Overpopulation in Asia

The type of the population’s food in the various regions in Java is mostly determined by the character of the agriculture in the area and is therefore dependent on quality of the ground for cultivation, climate, possibilities of irrigation, want of money and existing tradition among the population. So in sleman, Bantul and South Kulon Progo rice is the staple-food, while in gunung Kidul, where cassave is the principal crop, the staple-food is gaplek (dried cassave).
It was already known from diet-investigations during the pre-war years in prosperous parts of Java, as Patijet in West Java (research 1938/1939) and Kotawinangun in Central Java (research 1932/1933), where rice was the staple-food, that the food was rather deficient in protein, which was mostly got out of vegetable foodstuffs, and in Vit.A, and very rich in carbo-hydrates, while the number of calories per day-per head were amply sufficient, viz. 2,100-2,400 cal. Per day.
So in Patjet it was found at investigation that, if compared with other areas of Java, relatively many animal foodstuffs were eaten, vis. Dried or salt fish, to wit 26-37gr. Per head-per day. Rice provided 90% of the calories and 74% of the protein. It appeared that the grown-ups received relatively more calories than the children. In comparison with their own requirement of protein also the grown-ups appeared to have a better protein provision than the children. This was the case too with Vit. A provision. In consequence of various circumstances the food supply of the children proved to be more unfavourable than that of the grown-up people, even in this so prosperous region of Patijet, which was reckoned to be among the best fed regions of Java.
In Kotawinangun, where in 1932 and ‘33 a very extensive research was made into the money- and products-economy and where also the people’s diet and health-situation were drawn into the investigation, the diet appeared to be mostly vegetarian. The protein content of the diet varied from 40.2 – 60 gram. The protein-supply could not be called generous. It consisted for 90 – 99% of vegetable protein of the rice and soya-beans, which as sources of protein form a very good combination. (v. Veen ‘39).
About the sufficiency of the various vitamins in the diet at Kotawinangun the authors made no statement. In the investigation about the nutritional situation of the population the occurrence of xerophthalmia is not mentioned, so that evidently this deficiency-disease did not occur here. In this region the enjoyed food was not in general judged to be deficient. In the years of the inquiry there was no malnutrition. The diet of the people in the milieu, in which the malnutrition-patients, coming from the region of the D.I. Jogjakarta, have been born and have lived before they were admitted to the hospital, is less satisfactory than the diet of those mentioned above from Patjet and Kotawinangun, in the period before the second world war. The region of the D.I. Jogjakarta is not prosperous, but poor. The farmer possesses a very small plot of ground and many inhabitants do not even have that. That the food will become deficient first in its weak spots, may be expected. The diet, already on-sided in prosperous areas, limited in protein and sometimes in Vit.A and not rich in calories, directs our attention to these possible deficiencies in pre-school-children.

Table X – 9.

From fragmentary data we had the impression that also in the region of the D.I. Jogjakarta the Javanese mothers were accustomed to nurse their child as long as possible. To be able to form a judgment how many toddlers were still suckled at the age of 2 years, we inquired:

1. How many procents of the babies born in the hospital during the period 1957-’58 were suckled when going home on the 7th – 10th day. Further:
2. How many babies of the age of 5 – 7 months still received breast-feeding of all the babies of this age-group visiting our clinic.
3. The same for the infants of 11 – 13 months.
4. For the pre-school children of 16 – 20 months.
5. For the children of 22 – 26 months.

It concerned, except for the first group, all children, who visited the children’s ward in the years 195-1958 and with whom there was an opportunity to check the feeding-anamnesis. We left the evident malnutrition-patients out of consideration and we limited ourselves to the children in a good to moderate nutritional situation. The results of this inquiry are as follows:

Table X – 10.

These results agree in general with those of Stahlie (1959) in Thailand. The average duration of the nursing appear to be clearly shorter for the infants and toddlers living in the town. This we are apt to put down to the so much easier way in which in town, where a number of 13 Mother- and Child Health-centra exist, substitutes may be got in stead of mother’s-milk, up till now (1959).
We see that in both groups of infants and toddlers breast-feeding is continued very long, while this way of feeding after the 6th – 8th month of life is normally no longer sufficient, if exclusively given. What factors induce the mothers to protract this feeding so long, has not become quite clear to us.
In the course of years we received the following explanations by the ;mothers:

1. The conviction that this is good for the child;
2. The mother “dare not” refuse a crying child her breast;
3. Besides, it is an easy manner to silence crying children, by putting the nipple in their mouths;
4. That in this way there should be a slighter risk of a new pregnancy, which would increase poverty and cares. According to the investigation of Giorosa (1955) quoted by Stahie (1959) it appeared that the chance to become pregnant is for women during lactation smaller than in the period after weaning.

It is besides cheaper, for buying and preparing food for children costs money and trouble, so that this is only started when circumstances clearly compel to do so. We regularly had the experience that the mother declared full of conviction, that her child of 1.5-2 years old got sufficient or even a great quantity of mother’s-milk, while after admission to the children’s ward, when controlled, it appeared that the total production of mother’s-milk did not exceed 200 cc per day. The long-protracted breast-feeding, which was also quantitatively insufficient, was in a number of cases evidently one of the causes of malnutrition. The giving of supplementary food beside the breast-feeding starts mostly in the 5th - 6th month of life, but sometimes still later. It is mostly porridge of rice (water with rice-flour or soft-cooked rice, which is first given as a supplementary food, or banana, while very gradually the diet is extended a little with rice, vegetables, soyabean-products and some fruit. How far the decline in frequency of the disease of malnutrition at the age of 5 and older may be dependent on the care of the mother or on the initiative which the child itself is able to develop at that age, cannot be ascertained, but we think indeed the child’s own initiative important in connection with the improvement of his diet.
In a great number of malnutrition-patients we controlled the “enjoyed” diet by interrogating the mother for an extensive nutrition-anamnesis. Only the period of 2 – 3 months preceding the admission of the patients to the children’s ward were brought into this inquiry concerning the nutrition-anamnesis.
The quantities of foodstuffs stated by the mother were tested, after admission into the clinic, by the child’s appetite during its stay in the clinic. The acquired data therefore indicate only approximately the taken diet, but a more accurate investigation was not within our reach. Of some tens of foodstuffs consumed in that region it was controlled:

• what foodstuffs were eaten by the child (see table X-11).
• whether it was eaten daily or weekly or a few times a week by the child.
• and in what quantities the child received the mentioned foodstuff every time from the mother.

It appeared that during the first few years of life only a;small variety of foodstuffs is given to the infants and toddlers, viz. Mother’s milk, rice, banana, a few kinds of vegetables (a.o. Mung beans, Ind. Amaranth, Jack fruit) , tea, cassave and the soyabean-products tahu and tempe, and salt. Out of these ingredients the diet of toddlers is made up. These are all foodstuffs, which may easily be obtained in this area and belong to the cheapest articles of food. The diet of toddlers shows only little variety. A number of 853 patients we classed into 9 age-groups, as has been indicated, in the subjoined table X-12. The results of this anamnestic diet-in-quiry of these children we want to summarize as follows. In the various age-groups mostly a number of different diets were given. In the first 5 age-groups we distinguished 12 – 16 different types of diet. In the older age-groups after the third year this number grew ever smaller, viz. from 8 different types in the 5th year it fell to 3 in the 8th - 10th year. As it was not possible nor necessary for our aims to analyze all these different diets, we limited our survey to the most often occurring diets in the various age-groups and to those types of diet, which did not coincide with types of diet from other age-groups.

Table X – 11.

Table X - 12.

In the first half year of life the deficiency or lack in the production of mother’s-milk is the principal cause of malnutrition in these young babies. As the only full-value substitute of mother’s-milk (viz. Cow’s milk) is hardly or not at all to be got in this agrarian country and besides financially far out of reach for the population, the lack of breast-feeding means for a young baby an almost sure death. In these cases however it is possible at the welfare centres for M.C.H. To get cow’s milk at a symbolic price. These cases, if they develop well, naturally do not come under our eyes at the polyclinic as malnutrition; it is especially the cases in which an attempt was made to feed the young baby with air tadjin ( that is water in which rice is cooked and to which some salt or sugar is added). In this way the child receives almost exclusively fluid and no calories. In cases where there is too little mother’s-milk, this is often supplemented with very thin rice-porridge and/or banana.
Through the activities of the M.C.H. Many hundreds of babies are indeed annually helped with Unicef milk. However, a quantity of this milkpowder (esp. skimmilk powder) comes in the black market, a.o. because a number of mothers sell the milkpowder received and in this way try to improve the family-budget at the cost of its youngest member; it is this skimmilk-powder which is cheapest of all milkpowder in the shops, and which is also used instead of mother’s-milk.
Mostly it is used in a too thin solution (± 5%), supplemented – or not – with rice-porridge and/or banana. An analysis of three of the most frequently occurring diets, which we found in the anamnesis of malnutrition-patients younger than 6 months old, are subjoined here.

Table X – 13.

Type of diet A. B. C.
For 34 out of 56 babies with malnutrition we found one of these three types. Out of these 34 babies 15 also suffered from xerophthalmia. Six babies had had exclusively air tadjin. In seven cases we found a too thin solution of skimmilk, which was supplemented with rice porridge. In 6 babies it was the too scanty quantity of mother’s milk (hypogalactation), which was the cause of the malnutrition, as these children had received only some tea as a supply. For calculating the Vit. A content in the babies’ diet, we took the quantities of carotenoid and Vit. A in the mother’s-milk found by Meulemans and de Haas (1936) in their inquiry in Djakarta. They examined 509 samples of colostrum and mother’s-milk of Indonesian women in childbed, who were delivered in the maternity-ward of the University in Djakarta in the period of Febr. - Nov. 1935. also mother’s-milk was obtained from the mothers who came to the consultation bureaus to have their babies examined. The results of this examination were as follows.

Table X – 14.

The colostrum proved to be richer both in carotenoid as in vit.A. Also the colostrum of Chinese and European women was examined in addition to that of Indonesian women. The values found in the mother’s-milk of Chinese women were only slightly higher than those found in the Indonesian women’s. In European women from well-to-do families the values of Vit.A. and carotenoid in the mother’s-milk were much higher.
In the colostrum (168 observations) per 100 cc 67 gamma carotenoid and 150 I.U. Vit.A. were found, while in the mother’s-milk of the first three months were found resp. 24 gamma carotenoid and 127 I.U. Vit.A. and in the second three months 28 gamma carotenoid and 104 I.U. Vit.A. This however concerns only a limited number of observations, viz. In the first and second quarter resp. 95 and 92. The results of this investigation by Meulemans and de Haas gave important support to the presumption that the low values of carotenoid and Vit.A. In the Indonesian mothers’-milk might be an important factor in the pathogenesis of xerophthalmia in young babies.

In the second halfyear of life we find the same three types of diet, viz.
Breast-feeding with a supply of rice-porridge, bana or rice.
Substitute food (cow’s milk) with a supply of rice-porridge, banana, rice, sometimes already some vegetable and Mungbeans or cocoa-nut milk.
After weaning a diet of rice-porridge, banana, rice, vegetables, some maizena-porridge, in various combinations. The rice-porridge is mostly a ± 10% solution. Most frequent is breast-feeding, supplemented or not with rice-porridge or banana. Out of 108 children with malnutrition in the second halfyear of life, 59 had a similar diet. Of these 59 patients 8 had at the same time xerophthalmia. An analysis of three frequently occurring diets given to resp. 17, 12 and 27 patients are mentioned here below D.E.F. Table X-15.

Table X – 15.

Substitute food (skimmilk) was administered to 25 children, of whom 15 suffered from xerophthalmia. Entirely weaned and without cow’s milk in the diet were 24 children, of whom 11 suffered from xerophthalmia. In this period of life the banana proves to be the most important source of Vit.A. (carotenoid).

In the second year of life, during which breast-feeding in the diet has already a smaller singnificance than in the infant’s diet, we saw that out of 399 patients with malnutrition 123 still received breast-feeding, of whom 33 still got exclusively mother’s-milk with mostly tea as a supplement. A number of 50 toddlers had cow’s milk in their diet. Obtained via a welfare centre of the M.C.H., partly bought in a shop. The other 226 children got a diet consisting of rice, rice-porridge, cassave, banana or vegetables and sometimes a little tahu or tempe (soya-products). A number of three diets mostly given in this age-group, resp. to 74, 35 and 26 toddlers of whom resp. 21, 19 and 15 also suffered from xerophthalmia are the types G., H., J.-diets, mentioned here below.

Table X – 16.

The kind of vegetable that is given appears to be of great importance: Of the four most given kinds of vegetable, arranged according to frequency: gori (Jack fruit), mbajung (Yardlong-leaves), bajem (Ind. Amaranth) and kangkung (Swamp cabbage leaves), gori contains hardly any carotenoid and bajem is richest in carotenoid viz. 1,600 I.U. Per 100 gr. Fresh bajem.
In the third year of life breast-feeding proved to be of little importance any more. Only 13 out of 131 children were still suckled. Three of them still received exclusively breast-feeding with tea as a supply, the others got rice as a supply to the breast-feeding. Of these 13 children 6 had xerophthalmia. The quantity of mother’s-milk which these pre-school children got was mostly scarce (200 – 300 cc per day), as appeared from measuring during the first days after admission. Only 11 children received cow’s milk in their food. All the remaining 107 received rice as a chief diet and banana, vegetables, cassave, salt or mung beans as additional food. Of these 107 toddlers 72 suffered from xerophthalmia in addition to malnutrition. The analyses of three of the most frequent diets given to resp. 22 – 23 and 24 patients in the two months preceding the admission are subjoined. Resp. 14, 13 and 16 of these patients also suffered from xerophthalmia; diet K. L. M.

Table X – 17.

In the analysis of diet L the children are supposed to be given a slice of tahu (Soyabeancurd) and tempe (soyabeancake) daily, which undoubtedly was too high as an average.
In the fourth year of life it happened that some toddlers still got breast-feeding. Of the 80 children of that age with malnutrition whom we examined, 7 still received mother’s-milk, 5 of them even exclusively; the two others got rice as food in addition to the mother’s-milk. Only 2 children had got cow’s milk in their food, in addition to the rice. The other 71 children received rice as a chief diet and beside that vegetables, maize, banana, tahu, tempe or mungbeans as subordinate food. A number of three most customary diets, given to resp. 19, 14 and 9 children, of whom 13, 10 and 6 suffered in addition from xerophthalmia, are here subjoined, as diet N, O, P, see table X-18.
In these diets one may note that especially rice is here the main source of protein and the addition of tahu or tempe to the diet is already an improvement of the protein supply worth mentioning. For the Vit.A. supply only banana and vegetables appear to be important.

Table X – 18.

In the fifth year breast-feeding and cow’s milk are no longer present in the diet. Now only rice is the chief foodstuff with vegetables, banana, tahu, fruits or mung beans as subordinate food. There is no great difference with the third and fourth year. The most frequent diets were the above described types P.K.L. given to resp. 14, 11 and 6 children, of whom 12, 8 and 5 also suffered from xerophthalmia. It appears that the addition of cassave to the diet means deterioration as it leads to a reduction of the quantity of rice and thereby to a decrease of protein in the diet.
In the sixth and later years of childhood the same types of diet continue to occur, viz. rieas a basic food with the same subordinate food as above mentioned. They are mostly type Q and the above already mentioned types of diet P.L.M. and N, which are given to these malnutrition-patients.

Table X – 19.

In the analysis of the above mentioned diets we have made use of the analysis-data of the Institute for Popular Nutrition in Djakarta (1958). the data of the foodstuffs most frequently occurring in the diet for pre-school children are put together in table X-20.

Table X – 20.

The average diet which we found for a number of 23 well-fed toddlers, in the anamnesis according to the mother, we mention here below, table X-21.

Table X – 21.

It concerned pre-school children from a well-to-do milieu, who visited the polyclinic.
Measured with the norm of the Dutch foodstuffs-table of 1955, or with that of the food and Nutritional Board (U.S.A.) of 1953, concerning 1-6 year-old children, all described diets of the malnutrition-patients are far below the commended norm, see table X-22.

Table X – 22.

The quantity of calories is too low in all diets, as it is also the case with the quantity of protein in these diets. Dependent on the addition or not of banana and some kinds of vegetables, a number of the diets contain sufficient and a number of them insufficient quantities of carotenoid. This criterion, set up for European children, is intended to be optimal and in all likelihood very liberal. The minimum requirements of protein, mentioned for a normal growth of babies and pre-school children at the Princeton-conference (F.A.O./W.H.O.) in 1945 by Holt, Gyorgy, and other, were:
First 2 months of life 2.2 gr. milk-protein/kg. bodyweight
2-12 “ of “ 2.0 gr. milk-protein/kg. Bodyweight
1 year(till 6 year) 1.5 gr. milk-protein/kg. bodyweight
Thus the required quantities of protein in these years of life would amount to about half of those mentioned as “commended” by the Nutrition board (U.S.A.). We see that only the diets, in which the soyabean-products appear, approximately contain these minimal protein requirements, while the other diets without the soyabean-products remain far-below this minimum. At the Princeton Conference (Human protein requirements and their fulilment in practice, FAO/WHO 1957) the protein requirements were expressed in grammes of milk-protein. In the above mentioned diets of the malnutrition-patients this converns rice-and soyabean-protein, the equal biological value of which for the growth has not yet been ascertained, when compared with the milk-proteins. It is very likely that somewhat larger quantities of these vegetable proteins will be required than of the milk-protein. When surveying the data concerning the diets of the malnutrition-patients, we are struck by:

• the long maintained breast-feeding;
• the little variety in these children’s diet;
• that rice becomes the chief diet after the breast-feeding;
• the scarcity in protein and in pro Vit. a. in these diets;
• the practically total lack of animal food;
• the important improvement in the protein supply when soyabean-products as tahu or tempe is added to the diet, as soon as the amount of calories is sufficient;
• that the Vit. a. supply is dependent on the consumption of banana, swamp cabbage leaves, yardlong leaves and Ind.Amaranth. If these are deficient in the diet, it contains hardly any pro Vit. A. As the mother always chooses vegetables on the ground of other considerations than the Vit. A content, it is easily understood that the provision of it is continually in danger or insufficient;

• the insufficient amount of calories in these diets, so that the proteins received are not used for growth, but as a source of energy in the metabolism of the body.

As it is evident that a satisfactory diet may be obtained with a not too expensive improvement, it may be possible that instruction for the mothers, who do not belong to the most needy class of society, will bring some amelioration, in the diet of 1 – 3 years old pre-school children. By drawing the mothers’ attention to the soyabean-products (tahu/tempe) and the various pulses, the protein supply in the food of the young pro-school children may be improved. By giving the child a sufficient quantity of the cheap vegetables and the yellow cassaveroots, which contain enough carotenoid, the pro Vit. A. supply can be improved. Though in our opinion the factor of poverty is in the pathogenesis of greater importance than the mothers’ ignorance concerning the nourishment of the infants and toddlers, yet this last factor is certainly also of weight, and as soon as the poverty should once be conquered, it would become ever more important. For the time being the mothers’ ignorance seems to us of less importance than the parents’ poverty, as an advice given to the mother concerning the feeding of her toddler which would be financially beyond her reach, has little practical meaning.
In the year 1955 Oomen and his co-workers published the results of a diet-survey made in a district of the town of Djakarta. In 360 families with in a number of 462 toddlers a house-to-house investigation was made as to what diets were given to the babies and children of 1-6 years old. It appeared that in this district of Kemajoran, even if the financial resources allowed it, yet the children received poorer food than would have been possible financially in view of the local market prices of the foodstuffs. Breast-feeding was long continued, so that,
at the age of: 1 year 75% of the infants,
at the age of: 2 year 29% of the children and
at the age of: 3 year 9% of the children
still received breast-feeding. These children, fed on mothers’-milk, were worse off than the weaned children, so that the value for the physical development of nursing after the first year could not be proved.
The long-protracted nursing seemed rather to hamper the development of the toddlers’ diet. Among the children, who, older than 1 year, were still nursed, the number of malnutrition-patients proved to be larger than among the toddlers of 1-6 years old, who had already been weaned. The frequency of malnutrition among the first group of 80 still-nursed toddlers (1-4 years old) was 26 (=32%), and among the second group of 335 weaned children of 1-6 years old, 15 cases of malnutrition were observed (=4.5%). the diet of the 374 normal children, the data about whose diet were sufficiently extensive, appeared to improve considerably as to quality and very probably also as to quantity in the course of their years. The diet given by the mothers to the children of the age of 1-1½ years was very simple, viz. Rice, breast-feeding, a limited quantity of subordinate food (vegetables, pulse) and some bread and biscuits. In the course of the children’s life-years the diet was improved considerably. At the age of 4-6 the children received a more varied and extensive diet, which contained more protein, Vit.A. and probably also more calories. The provision with subordinate food (lauk pauk), which contributes especially to the supply of protein and Vit. A., is for the children of the age of 4-6 years much more liberal than for the younger toddlers. Cow’s milk did not take a prominent place in the Djakarta-toddlers’ diet. If the diet as is given to the children of the age of 4-6 years, should also be given to those of the age of 1-1½ years, much malnutrition would be prevented. It is “the ignorant poor mother, who is the source of infantile malnutrition in this society” (Oomen).
The period, needed by the poor and ignorant mother, to bring her baby with breast-feeding to the age of a toddler, who lives on a satisfactory and varied diet, thus takes up ± 4-5 years. And in this period the victims of malnutrition fall. The inquiry further showed, that a good physical development of the child was possible with the use of the foodstuffs, locally available. The weight-curve, made up on the basis of the weights of the 374 healthy toddlers, was almost identical with the weight-curve, made up by Tan Eng Dhong, Soekonto and de Haas of healthy toddlers in Djakarta in 1938.