Artikel Penelitian

Nutritional Status of Adolescent Girls in

Rural Coastal Area of Tangerang District

Yustina Anie Indriastuti Kurniawan,* Siti Muslimatun,**

Endang L. Achadi,*** Soemilah Sastroamidjojo**

*Directorate of Community Nutrition, Ministry of Health Republic of Indonesia

**Southeast Asian Ministers of Education Organization (SEAMEO) Tropical Medicine (TROPMED) and
Public Health Network Regional Center for Community Nutrition (RCCN), University of Indonesia
***Faculty of Public Health, University of Indonesia

Abstract: This screening was aimed to show the magnitude of nutritional problem among ado-
lescent girls. Female students (n = 1060) aged 10 – 12 years from 34 elementary schools in two
sub-districts of rural coastal area in Tangerang District were assessed using anthropometric
(weight and height) and biochemical (hemoglobin) methods. Age and age of menarche were
obtained through interview. Around 49.5% of the girls were underweight, 38.4% stunted and
26.7% wasted, which indicated that both acute and chronic malnutrition are the nutritional
problem among adolescent girls in this population. Hemoglobin measurement showed that
33.7% of the girls also suffered from anemia. Anemic girls had weight, height and body mass
index that are significantly lower than non-anemic girls. Age and menarche status were not
associated with anemia. It is recommended to explore further the inter-relationship between
anemia and other malnutrition.
Key words: stunted growth, anemia malnutrition, underweight, motherhood

140 Maj Kedokt Indon, Volum: 57, Nomor: 3, Mei 2007

 Nutritional Status of Adolescent Girls in Rural Coastal Area

Status Gizi Remaja Putri di Daerah Rural Pantai

Kabupaten Tangerang

Yustina Anie Indriastuti Kurniawan,* Siti Muslimatun,**

Endang L. Achadi,*** Soemilah Sastroamidjojo**

*Direktorat Bina Gizi Masyarakat, Departemen Kesehatan – Republik Indonesia

**Southeast Asian Ministers of Education Organization (SEAMEO) Tropical Medicine (TROPMED) and
Public Health Network Regional Center for Community Nutrition (RCCN), University of Indonesia.
***Fakultas Kesehatan Masyarakat, Universitas Indonesia.

Abstrak: Skrining ini memperlihatkan besarnya masalah gizi pada remaja putri. Pada murid
perempuan (n=1060) berusia 10-12 tahun dari 34 sekolah dasar di dua kecamatan daerah rural
pantai Kabupaten Tangerang, dilakukan pengukuran antropometri (Berat Badan/BB dan Tinggi
Badan/TB) dan pemeriksaan biokimia (hemoglobin/Hb). Data usia dan usia menarche didapatkan
melalui wawancara. Sekitar 49% responden mempunyai BB rendah, 38,4% pendek dan 26,7%
kurus. Hal tersebut mengindikasikan malnutrisi akut dan kronik merupakan masalah gizi pada
remaja putri di populasi ini. Pemeriksaan Hb menunjukkan 33,7% remaja putri juga menderita
anemia. Mereka yang menderita anemia mempunyai BB, TB dan Indeks Masa Tubuh/IMT secara
signifikan lebih rendah dari mereka yang tidak anemia. Usia dan menarche tidak berhubungan
dengan kejadian anemia. Direkomendasikan untuk meneliti lebih lanjut hubungan antara anemia
dan malnutrisi lain.
Kata kunci: stunted growth, anemia, malnutrisi, underweight, motherhood

Introduction many other health problems, for example excessive bleeding

Adolescence is a period characterized by dramatic
change in the life of every human being.1 One of the charac-
teristic is the rapid growth during this period, which needs
adequate energy and nutrients to support growth and de-
velopment as well as to maintain a good health. In Indo-
nesia, poor nutrition often starts in utero and extends into
childhood and adulthood. Nutritional deficiency is common
across age period, and the retained effect from each period
is usually carried on. Adolescent girls, as mothers to be, are
prone to nutritional deficiencies. Despite the high require-
ments for energy and nutrients for rapid growth, many ado-
lescent girls tend to reduce their weight merely dose to body
image by restricting their dietary intake. When these girls
enter marital life, they are likely to start pregnancy with poor
nutritional status and marginal iron status. On the other hand,
they need to double their food intake to support growth
both for themselves and their babies.
Iron deficiency and anemia are the main problems of
adolescent girls world wide, and improving their nutrition
before they enter pregnancy could help to reduce maternal
and infant mortality.2 Anemia during pregnancy will lead to
during labor among those who are severely anemic with its
consequences both to the woman and the baby, and higher
risk of having low birthweight babies. Chronic malnutrition
in earlier years is responsible for stunting in the later life and
adverse consequences at adolescence period. Stunted girls
tend to become stunted during adolescence and adulthood.
Several scattered studies found that the prevalence of un-
dernutrition (BMI <18.5 kg/m2) among adolescent girls in
Indonesia varied between 31% and 41.2%. National data
among children entering school,3 showed that the average
height of female students at age 10 years was 120.1 cm, while
at age 11 years the average height was 122.9 cm. These are
far below 50% of WHO-NCHS Standard, i.e. 138.3 cm and
144.6 cm respectively.4 Study on female elementary school
student in Jakarta and Bogor showed that the prevalence of
underweight (WAZ below - 2 SD) was 7.8%. 5
The Household Health Survey in 2001 showed that
around 30% adolescent girls (10-19 years) suffered from ane-
mia (Hb <120 g/L).6 This figure was not much different from
other studies which were between 22% and 44%.7 These
data confirmed that in Indonesia, anemia is still a public health

Maj Kedokt Indon, Volum: 57, Nomor: 5, Mei 2007 141

Nutritional Status of Adolescent Girls in Rural Coastal Area

problem (anemia prevalence >15%).8
A screening of female elementary school students aged
10–12 years was conducted to show the magnitude of their
anemia and nutritional status. This screening was the initial
phase of a bigger study on the effect of iron-zinc supple-
mentation on iron, zinc and morbidity status of anemic ado-
lescent girls.
Data was checked for its normal distribution using the
Kolmogorov-Smirnov test of normality. Mean ± Standard
Deviation (SD) and proportion (%) of numeric value was
calculated, and statistical tests employed were Independent
T-test to test the difference of numeric data of nutritional
status and Pearson’s Chi-Square to test the difference of its
categorical data.

Methods Ethical Approval

Subjects Subjects (parents) signed an informed consent sheet,
A sample selection was carried out among female stu- after they understood and approved the purpose and the
dents grade III-V from elementary schools in two sub-dis- procedure of the study. The study was conducted following
tricts of rural coastal area (Teluk Naga and Kosambi), the protocol, after approval by the Ethical Committee of the
Tangerang District, Banten Province. A number of 1060 chil- Faculty of Medicine, University of Indonesia and the local
dren aged 10–12 years were selected for laboratory and an- government of Tangerang Distrisct.
thropometric assessment to determine their anemia and nu-
tritional status. Subject identity, data of age and menarche Results
were collected by interview. Profile of Subjects
Study areas The socio-economic and education levels of the
subjects’ parents were considered low as the girls lived in
Teluk Naga and Kosambi sub-districts were located the poor rural coastal area of Tangerang District.12 Table 1
around 30 km West from Jakarta, in rural north-coastal area showed the profile of subjects with and without anemia in
of Java Island. Annually data statistic from Local Govern- terms of age, menarche, weight, height, body mass index and
ment showed the total population was 113 000, in which level of hemoglobin concentration.
23 000 (11.5%) were 10-14 years old. The illiteracy rate was
16% higher than the national figure, which was 10.2%. In-
come per capita was 4 million rupiahs per year in Teluk Naga Table 1. Age, Menarche, Weight (W), Height (H), Body Mass
and 2 million rupiahs per year in Kosambi,9 which were lower Index (BMI), and Hemoglobin Concentration Among
Anemic and Non-Anemic Subjects
compared to national level (7.4 million rupiahs per capita per
year).7 Variable Anemic† Non-anemic Total
(n=357) (n=703) subjects
Laboratory and Anthropometric Assessment (N=1060)
Mean ± SD
Hemoglobin assessment was performed using HemoCue
instrument, and the blood was drawn from finger prick,10 to Age (years) 10.5 ± 0.6 10.5 ± 0.6 10.5 ± 0.6
determine their anemia status. Subjects with hemoglobin Had menarche (n%) 12 (6.2) 37 (4.3) 1 49 (4.6)
Age of subjects with 11.0 ± 0.2 10.7 ± 0.6* 10.6 ± 0.6
concentration <120 g/L were determined as anemia.11
menarche (years)
Body weight and body height were measured by expe- Weight/W (kg) 26.8 ± 5.1 28.1 ± 5.9** 27.6 ± 5.8
rienced nutritionists according to the standard procedure.11 Height/H (cm) 131.7 ± 7.7 133.7 ± 8.0** 133.0 ± 7.9
A platform weighing Scale (770 alpha; SECA, Hamburg, Ger- Body Mass Index/BMI 15.3 ± 1.7 15.7 ± 2.2*** 15.5 ± 2.0
(kg/m2 )
many) was used for weight measurement with accuracy of
Hemoglobin/Hb. 111.6 ± 8.9 128.9 ± 6.6* 123.1 ±11.1
0.1 kg and Microtoise tape was used for height measure- concentration (g/L)
ment with accuracy of 0.1 cm.
Nutritional status was defined as percentile of Weight † Anemia is defined when hemoglobin concentration < 120 g/L1
for Age (W/A), Height for Age (H/A) and Body Mass Index Pearson’s Chi-Square
for Age (BMI/A) based on NHANES reference value (CDC, Sign. difference at *(p < 0.001), **(p < 0.01), ***(p < 0.05)
2002). Nutritional status was categorized as normal when (Independent T-test)
BMI/A lies between 5th percentile and 85th percentile, while
“underweight” was determined when W/A was below 3rd
percentik “stun-ting” when H/A was below 3rd percentile, The average age was comparable between the two
and “wasting” when BMI/A below 5th percentile. groups. Among anemic women, only 6.2% subjects had me-
narche suggested that anemia in this group was not yet af-
Statistical Analysis fected by menarche and subsequent menstruation. Anemic
Data were entered and analyzed using the Statistical subjects had lower weight, height and BMI than non-anemic
Package for Social Sciences (SPSS) for windows version 11.5. subjects (p < 0.01 and p < 0.05).

142 Maj Kedokt Indon, Volum: 57, Nomor: 5, Mei 2007

 Nutritional Status of Adolescent Girls in Rural Coastal Area
Anemia Status
It is shown in Table 1 that hemoglobin concentration of
subjects with anemia was only 111.6 g/L, which was signifi-
cantly lower (p < 0.001) than non-anemic subjects (128.9 g/
L) as expected. Menarche was not an underlying factor for
having anemia, as the hemoglobin concentration (124.1 g/L)
was equal on both subjects who had menarche or not.
Figure 1. The Proportion of Anemic Subjects with Different
Level of Hemoglobin Concentration
Figure 1 showed that the proportion of subjects who
suffered from anemia (Hb concentration <120 g/L) was 33.7%.
Most anemic subjects in this study had mild anemia. Among
total subjects, 18.7 % had Hb concentration <115 g/L and
5.6% of them had Hb concentration <110 g/L. Only one sub-
ject suffered from severe anemia Hb concentration <70
g/L.
Nutritional Status
The mean of BMI of adolescent girls in this study was
15.5 kg/m, categorized as 10th percentile, which is in the range
of normal value (5th percentile to below 85th percentile) based
on NHANES reference values.13 However, around one third
of subjects had low nutritional status; 49.5% were under-
weight, 38.4% stunting
Figure 2. The Proportion of Underweight, Stunting and Was-
ting Among Subjects with Anemia or Without Ane
mia
Maj Kedokt Indon, Volum: 57, Nomor: 5, Mei 2007
and 26.7% wasting. The proportions of underweight, stunt-
ing and wasting were slightly higher among subjects with
anemia compared to those without anemia (Figure 2).
In addition, younger subjects tend to have low nutri-
tional status, while menarche subjects were taller than non
menarche. Further analysis with Independent T-test showed
that the average mean of weight (29.0 kg vs. 26.6 kg), height
(135.2 cm vs. 131.2 cm) and body mass index (15.7 kg/m2 vs.
15.4 kg/m2) of subjects with age <10.5 years is significantly
higher than older subjects. The height of menarched sub-
jects was found significantly higher than non-menarched
(143.4 cm vs. 132.5 cm).
Discussion
The nutritional status of adolescent girls in this study
was considered low as shown by the high proportion of
underweight, stunting and wasting according to percentile
based on NHANES reference values which were around
49.5%, 38.4% and 26.7% respectively. Underweight repre-
sents both acute and/or chronic malnutrition, while wasting
represents acute and stunting represents chronic malnutri-
tion. These indicated that both acute and chronic malnutri-
tion were problems among adolescent girls living in rural
coastal area of Tangerang district. It seemed that chronic is a
bigger problem than acute malnutrition. This situation should
raise a more serious attention, as there was an indication that
malnutrition had happened before the girls reach their ado-
lescence period, i.e. during childhood or even during preg-
nancy.
This study also showed that adolescent girls with ane-
mia were more vulnerable to undernutrition. The young age
and menarche were not yet the underlying factors for having
anemia, because the proportions of these groups are small.
Subjects who have had menarche were taller than non-
menarched indicating that the increase of height velocity
had occurred among those who have had menarched.
The average height of adolescent girls in this popula-
tion was higher than female elementary school students en-
tering school, but below 50% of WHO-NCHS Standard.3,4
The nutritional status of adolescent girls in this population
is far below the nutritional status among urban primary school
children (8-10 years) in West Jakarta and Bogor.5 The pro-
portion of underweight in this study (49.5%) was higher com-
pared to the findings of a previous study, where the preva-
lence of underweight among girls in urban area was only
7.8%.
It should be noted that the proportion of underweight
among girls with anemia in this study was poorer, in which
53.8% of anemic subjects were also underweight. It is sug-
gested that the girls who live in poor rural area is more vul-
nerable to undernutrition compared to those who live in high
sosio-economic of urban area.13
This study showed that the prevalence of anemia in
this population is above 15% indicating a public health pro-
143
Nutritional Status of Adolescent Girls in Rural Coastal Area
blem.8 The anemia status of these girls was not severe, indi-
cated by the average mean hemoglobin concentration among
subjects with anemia was 111.6 g/L and only one subject
had severe anemia (Hb. concentration < 70 g/L}. The prob-
lem of anemia in these girls was lower than in other areas of
Tangerang district, in which the prevalence of anemia among
female elementary school children was 46.3%, but higher
than the survey which covered 2800 elementary school chil-
dren (boys and girls) in eight sub-districts of coastal area at
Tangerang district, which was 21.6%.12
This finding was comparable to the national data from
Household Health Survey in 2001, in which around 30% ado-
lescent girls (10-19 years) suffered from anemia.6 This figure
was higher compared to the study conducted in East Java
among adolescent girls 12-15 years, where the prevalence of
anemia was 25.8% and in between other scattered data in
Indonesia, in which the prevalence of anemia ranged 22% -
44%.14,15
The prevalence of anemia among these girls should be
seen as a serious problem. First, most of these girls have not
had menarche or menstruation, meaning that once they have
it they will be more at risk of having anemia and it is expected
that the prevalence of anemia will be higher when they are
older than the current age. Secondly, it is predicted that the
prevalence of iron deficiency is about 2.5 times that of the
prevalence of iron deficiency anemia, meaning that the real
problem is much bigger than the prevalence of anemia itself.
Third, these girls are mothers-to-be, therefore having them
enter pregnancy with anemia or iron deficient status will
increase their health risk and their babies.
Anemia and undernutrition are generally recognized as
the greatest nutritional problem among adolescents particu-
larly girls, and diet is likely a major factor.2 It is highly prob-
able that the dietary intake of these girls is low in energy and
nutrients, considering the low socio economic background.
Conclusion
Both acute and chronic malnutrition are the nutritional
problems affecting adolescent girls (10 -12 years) in the rural
coastal area of Tangerang district, particularly among those
who suffered from anemia, suggesting that the problem did
start during this age, but earlier. This study highlights the
urgent need for improvement of nutritional status of adoles-
cent girls through schools by the provision of health and
nutrition education, improvement of food consumption of
protein and iron rich sources. Similarly, the program for ado-
lescence should not be independent of the program for other
groups, i.e. pregnant women, infants and children. The fact
that malnutrition is inter-generational and that the effect of
early malnutrition influenced adulthood nutritional status, a
life-cycle approach in combating malnutrition is pre-ferable.
Micronutrient and food supplementation are suggested,
where resources are available. Improving the micronutritional
status of adolescent girls will help them to achieve better
144
school performance and provide a better preparation for their
reproductive performance.
Acknowledgments
The author would like to thank the students who par-
ticipated in this study, and acknowledge the enthusiastic
help from the school principles, teachers and staff of Teluk
Naga and Kosambi Health Centers. The author is grateful to
UNICEF Indonesia and the Ministry of Health for financially
supporting this study. Finally, the author appreciates the
attention and efforts of the staff of the Directorate of Com-
munity Nutrition, Ministry of Health, Republic of Indonesia
and SEAMEO-TROPMED, RCCN-University of Indonesia.
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