Abstract
One of the strategies to prevent adolescent girls anemia through efforts to identify the factors that cause anemia. Adolescent girls are are prospective mothers who must prepare physically, mentally, with good knowledge so that they do not experience anemia during pregnancy. The aim of the study was to analyze the risk factors for the incidence of anemia in adolescent girls in Banyumas Regency, Indonesia. Quantitative approach used to identify factors that influence anemia in adolescent girls. Research variables are menstrual period, knowledge, diet attitudes and behavior, perception of body image, role of friends in prevention of anemia, role, exposure to information, consumption of iron, consumption of inhibitors and iron enhancers. The population of this research is young women aged 12-19 years. The taking technique by simple random sampling was amount 100, Data analysis was univariate, bivariate (chi square) and multivariate (linear regression). The results showed that the prevalence of anemia was 20%. Based on the results of statistical tests, it was obtained a P-value of 0.005 (<0.05) meaning that there was an influence on adolescent dietary behavior, the role of adolescents in preventing anemia and the consumption of iron inhibitors on the incidence of anemia. Anemia in young girls. There is an influence of eating behavior in female adolescents, the role of female adolescents in preventing anemia and consumption of iron inhibitors on the occurrence of anemia in female adolescents.
Key words: diet behavior, inhibitors, adolescent girls, anemia
Introduction
One of the causes of maternal death is bleeding. This can be seen from the most common cases found bleeding at delivery of 18.4%. The main cause of bleeding during delivery is anemia during pregnancy. The prevalence of anemia in women globally reaches 29%. Anemia in pregnancy can occur as a manifestation of anemia in adolescence (1-3). Adolescents, especially girls, are one of the groups that are prone to suffer from iron deficiency anemia because they have a high need for iron. The failure to fulfill iron in young women is mainly due to the increased need for iron during menstruation. In addition, an imbalance in nutritional intake is also a cause of iron nutritional anemia in adolescent girls (4).
Research shows that 27% of girls aged 11-18 years do not meet their iron needs while boys only 4%. This shows that adolescent girls are more prone to experiencing nutritional deficiencies. In addition, adolescent girls are usually very concerned about body shape, so that many limit food consumption and a lot of dietary restrictions. When food intake is lacking, a lot of iron reserves are broken down to meet needs. This situation can accelerate the occurrence of iron nutritional anemia (5).
Data from the Ministry of Health shows that iron deficiency anemia among adolescent girls is 26.50%.1 In Central Java, 55.7% of adolescent girls and women of childbearing age experience anemia (6). Banyumas District Health Office (DKK) data for 2014 shows that There is still a problem of anemia in high school adolescent girls, which is 5.1%. Iron deficiency anemia is not limited only to the amount of iron intake alone, but also the rate of absorption. In the process of absorption of iron, interactions occur with other nutrients. The interactions that occur can be in the form of trigger effects (enhancers) or inhibitors (inhibitors) (7). Research to determine the right diet to treat iron nutritional anemia is by a combination of a diet high in Fe sources and Fe enhancers, and low in Fe inhibitors (8). Fe with anemia status in female students, and there is no correlation between consumption pattern of iron enhancer factor and anemia status of students (9). This study aimed to identify the effect of dietary behavior and inhibitor consumption on the incidence of anemia in adolescent girls in Banyumas Regency.
Material and methods
Study design
This study used quantitative research with a cross-sectional research design. The research variables were anemia, length of menstruation, knowledge, dietary attitudes and behavior of adolescent girls, perception of body image, role of friends in preventing anemia, role of adolescent girls, exposure to adolescent girls information, consumption of iron, consumption of iron inhibitors and enhancers (10).
Sampling methods
The population in this study were adolescent girlss and families in the area of Puskesmas I Kembaran and Puskesmas Kedungbanteng. The research sample was taken based on the sample formula and taken randomly using simple random sampling technique. The sample selection starts from the working area of Puskesmas I Kembaran and Puskesmas Kedungbanteng with the consideration that the Maternal Mortality Rate (MMR) is high in Banyumas Regency. Based on the two-tailed hypothesis test sample formula, the sample size is 100 adolescent girlss.
Data collections
Determination of anemia status in adolescent girls by testing Hb levels with the cyanmethemoglobin method at the Health Laboratory of Banyumas Regency with the category of Anemia (Hb<12 mg/dl) and not Anemic (Hb>12 mg/dl). The variable length of menstruation was measured by the distance from the first day of menstruation until menstrual bleeding stopped with the categories Brakimenorea (menstrual blood that came out <2 days), Normal (menstrual blood that came out 2-5 days) and Menorrhagia (menstrual blood that came out >6 days) (11).
The variables of knowledge, the attitude of the role of friends in preventing anemia, the role of adolescent girls about anemia and exposure to adolescent girls information were taken by means of interviews using a questionnaire, then grouped based on the normal distribution approach.
Diet behavior is an action aimed at reducing body weight by reducing the frequency of eating, choosing certain types of food, consumption of diet drugs, and physical activity. Perceptions of body image are individual perceptions of their own appearance including fear of being fat, feelings of fullness, thoughts about body shape, desire to diet, feeling sad when reflecting and awareness of body shape as measured by a body shape questionnaire with a dissatisfied category (score >25) and satisfied (score ≤25) (12).
The consumption pattern is a form of food consumption habits carried out by a person in his daily eating activities which include food ingredients that contain iron, iron inhibitors and enhancers obtained through the interview method with a 1 month semi-quantitative FFQ form tool. The consumption pattern category is given (1) Regular in consumption score 15-502, sometimes score 1-10 and never (13).
Data analysis
Quantitative data analysis methods in this study used univariate analysis, bivariate analysis (chi-square analysis), and multivariate analysis (logistic regression analysis).
Ethical consideration
This research has gone through ethical trials by the Health Research Ethics Commission, Faculty of Medicine, Jenderal Soedirman University with approval number 1242/UN23.07.5.1/PN.1/2017. Before collecting respondent data, we submitted informed consent as a sign of approval for the respondent's participation in this study. All respondents' identities were kept confidential and there was no compulsion for respondents to participate in the research. All data obtained was then stored on the researcher's laptop and could only be accessed by the research team.
Results
Based on Table I, it is known that the average age of the respondents is 15 years, the average hemoglobin level is 13 g/dl and the average length of menstruation is 6 days. (see the Table I).
Based on Table II, it is known that most (54%) knowledge of adolescent girls nutrition is good, adolescent girls attitudes are still not supportive of anemia prevention (51%), poor diet behavior (60%), good adolescent girls body image perception (56%), Menstruation duration of more than 6 days (74%), most of 52% of adolescent girlss make efforts to prevent anemia. Most (72%) adolescent girlss have not received information about anemia. Adolescent girls eating behavior is 54% influenced by friends, adolescent girlss still rarely consume iron source foods (57%), most (62%) rarely consume iron consumption inhibitors and 50% consume substances that increase iron absorption (enhancers). The results showed that the prevalence of anemia was 20%, anemia becomes a public health problem if the prevalence is above 20% (see the Table II).
Based on Table III, it shows that the adolescent girls dietary behavior variable (0.044), the role of adolescent girls in preventing anemia (0.05) and the consumption of iron inhibitors (0.012) according to the results of statistical tests, obtained P-value=0.005 (<0.05). It is concluded that statistically there is a relationship between adolescent girls diet behavior, the role of adolescent girls in preventing anemia and consumption of iron inhibitors with the incidence of anemia in adolescent girls (see the Table III).
There were four variables included in the prospective multivariate test using multiple logistic regression with a P-value ≤0.25 which were included in the prospective model, namely knowledge of adolescents, behavior of adolescents, role of adolescents and consumption of iron inhibitors. The next stage is the modeling stage with the condition that the P-value ≤0.05. There were only two variables that had P-values ≤0.05, namely adolescent behavior and consumption of iron inhibitors. Based on the statistical test results, it was obtained a P-value of 0.005 (<0.05), it can be concluded statistically that there is an effect of adolescent diet behavior, the role of adolescents in preventing anemia and the consumption of iron inhibitors on the incidence of anemia in adolescent girls (see the Table IV).
Discussion
Respondents are adolescent girls with an average age of 15 years. During adolescent, there is an increase in nutritional and health needs due to accelerated growth and increased physical activity (14,15) Gupta's research found that there was a significant correlation between Hb concentration and age in the 15-16 year age group (16). The average Hb level of the respondents was 13 g/dl, the interpretation of anemia based on Hb levels according to WHO is divided into 3 categories, namely: mild (11.0-11.9 g/dl), moderate (8.0-10.9 g/dl) and severe (<8 g/dl) (17). This shows that on average the respondents are not included in the anemia category. In this study, respondents had an average menstrual period of 6 days for 1 menstrual cycle. The existence of menstruation in adolescent girls is an additional burden which serves as a trigger for the factors causing anemia (16).
Table I.
Characteristic of adolescent girls.
| Variable | Minimum | Maximum | Mean |
|---|---|---|---|
| Age (Years) | 12 | 19 | 15 |
| Hb Consentration (g/dl) | 9,6 | 15,7 | 13 |
| Menstruation Duration (day) | 4 | 10 | 6 |
Knowledge is the result of knowing what happens after people sense certain objects. Knowledge is a guide in shaping a person (overt behavior). A person's knowledge can influence the occurrence of anemia, because knowledge can influence their behavior, including their lifestyle and eating habits. Most (54%) respondents already have good knowledge about anemia. This good knowledge was made possible because some respondents (26%) had already been exposed to information about anemia. Exposure to information media causes these adolescent girls to obtain more information than those who have never been exposed to information media, so the information they get will increase their knowledge (18). In a previous study, the possible reason for the high prevalence of anemia among students who never heard/know anemia could be poor knowledge regarding iron-rich foods compared to girls with knowledge about anemia that consider the prevention and control mechanism of anemia (19).
Some adolescent girls (51%) have less supportive attitudes in preventing anemia. Unsupportive behavior of female adolescents in anemia prevention efforts is influenced by knowledge levels, attitudes, perceptions, supporting environments, resources, and national policies (20). Adolescents with positive attitude will have better abilities in realizing health (21). Most of the respondents' diet behavior (60%) is still not good. The respondent's diet behavior is not good, namely that the respondent rarely consumes fruits that can help the absorption of substances iron and rarely do breakfast.
Adolescent girls are usually very concerned about body shape, so that many limit their consumption of food and many dietary restrictions such as the vegetarian diet. They imitate adults and behave with adult status or imitate the artists they idolize, such as by doing the actual diet in adolescence where they are still experiencing a period of growth (22). In this study the perception of body image of respondents was partly (56%) it is good and some adolescent (52%) have made efforts to prevent anemia. Most of the respondents (74%) had had their menstrual period longer than 6 days. The average length of menstruation that is considered normal is 3-5 days, if more than 7 or 8 days is considered abnormal (23). The results of this study are in line with Jaelani research which states that as many as 40% of adolescent girls experience abnormal menstrual lengths (menstruation >6 days) (24). Menstruation is the release of the uterine wall (endometrium) which is accompanied by bleeding and occurs every month except during pregnancy. Menstruation that occurs every month is known as the menstrual cycle. Normal menstruation usually lasts 2-5 days and if >6 is often referred to as having menorrhagia disorders (11) Friends have a role in adolescent girls eating behavior by 54%. The strong influence of peer groups or friends is because adolescents are more outside the home with their peers as a group, it is understandable that the influence of peers on attitudes, conversations, interests, appearance, and behavior is greater than the influence of family (22).
Table II.
Basic characteristics of adolescent girls.
| Amount | |||||||
|---|---|---|---|---|---|---|---|
| No. | Variable | n | % | ||||
| 1. | Menstruation Duration | ||||||
| 2-5 days (normal) | 26 | 26 | |||||
| ≥6 days (long) | 74 | 74 | |||||
| Total number of participant | 100 | 100 | |||||
| 2. | Knowledge | ||||||
| Well | 54 | 54 | |||||
| Lack | 46 | 46 | |||||
| Total number of participant | 100 | 100 | |||||
| 3. | Attitude | ||||||
| Well | 49 | 49 | |||||
| Lack | 51 | 51 | |||||
| 4. | Diet Behaviour | ||||||
| Well | 52 | 52 | |||||
| Lack | 48 | 48 | |||||
| 5. | Body Image Perception | ||||||
| Lack | 44 | 44 | |||||
| Well | 56 | 56 | |||||
| 6. | Peer Group Role | ||||||
| No | 46 | 46 | |||||
| Yes | 54 | 54 | |||||
| 7. | Fe Consumption | ||||||
| Often | 43 | 43 | |||||
| Rare | 57 | 57 | |||||
| 8. | Fe Inhibitor Consumption | ||||||
| Often | 62 | 62 | |||||
| Rare | 38 | 38 | |||||
| 9. | Fe Enhancer Consumption | ||||||
| Often | 50 | 50 | |||||
| Rare | 50 | 50 | |||||
| 10. | Role to prevent anemia | ||||||
| Well | 52 | 52 | |||||
| Lack | 48 | 48 | |||||
| 11. | Information Exposure | ||||||
| a. Exposure Source | 26 | 26 | |||||
| -Print Media | 2 | 8,0 | |||||
| -Health Worker | 11 | 42,0 | |||||
| -Internet | 2 | 8,0 | |||||
| -Television or Radio | 9 | 35,0 | |||||
| b. Not exposure | 74 | 74 | |||||
| 12 | Anemia in adolescent girls | ||||||
| Not anemic | 80 | 80 | |||||
| Anemia | 20 | 20 | |||||
Table III.
Relationship of determinant factors of anemia in adolescents girls.
| Not Anemic | Anemia | Amount | |||||||
|---|---|---|---|---|---|---|---|---|---|
| No. | Variable | n | % | n | % | n | % | P-value | |
| 1. | Knowledge | ||||||||
| Well | 46 | 85,2 | 8 | 14,8 | 54 | 100 | 0,249 | ||
| Lack | 34 | 73,9 | 12 | 26,1 | 46 | 100 | |||
| 2. | Attitude | ||||||||
| Well | 39 | 79,6 | 10 | 20,4 | 49 | 100 | 1,000 | ||
| Lack | 41 | 80,4 | 10 | 19,6 | 51 | 100 | |||
| 3. | Diet Behaviour | ||||||||
| Well | 46 | 88,5 | 6 | 11,5 | 52 | 100 | 0,044 | ||
| Lack | 34 | 70,8 | 14 | 29,2 | 48 | 100 | |||
| 4. | Body Image Perception | ||||||||
| Lack | 35 | 79,5 | 9 | 20,5 | 44 | 100 | 1,000 | ||
| Well | 45 | 80,4 | 11 | 19,6 | 56 | 100 | |||
| 5. | Menstruation Duration | ||||||||
| 2-5 days (normal) | 19 | 73,1 | 7 | 26,9 | 26 | 100 | 0,459 | ||
| ≥6 days (long) | 61 | 82,4 | 13 | 17,6 | 74 | 100 | |||
| 6. | Role to prevent anemia | ||||||||
| Well | 46 | 88,5 | 6 | 11,5 | 52 | 100 | 0,050 | ||
| Lack | 34 | 70,8 | 14 | 29,2 | 48 | 100 | |||
| 7. | Information Exposure | ||||||||
| a. Exposure Source | 19 | 73,1 | 7 | 26,9 | 26 | 100 | 0,459 | ||
| b. Not exposure | 61 | 82,4 | 13 | 17,6 | 74 | 100 | |||
| 8. | Peer Group Role | ||||||||
| No | 37 | 80,4 | 9 | 19,6 | 46 | 100 | 1.000 | ||
| Yes | 43 | 79,6 | 11 | 20,4 | 54 | 100 | |||
| 9. | Fe Consumption | ||||||||
| Often | 36 | 83,7 | 7 | 16,3 | 43 | 100 | 0,579 | ||
| Rare | 44 | 77,2 | 13 | 22,8 | 57 | 100 | |||
| 10. | Fe Inhibitor Consumption | ||||||||
| Often | 55 | 88,7 | 7 | 11,3 | 62 | 100 | 0,012 | ||
| Rare | 25 | 65,8 | 12 | 34,2 | 38 | 100 | |||
| 11. | Fe Enhancer Consumption | ||||||||
| Often | 42 | 84,0 | 8 | 16,0 | 50 | 100 | 0,453 | ||
| Rare | 38 | 76,0 | 12 | 24,0 | 50 | 100 | |||
Some respondents (57%) rarely eat iron-based foods, this can be seen from the dietary pattern of half of the respondents (56%) who rarely eat animal side dishes. Inadequate intake of iron uptake can cause anemia. Some respondents (38%) still consume iron inhibitors such as tea more than once a day and other inhibiting food ingredients such as chocolate, ice cream, milk and fried soybeans 1-3x/Sunday. Tea contains tannins which can inhibit the absorption of iron from other foods, besides black tea contains polyphenolic compounds which when oxidized will bind to minerals such as iron (25). Half of the respondents (50%) rarely consume iron enhancer such as fruits that contain lots vitamin C which can help iron absorption. The Sundanese plant-based diet did not affect the iron deficiency anemia (IDA) status. Instead, IDA was associated with consumption of less animal-based foods that have iron with higher bioavailability. Increased access to an animal-based menu at the school cafeteria could be an approach to prevent IDA in students at Islamic boarding schools in Indonesia (26).
In the research of Patimah et al which states that there is a relationship between dietary behavior and adolescent girls anemia (27). Behavior is the second largest factor after environmental factors that affect the health of individuals, groups and society. Therefore, to improve health status, one of the efforts is to increase awareness to behave healthily in everyday life for the whole community. Dietary behavior, it is known that more than half of the respondents (56%) rarely consume animal side dishes. Good sources of iron are animal foods such as meat, chicken and fish.27 In general, iron in meat, chicken and fish has high biological availability. Research by Kappala et al also shows a relationship between meat consumption and anemia in adolescent girls (28). Distribution of answers to the dietary behavior questionnaire shows that less than half of the respondents (74%) rarely and never have breakfast, lunch (66%), and dinner (73%). Most adolescent girls usually eat a complete meal only two times a day, namely a combination of breakfast-dinner or lunch-dinner. This can cause iron needs are not met. Research Shill et al shows that breakfast is associated with student anemia (29).
Table IV.
Multivariate analysis of anemia control models for adolescent girls.
| Variabel | P-value | Exp (B) |
|---|---|---|
| Diet Behaviour | 0,044 | 2,916 |
| Fe Inhibitor consumption | 0,050 | 3,836 |
| Constant | 0,012 | 0,072 |
Based on diet behavior, it is known that most respondents (73%) rarely eat fruits. The diet in Indonesia should consist of fruits that are rich in vitamin C. Vitamin C greatly helps the absorption of non-ferrous iron by changing the form of ferric to ferrous. There is a relationship between fruit consumption and anemia in students. Most of the respondents (86%) rarely exercise. Research from Jalambo et al shows a relationship between physical activity and anemia in adolescent girls. Activity performance will decrease due to a decrease in hemoglobin concentration and iron-containing tissue. The iron in hemoglobin, when the amount is reduced, can extremely alter work activity by decreasing oxygen transport (29).
The results of the bivariate analysis showed that there was a significant relationship between the consumption pattern of iron inhibitors and anemia (P=0.012). This is in accordance with the research conducted by Masthalina which states that there is a significant relationship between the consumption pattern of Fe inhibitor and anemia in adolescent girls because the consumption of inhibitors in adolescent girls with anemia is 47.6% in the usual category of consuming (9). Consuming food sources that contain iron inhibitors, because 42.3% of adolescent girls in the working area of Kembaran and Kedungbanteng often consume tea more than once a day as well as other inhibiting food ingredients such as chocolate, ice cream, milk and fried soybeans 1-3x/Sunday.
Black tea and coffee can reduce iron absorption into the body by 79-90%, herbal tea by 84%, chocolate 54%. Tea is a drink containing tannins which can reduce the absorption of non-heme iron by forming complex bonds that cannot be absorbed. If women consume 1-2 cups of tea a day will reduce iron absorption, both in women with anemia or not. Consumption of 1 cup of tea a day can reduce iron absorption by 49% in people with iron deficiency anemia, while consumption of 2 cups of tea a day reduces Fe absorption by 67% in people with iron deficiency anemia and 66% in the control group (30-32).
The higher the consumption of calcium will reduce the storage of iron in red blood cells from both heme and non-heme sources. Protein derived from cow's milk, cheese, and eggs cannot increase the absorption of non-heme iron because it has low bioavailability (33). The results of the study by Petry et al Stated that phytic acid contained in nuts can reduce the absorption of Fe in food consumed. and high polyphenol content in nuts can reduce Fe absorption by 27% (34). Research Isik Balci et al stated that the low consumption pattern of animal food sources causes anemia in adolescent girls (35).
Conclusions
The prevalence of this anemia is 20% among young women. There is a relationship and influence of dietary behavior in female adolescents, the role of female adolescents in preventing anemia and consumption of iron inhibitors on the incidence of anemia in adolescents girls. The approach that needs to be taken is through increasing understanding of the importance of nutritional consumption by improving eating behavior by utilizing the role of social media and the role of school health efforts.
Acknowledgments
An acknowledgement of a research paper that gives to BLU LPPM Jenderal Soedirman University that have provided support and assistance.
Funding Statement
Funding: This research was funded by the Ministry of Research, Technology and Higher Education, Applied Product Research Scheme.
References
- 1.Kementerian Kesehatan RI: Data dan Informasi Profil Kesehatan Indonesia 2016 [Internet]. Jakart, 2017 [cited 2018 Feb 21]. Available from: http://www.depkes.go.id/resources/download/pusdatin/lain-lain/DatadanInformasiKesehatanProfilKesehatanIndonesia2016-smallersize-web.pdf. [Google Scholar]
- 2.Balitbangkes RI: Riset Kesehatan Dasar (RISKESDAS) 2013 [Internet]. Riset Kesehatan Dasar. RISKESDAS 2013. Jakarta: Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan Republik Indonesia; pp1-384, 2013. Available from: http://www.depkes.go.id/resources/download/general/HasilRiskesdas2013.pdf. [Google Scholar]
- 3.World Health Organization (WHO): Iron deficiency anaemia Assessment, Prevention, and Control. A guide for programme managers [Internet]. Vol. 387, WHO. pp90-16, 2001. [cited 2018 Mar 6]. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673615608650. [Google Scholar]
- 4.National Anemia Action Council: Anemia in Adolescents. Teen Scene. Januari 14, 2014. [Google Scholar]
- 5.Webster-Gandy J, Madden A, Michelle Holdsworth: Oxford Handbook of Nutrition and Dietetics. English, Oxford Public Press, 2012. [Google Scholar]
- 6.Dinas Kesehatan Provinsi Jawa Tengah. Profil Kesehatan Provinsi Jawa Tengah 2016 [Internet]. 2017 [cited 2018 Feb 27]. Available from: http://www.dinkesjatengprov.go.id/v2015/dokumen/profil2016/mobile/index.html#p=1. [Google Scholar]
- 7.Collings R, Harvey LJ, Hooper L, Hurst R, Brown TJ, Ansett J, King M, Fairweather-Tait SJ: The absorption of iron from whole diets: A systematic review. Am J Clin Nutr 98: 65-81, 2013. [DOI] [PubMed] [Google Scholar]
- 8.Beck KL, Conlon CA, Kruger R, Coad J: Dietary determinants of and possible solutions to iron deficiency for young women living in industrialized countries: A review. Nutrients 6: 3747-3776, 2014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Masthalina H: Pola Konsumsi (Faktor Inhibitor Dan Enhancer Fe) Terhadap Status Anemia Remaja Putri. J Kesehat Masy: 80, 2015. [Google Scholar]
- 10.World Health Organization. Worldwide Prevalence of Anemia [Internet]. Rome, 2008. Available from: http://apps.who.int/iris/bitstream/handle/10665/43894/9789241596657_eng.pdf?sequence=1. [Google Scholar]
- 11.Hestiantoro A, Hadisaputra W, Pramayadi C: Masalah Gangguan Haid dan Infertilitas. Jakarta, FKUI, 2008. [Google Scholar]
- 12.Evans C, Dolan B: Body shape questionnaire: Derivation of shortened ‘alternate forms’. Int J Eat Disord 13: 315-321, 1993. [DOI] [PubMed] [Google Scholar]
- 13.Thompson FE, Subar AF: Dietary assessment methods. Obesity Epidemiol. 84-118, 2009. [Google Scholar]
- 14.Arisman. Gizi Dalam Daur Kehidupan. Jakarta: Penerbit Buku Kedokteran EGC, 2014. [Google Scholar]
- 15.Ramachandran R, Majumdar A, Kar S: Prevalence and risk factors of Anaemia among adolescent girls residing in a rural community of puducherry. Indian J Matern Child Heal 15: 1-10, 2013. [Google Scholar]
- 16.Gupta A, Parashar A, Thakur A, Sharma D: Anaemia among Adolescent Girls in Shimla Hills of North India: does BMI and onset of menarche have a role? Indian J Med Sci 66: 126-130, 2012. [PubMed] [Google Scholar]
- 17.World Health Organization (WHO). Nutrition Micro Nutrient Deficiencies, Iron Deficiency Anemia, the Challenge, 2018. [Google Scholar]
- 18.Novasari DH, Nugroho D, Winarni S: Hubungan pengetahuan, Sikap Dan Paparan Media Informasi Dengan Praktik Pemeriksaan Payudara Sendiri (Sadari) Pada Santriwati Pondok Pesantren Al Ishlah Tembalang Semarang Tahun 2016. J Kesehat Masy 4: 186-194, 2016. [Google Scholar]
- 19.Ahmed A, Mohammed A: Anemia and its associated factor among adolescent school girls in GODEY and DEGEHABUR council Somali region, eastern Ethiopia. BMC Nutr 8: 4-9, 2022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Roche ML, Bury L, Yusadiredjai IN, Asri EK, Purwanti TS, Kusyuniati S, Bhardwaj A, Izwardy D: Adolescent girls' nutrition and prevention of anaemia: A school based multisectoral collaboration in Indonesia. BMJ 363: k4541, 2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Guerin RJ, Toland MD: An application of a modified theory of planned behavior model to investigate adolescents' job safety knowledge, norms, attitude and intention to enact workplace safety and health skills. J Safety Res 72: 189-198, 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hurlock EB: Developmental psycology a life span approach. Jakarta, Penerbit Erlangga, 2000. [Google Scholar]
- 23.Reed BG, Carr BR: The Normal Menstrual Cycle and the Control of Ovulation. Endotext [Internet]. 2000. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25905282. [Google Scholar]
- 24.Jaelani M, Simanjuntak BY, Yuliantini E: Faktor Risiko yang Berhubungan dengan Kejadian Anemia pada Remaja Putri. J Kesehat 8: 358-368, 2017. [Google Scholar]
- 25.Alamsyah PR, Andrias DR: Hubungan kecukupan zat gizi dan konsumsi makanan penghambat zat besi dengan kejadian anemia pada lansia. Media Gizi Indones 11: 48-54, 2016. [Google Scholar]
- 26.Rahfiludin MZ, Arso SP, Joko T, Asna AF, Murwani R, Hidayanti L: Plant-based Diet and Iron Deficiency Anemia in Sundanese Adolescent Girls at Islamic Boarding Schools in Indonesia. J Nutr Metab 2021: 6469883, 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Patimah S, Royani I, Mursaha A, Thaha AR: Knowledge, attitude and practice of balanced diet and correlation with hypochromic microcytic anemia among adolescent school girls in Maros District, South Sulawesi, Indonesia. Biomed Res 27: 165-171, 2016. [Google Scholar]
- 28.Prasanna Kappala V, Doddaiah V, Raghavendra B, Nagammanavar R, Kamble S, Gangadhara Goud T, Sridhara K S: A study of prevalence and determinants of anaemia among adolescent girls of Urban Slums in Bellary City. Int J Heal Sci Res 174: 17-25, 2014. [Google Scholar]
- 29.Shill K, Karmakar P, Kibria M, Das A, Rahman M, Hossain M, Sattar MM: Prevalence of Iron-deficiency Anemia among University Students in Noakhali Region, Bangladesh. J Heal Popul Nutr 32: 103-110, 2014. [PMC free article] [PubMed] [Google Scholar]
- 30.Hurrell RF, Reddy MB, Cook JD: Inhibition of non-haem iron absorption in man by polyphenolic-containing beverages. Br J Nutr 81: 289-295, 1999. [PubMed] [Google Scholar]
- 31.Thankachan P, Walczyk T, Muthayya S, Kurpad AV, Hurrell RF: Iron absorption in young Indian women: The interaction of iron status with the influence of tea and ascorbic acid1-3. Am J Clin Nutr 87: 881-886, 2008. [DOI] [PubMed] [Google Scholar]
- 32.Temme EHM, Van Hoydonck PGA: Tea consumption and iron status. Eur J Clin Nutr 56: 379-386, 2002. [DOI] [PubMed] [Google Scholar]
- 33.Roughead ZKF, Zito CA, Hunt JR: Inhibitory effects of dietary calcium on the initial uptake and subsequent retention of heme and nonheme iron in humans: Comparisons using an intestinal lavage method. Am J Clin Nutr 82: 589-597, 2005. [DOI] [PubMed] [Google Scholar]
- 34.Petry N, Egli I, Gahutu JB, Tugirimana PL, Boy E, Hurrell R: Stable Iron isotope studies in rwandese women indicate that the common bean has limited potential as a vehicle for iron biofortification. J Nutr 142: 492-497, 2012. [DOI] [PubMed] [Google Scholar]
- 35.Işık Balcı Y, Karabulut A, Gürses D, Ethem Çövüt I: Prevalence and risk factors of Anemia among adolescents in Denizli, Turkey. Iran J Pediatr 22: 77-81, 2012. [PMC free article] [PubMed] [Google Scholar]