In the past three decades, the Southeast Asian countries have made efforts in improving child health and have seen great progress in protecting people from diseases via vaccination. It is attributable to the concerted effort by nations and global organizations, such as the WHO guidelines on nutrition for the management of severe malnutrition and overnutrition, and the National Immunization Programme (NIP) to prevent a range of diseases.

However, various socio-economic and cultural factors are intertwined in impacting the prevalence of health conditions and disease among infants and children with regional differences across countries. Of the five subregions in Asia, Southeast Asia has the second-highest prevalence and total number of children who are stunted,Footnote 1 measuring 29.4% amounting to 15.6 million, wasted,Footnote 2 measuring 9.4% amounting to 5.0 million, and underweight measuring 18.3% amounting to 9.7 million (Thet et al., 2016).

The following chapter will begin with a discussion on the prevalence of low-birthweight babies and overweight children, together with the nutrition profile of children from the severe wasting and exclusive breastfeeding rate.

1 Low-Birthweight Babies

According to the World Health Organization (WHO)’s definition, low-birthweight babies refer to infants whose weight at birth is less than 5.5 pounds (Hughes et al., 2017). Compared to typically developing babies, the mortality rate for low-birthweight babies is 20 times higher (McCormick, 1985; Wilcox, 2001). In 2004, the United Nations Children’s Fund and World Health Organization reported that a higher number of low-birthweight babies are indicative of poorer health status in the country. Low parental education levels, young maternal age, below average mother’s body measurements, and poor nutrition during pregnancy are the potential factors contributing to the high rates of low-birthweight babies (Sananpanichkul & Rujirabanjerd, 2015).

According to Fig. 7.1, most countries have 5% to 15% low-birthweight babies given each country’s total number of births. A notable exception is the Philippines at 15.9%. The Philippines started at 17.9% in 1990, fluctuated over the years, and decreased to 16% in 2010. The World Bank database on Gender Statistics in 2014 marked an increase of over 22% in the last 20 years on adolescent fertility rate in the Philippines. Golding and Shenton (1990) mentioned that younger maternal age increases the probability of giving birth to low-birthweight babies.

Fig. 7.1
figure 1

Low-birthweight babies (% of births) of Southeast Asian countries, 1990–2015. Source UNICEF, State of the World’s Children, Childinfo, and Demographic and Health Surveys. Notes Data available only for Brunei 1999–2011, Cambodia 2000–2010, Indonesia 1991–2010, Laos PDR 2000–2012, Malaysia 1998–2012, Myanmar 2000–2010, Philippines 1993–2011, Singapore 2000–2011, Thailand 2001–2010, Timor-Leste 2002–2003, and Vietnam 2000–2011

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Myanmar and Vietnam also showed a decline in low-birthweight babies over the period. Myanmar experienced a steep drop of 6% from 2000 to 2010, which can be attributed to Myanmar’s increasing government health expenditure and increased access to basic health services in rural areas since 1992 (Myanmar, 2012). Vietnam showed a lesser degree of decline and dropped from 8.8% in 2000 to 5.1% in 2011. Studies showed that the implementation of a comprehensive economic reform contributed to people’s consumption power for nutritious food to safeguard mothers’ and babies’ nutritional status. This improvement played a significant role in the decreasing trend of low-birthweight babies (Hanieh et al., 2014; Tuan et al., 2007).

However, other countries are on the opposite end of the trend with varying degrees of increase in low-birthweight babies. Thailand and Timor-Leste both experienced a sudden surge of 4–5 percentage points in one year, from 2009 to 2010 and 2002 to 2003, respectively. Lao PDR and Cambodia experienced a drop of 3.5% to 5% before the increase to 14.8% in 2012 and 11.3% in 2010, respectively. These countries spent effort on comprehensive health care, but these schemes are yet to be comprehensive to cover all populations. For instance, in the case of Lao PDRs and Cambodia, the health coverage cannot cover all rural and provincial areas, together with the fact that there was a small formal medical workforce, the number of Cambodia and Lao PDRs inevitably increases back to a similar level in 2011 (Ministry of Health, 2013; Pridmore & Car-Hill, 2009). Events like the global food crisis in Thailand also pose challenges to Thailand’s nutrition progress and hindered children and mother nutrition profile to impact on nutritional status (Heaver & Kachondam, 2002). The above situations indicated that even with governmental efforts in healthcare planning, other socio-economic factors interfere with the increasing trend of low-birthweight babies.

While there are other factors such as policy and legislation in safeguarding nutrition status, studies found that diminished policy attention on undernutrition could be due to the rising concern on overweight and obesity (Gillespie et al., 2016). The following chapter will give an overview of the trend and prevalence of overweight children, which is closely related to low birthweight rates, among Southeast Asian countries.

2 Prevalence of Overweight (% of Children Under 5)

WHO defines overweight for children under five years of age as weight-for-height greater than two standard deviations above WHO Child Growth Standard median. Globally, there is also a shift of trend from high-income countries to rising numbers in low- and middle-income countries, most commonly seen in urban settings (World Health Organization, 2018). Lindsay et al. (2017) found that the rapid economic growth in Southeast Asian countries has contributed to the increasing number of overweight children, particularly in urban areas. The situation is phenomenal in all countries except for Myanmar and Cambodia.

Indonesia, with the highest rate of increase, also accounted for the most number of overweight children at 11.5% in 2015. As Fig. 7.2 shows, the number of overweight children in Indonesia drastically increased from 2000 at 1.5% to 12.3% in 2010, and then it dropped slightly to 11.5% in 2013. Indonesia is followed by Thailand at 10.9% and Brunei Darussalam at 8.3% in 2009. In Thailand, it gradually rose by 9.6 percentage points (from 1.3% in 1987 to 10.9% in 2012) in 25 years. Indonesia spent only 10 years, as compared to 25 years for Thailand for the similar range of increase in overweight children. The remaining countries grew at a steady rate.

Fig. 7.2
figure 2

Prevalence of overweight (% of children under 5) of Southeast Asian countires, 1974–2015. Source World Health Organization, Global Database on Child Growth and Malnutrition. Notes Data available only for: Brunei 2009, Cambodia 1996–2014, Indonesia 2000–2013, Laos PDR 2000–2011, Malaysia 1999–2015, Myanmar 1997–2009, Philippines 1973–2011, Singapore 1974–2000, Thailand 1987–2012, Timor-Leste 2002–2009, and Vietnam 1993–2014

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Research shows that factors such as overweight mothers before pregnancy, high birthweight of children, higher than the required portion of food taken by children, and consumption of high caloric food contribute to childhood obesity in Thailand and Indonesia (Droomers et al., 1995).

The situation is explained by the “double burden of nutrition” (coexistence of under- and overweight) in Indonesia and “nutrition in transition” (trend from undernutrition to overnutrition) in Thailand, where urban households are the highly vulnerable ones (Mahmudiono et al., 2016; Yamborisut et al., 2006). The higher household income is contributing to improved access to high-calorie food taken by children, accompanied by low physical activities and poor parental monitoring on eating behaviour by children, creating nutritional imbalance (Yamborisut et al., 2006).

On the other end, despite a 54% increase in global childhood overweight prevalence from 1990 to 2011, both Myanmar and Cambodia show a decreasing trend. Cambodia plummeted from 6.5% to 1.7% between 1996 and 2005, while Myanmar experienced a sharp decline from 11.6% to 2.4% between 1997 and 2000 in the three years. After the fall, both countries remain at the low level at 1.7% and 2.4%, respectively. The drop in overweight children is within the same period as Myanmar’s National Food Law enactment in 1997, where the law enabled people to consume quality food and initiated the prevention of harmful food habits.Footnote 3 The Ministry of Health of Cambodia also started the Health Coverage Plan in 1996 for better public access to information on health and nutrition and improving the health of pregnant mothers.Footnote 4 While the underlying reason behind the gradual decrease remains unclear, Fig. 7.1 shows that in a similar period, Cambodia experienced an increase of low-birthweight babies, starting from 2000 until 2005.

The above situation also created the paradox of the developing regions among Southeast Asia, where overweight, underweight, and undernutrition have coexisted due to wider socio-economic disparities. Besides Cambodia, Indonesia is one example with 11.1% of low-birthweight babies in the 2010s, and at the same time 12.3% of overweight children in the 2010s. Malaysia also faces a similar “double burden” syndrome for having more overweight counterparts than low birthweight counterparts, and not much difference for its prevalence between rural and urban areas (Mustapha, 2017). The following section will further evaluate the nutrition shift from undernutrition to overnutrition in Southeast Asian countries by looking specifically at the figure of wasting and breastfeeding rate to give a complete overview of the underlying causes and effects in recent decades.

3 Prevalence of Wasting (% of Children Under 5)

World Health Organization (2018) defines wasting as acute malnutrition, which refers to the sudden and drastic lack of nutrients due to sickness and lack of food availability. Wasting is a stronger predictor of mortality than stunting or being underweight (Greffeuille et al., 2016).

Most Southeast Asian countries in Fig. 7.3a are concentrated below 15% of wasting for children under 5. Timor-Leste is an exception, having the highest figure and steepest increase to 24.5% in 2007 followed by a more recent fall. About 7.5% of these children are in severe wasting (see Fig. 7.3b). Since the independence of Timor-Leste in 2002, the young nation is developing its economy and recovering from political unrest (Bank, 2011). Risk factors such as high malnutrition rate among women, early age at first birth, low contraceptive prevalence, and high fertility are all potential reasons leading to the sudden increase in wasted children (Provo et al., 2017). The upward trend is then mediated by the 2009 initiative from UNICEF and the Ministry of Health’s effort in introducing the National Nutrition Strategy to all districts (UNICEF, 2013).

Fig. 7.3
figure 3

a Prevalence of wasting (% of children under 5), 1970–2015, b prevalence of severe wasting, weight for height (% of children under 5), 1970–2015. Source World Health Organization, Global Database on Child Growth and Malnutrition. Notes Data available only for: Brunei 2009, Cambodia 2000–2013, Indonesia 2000–2013, Laos PDR 2000–2011, Myanmar 2000–2009, Philippines 2003–2011, Singapore 2000, Thailand 2006–2012, Timor-Leste 2002–2009, and Vietnam 1993–2010; missing data for Malaysia

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The prevalence of wasting is also high in Laos and Cambodia. In Lao, it was 11.8% in 1993 which subsequently reached a peak at 17.5% in 2000 and then decreased rapidly to 6.7% in 2012. In Cambodia, the rate was 13.4% in 1996 reaching a peak at 16.9% in 2000 and declined to 9.6% in 2014. In 2000, Cambodia and Lao PDR also recorded a high percentage of severe wasting at 7.5% and 7.6%, with Indonesia catching up with the trend at 6.8% in 2007 (Fig. 7.3b). Studies found that the socio-economic status of families has a strong relation to wasting. Economic inequality pertaining to mothers influence the access to nutrition for children in their first two years of age (Greffeuille et al., 2016). In the past, healthcare funding in Laos relied heavily on out-of-pocket payments. Sixty-three percentage of healthcare expenditure was sourced from household expenditure (World Health Organization, 2012). In Cambodia, health policies were influenced by political instability up till 1997, partly accounting for the peak in the percentage of wasted children in the 2000s. Following the introduction of health policies and planning through the comprehensive Primary Health Care Policy (2000) and Sixth and Seventh National Health Sector Development Plans (2006–2010) in Laos and Health Sector Reform in Cambodia since the 1990s, these countries made impressive progress in health outcomes. There was a significant decrease in the number of wasted children starting from the 2000s (Grundy et al., 2009).

Indonesia recorded a jump from 5.5% in 2000 to 14.4% in 2004 in the percentage measure of wasting (Fig. 7.3a). In mid-1997, Indonesia was hit by the Asian financial crisis, and purchasing power of citizens for food and health products had decreased (Bloem et al., 2000). This effect was coupled with the decentralization of the health system in 1999, which indirectly led to discrepancies in the provision of health services for the public; thus, the figure on wasting jumped rapidly starting from 2000 (Mahendradhata et al., 2017).

4 Exclusive Breastfeeding Rate

WHO recommends that children should be breastfed exclusively for 6 months, followed by continued breastfeeding along with the introduction of complementary (semi-solid and solid) food that is safe, appropriate, and adequate for up to 2 years of age and beyond (World Health Organization, 2018). Breastfeeding is also one of the most effective interventions in malnutrition among early childhood (Prak et al., 2014). Figure 7.4 shows that as of 2015, all countries showed an increasing trend of breastfeeding with varying degrees of increment from 2000 to 2010. The notable exception includes the decrease in Indonesia and the Philippines since early 2000.

Fig. 7.4
figure 4

Exclusive breastfeeding (% of children under 6 months) of Southeast Asian countries, 1995–2015. Source UNICEF, State of the World’s Children, Childinfo, and Demographic and Health Surveys. Notes Data available only for: Cambodia 2000–2014, Indonesia 2003–2012, Laos PDR 2000–2012, Myanmar 2000–2010, Philippines 2003–2011, Singapore 2000, Thailand 1995–2012, Timor-Leste 2002–2013, Vietnam 2002–2014, and Malaysia 1996. Missing data for Brunei and Singapore

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Cambodia marks the highest percentage of breastfeeding babies peaking at 73.5% in 2010 although a decline to 65.2% in 2014 is observed. Public health campaigns contributed to the high percentage of breastfeeding babies in Cambodia through effective intervention to promote and protect breastfeeding practices. But it lacked sustained effort starting in 2005 leading to a decline since 2010. A study shows that during this period, illegal promotion of breastfeeding substitutes filled the market to dislodge breastfeeding practices among vulnerable groups (Prak et al., 2014).

Timor-Leste showed a steep increase since early 2000 from 30.7% in 2003 to 62.3% in 2013. This may be attributed to the fact that maternal and child health interventions following the 5-year (2002–2006) National Development Plan (NDP) became more stable after the conflict in 2003 (Khanal et al., 2014; Thet et al., 2016; Tilman, 2004).

Myanmar marked 11% in 2000 to 51.2% in 2016. This increase can be attributed to the effort by WHO and UNICEF, which is promoting more trained workers and community support.

In contrast, Thailand and Vietnam maintain a low prevalence and a sluggish increase in exclusive breastfeeding rates for children under 6 months. Thailand is at 12.3% in 2012, and Vietnam is at 24.3% in 2014, which is lower than the world average of 35%. A review on Thailand’s and Vietnam’s health policy during the period of 2001 to 2016 shows that various factors facing the health professional and healthcare system, and family and social context are creating an intertwined influence on the exclusive breastfeeding rate in both Thailand and Vietnam, coupled with the premature introduction of complementary food in Vietnam (Duong et al., 2004; Thepha et al., 2017).