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Vol. 3, No. 1, 2021, pp. 21-27 ISSN 2656-6052 (online) | 2656-1107 (print) 
 
 

      10.26555/eshr.v3i1.3635 21  
  

Research Article  
 
Differences of Toddler Obesity Based on Exclusive 
Breastfeeding History in Tegalrejo Health Center, 
Yogyakarta 
 
Suci Musvita Ayu 1,*, Arini Mayang Fa'uni 1  
1 Faculty of Public Health, Ahmad Dahlan University, Yogyakarta, Indonesia 
 
* Correspondence: suci.ayu@ikm.uad.ac.id. Phone: +6285261614043 
 
Received 05 February 2021; Accepted 03 March 2021; Published 04 March 2021 
 

ABSTRACT  

Background: Obesity is a global problem and continues to affect low and middle-income 
countries, mainly urban areas. In Indonesia, the obesity rate of children was 11.5% and was 
ranked 21st in the world by 2016. Even according to WHO, the number of obese children 
will continue to increase every year. Several studies have shown that a history of exclusive 
breastfeeding can reduce the risk of obesity in toddlers. This study aimed to determine the 
differences in the obesity status of children under five based on a history of exclusive 
breastfeeding in the Tegalrejo Health Center, Yogyakarta City. 
Method: This research employed an analytical observational study with a case-control 
design. The research sample consisted of 34 toddlers aged 6-24 months, calculated using 
the difference of two proportions: 17 cases of obese children under five and 17 controls 
under five who were not obese. A questionnaire was used to collect the data. A Chi-square 
test was used to analyse the data. 
Results: There were children under five without exclusive breastfeeding in the group of as 
many as 41.7% and 29.4% in the control group. 52,9% of children in the case group had 
exclusive breastfeeding, and 70% in the control group. The bivariate analysis showed no 
difference in the obesity status of children under five based on a history of exclusive 
breastfeeding with a value of p = 0.480 and OR = 2.133 (95% CI = 0.519-8.751). 
Conclusion: There was no difference in the obesity status of children under five based on 
a history of exclusive breastfeeding, but children without a history of exclusive breastfeeding 
were 2.133 times more likely to have obesity than children with exclusive breastfeeding. 

Keywords: Obesity; Toddler; Exclusive Breastfeeding 

INTRODUCTION 

Obesity is a serious global problem and continues to affect low and middle-income countries, 
mainly urban areas. The World Health Organization states that in 2015 there were 24 million 
children who were overweight, this number increased by 31 million from 2000. Trends show 
that the number will continue to grow that predicted 70 million in 2025 (1). The obesity rate in 
children in Indonesia is 11.5% and is ranked 21st in the world (2). Data from the Nutrition 
Status Monitoring notes that 1.6% of children aged 0-59 months are overweight, with the 
highest prevalence in Jakarta and Bali (3.3%) and Papua (2.7%)(3). 

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The results of Nutritional Status Monitoring in Yogyakarta Province (DIY) from 2013 to 2015 
show that overweight toddlers (bodyweight per age) in 2014 were 5.84%, decreasing to 3.81% 
(2015) and 3.11% (2016) and fell to 2.80 (2017). Observations in August 2018 explained that 
164 toddlers aged 0-24 months are overweight or obese out of the 5,595 number of toddlers 
spread across 18 Puskesmas Yogyakarta City (4). 

Children with obesity have a 1.8 times higher risk to be adult with obesity (5). Obesity in 
children impacts decreased learning achievement and psychosocial effects, such as lack of 
self-confidence and social withdrawal (6). Several factors contribute to obesity in children, 
including heredity or genetics, food supply, physical activity, feeding histories such as 
breastfeeding, birth weight, and parental obesity (5). 

Exclusive breastfeeding is an act of giving breast milk to babies without giving fluids or other 
foods from birth to 6 months of age (7). The WHO recommended exclusive breastfeeding for 
six months and continued until two years of age due to the benefit of maintaining the baby's 
health and survival. It is because babies who are exclusively breastfed have a better immune 
system than babies who are not. Babies rarely attack from disease and avoid nutritional 
problems than babies who are not given exclusive breastfeeding. Lack of breast milk intake 
results in an imbalance in the baby's dietary needs. The inequality of nutritional fulfilment in 
infants will harm the quality of human resources, which can be seen from the obstruction of 
infants' optimal growth and development (8). Breastfeeding can also prevent obesity in 
children because breastfed babies can regulate energy intake concerning the internal 
response to satiety. The insulin and hormone leptin levels are more balanced in babies who 
are given breast milk to prevent obesity (5). 

Exclusive breastfeeding coverage worldwide was only around 36% during 2007-2014 (9). This 
number indicates that globally the number of children that getting breastfeed is still low. Based 
on data from the United Nations Children's Fund (UNICEF) in 2012, only 39% of babies under 
six months are exclusively breastfed worldwide. This number is stable in 2015 - only 40% 
success of exclusive breastfeeding worldwide (10). China, one of the countries with a large 
population globally, has a success rate of exclusive breastfeeding of 28%. 

In Indonesia, the coverage of infants receiving exclusive breastfeeding is 61.33%. This 
number has exceeded the 2017 Strategic Plan target of 44%. The highest percentage of 
complete breastfeeding coverage was found in West Nusa Tenggara at 87.35%, while the 
lowest rate was in Papua at 15.32%. Five provinces have not reached the 2017 Strategic Plan 
target, namely Riau Islands province 44.42%, North Sulawesi 36.93%, Banten 35.87%, West 
Papua 24.65% and Papua 15.32% (11). While in Yogyakarta Province, where this research 
was conducted, exclusive breastfeeding coverage 0-6 months in Kulon Progo district 77.00%, 
Bantul 74.27%, Gunungkidul 66.75%, Sleman 82.62%, Yogyakarta City 66.13% with an 
average total coverage of exclusive breastfeeding in Yogyakarta Province was 74.90% (4). 
According to this data, Yogyakarta City had the lowest breastfeeding coverage. One health 
centre that having the highest toddler obesity was Tegalrejo Health Centre.  

The actual phenomenon in society is that mothers thought that obese toddlers are healthy 
because their children have sufficient food supply. Obesity will interfere with the development 
process of toddlers. Accordingly, assessing the differences in breastfeeding history and 
obesity is required to provide evidence to society about the importance of giving exclusive 
breastmilk to their babies. 

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METHOD 

This was an analytic observational study with a case-control design conducted in Tegalrejo 
Health Centre of Yogyakarta City from June to July 2019. We used data from the health centre 
that was Body Weight Standard to see under-fives children with obesity. This measurement 
uses a standard tool from the Indonesia Ministry of Health – Kartu Menuju Sehat (KMS) to 
know the birth weight and obesity status. A set of questionnaires was employed to know the 
history of breastfeeding refers to the Guttman scale.  

This study population were all toddlers aged 6-24 month who checked their weight in Tegalrejo 
Health Centre from January 2018 - June 2019 (n=492). The sample was calculated using the 
Lemeshow formula and 17 children in each group – case and control. We selected children in 
each group purposively refer to our inclusion criteria – for case group children with z-score > 
2 SD or obese and control group children with z-score < 2 SD or not obese. Data were 
analysed using the chi-square test with 95% confidence intervals.  

RESULTS 

Table 1 shows that, in total, we recruited 34 respondents for both groups. The highest mother 
education was graduated from senior high school (76.5%). Most of the respondent (mother of 
the toddler) said they do not have a formal job or as housewives (79.4%). Almost half of the 
observed children in this research aged 19-24 months. More than 50% of the toddler observed 
were male. Nearly 60% of the toddler had birth weigh between 3.30-3.80 kg. Among the 34 
children, more than 90% of them reported do not have disease history before this research.  

Table 1. Characteristics of Toddler Obesity Status data 

Variable Case Control Total Percentage N % n % 
Mother's Education       

Graduated from elementary school 2 11.8 0 0.0 2 5.9 
Graduated from junior high school 2 11.8 2 11.8 4 11.8 
Graduated from senior high school 12 70.6 14 82.4 26 76.5 
Graduated from diploma three or 

bachelor 
1 5,9 1 5.9 2 5.9 

Mother's occupation       
Housewife 12 70.6 15 88.2 27 79.4 
Freelancer 2 11.8 0 0.0 2 5.9 
Employees 2 11.8 2 11.8 4 11.8 
Labour 1 5.9 0 0.0 1 2.9 

Toddlers age in month       
 6-12 months 0 0.0 14 82.4 14 41.2 
13-18 months 4 23.5 0 0.0 4 11.8 
19-24 months 13 76.5 3 17.6 16 47.1 

Toddler Sex       
Male 9 52.9 9 52.9 18 52.9 
Female 8 47.1 8 47.1 16 47.1 

Toddler Birth body weight (kg) 
2.50 - 2.80 3 17.6 2 11.8 5 14.7 
2.90 - 3.20 2 11.8 5 29.4 7 20.6 
3.30 - 3.80 11 64.7 9 52.9 20 58.8 
3.90 - 4.30 1 5.9 1 5.9 2 5.9 

Toddler Disease History 
Yes 1 5.9 0 0.0 1 2.9 
No 16 94.1 17 100 33 97.1 

 

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Table 2 reports the number of children under five with obesity and non-obesity status has the 
same number, namely 17 (50%), because we used a 1:1 comparison between case and 
control. Among the children observed (n = 34), more than 60% reported exclusive 
breastfeeding, and the rest were not. 

Table 2. Univariate Results of Toddler Obesity Status and Exclusive Breastfeeding 
History 

Variable N % 
Toddler Obesity Status   

Obesity 17    50.0 
No Obesity 17 50.0 

Exclusive breastfeeding history 
Yes 21 61.8 
No 13 38.2 

 

Table 3 explains that more than half (52.9%) of a toddler with exclusive breastfeeding were in 
obese status, and 70.6% of a toddler who received exclusive breastfeeding were in not obese 
status. From the Odds Ratio calculation, the OR value is 2.13 or > 1 with a Confident Interval 
(CI) of 0.51 - 8.75; this shows that children with a history of not exclusively breastfed have a 
2.13 times risk of being obese compared to toddlers with exclusive breastfeeding history. 

Table 3. Differences in Toddler Obesity Status based on Exclusive Breastfeeding  
History 

History of 
Exclusive 

Breastfeeding 

Obesity Status 
OR 95% CI P-Value Obesity   Not obese  

n % n % 
Not 8 47.1 5 29.4 2.13 0.51-8.75 0.480 
Yes 9 52.9 14 70.6    

 
However, from statistical test between the history of exclusive breastfeeding and the obesity 
status of children under five using the Chi-Square test in Table 3, there was no significant 
association between the obesity status of children under five based on a history of exclusive 
breastfeeding. 

DISCUSSION 

In this research, we found that children without exclusive breastfed have a 2.13 times risk of 
being obese compared to toddlers with exclusive breastfeeding history, even though it was 
not significantly associated. Our finding was not in line with the results of research conducted 
by Ginting, who reported a significant relationship between exclusive breastfeeding and 
obesity in children under five. Toddlers who are not exclusively breastfed have a greater risk 
of obesity (12). Most likely, the statistical results obtained are not significant because our 
sample involved was small.  

Information from the cadre was different among the village cadre in Tegalrejo. In Kricak Village, 
which is part of the Tegalrejo working area, reported that generally, the breastfeeding coverage 
in this health centre is sufficient because most of the parents are educated. Still, most of them 
not working in the formal sector and stay at home. Accordingly, they have proper time to 
breastfeed their children. Our result is consistent with the research conducted by Sarlis and 
Cindy, which shows that there is no significant relationship between exclusive breastfeeding 
and the normal and abnormal nutritional status of toddlers (13). This is, of course, in contrast 

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to the data obtained from Riskesdes 2018 that the number of babies who receive exclusive 
breastfeeding in Indonesia is only 37.3% of 1,100 babies (14). While in Bener village, a cadre 
reported that exclusive breastfeeding coverage in their place was low. This happens because 
of the mother's lack of knowledge about the importance of giving exclusive breastfeeding to 
the baby. Besides, the child's parents are also busy with daily work activities (15). 

Based on the mother responses to the questionnaire, it was known that all toddlers with a 
history of not exclusive breastfeeding are toddlers who are fed formula or additional milk. This 
was because the toddler's mother considers that breast milk alone is not enough for their 
nutrition. During the first six months of a baby's life, exclusive breastfeeding has been 
recommended by UNICEF and WHO as a key to important child's survival (16). Breast milk is 
the most important source of energy and nutrition for children aged 6-24 months. Breast milk 
meets more than half of the energy needs of children aged 6-12 months and one-third of 
children aged 12-24 months. Breast milk is also an essential nutrient source in the healing 
process when a child is sick (14). 

Breast milk reduces the risk of being overweight and obese by 10% compared to formula milk 
(14). Children with a history of not exclusive breastfeeding or children who are given formula 
milk can become obese. Toddlers who consume formula milk before six months have a 6.19 
times greater risk of being overweight. This is because the provision of formula milk with a 
high protein content early in life can modulate the concentration of the hormone Insulin-like 
Growth Factor-1 (IGF-1). The hormone IGF1 regulates growth and regulates the development 
of fatty tissue through endocrine pathways. High protein intake such as branched-chain amino 
acids (BCAAs) or bound-chain amino acids increases the secretion of insulin and IGF1, which 
impacts increasing preadipocyte differentiation and increasing the number of adipocytes in the 
child's body ( 17). This study's results were supported by research conducted previously, which 
said that infants and toddlers identified as obese were primarily identified as consuming 
formula milk (41.9%). However, giving formula milk is not automatically considered a trigger 
for obesity in infants and toddlers because other factors are found to influence, such as 
consuming junk food (18). 

The age characteristics showed that the toddler with the highest obesity was the 19–24-month 
age group with a percentage of 76.5%. Previous research states that the older the child needs 
more intake that will affect the children weight. The gender characteristics showed that the 
toddler with the highest obesity was male, with a percentage of 52.9%. This is because men 
need more energy and protein intake than women, and men's body surface area is more 
expansive than women (19). 

The findings from the observations show that obese toddlers have obese mothers. One of the 
toddlers was advised to diet by the health centre because his weight was increasing 
continuously. This toddler received exclusive breastfeeding, but it was suspected that his 
obesity is an inheritor of his parents. It is in line with Sudiawan's research, on the nutritional 
status of the mother, the p-value is 0.009 or 0.9% <5% with an OR (odds ratio) of 2.322, which 
shows that children who have a history of overweight or obese mothers have a 2.3 times 
greater risk of being overweight or obese compared to respondents who do not have a history 
of fat mothers (20). 

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Obesity is a health dilemma. Obesity can cause a variety of physical and psychological 
problems. When obesity in childhood continues into adulthood, it can lead to various diseases 
such as hypertension during adolescence, hyperlipidaemia, atherosclerosis, coronary heart 
disease, malignant hypertension in adults, diabetes and Pickwickian Syndrome (21). 
Accordingly, preventing obesity is much better than treating obesity. Prevention should be as 
early as possible, starting in infancy, namely by giving breast milk. Kartu Menuju Sehat (KMS) 
is needed to monitor children's growth to know any directional deviations from their weight. 
Children as early as possible are introduced to physical activity, either through playing or 
sports (21). 

As a developing country and has a diverse population background, to deal with obesity cases 
in Indonesia, the government has compiled the National Asian Movement Plan for the 
Archipelago Movement to Reduce Obesity Rates (RAN-GENTAS) (22). Besides, many 
Indonesian government policies have been made to tackle obesity in Indonesia, one of which 
is in the school sector. For example, such as assessing the nutritional status of new children 
entering school, school health program, public health education programs through KADARSI 
(nutrition-conscious families), development of general health-based obesity management and 
control programs, obesity prevention and control policies at the school and health centre 
levels, and school canteen development (23).  

CONCLUSION 

In summary, from this research, we know that there is no difference in the obesity status of 
children under five based on the history of exclusive breastfeeding in the working area of the 
Tegalrejo Health Center, Yogyakarta City, with a p = 0.480 and an Odds Ratio of 2.133.  

Authors 'Contribution 

All researchers contribute to research design from surveys, data collection, data analysis, and 
research reports preparation. 

Acknowledgements  

Researchers would like to thank Ahmad Dahlan University Yogyakarta for providing support 
and funding for this research.  

Conflict of interest 

There are no conflicts of interest. 

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