Associations between food consumption/dietary habits and the risks of obesity, type 2 diabetes, and hypertension: a cross-sectional study in Jakarta, Indonesia

In Indonesia, as in several other countries worldwide, diet and dietary change currently lie at the heart of pressing public health challenges. Over the past decades, Indonesia, the world’s fourth most populous and largest island country, has undergone dietary-pattern shifts and a rapid nutritional transition that have led to the increased prevalence of diet-related chronic diseases [1]. This nutritional transition, which entails unhealthy dietary choices and reduced physical activity, has played a major role in increasing the behavioral and metabolic risk factors for non-communicable and chronic diseases [2]. Poor dietary habits are also indicative of the growing risk of chronic diseases, such as obesity, diabetes, and hypertension (HTN) [3].

According to the Indonesian Health Ministry [4], the prevalence of obesity increased from 8.80% of the population in 2013 to 21.8% in 2018, such that as of 2018, more than 58 million people had been reported to have obesity. Regarding type 2 diabetes (T2D), more than 29 million patients had diabetes in 2018, and the prevalence of T2D increased from 6.9% of the population in 2013 to 10.9% in 2018 [4]. The overall number of people with HTN as well as the rate at which this figure is increasing is even more alarming than that of people with diabetes and obesity. Indeed, the prevalence of HTN increased dramatically from 25.8% of the population in 2013 to 34.1% in 2018 [4]. Thus, over a third of Indonesia’s population, or approximately 90 million people, suffer from HTN, which co-occurs with the risk of decreasing health status.

Numerous studies conducted over the past few decades have underscored the important role current dietary-intake modification plays in the development of obesity, diabetes, and HTN. However, current data on the food consumption and dietary habits of Indonesians remains lacking, and these phenomena urgently need to be assessed. In particular, information on the associations of food consumption and eating habits with the risks of obesity, T2D, and HTN in the Indonesian population, especially in Jakarta, is limited. Therefore, conducting a study in this area is crucial. Additionally, the Indonesian government exclusively focuses on school-based nutritional intervention initiatives, such as nutrition education, school feeding, and vitamin and mineral supplementation for children and adolescents across all school levels. To aid in the development of future interventions that target people from various sociodemographic backgrounds, not just children, this study selected adults aged 20–85 yrs as its participants.

This study aimed to 1) examine the average daily dietary intakes of different food groups; 2) analyze the sociodemographic factors that influence food consumption; 3) determine the association between food intake and the prevalence of specific diseases (obesity, T2D, and HTN); and 4) assess dietary habits and their impact on the prevalence rates of obesity, T2D, and HTN. The overarching goal of this study was to improve diet quality, promote healthy eating habits, and increase nutritional knowledge in a bid to lower the risk of chronic diseases across various sociodemographic groups in Indonesia.

This study revealed that Jakartans generally consume less than the recommended daily intakes of cereals and tubers (285 g/day against 300 g/day), vegetables (111 g/day against 250 g/day), and fruits (46 g/day against 100–150 g/day). The average amount of protein consumed from meat, poultry, seafood, and legumes was within the recommended range (87.46 g/day against 70–140 g/day). However, sugar and salt intakes exceeded the recommended guidelines (sugar: 40.58 g/day against 40 g/day; salt: 10 g/day against 6 g/day), indicating poor diet quality and increased disease risk.

The prevalence of being overweight and obese was found to be significantly associated with the consumption of cereals and tubers (≥ 318 g/day), UPFs (≥ 81 g/day), and sugars (≥ 39 g/day). In this study, the major component in the cereal and tuber food group was polished or white rice, a staple food of Indonesians. Previous studies have investigated the association between cereal and grain intake, particularly that of white rice, and the risk of weight gain. One study by Sawada et al. [8] found that Japanese workers who consumed ≥ 188.8 g of white rice per day experienced a one-year body-weight gain of ≥ 3 kg. In addition, Radhika et al. [9] reported that those in the highest quartile of refined grain/white rice intake (488.8 g/day) exhibited a higher body-weight gain of 12.1% than those in the lowest quartile (218.1 g/day). Regarding UPF consumption, a cross-sectional study in the US found that consuming ≥ 74.2% vs. ≥ 36.5% of total energy from UPFs was linked to 48%, 53%, and 62% higher probabilities of becoming overweight, obese, and abdominally obese, respectively [10]. Consistent with this study, a 12-y follow-up study demonstrated that those who consumed ≥ 1.9 servings/day of fruits and 3.2 servings/day of vegetables had a 24% of lower risk of becoming obese [11]. The protective effects of fruits and vegetables against obesity are presumably related to their soluble-fiber content, which promotes feelings of satiety and delays gastric emptying while enhancing insulin sensitivity [12].

The significantly positive association that this study established between the cereal and tuber food group and T2D corroborates the findings of previous studies [13, 14, 15]. A 9.5-yrs follow-up study found that a greater consumption of white rice (≥ 450 vs. < 150 g/day) was significantly associated with an increased risk of diabetic incidents [13]. White rice, a valuable source of available carbohydrates, increases blood glucose rapidly due to its high glycemic response [14, 15]. Moreover, UPF consumption was also significantly linked to the risk of T2D. A study by Srour et al. [16] revealed that consuming 100 g/day of UPFs was consistently associated with T2D risk, even after adjusting for the absolute quantity of unprocessed food consumed. Research has demonstrated that UPFs elicit a higher glycemic response but lower satiety potential than their less-processed alternatives, therefore increasing the risk of T2D [17]. In the fat and oil group, palm oil was the most widely used cooking oil in Jakarta. Although a link was discovered between palm oil consumption and T2D incidence, insufficient evidence was available to support this finding. An earlier review was unable to collate compelling evidence to either support or refute the association between palm oil consumption and cardiovascular disease risk, including T2D. However, the major factor potentially underlying the association between fat and oil consumption and T2D risk is the presence of elevated triglyceride levels. This major component of fats and oils can decrease insulin sensitivity, thus increasing the risk of developing T2D [18]. The “added sugar” group in this study was characterized by a high intake of granulated white sugar. An earlier study suggested that it is the fructose contained in white sugar, more than the glucose, that potentially increases the levels of total cholesterol, uric acid, and postprandial triglycerides, which can trigger T2D onset [19]. High fructose doses (≥ 50 g/day) in humans have been implicated in insulin resistance and intra-abdominal fat accumulation [20].

A significantly inverse connection persisted between vegetable consumption and T2D, even when the study participants’ daily vegetable consumption was less than the recommended amount (400 g/day). This finding is consistent with that of a prior prospective analysis of 54,793 participants with 7,695 cases of incident T2D wherein those who consumed more vegetables (≥ 319 g/day) were found to have a 21% lower risk of T2D than those who consumed less vegetables (67 g/day) [21]. The biological mechanism underlying the inverse association between vegetable consumption and T2D has not yet been fully elucidated [21]. Nevertheless, the bioactive compounds in vegetables have been suggested to possess the potential to reduce body weight, plasma glucose, and insulin resistance, thereby regulating glucose–insulin homeostasis and preventing T2D owing to their antioxidant, anti-inflammatory, and immune-protective properties [22].

This study found that a greater consumption of seasonings increased the OR of HTN among participants. Meanwhile, increased fruit intake exhibited an inverse relationship with the risk of HTN. Table salt and mono sodium glutamate (MSG) were the two major types of seasonings consumed by participants. The use of condiments, such as table salt, MSG, and soy sauce, contributed to the significantly high intake of dietary sodium [23]. Existing literature reveals similar findings regarding the association between sodium intake and HTN risk. A study by Erdem et al. [24] reported that a salt consumption of approximately 15 g/day resulted in a 5.8-mmHg increase in systolic BP and 3.8-mmHg increase in diastolic BP. The mechanisms by which salt raises blood pressure remain unclear. However, growing evidence suggests that the increased plasma sodium concentration may be directly related to elevated blood pressure [25]. Consistent with this study’s findings, an inverse association between fruit consumption and HTN has also been demonstrated by earlier studies [26, 27]. In this study, even a relatively low fruit intake (≥ 39 g/day) was found to be inversely associated with HTN. A meta-analysis revealed that increasing daily fruit servings (106 g/day) decreased the risk of HTN by 1.9% [26]. In addition, three prospective cohort studies in the US found long-term fruit intake to be associated with a decreased risk of developing HTN, whereas vegetable intake was not associated with HTN risk [28]. The anti-hypertensive effect of fruits may emanate from their antioxidant vitamins, dietary fiber, flavonoids, polyphenols, anthocyanins, and procyanidins [28].

Furthermore, our findings revealed significantly inverse associations of late-night eating with obesity, T2D, and HTN. Late-night eating, especially after 8 PM, has been identified as a risk factor for obesity [29], T2D [30], and HTN [31]. Late-night eating potentially leads to circadian misalignment, reduced energy expenditure (reduced leptin levels), increased appetite sensations, and weight gain [32]. Food intake at night may also induce visceral fat accumulation [29]. Additionally, once obesity develops, insulin resistance and metabolic inflammation due to adipocytokine-secretion dysfunction are triggered, resulting in metabolic dysfunction [33]. Finally, postprandial glucose, insulin, and triglyceride levels are significantly elevated when food is consumed at night compared with that during the day, and this phenomenon decreases insulin sensitivity [34]. The mechanism underlying the association between late-night snacking and blood pressure may be related to increases in other risk factors for HTN, such as increased total and low-density lipoprotein cholesterol levels, as well as the reduction of fat oxidation resulting from snacking at night.

A range of observational studies have associated increased portion sizes with overweight and obesity [35]. People with obesity report significantly larger food-portion sizes than those without obesity, and this potentially leads to a higher energy intake, overconsumption, and body-weight gain [36]. Similarly, the habitual addition of sugar to beverages was also positively associated with T2D and HTN owing to the high glucose content in granulated white sugar. Indonesian meals, which are rich in macronutrients, especially carbohydrates, in every meal serving, tend to have a high glycemic index and glycemic load. Therefore, consuming a large portion of a meal rich in carbohydrates or habitually adding extra sugar may have a harmful effect on glucose metabolism and insulin resistance, thereby increasing the risk of developing obesity, T2D, and HTN [37, 38].

To the best of our knowledge, this study is the first in Indonesia to investigate food group consumption based on sociodemographic factors in participants aged 20–85 yrs. It is also the first to investigate the associations between food group consumption and the risks of obesity, T2D, and HTN in Jakarta, Indonesia. However, this study has certain limitations. First, the sample size was relatively small (600 individuals out of Jakarta’s population of 10.56 million). Second, the study was limited to one province, Jakarta, out of the 34 provinces in Indonesia. Hence, the findings cannot be generalized to the whole population of Indonesia. Third, the “genetic history” variable was not included as one of the confounding variables, and this might have affected the results. Fourth, our study followed a single cross-sectional design, thus imposing a limit on examining causality. Fifth, despite conducting a feasibility test with a modified FFQ from a validated semi-quantitative FFQ developed in the previous study [39], we did not validate the modified FFQ that we created. As a result, we recommend that future research validate the modified FFQ that we developed in this study. Sixth, the CI presented in the table was quite wide, which could be related to the study’s small sample size. Further investigation and more in-depth research into the associations between food group consumption and the risks of obesity, T2D, and HTN are necessary to establish causality, especially regarding the Indonesian population at large.

Finally, to prevent chronic diseases, such as obesity, T2D, and HTN, strategies that will instill healthy eating habits in Indonesians from various sociodemographic backgrounds are warranted. These strategies must aim to improve dietary intake and knowledge, promote healthy eating habits, and establish a healthy lifestyle via a complementary increase in physical activity and exercise. The Indonesian government should also consider advocating and promoting healthier lifestyles. Such campaigns should persuasively convey messages regarding the adoption of healthy eating habits, for example, reducing the consumption of sugar, salt, and UPFs. Furthermore, the government should also establish means of supporting adequate nutritional intake and physical activity as strategies of preventing these avoidable diseases. To assess the health and nutritional statuses of people from different sociodemographic backgrounds in Indonesia, annual comprehensive surveys must be conducted in all the country’s provinces. This will culminate in the establishment of an Indonesian equivalent of the National Health and Examination Survey database. Finally, the Indonesian government must collaborate with decision-makers and healthcare professionals in updating the dietary recommendations for its citizens every 5 yrs. This will assist Indonesians in becoming and remaining healthy for life.

Supplementary Table 1

Food groups

Supplementary Table 2

Standard serving size for each food item

Supplementary Table 3

Indonesia’s national dietary guidelines