Keywords: rice, diabetes mellitus, diversification, food security, socioeconomic, and policy analysis
Nearly 80% of the world's population with diabetes mellitus live in developing countries that are low to middle-income countries (Ministry of Health, 2020). Indonesia is the world's fourth-largest country with diabetes mellitus after India, China, and the United States, and in 2030, estimates an increase of 21.3 million (WHO, 2016). According to the World Health Organization report, diabetes mellitus type 2 is the most common illness in Indonesia, followed by hypertension, cardiovascular disease, bronchitis, pulmonary tuberculosis, fractures, and cancer. Indonesian Ministry of Health recorded that in 2020, people with diabetes mellitus type 2 had reached the 10.8 million mark.
Diabetes mellitus type 2 is a degenerative disease, where carbohydrate, fat, and protein metabolic disorders occur. It is characterized by hyperglycemia and glucosuria caused by insulin deficiency or resistance (Rismayanthi, 2010). Soviana et al. 2019 and Hu et al. 2012 have proven that a food consumption habit with a high glycemic load (white rice) when the body experiences insulin resistance causes the body to respond by increasing insulin secretion, which increases the causes of type 2 diabetes mellitus.
White rice, as high-calorie and nutritious, refined grain is generally accessible for everyone and everywhere as an essential diet base. However, Bhavadharini et al. 2020 studied that higher consumption of white rice is closely associated with an increased risk of type 2 diabetes mellitus. White rice has a high Glycemic Index, emerges in high postprandial blood glucose and insulin levels. Nearly all countries with the most significant number of diabetes cases globally possess rice as the leading staple food (IDF, 2019). On the other hand, some research shows that white rice consumption indirectly causes diabetes mellitus type 2, but lack of diversification results in nutrition deficiency.
Responding to the estimated prevalence of diabetes that continues to increase, the Indonesian government and the community began emphasizing diabetes prevention and healthy community action through policies, regulations, and action plans. The government has been promoting the food diversification program for a long time but has been unsuccessful. The market demand for rice is still irreplaceable, and has even been increasing over the years. The Indonesian Agency for Agricultural Research and Development launched analog rice research; it is processed rice from non-rice ingredients with size and taste similar to rice, has a higher nutrient content, and lower glycemic index.
This article also involves a scientifically proven case study of analog rice development in Indonesia. The advantages of arrowroot starch and seaweed flour analog rice are: it has a higher content in dietary fiber and has the potential to reduce postprandial glucose levels; it improves glucose metabolism, and develop insulin resistance; it is suitable to staple food consumption for the Indonesian community as a diabetes mellitus prevention food.
This article analyzes food security and public health policy that supports diabetes mellitus reduction control in Indonesia. This article aims to use the perspective in other policy areas to congregate a broad set of possible suggestions for addressing better policy to alleviate diabetes mellitus while achieving food sustainability. It comprises the overview of diabetes mellitus and its socioeconomic connection, a review on the legal basis, and government strategy. The last section of this article will include a scientifically proven case study of analog rice development to solve diabetes mellitus management.
Food security is generally defined as food production, sovereignty, and food calorie, losing sight of the fact that food security includes secure access to the foods needed for a nutritionally balanced diet (World Food Summit, 1996). FAO defines micronutrient deficiency as referred to hidden hunger because it is associated with the inadequate energy amount of the community. However, the Indonesian government stipulates that rice is a staple commodity for agricultural products, considering that rice greatly influences economic stability and the interests of the public as an indicator of national food security and sufficiency[1]. Indonesia's food security development history is an indication of pro-poor economic growth and a Green Revolution led by investment in rural infrastructure, irrigated agriculture, and availability of fertilizers, mainly for varieties of large-scale rice production (Timmer, 2008).
Correlation of public health, diabetes, and socioeconomics
Economic growth in Indonesia is incomparable to national investments in human development. The economic situation dramatically influences all aspects of national optimal nutrition care. The increase in diabetes mellitus incidence and prevalence directly affects a significant drop in economic impact (Jönsson, 1998; Ray & Linden, 2018). Bloom et al. (2004) studied that the increase of national health improvements is also in line with labor productivity and capital accumulation output. Essentially, World Bank Data recorded that Indonesia had the third-lowest expenditure on social health as Gross Domestic Product (GDP) percentage in 2018 (2.9%) of any Southeast Asian countries, within Brunei Darussalam (2.4%) and Lao People's Democratic Republic (2.3%) is lagging.
Minimal investments in developing public health and services are emulated in malnutrition trends in Indonesia (SMERU, 2015). Micronutrient deficiencies promote diabetes mellitus (Via, 2012); thus, it is affected by energy and nutrition imbalance associated with obesity (Wells, 2013). While obese and overweight directly constitutes a health risk associated with diabetes mellitus type 2 due to unseasonably insulin resistance and defective insulin secretion (Golay & Ybarra, 2005). The imbalance of glucose control can also increase the risk of cardiovascular disease, even mortality (Kelly et al., 2009).
Trend in modern dietary pattern and consumer behavior in Indonesia
In addition to poverty, social behavior-related and consumption-related factors are essential factors of diabetes mellitus. As presented in Table 3, energy consumption in Indonesia from year to year has increased at an increasing rate of 2.8% per year; surprisingly, the primary consumption was white rice as a carbohydrate source which occupied more than half of the energy intake per day. In line with the objectives of the Food Security Agency of the Indonesia Ministry of Agriculture (refer to paragraph 3 Policy Directions and Strategy for Management of Economic Resources in the Narrative 4th of 2020-2024 Middle-Term National Development Plan), it is suggested to balance the increased consumption of tubers and other alternative carbohydrate sources. White rice consumption still dominates the daily energy contribution. It causes the aggregate amount of white rice consumption needs to remain high over the years.
White rice is categorized as a refined grain because it is deprived of its bran and germ. Aune et al. (2013) studied that a high intake of refined grains is positively associated with the increased type 2 diabetes risk. Consumption of whole grains is beneficial to health, while refined grains, which contain only the endosperm (starch), have a detrimental effect on cardio-metabolic risk factors, including glucose intolerance and diabetes (Radhika et al., 2009).
Although numbers of researches show a close relationship between white rice consumption and diabetes mellitus, however, as shown in Table 3 as national data on average Indonesian consumption, high rice consumption is associated with low consumption of many other food groups, resulting in an imbalance in nutrition intake, lacking in fiber, micro and macronutrients, healthy fatty acids, and protein.
RATIONAL BASIS REVIEW OF INDONESIAN FOOD AND HEALTH POLICY
Policies engagement in the control of diabetes mellitus
In Table 4, Government Regulation No. 17 of 2015 concerning food security and nutrition, is a detailed description of regulating both availability, affordability, and proper utilization according to the mandate of Law No.18 of 2012. Efforts to consolidate food security based on sovereignty and independence are based on three main points, namely:
- Food availability based on optimal utilization of local resources;
- Food affordability in physical and economic aspects by the whole community; and
- Proper utilization of food consumption and nutrition for a healthy, active, and productive community.
Through Government Regulation No. 68 of 2002 and No. 28 of 2004, the government has implemented nutrition labeling, monitoring systems, and food safety for the community. The government also sets specific artificial sweeteners standards for diabetics. Regarding National Mid-Term Development Plan (RPJMN), food diversification is the main point of the Ministry of Agriculture in improving community health through balanced food nutrition. Increased food production and access are essential in achieving significant nutritional improvement in sufficient quantities and fine qualities. Food diversification production requires the collaboration of multidisciplinary areas, such as agriculture, fishery, forestry, animal husbandry, food industry, marketing, communications, home economics, and nutrition. The wide application of proven technologies and approaches in these fields will solve nutritional problems, which farmers as producers, supply chain distributors, and consumers need to be involved and educated on to achieve nutritional balance (FAO, 1997). The strategies of food diversification development in Indonesia include improving local food availability by increasing productivity and expanding the planting area, stabilizing supply and prices, expanding business scale and partnerships, education, and promotion to the community.
In Table 5, Government Regulation No. 2 of 2018, Minister of Home Affairs Regulation No. 100 of 2018, Ministry of Health Regulation No. 52 of 2016, and No. 4 of 2019 have determined that efforts to control diabetes mellitus are the minimum and mandatory efforts of every local government. Each citizen with diabetes mellitus will receive standardized services at least once a month, including blood sugar measurement, therapy, and education. Presidential Instruction No. 1 of 2017, concerning Germas Program, to build the culture of healthy community behavior. However, in contrast, in the guidebook Public Health Program Action Plan 2020-2024 from the Directorate General of The Ministry of Health, diabetes mellitus is unquoted as a national priority program for public health and dietary.
The President’s regulation is the cornerstone of the national future regulatory strategies. President regulation No. 18 of 2020 concerns the middle term national development plan for 2020-2024 IV. 26 No 3.3 concerns the policy direction and strategies to increase diabetes control. Below are the following regulations:
- Prevention and control of disease risk factors, including expansion of early detection coverage, strengthening of accurate time surveillance and vector control;
- Strengthening health security, significantly increasing capacity for prevention, detection, and rapid response to disease threats, including strengthening the alert system for extraordinary events and health quarantine;
- Increase coverage of case finding and treatment;
- Strengthening management of disease and injury; and
- Community empowerment in disease control.
Addressing the credibility of policies for national health and diabetics alleviation
A combination of public policy on food and health issues makes the credibility of future commitments essential for Indonesia's agriculture and food policy development. This section discusses perspectives in other policy areas for compiling a series of legal possibilities to reduce diabetes mellitus while achieving food sustainability.
According to the review of a series of regulations and decree regarding agriculture, food, food safety, and nutrition-related to diabetes mellitus (Refer to Table 4), it can be concluded that currently, the primary efforts of the central government are curing diseases and diabetes control rather than specific diabetes prevention. The central government has mandated the Minister of Health and Agriculture to reduce dependence on rice consumption through a food diversification program. In addition to reducing the prevalence of type 2 diabetes mellitus, it is also to improve food security, food sustainability, and a healthier community.
As shown in Table 5, the Indonesian government has regulations, policies, action plans to increase the community's physical activity, guidelines for balanced nutrition, prevention of non-communicable disease, and medical management for diabetes; however, the government has yet to deregulate the specific diabetes control, overweight, and obesity reduction.
The Indonesian government has followed the 1989 Resolution of The World Health Assembly on Prevention and Control of Diabetes Mellitus with a policy and action plan to measure the community on blood glucose and national registration. However, based on a review of regulations, strategies and national action plans, the government is inexperienced in dealing with overweight, obesity, and diabetes prevention.
CASE STUDY: ANALOG RICE AS FOOD DIVERSIFICATION
Rice is the leading staple food of Indonesian people. The limited land availability for rice production is increasingly unable to meet the market needs. The national rice consumption from January to September 2018 reached 22.11 million tons (Central Bureau of Statistics, 2018). Nevertheless, rice is also a symbol of social prestige in Indonesian society. Based on Kusmiadi's 2012 study in Sudiharto, 2020 of the social paradigm phenomena that develops in Indonesian society, people who refrain from consuming rice as a staple food will be classified in the lowest social hierarchy. Meanwhile, the glycemic index contained in rice is relatively high and unsuitable for diabetes mellitus type 2 patients. Rice consumption in Indonesia is a contradiction and became the inner pressure of social conformity.
Through its food diversification programs and regulation for a healthier community, the central government supports regional governments, educational institutions, and the private sector for analog rice production (Ministry of Agriculture, 2020). Table 6 is a case list of research for analog rice projects that have been successful and distributed nationally. This section presents rice analogs made from arrowroot and seaweed that have been clinically tested the Department of Food Science, Muhammadiyah University Malang. The arrowroot material has the lowest glycemic index with high fiber, which is the low-cost, adequate, and environmentally friendly material for Indonesia's food sustainability (Wu, et al. 2020).
The glycemic index of white rice and other staple foods
Carbohydrate sources besides rice are very diverse; Table 7 explains the various nutrition content and glycemic index contained by the most available carbohydrate source in Indonesia. The glycemic index is related to glucose derived from carbohydrates (Puspowidowati, et al., 2011); the glycemic index in table 7 (Boiling or Moist-Heat Cooking Method). A control diet in diabetes mellitus patients manages the diet composition by controlling blood sugar levels through low glycemic index food consumption (Rianawati & Mahmudy, 2015). Low glycemic index food effectively improves insulin sensitivity and decreases the glucose absorption rate. For people with diabetes mellitus type 2, free radicals can accumulate due to an increase in fatty acid peroxidation. An increase in the formation of free radicals extended by an increase in antioxidant intake will cause oxidative stress. The best type of functional food that can be developed is beneficial analog rice from modified arrowroot starch.
Arrowroot plants consist of two essential types of cultivars, namely creole and banana. Creole cultivar arrowroot garlic is a source of carbohydrates; that is, most of the constituent carbohydrates are starches. The levels of creole tuber starch cultivars were slightly higher (20.96%) compared to banana cultivars (19.40%). Both arrowroot tuber cultivars are relatively high in carbohydrates, low in glycemic index (Refer to Table 7), high in starch digestibility or fiber, and low in reducing sugar rate (Refer to Table 8).
Seaweed is the primary source of phycocolloid to produce functional food because it contains high fiber food, antioxidants, nucleic acids, amino acids, vitamins (A, B, C, D, E, and K), and minerals (calcium, selenium, iron, manganese, and sodium). The content of amino acids, vitamins, and minerals in seagrass is 10-20 times more than terrestrial plant (Chan et al. 2014). Seaweed Gracilaria sp. is generally cultivated in shallow waters at a depth of 0-20 m, with an optimum temperature of 19° to 23° Celsius and high light intensity. Gracilaria sp. is a material that has sufficient ability in the process of gelling, thickening, and flexibility in low shrinkage. Polysaccharides in Gracilaria sp. are composed of β-D-galactose and 3,6-anhydrous-α-L-galactose, which is inversely proportional to sulfate content and directly proportional to the strength of gelatin (Reeves, 1993).
CONCLUSION AND RECOMMENDATIONS
Diabetes Mellitus is a global public health crisis that threatens the economies of all countries, especially developing countries. Triggered by rapid urbanization, nutritional transitions, and increasingly erratic lifestyles, this epidemic has evolved by increasing the incidence of obesity throughout the world. Although diets and nutrient intake are widely believed to play an essential role in developing type 2 diabetes mellitus, specific dietary factors have never been clearly defined. There are a number of controversies regarding the correlation between fat and carbohydrate consumption with the diabetes mellitus risk. A low glycemic index diet with a higher amount of fiber and processed whole wheat products minimally reduces glycemic and insulinemic responses and decreases the risk of type 2 diabetes.
The reduction of white rice consumption in Indonesia can achieve a balanced dietary pattern with diverse other food groups such as whole grains, fruits, vegetables, nuts, tubers, and healthy fatty acids. Nutritional balance leads to the prevention of type 2 diabetes and cardiovascular diseases. Scientifically, arrowroot and seaweeds are low in glycemic index and has high amount of fiber, making them suitable as the proper food solution for diabetes mellitus. This paper presents a resume of an analog rice case study made from arrowroot and seaweeds which is a breakthrough in the Indonesian food industry that can overcome diabetes mellitus and puts pressure from social conformity in Indonesian society. The Indonesian government supports its research and development through food security regulations.
The WHO and other international guidelines may provide the countries with ratification to introduce crucial public health protection on diabetes; however, in contrast, the Indonesian public policy and expenditure on health, diabetes control, and community nutrition remain weak. As a policy recommendation, diabetes prevention starts in early childhood through education on proper dietary and nutrition and strengthening food diversification at community levels. The national guideline does exist; however, it requires the vigorous cooperation of each local/regional government and private stakeholders to apply its policies to the community.
Hsu et al. 2019 studied the successful accomplishments of Taiwan in diabetes care. The series reported that Taiwan had significantly ameliorated aspects of quality care for diabetes patients. As a result, the drastic drop in the national mortality rate, the gap between the life expectancies of diabetes patients and the general population, and the rates of hospitalization because of non-communicable disease. Taiwan's achievement is due to the excellent joint efforts of the government, medical society, and academicians. For example, Taiwan has a specific policy on Diabetes Prevention and Control (Guidelines for Diabetes Prevention, Diagnosis, and Control Processes) from the National Department of Health and Welfare. There are also suggestions for dietary, nutrition, medical control, and access to blood sugar monitoring in this regulation, which Indonesia’s policymakers can emulate.
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[1] Statement of the Indonesian Bureau of Logistics: "The strategic value of rice is also since rice is the most important staple food. The rice industry has a great influence on the economy (in terms of employment, growth, and rural economic dynamics, as wage good), environment (maintaining water use and air cleanliness), and socio-politics (as the glue of the nation, creating order and security). Rice is also the main source of nutritional fulfillment, which includes calories, protein, fat, and vitamins." Retrieved from http://www.bulog.co.id/beraspangan/ketahanan-pangan/
Food Diversification Promoting Food Security and Diabetes Mellitus Alleviation in Indonesia
ABSTRACT
Non-communicable disease (NCD)– diabetes mellitus is one of the health problems that impact productivity and a decline in human resources of a country. World Health Organization reported that in 2019, there were an estimated 463 million people with diabetes, or about 9.3% of the total world adult population (20-79 years), specifically in low-and middle-income countries. The number increased compared to 1980 data, which was only 108 million people (4.7%). Specifically, in Indonesia, the Ministry of Health recorded in 2020, people with diabetes had reached 10.8 million people, which is predicted to increase to 21.3 million people by 2030. Diabetes Mellitus Type 2 is now considered one of the five causes of significant deaths throughout the nation and worldwide. Nearly 80% of the world population with diabetes mellitus are living in developing countries. The burden of diabetes mellitus present significant implications for socio-economic development globally but specifically for low- and middle-income countries. Apart from economic, GDP growth, technological advances, and medical systems, public policies play an active role in national economy and health. Indonesia has ratified a clear vision of the World Health Organization to overcome the diabetes pandemic through national regulation and action plans on food and public health. However, it seems ineffective; lessons learned from previous years’ experience, and still, the number of diabetics in Indonesia keeps increasing over time. Management of diabetes mellitus cure requires a big budget for long-term treatment. Moreover, it will worsen along with the lack of attention to the country’s standard regulations on food, agriculture, and public diet. There is a strong correlation between diabetes mellitus and the impact on the low socio-economic of the nation. The Government of Indonesia has been trying to reduce the number of diabetes mellitus patients with various measures such as diabetes mellitus prevention plan, food and agriculture inspection standard, and public nutrition control. Specifically, this research article provides government policy and strategy analysis that supports food diversification program development in line with the food security, sustainability, diabetes mellitus control, and sustainability mission. This research includes a scientific case study regarding the analog rice made from modified arrowroot starch and seaweed flour to substitute conventional white rice, analog rice as a practical and effective solution to reduce diabetes mellitus.
Keywords: rice, diabetes mellitus, diversification, food security, socioeconomic, and policy analysis
INTRODUCTION
Background
Food security is essential and strategic for a nation, considering that food is a basic human need. In Indonesia, food security development is affirmed in the Food Law Number 7 of 1995 concerning Food and Government Regulation Number 68 of 2002 concerning Food Security. Regarding those regulations, the definition of food security is a condition for meeting a household's food needs, which is reflected in the availability of sufficient food, both in quantity and quality, and is safe, equitable, and affordable. Food diversification is one of the main pillars in realizing food security in Indonesia which is an important measure of well-being of country. The sharp increase in Disability-adjusted life years lost from 1990 to 2017 was mainly seen in diabetes mellitus (157.1%), ischemic heart disease (113.9%), and lung cancer (113.1%). A study on the estimation of global and regional diabetes prevalence by Saeedi, P. et al. 2019 explained that the worldwide diabetes prevalence in 2019 was estimated at 9.3% (463 million people), increasing to 10.2% (578 million people) in 2030 and 10.9% (700 million people) in 2045.
Nearly 80% of the world's population with diabetes mellitus live in developing countries that are low to middle-income countries (Ministry of Health, 2020). Indonesia is the world's fourth-largest country with diabetes mellitus after India, China, and the United States, and in 2030, estimates an increase of 21.3 million (WHO, 2016). According to the World Health Organization report, diabetes mellitus type 2 is the most common illness in Indonesia, followed by hypertension, cardiovascular disease, bronchitis, pulmonary tuberculosis, fractures, and cancer. Indonesian Ministry of Health recorded that in 2020, people with diabetes mellitus type 2 had reached the 10.8 million mark.
Diabetes mellitus type 2 is a degenerative disease, where carbohydrate, fat, and protein metabolic disorders occur. It is characterized by hyperglycemia and glucosuria caused by insulin deficiency or resistance (Rismayanthi, 2010). Soviana et al. 2019 and Hu et al. 2012 have proven that a food consumption habit with a high glycemic load (white rice) when the body experiences insulin resistance causes the body to respond by increasing insulin secretion, which increases the causes of type 2 diabetes mellitus.
In a different view, the modern diet of processed, unhealthy foods affect the national health because improper diets lead to chronic disease and low productivity labor (Puspowidowati, 2011). Veridiana & Nurjana's (2018) study shows that the lifestyle changes (unhealthy diet of Indonesian people) are directly proportional to the number of type 2 diabetes mellitus patients, especially in Indonesia's young age group and young adults. At present, efforts to tackle diabetes mellitus type 2 remain the minor priority scale in national health services. Thus, the negative impacts are quite significant, including chronic complications in chronic heart disease, hypertension, brain damage, nervous system, liver, eyes, and kidneys.
Shaikh et al., 2018 studied the strong correlation between diabetes mellitus and the socioeconomic decline of the nation. Childhood poverty can affect the development of many non-communicable diseases, such as respiratory disease, diabetes, psychiatric disorders, and cancers. Diabetes is a fatal risk for the lowest income community in developing countries. According to Maty et al.'s 2008 study, there was an 80% more chance of adulthood diabetes in children growing from lower socioeconomic status. Thus, poverty has an impact on diabetes that extends beyond resource-poor countries.
White rice, as high-calorie and nutritious, refined grain is generally accessible for everyone and everywhere as an essential diet base. However, Bhavadharini et al. 2020 studied that higher consumption of white rice is closely associated with an increased risk of type 2 diabetes mellitus. White rice has a high Glycemic Index, emerges in high postprandial blood glucose and insulin levels. Nearly all countries with the most significant number of diabetes cases globally possess rice as the leading staple food (IDF, 2019). On the other hand, some research shows that white rice consumption indirectly causes diabetes mellitus type 2, but lack of diversification results in nutrition deficiency.
Responding to the estimated prevalence of diabetes that continues to increase, the Indonesian government and the community began emphasizing diabetes prevention and healthy community action through policies, regulations, and action plans. The government has been promoting the food diversification program for a long time but has been unsuccessful. The market demand for rice is still irreplaceable, and has even been increasing over the years. The Indonesian Agency for Agricultural Research and Development launched analog rice research; it is processed rice from non-rice ingredients with size and taste similar to rice, has a higher nutrient content, and lower glycemic index.
This article also involves a scientifically proven case study of analog rice development in Indonesia. The advantages of arrowroot starch and seaweed flour analog rice are: it has a higher content in dietary fiber and has the potential to reduce postprandial glucose levels; it improves glucose metabolism, and develop insulin resistance; it is suitable to staple food consumption for the Indonesian community as a diabetes mellitus prevention food.
Objective
This article analyzes food security and public health policy that supports diabetes mellitus reduction control in Indonesia. This article aims to use the perspective in other policy areas to congregate a broad set of possible suggestions for addressing better policy to alleviate diabetes mellitus while achieving food sustainability. It comprises the overview of diabetes mellitus and its socioeconomic connection, a review on the legal basis, and government strategy. The last section of this article will include a scientifically proven case study of analog rice development to solve diabetes mellitus management.
OVERVIEW OF HUMAN DIETARY PATTERNS IN INDONESIA
Food Security and Nutrition in Indonesia
Food security is generally defined as food production, sovereignty, and food calorie, losing sight of the fact that food security includes secure access to the foods needed for a nutritionally balanced diet (World Food Summit, 1996). FAO defines micronutrient deficiency as referred to hidden hunger because it is associated with the inadequate energy amount of the community. However, the Indonesian government stipulates that rice is a staple commodity for agricultural products, considering that rice greatly influences economic stability and the interests of the public as an indicator of national food security and sufficiency[1]. Indonesia's food security development history is an indication of pro-poor economic growth and a Green Revolution led by investment in rural infrastructure, irrigated agriculture, and availability of fertilizers, mainly for varieties of large-scale rice production (Timmer, 2008).
In 2020, the Global Food Security Index report that Indonesia ranks 65th out of 113 countries for food security. Indonesia performed excellently in food safety net programs, volatility of agricultural production, food safety, food loss, and agricultural import tariffs. Otherwise, Indonesia performed worst (under the performance of world average) in dietary diversity, nutritional standard, micronutrient availability, and protein quality (refer to tables 1 and 2).
Correlation of public health, diabetes, and socioeconomics
Economic growth in Indonesia is incomparable to national investments in human development. The economic situation dramatically influences all aspects of national optimal nutrition care. The increase in diabetes mellitus incidence and prevalence directly affects a significant drop in economic impact (Jönsson, 1998; Ray & Linden, 2018). Bloom et al. (2004) studied that the increase of national health improvements is also in line with labor productivity and capital accumulation output. Essentially, World Bank Data recorded that Indonesia had the third-lowest expenditure on social health as Gross Domestic Product (GDP) percentage in 2018 (2.9%) of any Southeast Asian countries, within Brunei Darussalam (2.4%) and Lao People's Democratic Republic (2.3%) is lagging.
Minimal investments in developing public health and services are emulated in malnutrition trends in Indonesia (SMERU, 2015). Micronutrient deficiencies promote diabetes mellitus (Via, 2012); thus, it is affected by energy and nutrition imbalance associated with obesity (Wells, 2013). While obese and overweight directly constitutes a health risk associated with diabetes mellitus type 2 due to unseasonably insulin resistance and defective insulin secretion (Golay & Ybarra, 2005). The imbalance of glucose control can also increase the risk of cardiovascular disease, even mortality (Kelly et al., 2009).
Trend in modern dietary pattern and consumer behavior in Indonesia
In addition to poverty, social behavior-related and consumption-related factors are essential factors of diabetes mellitus. As presented in Table 3, energy consumption in Indonesia from year to year has increased at an increasing rate of 2.8% per year; surprisingly, the primary consumption was white rice as a carbohydrate source which occupied more than half of the energy intake per day. In line with the objectives of the Food Security Agency of the Indonesia Ministry of Agriculture (refer to paragraph 3 Policy Directions and Strategy for Management of Economic Resources in the Narrative 4th of 2020-2024 Middle-Term National Development Plan), it is suggested to balance the increased consumption of tubers and other alternative carbohydrate sources. White rice consumption still dominates the daily energy contribution. It causes the aggregate amount of white rice consumption needs to remain high over the years.
White rice is categorized as a refined grain because it is deprived of its bran and germ. Aune et al. (2013) studied that a high intake of refined grains is positively associated with the increased type 2 diabetes risk. Consumption of whole grains is beneficial to health, while refined grains, which contain only the endosperm (starch), have a detrimental effect on cardio-metabolic risk factors, including glucose intolerance and diabetes (Radhika et al., 2009).
Although numbers of researches show a close relationship between white rice consumption and diabetes mellitus, however, as shown in Table 3 as national data on average Indonesian consumption, high rice consumption is associated with low consumption of many other food groups, resulting in an imbalance in nutrition intake, lacking in fiber, micro and macronutrients, healthy fatty acids, and protein.
RATIONAL BASIS REVIEW OF INDONESIAN FOOD AND HEALTH POLICY
Policies engagement in the control of diabetes mellitus
In Table 4, Government Regulation No. 17 of 2015 concerning food security and nutrition, is a detailed description of regulating both availability, affordability, and proper utilization according to the mandate of Law No.18 of 2012. Efforts to consolidate food security based on sovereignty and independence are based on three main points, namely:
Through Government Regulation No. 68 of 2002 and No. 28 of 2004, the government has implemented nutrition labeling, monitoring systems, and food safety for the community. The government also sets specific artificial sweeteners standards for diabetics. Regarding National Mid-Term Development Plan (RPJMN), food diversification is the main point of the Ministry of Agriculture in improving community health through balanced food nutrition. Increased food production and access are essential in achieving significant nutritional improvement in sufficient quantities and fine qualities. Food diversification production requires the collaboration of multidisciplinary areas, such as agriculture, fishery, forestry, animal husbandry, food industry, marketing, communications, home economics, and nutrition. The wide application of proven technologies and approaches in these fields will solve nutritional problems, which farmers as producers, supply chain distributors, and consumers need to be involved and educated on to achieve nutritional balance (FAO, 1997). The strategies of food diversification development in Indonesia include improving local food availability by increasing productivity and expanding the planting area, stabilizing supply and prices, expanding business scale and partnerships, education, and promotion to the community.
In Table 5, Government Regulation No. 2 of 2018, Minister of Home Affairs Regulation No. 100 of 2018, Ministry of Health Regulation No. 52 of 2016, and No. 4 of 2019 have determined that efforts to control diabetes mellitus are the minimum and mandatory efforts of every local government. Each citizen with diabetes mellitus will receive standardized services at least once a month, including blood sugar measurement, therapy, and education. Presidential Instruction No. 1 of 2017, concerning Germas Program, to build the culture of healthy community behavior. However, in contrast, in the guidebook Public Health Program Action Plan 2020-2024 from the Directorate General of The Ministry of Health, diabetes mellitus is unquoted as a national priority program for public health and dietary.
The President’s regulation is the cornerstone of the national future regulatory strategies. President regulation No. 18 of 2020 concerns the middle term national development plan for 2020-2024 IV. 26 No 3.3 concerns the policy direction and strategies to increase diabetes control. Below are the following regulations:
Addressing the credibility of policies for national health and diabetics alleviation
A combination of public policy on food and health issues makes the credibility of future commitments essential for Indonesia's agriculture and food policy development. This section discusses perspectives in other policy areas for compiling a series of legal possibilities to reduce diabetes mellitus while achieving food sustainability.
According to the review of a series of regulations and decree regarding agriculture, food, food safety, and nutrition-related to diabetes mellitus (Refer to Table 4), it can be concluded that currently, the primary efforts of the central government are curing diseases and diabetes control rather than specific diabetes prevention. The central government has mandated the Minister of Health and Agriculture to reduce dependence on rice consumption through a food diversification program. In addition to reducing the prevalence of type 2 diabetes mellitus, it is also to improve food security, food sustainability, and a healthier community.
As shown in Table 5, the Indonesian government has regulations, policies, action plans to increase the community's physical activity, guidelines for balanced nutrition, prevention of non-communicable disease, and medical management for diabetes; however, the government has yet to deregulate the specific diabetes control, overweight, and obesity reduction.
The Indonesian government has followed the 1989 Resolution of The World Health Assembly on Prevention and Control of Diabetes Mellitus with a policy and action plan to measure the community on blood glucose and national registration. However, based on a review of regulations, strategies and national action plans, the government is inexperienced in dealing with overweight, obesity, and diabetes prevention.
CASE STUDY: ANALOG RICE AS FOOD DIVERSIFICATION
Rice is the leading staple food of Indonesian people. The limited land availability for rice production is increasingly unable to meet the market needs. The national rice consumption from January to September 2018 reached 22.11 million tons (Central Bureau of Statistics, 2018). Nevertheless, rice is also a symbol of social prestige in Indonesian society. Based on Kusmiadi's 2012 study in Sudiharto, 2020 of the social paradigm phenomena that develops in Indonesian society, people who refrain from consuming rice as a staple food will be classified in the lowest social hierarchy. Meanwhile, the glycemic index contained in rice is relatively high and unsuitable for diabetes mellitus type 2 patients. Rice consumption in Indonesia is a contradiction and became the inner pressure of social conformity.
Through its food diversification programs and regulation for a healthier community, the central government supports regional governments, educational institutions, and the private sector for analog rice production (Ministry of Agriculture, 2020). Table 6 is a case list of research for analog rice projects that have been successful and distributed nationally. This section presents rice analogs made from arrowroot and seaweed that have been clinically tested the Department of Food Science, Muhammadiyah University Malang. The arrowroot material has the lowest glycemic index with high fiber, which is the low-cost, adequate, and environmentally friendly material for Indonesia's food sustainability (Wu, et al. 2020).
The glycemic index of white rice and other staple foods
Carbohydrate sources besides rice are very diverse; Table 7 explains the various nutrition content and glycemic index contained by the most available carbohydrate source in Indonesia. The glycemic index is related to glucose derived from carbohydrates (Puspowidowati, et al., 2011); the glycemic index in table 7 (Boiling or Moist-Heat Cooking Method). A control diet in diabetes mellitus patients manages the diet composition by controlling blood sugar levels through low glycemic index food consumption (Rianawati & Mahmudy, 2015). Low glycemic index food effectively improves insulin sensitivity and decreases the glucose absorption rate. For people with diabetes mellitus type 2, free radicals can accumulate due to an increase in fatty acid peroxidation. An increase in the formation of free radicals extended by an increase in antioxidant intake will cause oxidative stress. The best type of functional food that can be developed is beneficial analog rice from modified arrowroot starch.
Arrowroot plants consist of two essential types of cultivars, namely creole and banana. Creole cultivar arrowroot garlic is a source of carbohydrates; that is, most of the constituent carbohydrates are starches. The levels of creole tuber starch cultivars were slightly higher (20.96%) compared to banana cultivars (19.40%). Both arrowroot tuber cultivars are relatively high in carbohydrates, low in glycemic index (Refer to Table 7), high in starch digestibility or fiber, and low in reducing sugar rate (Refer to Table 8).
Seaweed is the primary source of phycocolloid to produce functional food because it contains high fiber food, antioxidants, nucleic acids, amino acids, vitamins (A, B, C, D, E, and K), and minerals (calcium, selenium, iron, manganese, and sodium). The content of amino acids, vitamins, and minerals in seagrass is 10-20 times more than terrestrial plant (Chan et al. 2014). Seaweed Gracilaria sp. is generally cultivated in shallow waters at a depth of 0-20 m, with an optimum temperature of 19° to 23° Celsius and high light intensity. Gracilaria sp. is a material that has sufficient ability in the process of gelling, thickening, and flexibility in low shrinkage. Polysaccharides in Gracilaria sp. are composed of β-D-galactose and 3,6-anhydrous-α-L-galactose, which is inversely proportional to sulfate content and directly proportional to the strength of gelatin (Reeves, 1993).
CONCLUSION AND RECOMMENDATIONS
Diabetes Mellitus is a global public health crisis that threatens the economies of all countries, especially developing countries. Triggered by rapid urbanization, nutritional transitions, and increasingly erratic lifestyles, this epidemic has evolved by increasing the incidence of obesity throughout the world. Although diets and nutrient intake are widely believed to play an essential role in developing type 2 diabetes mellitus, specific dietary factors have never been clearly defined. There are a number of controversies regarding the correlation between fat and carbohydrate consumption with the diabetes mellitus risk. A low glycemic index diet with a higher amount of fiber and processed whole wheat products minimally reduces glycemic and insulinemic responses and decreases the risk of type 2 diabetes.
The reduction of white rice consumption in Indonesia can achieve a balanced dietary pattern with diverse other food groups such as whole grains, fruits, vegetables, nuts, tubers, and healthy fatty acids. Nutritional balance leads to the prevention of type 2 diabetes and cardiovascular diseases. Scientifically, arrowroot and seaweeds are low in glycemic index and has high amount of fiber, making them suitable as the proper food solution for diabetes mellitus. This paper presents a resume of an analog rice case study made from arrowroot and seaweeds which is a breakthrough in the Indonesian food industry that can overcome diabetes mellitus and puts pressure from social conformity in Indonesian society. The Indonesian government supports its research and development through food security regulations.
The WHO and other international guidelines may provide the countries with ratification to introduce crucial public health protection on diabetes; however, in contrast, the Indonesian public policy and expenditure on health, diabetes control, and community nutrition remain weak. As a policy recommendation, diabetes prevention starts in early childhood through education on proper dietary and nutrition and strengthening food diversification at community levels. The national guideline does exist; however, it requires the vigorous cooperation of each local/regional government and private stakeholders to apply its policies to the community.
Hsu et al. 2019 studied the successful accomplishments of Taiwan in diabetes care. The series reported that Taiwan had significantly ameliorated aspects of quality care for diabetes patients. As a result, the drastic drop in the national mortality rate, the gap between the life expectancies of diabetes patients and the general population, and the rates of hospitalization because of non-communicable disease. Taiwan's achievement is due to the excellent joint efforts of the government, medical society, and academicians. For example, Taiwan has a specific policy on Diabetes Prevention and Control (Guidelines for Diabetes Prevention, Diagnosis, and Control Processes) from the National Department of Health and Welfare. There are also suggestions for dietary, nutrition, medical control, and access to blood sugar monitoring in this regulation, which Indonesia’s policymakers can emulate.
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[1] Statement of the Indonesian Bureau of Logistics: "The strategic value of rice is also since rice is the most important staple food. The rice industry has a great influence on the economy (in terms of employment, growth, and rural economic dynamics, as wage good), environment (maintaining water use and air cleanliness), and socio-politics (as the glue of the nation, creating order and security). Rice is also the main source of nutritional fulfillment, which includes calories, protein, fat, and vitamins." Retrieved from http://www.bulog.co.id/beraspangan/ketahanan-pangan/