Introduction
In 2023, an estimated 4.8 million children under the age of five died worldwide. This marks a 61 percent reduction in the global under-five mortality rate, which fell from 94 deaths per 1,000 live births in 1990 to 37 per 1,000 in 2023. Despite these gains, infectious diseases—particularly pneumonia, diarrhoea, and malaria—remain among the foremost causes of mortality in this age group, alongside complications related to preterm birth and intrapartum events [
1,
2]. Indonesia is among the top 10 countries with the highest under-5 mortality rates [
2]. In Indonesia, the under-5 mortality rate is 32 deaths per 1,000 live births, representing a decrease from 40 per 1,000 live births in 2012 [
3]. However, this rate remains high and far from achieving the target of 25 deaths per 1,000 live births set by the Sustainable Development Goals (SDGs) [
2].
One of the primary reasons for Indonesia’s high under-5 mortality rate is the prevalence of infectious diseases, which account for nearly 83% of deaths in this age group [
4]. In 2021, pneumonia and diarrhea continued to be the leading causes of post-neonatal mortality, contributing to 14.4% and 14% of deaths, respectively. Congenital anomalies also accounted for 10.6% of deaths. Similarly, among children aged 12 to 59 months, diarrhea contributed to 10.3% of deaths, pneumonia to 9.4%, congenital diseases to 10%, and other causes such as neonatal complications, injuries, measles, and malaria in endemic regions [
4,
5].
Infectious diseases in toddlers are associated not only with under-5 mortality rates but also with stunting. Indonesia’s stunting rate has steadily declined from 31% in 2018 to 24.4% in 2021, with the latest data from 2022 indicating a further reduction to 21.6% [
4,
6,
7]. However, stunting remains a critical issue, as the current rate still exceeds the WHO standard of 20% [
8]. Indonesia aims to reduce stunting prevalence to 14% by 2024 [
9]. Given the significant impact of infectious diseases on stunting and under-5 mortality, reducing the prevalence of infectious diseases among toddlers is crucial for Indonesia.
According to United Nations International Children’s Emergency Fund (UNICEF)’s 1998 framework, a bidirectional relationship exists between nutritional status and infectious diseases, wherein poor nutrition increases susceptibility to infections, and infections further compromise nutritional status. Additionally, poverty, food insecurity, and educational attainment serve as indirect factors influencing both infectious diseases and nutritional status [
10]. Among the various factors contributing to infectious diseases, this study focuses primarily on food insecurity as the independent variable. A household is considered food insecure when it lacks sufficient safe and nutritious food for normal growth and development and to maintain an active and healthy life. This insecurity may result from the unavailability of food and/or insufficient resources to obtain it [
11]. Data from the Central Bureau of Statistics indicate that the prevalence of moderate or severe food insecurity, measured using the food insecurity experience scale (FIES), has been steadily decreasing, from 5.42% in 2019 to 4.02% in 2024 [
12].
Food insecurity leads to malnutrition, compromising toddlers’ immunity and making them more susceptible to diseases. Malnutrition can increase the production of pro-inflammatory cytokines, which inhibit immune responses [
13]. Additionally, malnutrition resulting from protein deficiency may cause dysfunction of T cells and B cells, key components in the adaptive immune response [
14]. Consequently, malnourished toddlers are more susceptible to infectious diseases such as diarrhea and pneumonia, which are leading causes of childhood mortality in developing countries [
15].
A study conducted in Brazil demonstrated a significant relationship between morbidity and food insecurity. Children from severely food-insecure families were more likely to experience coughing (adjusted odds ratio [OR], 1.79) and to be hospitalized due to diarrhea (adjusted OR, 2.55) [
16]. Similarly, research in the United States found that children living in food-insecure households were 1.9 times more likely to have poor health status and 1.31 times more likely to be hospitalized since birth compared to children from food-secure households [
17]. Similar results were observed among infants in Ghana [
18].
Although existing evidence suggests an association between food insecurity and infectious diseases among toddlers in countries such as Brazil, the United States, and Ghana, these studies focused on specific diseases—such as cough, fever, diarrhea, and pneumonia in Brazil; general poor health status in the United States; and respiratory infections restricted to rural areas in Ghana. Furthermore, research on this relationship remains limited in low- and middle-income countries, particularly in Indonesia. Given that the impact of food insecurity may differ between developed and developing countries, context-specific research is essential. Therefore, this study aims to comprehensively investigate the association between food insecurity and the risk of infectious diseases—including acute respiratory infections (ARIs), diarrhea, pneumonia, measles, and helminthiasis—among toddlers in Indonesia.
Materials and Methods
This study employs a cross-sectional design utilizing secondary data obtained from the 2021 Indonesian Nutritional Status Survey (Survei Status Gizi Indonesia, SSGI), covering samples from 34 provinces. The sample included children aged 0 to 59 months who participated in the SSGI and met specific inclusion criteria. Inclusion criteria were children aged 0–59 months who had complete data on infectious diseases (ARIs, diarrhea, pneumonia, pulmonary tuberculosis, measles, and helminthiasis) and comprehensive data on all relevant research variables. A total of 84,115 children met these criteria and were included in the analysis.
Variables
The research applies a causal model, with food insecurity as the primary independent variable measured by the FIES, and infectious disease status as the dependent/outcome variable. The analysis also includes covariates such as child characteristics (age, gender, low birth weight status, immunization status), parental characteristics (mother’s education, father's education, mother’s employment status), and household characteristics (area of residence, wealth quintile, household size, number of children under 5, water source, and sanitation).
The dependent/outcome variable, infectious disease status, was defined based on whether a child had experienced 1 or more of 6 diseases (ARIs, diarrhea, pneumonia, pulmonary tuberculosis, measles, and helminthiasis) at least once, based on diagnostic and symptom history. Children were categorized into 2 groups: those without infectious diseases and those with 1 or more infectious diseases.
Food insecurity, the primary independent variable, is defined as limited or uncertain availability of nutritionally adequate and safe food or limited or uncertain ability to acquire acceptable food in socially acceptable ways [
19]. The FIES measures the percentage of individuals within a national population who have experienced moderate or severe food insecurity at least once within the past 12 months. The FIES instrument has been validated in Indonesia through Rasch model analysis, showing strong reliability (Rasch reliability, 0.77), good item fit (infit statistics, 0.7–1.3), and no significant residual correlations (all below the 0.4 threshold). These results confirm that FIES is a valid and reliable instrument for assessing food insecurity within the Indonesian context [
20]. The FIES instrument comprises 8 sequentially ordered questions describing progressively increasing severity of food insecurity based on respondents’ experiences: (1) worrying about not having enough food due to lack of money or other resources, (2) being unable to eat healthy and nutritious food due to lack of money or other resources, (3) eating only a little due to lack of money or other resources, (4) skipping a meal on a specific day due to lack of money or other resources, (5) eating less than needed due to lack of money or other resources, (6) running out of food due to lack of money or other resources, (7) feeling hungry but not eating due to lack of money or other resources, and (8) not eating for an entire day due to lack of money or other resources. Respondents answered “yes” (coded as 1) or “no” (coded as 0) to each of the 8 items, yielding a total score ranging from 0 to 8. Food insecurity levels were categorized as follows: (1) food secure (score 0); (2) mild food insecurity if respondents answered “yes” to items 1, 2, or 3; (3) moderate food insecurity if respondents answered “yes” to items 4, 5, or 6; and (4) severe food insecurity if respondents answered “yes” to items 7 or 8. This categorization is based on the assumption that the FIES questions progressively represent increasing severity of food insecurity, with questions 1–3 indicating mild, 4–6 moderate, and 7–8 severe food insecurity [
21].
Data Analysis
Data analysis was conducted in sequential stages: univariate, bivariate, and multivariate. Univariate analysis described the characteristics of each variable. Bivariate analysis examined relationships between independent and dependent variables, calculating crude ORs. Subsequently, multivariate analysis using multiple logistic regression was performed to obtain adjusted ORs with 95% confidence intervals (CIs). Missing data were handled by exclusion, where participants with missing data on key variables were omitted from analysis. A sensitivity analysis was also conducted to assess potential impacts of excluding missing data, ensuring this approach did not introduce bias or compromise the validity of the study results.
Ethical Consideration
This study received ethical approval from the Ethics Committee of Faculty of Public Health, Universitas Indonesia (No: Ket-165/UN2.F10.D11/PPM.00.02/2023).
Results
The characteristics of the study respondents are presented in
Table 1. Among the respondents, 23.78% of children under 5 experienced at least 1 infectious disease. More than half of the respondents were food secure; however, 26.5% of households experienced mild food insecurity, 13.6% experienced moderate food insecurity, and 6.5% experienced severe food insecurity. Age distribution among respondents was relatively balanced: 0–11 months (18.8%), 12–23 months (21.7%), 24–35 months (21.1%), 36–47 months (20.3%), and 48–59 months (18.1%). Slightly more respondents were male (51.2%) than female. Most children had a normal birth weight (93.3%), normal nutritional status (76.6%), and the majority had received complete immunizations appropriate for their age (60.8%).
Parental education levels were evenly distributed, with slightly higher proportions of mothers and fathers having attained higher education. A higher proportion of mothers were unemployed (65.7%). More respondents resided in rural areas (52.2%). The distribution across wealth quintile index was nearly even, with the highest proportion in the fifth quintile (wealthiest group, 21.6%) and the lowest in the first quintile (poorest group, 17.3%). Over half of the respondents belonged to households consisting of 4 members or fewer (50.8%). Most households had only 1 child under 5 (78.1%), access to safe drinking water (87.3%), and proper sanitation (85.7%).
Table 2 presents the bivariate analysis examining associations between risk factor variables and infectious diseases. Children from households experiencing mild food insecurity had a 1.496 times greater likelihood (95% CI, 1.441–1.554) of contracting infectious diseases compared to children from food-secure households. The likelihood increased to 1.708 times (95% CI, 1.628–1.791) among children from households experiencing moderate food insecurity, and further increased to 1.777 times (95% CI, 1.666–1.896) among those experiencing severe food insecurity, compared to children from food-secure households. The relationship between the level of food insecurity and infectious disease status was statistically significant (
p=0.001).
These findings indicate that the risk of contracting infectious diseases among children under 5 increases progressively with higher levels of household food insecurity. Additionally,
Table 2 demonstrates statistically significant relationships between all risk factor variables and infectious diseases in children, with the exception of household size.
Based on
Table 3, the final multivariate analysis confirms that the risk of infectious diseases among children under 5 increases with household food insecurity severity. Specifically, children from households with mild food insecurity were 1.367 times more likely (95% CI, 1.308–1.428) to suffer infectious diseases. This risk further increased to 1.490 times (95% CI, 1.399–1.588) for children from households with moderate food insecurity, and to 1.500 times (95% CI, 1.374–1.638) for children from households experiencing severe food insecurity, compared to children from food-secure households. Subgroup analysis also revealed that children living in rural areas faced a higher risk than those in urban areas. The association between food insecurity level and infectious disease status remained statistically significant (
p=0.001).
Discussion
Food insecurity emerged as a significant risk factor in this study. The multivariate analysis demonstrated a dose-response relationship between the level of household food insecurity and the risk of infectious diseases among toddlers. Compared to children from food-secure households, those from households experiencing mild food insecurity had a 36.7% higher likelihood (OR, 1.367; 95% CI, 1.308–1.428) of contracting infectious diseases. This risk increased to 49.0% (OR, 1.490; 95% CI, 1.399–1.588) among children from moderately food-insecure households, and further rose to 50.0% (OR, 1.500; 95% CI, 1.374–1.638) for those from severely food-insecure households. These findings are consistent with studies from Brazil and the United States, which reported significantly higher risks of infectious diseases among children from severely food-insecure households [
16,
17]. Similar results have been observed in other low- and middle-income countries, such as India, Pakistan, Bangladesh, Nepal, and Sri Lanka, where food insecurity—compounded by poverty and poor sanitation—contributes substantially to high rates of infectious diseases among children [
22].
While the findings of this study align with previous international research, Indonesia's unique geographic and socioeconomic conditions may influence the strength and extent of the observed association. As an archipelagic nation with substantial disparities in healthcare access, sanitation, and nutritional conditions, the health impact of food insecurity on children may be especially pronounced in certain regions [
23]. The subgroup analysis revealed that the risk of infectious diseases was notably higher among children residing in rural areas compared to their urban counterparts.
To gain deeper insight into this relationship, it is crucial to consider the interconnected pathways through which food insecurity affects infectious diseases. These pathways include socioeconomic constraints, malnutrition, impaired immune function, limited healthcare access, psychological distress, and environmental enteric dysfunction (EED). Socioeconomic status plays a pivotal role since food insecurity often reflects broader poverty conditions. Studies conducted in Ethiopia revealed that children from the lowest wealth quintiles were significantly more likely to experience food insecurity [
24]. This study confirmed a similar trend, with households in the poorest quintile exhibiting the highest risks of infectious diseases in a dose-response relationship. Research from Bangladesh supports this observation, demonstrating that children from poorer households were 1.3 times more likely to suffer from respiratory infections due to limited access to adequate food and healthcare [
25,
26].
Malnutrition is another critical pathway linking food insecurity to increased infection susceptibility. Deficiencies in essential nutrients such as protein, vitamin A, iron, and zinc can weaken immune responses, decrease immune cell production, diminish antibody activity, and impair mucosal defenses, making individuals more vulnerable to infections and delaying recovery [
27,
28]. A study conducted in Indonesia reported that toddlers from food-insecure families had a 1.24 times higher risk of stunting, with the risk rising to 1.39 among those from severely food-insecure households [
29]. Similarly, Malaysian studies have indicated that food insecurity is associated with a 2.15 times greater risk of underweight status [
30]. Food insecurity can be linked to malnutrition, referring to the loss and reduction in both quantity and quality of food due to economic constraint [
31].
Limited healthcare access exacerbates the adverse health outcomes linked to food insecurity. Households facing financial constraints may prioritize basic food needs over pediatric healthcare, leading to reduced healthcare utilization. A study conducted in the United States found that individuals from food-insecure households were significantly less likely to have a regular healthcare provider or receive home health visits compared to their food-secure counterparts [
32,
33]. Due to data limitations and potential biases arising from the coronavirus disease 2019 pandemic, healthcare utilization variables were not included in this study.
Psychological distress, particularly among mothers, further mediates the relationship between food insecurity and child health outcomes. Mothers experiencing food insecurity often report high stress and anxiety levels, impairing their caregiving abilities [
34]. According to UNICEF’s conceptual framework, inadequate maternal and child care practices represent indirect factors contributing to malnutrition and increased infection risks [
10]. An analysis of data from the Indonesia Family Life Survey highlighted a significant association between food insecurity and depressive symptoms among mothers [
35]. Similar findings have been reported in African countries and India, where women from food-insecure households exhibit heightened levels of anxiety and depression, potentially affecting their caregiving practices [
36].
Another critical factor linking food insecurity with infectious diseases is EED, a chronic intestinal disorder resulting from repeated pathogen exposure and inadequate sanitation. EED causes intestinal inflammation, increased gut permeability, and impaired nutrient absorption, further worsening malnutrition and increasing susceptibility to infections, particularly diarrhea and respiratory illnesses [
37]. This harmful cycle illustrates that food insecurity not only leads to undernutrition but also exacerbates vulnerability to infectious diseases through impaired immune function, gut dysfunction, inadequate healthcare access, and psychological distress. These findings underscore the urgency for comprehensive interventions addressing both nutritional and socioeconomic determinants of child health.
The results of this study have significant implications for achieving the SDGs, particularly SDG 2 (zero hunger) and SDG 3 (good health and well-being). Tackling food insecurity through targeted assistance programs and integrating nutritional support with immunization initiatives aligns closely with global efforts aimed at reducing malnutrition and improving child health outcomes. Strengthening such interventions can significantly contribute toward meeting SDG targets by enhancing access to nutritious food, reducing childhood morbidity, and supporting overall health equity.
Addressing food insecurity necessitates comprehensive strategies targeting both direct and underlying factors. Government-led initiatives, such as food assistance programs, nutritional supplementation, and economic support, are critical for mitigating the adverse effects of food insecurity. In Indonesia, the Bantuan Pangan Non-Tunai program has been implemented to improve household access to nutritious food, essential for preventing stunting and reducing infectious diseases among children [
38], the Program Keluarga Harapan provides financial assistance to low-income families, enabling them to prioritize healthcare and better nutrition for their children [
39].
Moreover, ensuring universal immunization coverage represents another essential intervention for reducing infection risks among children from food-insecure households. Research indicates that children with incomplete immunization schedules are at higher risk of severe infections and hospitalizations, particularly in resource-limited settings [
40]. Integrating immunization efforts with food security programs could enhance outreach and significantly improve child health outcomes.
Strengths and Limitation
This study has several notable strengths. First, it utilized a relatively large sample derived from a robust sample-size calculation, ensuring high statistical power. The sample was selected using multistage random sampling, enabling generalization of the findings to the national level. Additionally, the research employed a validated instrument to measure food insecurity—the FIES—which has been utilized by the Central Bureau of Statistics in the National Socioeconomic Survey since 2017. Interviews were conducted by trained enumerators, which helps to minimize interviewer-related bias.
Despite these strengths, the study has several limitations, primarily related to its reliance on secondary data from the 2021 Indonesian Nutritional Status Survey, restricting the range of available variables. One potential limitation arises from the reliance on self-reported food insecurity data, which may introduce recall bias or social desirability bias. Respondents might underreport or overreport their food insecurity experiences due to memory limitations or the desire to provide socially acceptable answers. Such biases could lead to misclassification, potentially resulting in an underestimation or overestimation of the true association between food insecurity and infectious diseases in children.
Although multivariate analysis was employed to control for confounding variables, several relevant factors (e.g., dietary intake and healthcare access) could not be included due to data limitations. Specifically, dietary intake data were available only for children aged 0 to 23 months, and healthcare access data were limited to sick children. Additionally, the cross-sectional design of the study introduces temporal ambiguity, preventing determination of whether exposure (food insecurity) preceded the outcome (infectious diseases). Therefore, the study cannot establish causality between food insecurity and infectious diseases. Future research employing more robust designs, such as longitudinal or cohort studies, is necessary to address these limitations.
