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 kwashiorkoris a disease caused by a deficiency of the protein, and
often occurs at age 1-3 years because in this age of high protein needs.
Although the main cause of kwashiorkor is a lack of protein, but because
of foodstuffs consumed less menggandung other nutrients as well as the
consumption of different local areas, there will be a difference picture of
kwashiorkor in various countries.

Clinical symptoms of kwashiorkor, among others:

Edema (on both back legs, can the whole body), and when pressed long
back

Thin hair, hair the color of corn, easily removed without pain, loss

Skin disorders (dermatoses) and enlargement of the liver

Rounded and swollen face

Glassy eyes, apathy and irritability

Often accompanied by acute infectious diseases, diarrhea, acute

respiratory infection, etc.

Muscles shrink (hipotrofi).

c. Marasmus-Kwashiorkor

Marasmus-kwashiorkor is basically a mixture of symptoms of

marasmus and kwashiorkor, a characteristic that can be seen clinically
namely:
Some of the clinical symptoms of marasmus, looks very bad in terms of
weight (W / A) and, if confirmed by the W / H categorized as very thin.

Kwashiorkor clinically inconspicuous edema on both the back foot

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 Malnourished children with clinical signs can be detected in protein
energy deficiency through:

a. Monthly weighing in IHC including efforts to pursue timbangnya

b. Nutritional surveillance / outbreak of nutrition

c.Integrated Management of Childhood Illness and Polyclinic KIA / growth.

2. GAKI (Iodine Deficiency Disorders)

Iodine deficiency disorders (GAKI) is a set of symptoms or

abnormalities are caused due to the body suffering from iodine deficiency
are kept - continuously in a long time that have an impact on human
growth and development (MOH RI, 1996). The more the level of iodine
deficiency experienced by more and more complications or disorders
caused, includes enlargement of the thyroid gland and the various stages
until the resulting deaf and mental disorders due to cretinism (Chan et al,
1988), abnormal growth, delays in mental development, and a low level of
intelligence.
Kodyat (1996) said that in general, this problem occurs more
frequently in mountainous areas where food is consumed depends on the
production of food derived from local plants that grow in soil with low
iodine content.
The problem of Iodine Deficiency Disorders (GAKI) is a serious
problem because of the impact it directly affects the survival and quality of
their human. Groups of people who are very vulnerable to the impact of
iodine deficiency problem is women of childbearing age (WUS), pregnant
women, toddlers and school-age children (Jalal, 1998).

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 According Djokomoeldjanto (1994) that GAKI very closely related to
the geographical location of a region, because in general, this problem is
often found in mountainous regions such as the Himalayas, the Alps,
Andres and in Indonesia goiter is common in the mountains as Bukit
Barisan in Sumatra and mountains Kapur South ,
Areas that normally receive food supplies from other areas of
agriculture and food production, such as mountainous regions
notabenenya a poor area of the iodine content in water and soil. In the
long term, but certainly the area will experience a deficiency of iodine or
iodine endemic area (Soegianto, 1996 in Koeswo, 1997). GAKI endemic
areas pregnant women will experience a variety of disorders including
pregnancy, abortion, stillbirth, and neonatal hipothyroid.

3. AGB (Nutritional Anemia Iron)

Approximately 47% of the 25 million children under five and 26.5%

of the approximately 80 million school-age children and adolescents in
Indonesia anemic iron deficiency (anemia), said Director of Community
Nutrition Ministry of Health, Dr. Rachmi Untoro MPH. "Clinically Anemia
symptoms marked '5L' is lethargic, weak, tired, tired and inattentive," he
said at a seminar on Nutritional Anemia Iron Impact on Children
Intelligence, in Jakarta, Thursday (04/08).
Anemia in infants and children will have an impact on the increase
in morbidity and mortality, brain development, physical, motor, mental and
intelligence is also inhibited, decreased learning comprehension and
reduced social interaction.

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 AGB can be suffered by anyone, but there are vulnerable period
AGB. Including during pregnancy, toddlers, teenagers, young adults and
elderly age. In pregnant women, the prevalence of anemia deficiency
ranges from 45-55%, which means one of two pregnant women suffer
from AGB. Pregnant women are prone to AGB because the content of iron
stored is not proportional to the increase in blood volume that occurs
during pregnancy, coupled with the additional volume of blood from the
fetus.
Women by nature have to lose blood every month due to
menstruation, women therefore higher risk than men affected AGB.
Children and teenagers are also prone AGB age because a fairly high iron
requirements are necessary during growth. If the intake of iron is less then
the risk becomes very large AGB. Chronic diseases such as inflammation
of the gastrointestinal tract, cancer, kidney and heart can interfere with the
absorption and distribution of iron in the body that can lead to AGB.
According Soedjatmiko, children under five are anemic since it can
not be treated again. As for the affected children at school age, they can
be treated with iron supplements. In principle, there should be a healthy
diet.

4. Vitamin A deficiency (VAD)

Vitamin A deficiency (VAD) is still a widespread problem throughout

the world especially in developing countries and can occur at any age,
especially during growth (toddlers). Vitamin A deficiency can decrease the
immune system and lowers epitelisme skin cells. Children who suffer from

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lack of vitamin A, when stricken with measles, diarrhea or other infectious
diseases, the disease will get worse and can lead to death. Infection will
inhibit the body's ability to absorb nutrients and at the same time will
scrape out a store of vitamin A in the body.
Babies who are not breastfed have a higher risk to suffer from VAD,
because milk is a good source of vitamin A. Low consumption of vitamin A
and pro-vitamin A to pregnant women to give birth will provide low levels of
vitamin A in breast milk.

Lack of vitamin A for a long time also will cause disturbance to the
eyes, and if the child does not immediately receive vitamin A can lead to
blindness. Lack of vitamin A also causes the layer of cells that covers the
lungs do not expel mucus, making it easy to enter microorganisms,
bacteria, and viruses that can cause infection. If this occurs on the surface
of the intestinal wall, will cause diarrhea.
Vitamin A can be obtained from breast milk or foods that come from
animals, green vegetables and fruits. In an emergency, where food has
become very limited natural resources, supplementation of vitamin A is
very important to increase the body's resistance to disease.
Problems subclinical vitamin A deficiency (vitamin A serum levels
<20 ug / dl) in some provinces are still quite alarming, because 50%
children still have low vitamin A status. Lack of vitamin A will decrease the
body's resistance to diseases that affect child survival. 9.8 percent of
Indonesian children under five are still deficient in vitamin A. Vitamin A
prevention program in Indonesia has been implemented since 1995 with
supplementation of high doses of Vitamin A supplements, to prevent
blindness due to lack of Vitamin A, and to increase endurance. Vitamin A
supplements to support a decrease in morbidity and child mortality (30-
50%). then in addition to preventing blindness, the importance of vitamin A
is now more associated with child survival, health and growth.

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D. As a result of Nutrition Impact Generated Less

Undernourishment lowers the body's resistance to infection,

menyebabkann many chronic diseases, and cause people to be possible
to do the hard work. Someone malnutrition will be susceptible to disease,
and growth will be disturbed (Supariasa et al, 2002).

When mothers were malnourished during pregnancy may cause

problems, both in the mother and fetus. Undernourishment in pregnant
women can lead to the risk and maternal complications include: anemia,
bleeding, maternal weight not grow normally, and infectious diseases.

The influence of malnutrition on labor can result in difficult and long

labor, labor prematurely (premature), bleeding after childbirth, as well as
delivery to the operation is likely to increase. Malnutrition in pregnant
women also may affect fetal growth and can lead to miscarriage, abortion,
stillbirth, neonatal death, congenital defects, anemia in infants, asphyxia
intra partum (die in the womb), born with low birth weight (LBW) , Pregnant
women are also suffering from Protein Energy Malnutrition will affect the
physical, mental and intelligence of children, and also increases the risk of
babies born less iron. Infants less iron can have an impact on growth
disorders of brain cells, which later may reduce a child's IQ. In general
malnutrition among infants, toddlers and pregnant women can create a
generation of physically and mentally weak.

In general, the impact of malnutrition among other things, the

growth of children to be disrupted, energy production (energy) less
affecting activity, decreased immune defense and disruption of brain
function that may create a generation and less qualified human resources.

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 E. Impact of Short-Term And Long Term Malnutrition

 Most (90%) growth and brain development during fetal berlangsunf until birth.

 Less energy and protein during pregnancy will result in babies born with low
weight (LBW)

 LBW will interfere with mental development and motor skills.

 Relations LBW and childhood malnutrition will increase the risk of non-
infectious diseases

(Obesity, diabetes, heart disease, cancer, high blood pressure and stroke) in
adulthood.

 Research results Baker (1980), adults when born LBW noted to death due to
heart disease

 The economic crisis led to a "lost generation"

 Generation with millions of malnourished children so that the child's

intelligence (IQ) lower, this condition will impact the low quality of human
resources (HR)

 Low-quality human resources will reduce labor productivity

 Low-quality human resources will be a heavy burden in the face of free

competition in the era of globalization.

F. How to Prevent and Eradicate Nutritional Problems Less

Some ways to prevent the occurrence of malnutrition among others, the

following:
1. Familiarize Behavior Clean and Healthy Lifestyle (PHBs) and pay attention
to a regular diet with balanced nutrition.

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2. Good nutrition is required a pregnant woman so that fetal growth is not
congested, and then give birth to babies with normal weight. With good
health, normal reproductive system, not sick, and no nutritional disorder in
the pre pregnant or during pregnancy, the mother will give birth to a baby
bigger and healthier than mothers with pregnancy condition otherwise.
3. give exclusive breastfeeding (Only ASI) to childaged6 months, After
that,childwas introduced byfoodadditional weaning according to age
levels.
4. Diligent weigh and measure the height of a child by following Posyandu
program to determine whether the child's growth in accordance with the
standard at KMS. Thus, if it is not appropriate or found any symptoms of
malnutrition then it can be addressed immediately.
5. Improve public knowledge especially parents about nutrition through
outreach to the wider community, especially in rural areas and in remote
areas. Because, according to Samuel, a need for increased knowledge
and awareness of the importance of a balanced nutritious diet in infancy
and composition of foods such as what is required by their children.
Providing appropriate and balanced meals to children consisting of
carbohydrates, proteins, fats, minerals and vitamins. Fat minimal given
10% of the total calories needed, while the protein is given 12% of total
calories. The rest is carbohydrates. "The quantity of food consumed
should be tailored to the needs of children, because each child has
different nutritional needs depending on age, gender and activity."
6. Needed a good role of family, health practitioners, and the government.
The government should improve the quality of the Posyandu and other
health services, not just for weighing and vaccinations, but must be
improved in terms of quality nutritional counseling and supplementary
feeding, as well as improving the welfare of the people to access food is
not compromised.

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7. Mobilize and empower people to live healthier by improving community
access to quality health services and improve the system of surveillance,
monitoring and health information

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 CHAPTER III
CLOSING

A. Conclusion
Nutrition is part of the process of life and a person's growth process,
so that the nutritional needs adequately determining the quality of growth
and development as human resources in the future. Undernourishment are
health problems caused by deficiency or imbalance of nutrients needed for
growth, the activity of thinking and all the things associated with life. The
cause of the occurrence of malnutrition is due to social factors, poverty,
population growth rate, infections, and many other factors, both of which
affect directly or indirectly.
From the discussion above it can be concluded that the nutritional
problem is complex in Indonesia. Until now there are four main nutritional
problem in Indonesia, namely Protein Energy Malnutrition (PEM), Iodine
deficiency disorders (GAKI), Nutritional Anemia Iron (AGB), and Lack of
Vitamin A (KVA). Many factors affect the nutritional intake of the
community. From day to day the numbers of the problems above
continued to increase, which automatically also increases the mortality
rate of the population. The impact of undernutrition is very influential in
one's life as a whole such as, physical, mental and intelligence. As for
preventing undernutrition is to PHBs and increased consumption of
adequate and balanced nutrition, counseling, increase public knowledge
about nutrition, etc. So, on the whole preventing and addressing the
problem of malnutrition in the form of government participation, health
workers and the whole community.

B. Suggestion
Instead, to reduce the high problems of malnutrition in the above,
the government launched the program more effective and sustainable as,
increased efforts maternal health to reduce infant with low birth weight,

17
improve nutrition programs based on community, and improve other
sectors closely related to nutrition (water, sanitation, protection, community
development and gender issues), so that little by little figures above due to
nutritional problems can be reduced.
Need to increase the public's knowledge about malnutrition and its
most serious consequence is poor nutrition, following up on its causes.
Thus, here takes the important role of social support. Social support is
needed for the problem of malnutrition is caused by many factors, both
internal and external factors. In order to provide guidance in the
atmosphere in the prevention and eradication of malnutrition is successful,
partnership and advocacy for health also needs to be done, so that the
community empowerment in efforts to improve nutrition can also run well

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