Optimal nutrition during lactation is essential for maternal and infant health, supporting milk production, maternal recovery, and overall well‐being. Nutrient demands increase substantially during this period, particularly for key micronutrients such as iron, zinc, vitamin A, and vitamin B12, which are vital for immune function, cognitive development, and red blood cell production in both mothers and infants. Despite the critical role of these micronutrients in maternal health and their risk of deficiency, dietary guidelines in many countries, including Indonesia's Dietary Guidelines (IDGs), are primarily designed for the general population and heavily oriented toward non‐communicable disease (NCD) prevention, such as obesity, hypertension, and cardiovascular disease, rather than maternal or lactation‐specific outcomes. It remains unclear whether these general recommendations adequately address the unique nutritional demands of lactating women, particularly concerning micronutrient status, postpartum weight, and infant growth.
This article explores the adherence to dietary guidelines and its implications for lactating women, drawing on a study conducted in Indonesia. The study investigated adherence to Indonesia's Dietary Guidelines (IDG) among lactating women, examining related factors and association with nutrient intake adequacy, maternal and infant biomarkers, body mass index, and growth. The intention is to determine whether existing guidelines are compatible with the nutritional needs of lactating women and provide evidence to inform the refinement of FBDGs for this population in Indonesia and similar LMICs contexts.
Dietary Imbalances in Lactating Women in Indonesia
In Indonesia, diets are typically dominated by white rice, with relatively low and irregular consumption of animal‐source foods, fruits, and vegetables. Cultural norms, economic limitations, and meal structuring practices often prioritise staple energy sources over nutrient diversity. A study involving 220 lactating women from urban and rural West Java, Indonesia, revealed significant dietary imbalances. Participants were recruited from both urban (Bandung, n = 113) and rural (Sumedang, n = 107) areas in West Java, Indonesia, by local community health cadres. The sample size for this study (n = 220) was derived from the parent cohort study, which aimed to distinguish exclusively breastfed (EBF) from partially breastfed (PBF) infants during the first 6 months of life. It was calculated that 100 mother-infant pairs per group would provide sufficient power, accounting for dropout, and is adequate to support the multivariable regression analyses used in this investigation. Inclusion criteria required women to be without chronic diseases or acute malnutrition, have given birth to a full‐term infant weighing at least 2500 g, and be breastfeeding. Starchy staples intake exceeded recommendations by nearly double (median 7.1 vs. recommended 3-4 servings/day), while vegetable (0.5 servings/day), fruit (1.0), and water (1300 mL/day) intake fell notably short. Protein‐rich food intake (3.5 servings/day) was closer to target. Only 1% of participants met three out of four food group targets. Adherence to the meal‐based MyPlate framework showed similar imbalances, with 68% of the plate occupied by starchy staples versus the recommended 33%.
The MyPlate Framework
To provide practical guidance on meal composition, the MyPlate (Isi Piringku) model, derived from the IDGs, offers a structured framework for balanced nutrient intake. To assess adherence to the MyPlate (Isi Piringku) guidelines, the total intake (grams per meal) of starchy staples, protein‐rich foods, vegetables, and fruits was calculated and expressed as proportions of the total food intake per meal. These proportions were then averaged across all meals for the 3 days for each participant. A scoring system was developed to assess adherence, comparing the observed intake proportions per meal to MyPlate recommendations, which allocate one-third (33%) of the plate to starchy staples, one-third (33%) to vegetables, one-sixth (17%) each to protein-rich foods and fruit.
Factors Influencing Dietary Adherence
Sociodemographic factors, including education, wealth, and family size, were associated with adherence to IDG components. For instance, women in the highest wealth quintile had higher adherence scores for starchy staple moderation (mean 4.3) than those in the lowest (mean 2.9). This highlights the role of socioeconomic status in shaping dietary choices and adherence to guidelines. Sociodemographic data were collected through an interviewer‐administered questionnaire at 2 months postpartum (±1 week). A wealth index was established using principal component analysis based on household assets, following the Demographic and Health Surveys guidelines.
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The Scoring System
We reviewed the IDG and specific recommendations for lactating women to determine the scoring system (Ministry of Health Republic Indonesia 2014). Adherence was assessed using a scoring system adapted from the Healthy Eating Index (HEI) 2020 (Krebs‐Smith et al. 2018; Shams‐White et al. 2023). The HEI scoring method was chosen because it generates continuous adherence values, allowing for a more detailed analysis of how adherence levels relate to nutrient adequacy and nutritional biomarkers. Ten dietary components were measured, aligned with IDG recommendations, and adjusted for lactating women. The IDG suggests 3-4 servings/day for starchy staples and vegetables, 2-3 servings/day for fruits, and 2-4 servings/day for protein‐rich foods that apply to all populations. Guidelines for salt (sodium) (< 2000 mg), sugar (< 0% energy), and fat (< 25% energy) follow global standards (World Health Organization 2012, 2015). During lactation, the IDG allows up to three cups of coffee daily and recommends a daily water intake of 3000 mL/day. The scoring system, with a maximum of 100 points, assessed intake per 1000 kcal or as a percentage of energy intake. Components of the IDGs were divided into two groups for scoring: adequacy and moderation. Adequacy scoring was applied to the consumption of vegetables, fruits, protein‐rich foods, and water, with a minimum score assigned for no consumption and a maximum score when intake met the recommended level. Moderation scoring was used for starchy staples, sugar, salt, fats and oils, and coffee. Starchy staples were placed in this group because the IDG does not distinguish between whole and refined grains, and here, only 1% of all starchy staples consumed were whole grains. For moderation components, a minimum score was assigned if intake exceeded the recommendation. For starchy staples, intakes exceeding 5.7 servings per 1000 kcal were assigned a minimum score. This threshold was determined by adopting the HEI‐2020 refined grain scoring system. In the US dietary guidelines, the minimum score is assigned when intake exceeds 4.3 servings per 1000 kcal, corresponding to a daily maximum of three servings. To align this with the Indonesian recommendation of four servings per day, the threshold was proportionately adjusted to 5.7 servings per 1000 kcal. For fats and oils, salt and coffee, the minimum score was twice the recommended level, whereas, for sugar, it was four times the recommended level, an approach adapted from the HEI‐2020 scoring system (Krebs‐Smith et al. 2018; Shams‐White et al. 2023). Daily breakfast was defined as a meal consumed between waking and 9:00 AM (Ministry of Health Republic Indonesia 2014). The maximum score for breakfast was achieved if participants had breakfast on all 3 days of a nonconsecutive 3‐day diet record.
Association with Nutrient Intake Adequacy and Biomarkers
Adherence to IDG components correlated positively with nutrient intake adequacy (e.g. protein‐rich food and overall adequacy: r = 0.19, 95% CI: 0.06-0.32) but not consistently with maternal or infant biomarkers. This suggests that while adherence to dietary guidelines can improve nutrient intake, its impact on specific health outcomes may vary.
Assessing Nutrient Intake
Dietary intake was assessed over three nonconsecutive days for all participants. In rural areas, trained cadres conducted 12‐h in‐home food weighing due to limited literacy and capacity among participants to conduct self‐recording, while in urban areas, mothers were trained to weigh and record their own food and beverage intake using digital scales provided by the investigators. Data collection was staggered across the calendar year, with participants recruited throughout both dry and rainy seasons, including during the Ramadan fasting period. This distribution helped minimise systematic seasonal bias. Supplement use was recorded through the dietary records. Foods were categorised into starchy staples (e.g., rice, noodles), vegetables, fruits, and protein‐rich foods. Nutrient intakes were estimated using the Indonesian Food Composition Table (FCT), incorporating mandatory wheat flour fortification with thiamine, riboflavin, iron, zinc, and folic acid. Salt intake was estimated from intrinsic sodium (FCT) and discretionary salt in cooking based on standard recipes. Sugar intake included natural sources (fruits, dairy), added sugars in processed foods, and additional sugar in homemade foods and beverages. Fats and oils were derived from intrinsic fat content and cooking oils, calculated using recipes.
The multiple source method (Harttig et al. 2011) was applied to estimate the usual intake of energy and nutrients for the study population. For iron and calcium, the EARs from IOM were applied (Institute of Medicine IOM 2001; Ross et al. 2011), assuming 10% bioavailability for iron reflecting mixed rice‐based diets of non‐menstruating lactating women (Institute of Medicine [IOM] 2001). PA was assigned as 1 or 0 if the usual intake of the nutrient was ≥ or below the corresponding EAR. The Total PA Score, summing PAs across all nutrients, provided an overall measure of nutrient adequacy for each participant.
Biomarker Analysis
At 5 months postpartum (±1 week), anthropometric measurements, blood, and breast milk samples were collected in the community health centre. Blood was drawn by trained phlebotomists, separated, and serum stored at −20°C until analysis (Centre de toxicologie du Québec [CTQ] 2021). Serum biomarkers, including ferritin, retinol‐binding protein (RBP), C‐reactive protein (CRP), and α−1‐acid glycoprotein (AGP), were measured via sandwich enzyme‐linked immunosorbent assay (Erhardt et al. 2004). Serum vitamin B12 was assessed via electrochemiluminescence immunoassay (Roche Diagnostics, GmbH), and serum zinc via inductively coupled plasma mass spectrometry (Agilent 7500 ICP‐MS) at the Centre for Trace Element Analysis, University of Otago, New Zealand. Breastmilk intakes at 5 months were measured via the deuterium oxide dose‐to‐mother technique (Gibson et al. 2020). Breastmilk from one full breast was collected in the morning using a breast pump under strict contamination precautions, aliquoted into acid‐washed containers, and stored at −80°C. Breastmilk iron and zinc were analysed via ICP‐MS at the University of Otago, while vitamin B12 was assessed via chemiluminescent immunoassay at the USDA WHNRC, USA. Retinol and provitamin A carotenoids were measured via high-performance liquid chromatography at WHNRC, USA. Detailed collection and micronutrient analysis procedures are described elsewhere (Daniels et al. 2019).
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Implications and Recommendations
Most lactating women in Indonesia consume excessive starchy staples and insufficient vegetables, fruits, and water, while protein‐rich food intake is closer to recommendations. These findings underscore the need for targeted interventions to improve dietary habits among lactating women.
Infant Dietary Intake
Infant dietary intake was recorded alongside maternal diet. For EBF infants, nutrient intake was estimated based on breastmilk volume measured using the deuterium oxide dose‐to‐mother technique and its analysed nutrient composition. Infant weight and length were measured by trained research assistants using calibrated digital weighing scales (precision ± 10 g) and infant length boards (precision ± 1 mm) following standardised anthropometric procedures (de Onis et al. 2004). Z‐scores for weight‐for‐age (WAZ), length‐for‐age (LAZ), and weight‐for‐length (WLZ) were calculated using the WHO Child Growth Standards (WHO Multicentre Growth Reference Study Group 2006). Measurements were taken during the same visit as biological sample collection (at 5 months postpartum).
Statistical Analysis
Data were analysed using Stata 14.2. Adherence scores were reported as means with standard deviations, while the proportions of participants meeting recommendations were presented as percentages. Associations between adherence scores and sociodemographic characteristics were examined using multiple linear regression. Pearson correlation coefficients were calculated to assess associations between adherence scores for each dietary component and nutrient PA scores. Multiple linear regression models were used to evaluate associations between maternal adherence to dietary guidelines and various nutritional outcomes. These outcomes included maternal BMI, serum biomarkers (iron, zinc, RBP, vitamin B12), breastmilk composition (iron, zinc, retinol, vitamin B12), infant anthropometry (WAZ, HAZ, WHZ), and infant serum biomarkers (iron, zinc, vitam…
Refining Dietary Guidelines
Given the unique nutrient demands during lactation and the absence of lactation-specific dietary guidance, there is a clear need to refine food-based dietary guidelines (FBDGs) for this population in Indonesia and similar LMICs contexts. This refinement should consider:
- Increased emphasis on micronutrient-rich foods: Encourage the consumption of diverse fruits, vegetables, and animal-source foods to meet the increased micronutrient demands of lactation.
- Education on balanced meal composition: Promote the MyPlate model with specific guidance on portion sizes and food group ratios for lactating women.
- Addressing socioeconomic barriers: Implement strategies to improve access to nutritious foods for women from low-income backgrounds.
- Lactation-specific recommendations: Develop specific guidelines that address the unique nutritional needs of lactating women, including recommendations for portion sizes, micronutrient intake, and hydration.
The Broader Context of Weight and Health
The study on dietary adherence in lactating women highlights the importance of nutrition for specific populations. However, it's crucial to consider the broader context of weight, health, and societal biases.
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Adipose tissue, commonly known as fat, plays essential roles in storing energy, signaling molecules, cushioning organs, and supporting the immune system. Despite its importance, fat is frequently viewed negatively. Studies often attribute health issues to "diet-induced obesity" without fully considering other factors such as diet composition, exercise, or drug exposure.
The Impact of Bias and Stigma
Medical provider bias against larger individuals is prevalent. Studies have revealed that a significant percentage of medical students hold explicit biases against fat people. This bias can influence the quality of care and the focus of research. It's crucial to recognize that correlation does not equal causation, and attributing all health problems in a fat person to their weight is an oversimplification.
Socioeconomic and Environmental Factors
Body weight is often perceived as an individual dietary choice, but this perspective overlooks the influence of socioeconomic and environmental factors. For instance, communities exposed to public poisoning through contaminated water or living near Superfund sites may experience metabolic diseases exacerbated by these environmental factors. The models and frameworks used in biomedical research often focus on individual behaviors rather than community-level influences.
Reimagining Body Weight
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