Relationship Between Nutritional Status, Food Intake, Nutritional

Knowledge, and Family Income with the Incidence of Anemia

Nurwana

, Lintang Purwara Dewanti

and Imawati Eka Putri

Faculty of Health Science, Muhammadiyah Prof. Dr. HAMKA University, Jakarta, Indonesia

Faculty of Health Science, Esa Unggul University, Jakarta, Indonesia

Keywords: Anemia, Food Intake, Family Income, Nutritional Knowledge.

Abstract: The impact of anemia on adolescent girls includes decreased academic school grades, difficulty concentrating,

lack of passion for learning so that it affects the learning achievement of adolescent girls. This study aimed

to determine a relationship between nutritional status, food intake, nutritional knowledge and family income

with the incidence of anemia in high school students of Muhammadiyah 15 Jakarta. A cross-sectional design

was used. This research was conducted at SMA Muhammadiyah 15 Jakarta in February 2023. Primary data

will be collected by checking hemoglobin, measure nutritional status, conducting food intake interviews using

SQ-FFQ, measuring student knowledge related to nutrition and informed consent along with characteristic

data. The results showed that a nutritional status (p=0.048), protein intake (p=0.000), iron intake (p=0.003),

nutritional knowledge (p=0.009) and family income (p=0.019) have a correlation with the incidence of anemia

in adolescent girls.This study shows that more than half of young women experience anemia so that it is

expected that young women will add insight regarding nutritional anemia by participating in counseling both

online through social media and offline through internal or external school activities, routinely consuming

blood supplement tablets given by the school and checking hemoglobin levels regularly and maintaining

adequate intake.

1 INTRODUCTION

Anemia is a condition in which the amount of

hemoglobin in the body is less than normal (<12

mg/dl) for young women (WHO, 2011). Young

women are vulnerable to anemia because young

women experience menstruation every month,

especially during their teenage years where there is an

increase in nutritional needs (Eka, 2019). The impact

is that young women will get sick more easily due to

decreased immunity, lack of motivation to carry out

daily activities, lack of interest in learning so that

academic achievement decreases. In the long term,

the incidence of anemia in young women is at risk of

giving birth to babies with low birth weight (LBW),

asphyxia, experiencing bleeding during childbirth, to

death of the mother or baby (Anggoro, 2020).

The world prevalence of anemia reaches 50-80%

(WHO, 2015). According to RISKESDAS 2018 data,

anemia has increased by 48.9% (RISKESDAS,

2018). Adolescent girls who experience anemia in the

West Jakarta area with an age range of 10-19 years

account for 6.55% of anemia cases in 2018,

experienced an increase in 2019, namely 19.10% of

anemia cases, and increased again in 2020 to 49.27 %

cases (Delima, 2020).

One of the main causes of anemia is nutritional

status. This condition is more likely to occur in young

women who tend to pay attention to their appearance

so they apply an inappropriate diet in order to have a

slim body shape, are used to consuming less

nutritious food and instant food and often skip

breakfast. If this goes on for too long it will affect the

nutritional status of young women and the body will

continue to lose hemoglobin levels until they become

anemic due to a lack of the diversity of nutrients

needed to form hemoglobin (Parliani, 2018). In line

with that, young women who have a thin nutritional

status have a 1.4 times higher risk of developing

anemia than young women who have normal

nutritional status (Anjaya & Rohmah, 2020).

Inadequate nutritional intake is a major factor in

the problem of anemia, lack of nutritional intake can

be affected by food intake that is consumed not

according to needs. Adolescent girls who do not

eat a variety of foods, especially foods that help the

104

Nurwana, , Dewanti, L. P. and Putri, I. E.

Relationship Between Nutritional Status, Food Intake, Nutritional Knowledge, and Family Income with the Incidence of Anemia.

DOI: 10.5220/0012901400004564

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 104-110

ISBN: 978-989-758-727-6; ISSN: 2975-8297

process of forming hemoglobin, namely foods that

are rich in protein and iron, can be at risk of

developing anemia. A study by Niematush Sholihah

explains that young women intake of protein and iron

has a high chance of experiencing anemia, namely 33

times and 8.7 times (Ni’matush Sholihah et al., 2019).

Nutritional knowledge of young women plays an

important role in anemia, lack of knowledge of

adolescents will certainly affect eating behavior,

lifestyle and eating habits of young women

(Hamdani, 2019). Lack of knowledge of anemia

related to nutrition will result in young girls

consuming foods containing little iron so that iron in

young girls cannot be fulfilled, this is in line with

research conducted by Misroh Mulianingsih obtained

statistical test results with a p value of 0.000 (<0.05)

indicating there is the relationship between

knowledge and the incidence of anemia in young

women (Misroh mulianingsih, 2021). Other research

is also in line with this, namely research conducted by

Nurhayati found that around 75.6% of students who

had less knowledge experienced anemia with a p

value of 0.000 (<0.05) which means there is a

relationship between this knowledge and the

incidence of anemia young women of MAN 1

Banjarmasin class of 2020 (Nurhayati et al., 2020).

Adolescent girls who have low-income families

affect the availability of food both in terms of quality

and quantity and low family income also affects

access to health services to prevent and treat anemia

in female adolescents (Devinia, 2020). in line with

Theresia's research and concluded that there is a

relationship between parental income and the

incidence of anemia in young women. (Theresia &

Putri, 2021).

2 RESEARCH METHOD

This research is quantitative research with

observational analytic design with a cross sectional

approach. This study aims to see the relationship

between the dependent variable, namely the incidence

of anemia and the independent variables, namely

nutritional status, food intake, nutritional knowledge,

and family income which was conducted at SMA

Muhammadiyah 15 Jakarta in February 2023. The

sample technique used was purposive sampling with

a sample of 65 respondents. This study used the chi

square and fisher's exact tests. Primary data was

collected by checking hemoglobin using a digital

hemoglobin tool with the easy touch brand to check

hemoglobin levels, taking anthropometric

measurements (weight and height) using digital

scales and microtoise to determine nutritional status,

conducting food intake interviews to determine food

intake (source protein, and iron) using the SQ-FFQ

form, filling out a questionnaire related to nutritional

knowledge filled out by female students to measure

the student's knowledge and filling out the consent

form along with characteristic data which includes

age, number of family dependents and family income.

3 RESULT AND DISCUSSION

3.1 Univariat

Table 3.1: Univariate Result.

The results of this study indicate that more than half

of female adolescent experience anemia, namely as

many as 52.3% with a hemoglobin level of at most

11.9/dL. teenage girls who have more nutritional

status as much as 27.7% and less nutritional status as

much as 9.2% with an average normal nutritional

Variable n %

Age

15 years old

11 16.9

16 years old

32 49.2

17 years ol

22 33.8

Incidence of Anemia

Anemia

34 52.3

Not Anemic

31 47.7

Nutritional Status

Thinnes

6 9.2

Normal

41 63.1

Overweight

18 27.7

Protein Intake

Inadequate intake

32 49.2

sufficient intake

28 43.1

More Intake

5 7.7

Iron Intake

Inadequate intake

51 78.5

sufficient intake

10 15.4

More Intake

4 6.2

Nutritional Knowledge

Less nutritional knowledge

42 64.6

Enough nutritional knowledge

13 20.0

Good nutritional knowledge

10 15.4

Family Income

Less family income

40 61.5

Enough family income

25 38.5

Amount 65 100

Relationship Between Nutritional Status, Food Intake, Nutritional Knowledge, and Family Income with the Incidence of Anemia

105

status of young women (0.056 SD). Almost a small

proportion of young women lack protein intake,

namely as much as 49.2% with an average protein

intake of 58.3 g/day. Most young women lack iron

intake, namely as much as 78.5% with an average iron

intake of 9.3 g/day. More than half of young women

have less knowledge, namely as many as 64.6% with

the highest score of 50 points. young women who

have a low family per capita income of 61.5% with a

maximum per capita income of IDR 950,000.

3.2 Bivariate

Table 3.2: Bivariate Result.

3.2.1 Incidence of Anemia

Based on table 3.1 as many as 52.3% of young women

at SMA Muhammadiyah 15 Jakarta experienced

anemia and obtained a median value of 11.9 g/dL

with the lowest hemoglobin level being 8.6 g/dL

where this category is included in the category of

moderate anemia (WHO, 2011). From the results of

these it can be concluded that the incidence of anemia

in young women at SMA Muhammadiyah 15 Jakarta

is quite high compared to the prevalence in the East

Jakarta area in 2021, which is 25.6% Warda &

Fayasari (2021) and in 2022 in the South Jakarta area

with the prevalence of anemia in young women,

namely 50.6% (Mahardika et al., 2022).

The main factor in the occurrence of anemia is

influenced by the food intake consumed by young

women, namely the lack of consumption of

hemoglobin-forming substances such as protein and

iron. The protein requirement for female adolescents

aged 13-18 years is 65 grams/day and the iron

requirement is 15 mg/day. If female adolescents

experience menstruation, the iron requirement

increases to 26 mg/day (Agustina & Fridayanti,

2017). Based on the results of the interviews, young

women who are anemic often skip breakfast, eat their

main meal every day with iced tea, like to consume

coffee, rarely consume vegetables and fruit, and are

disobedient in taking iron tablets. In addition, the high

prevalence of anemia in SMA Muhammadiyah 15

Jakarta can occur due to young girls who do not

consume iron tablets given by the school where SMA

Muhammadiyah 15 West Jakarta already has a

program for giving blood tablets to teenage girls by

regional health centers. Aligned research by Nirmala

et al (2021), it was stated that the results of interviews

with the West Jakarta Health Center for young

women were 98.6% disobedient in taking iron tablets

(Nirmala et al., 2021).

3.2.2 Nutritional Status

Based on table 3.1, as many as 63.1% of female

adolescents had normal nutritional status, 27.7% of

female adolescents had excess nutritional status and

9.2% of female adolescents had underweight

nutritional status. From these results, the average

Variable

Incidence of Anemia

Total

(95% Confident Inteval)

P Value Anemia Not Anemic

n % n % n %

Nutritional Status

Thinnes 6 100 0 0.0 6 100 - 0.048

Normal 19 46.3 22 53.7 41 100

Overwei

ht 9 50 9 50 18 100

Protein Intake

Inade

uate 25 78.1 7 21.9 32 100 - 0.000

Sufficient 6 21.4 22 78.6 28 100

more 3 60 2 40 5 100

Iron Intake

Inade

uate 32 62.7 19 37.3 51 100 - 0.003

Sufficient 2 20.0 8 4.8 10 100

more 0 0.0 4 100 4 100

Nutritional Knowledge

Less 27 64.3 15 35.7 42 100 4.114

(1.384 - 12.232)

0.009

Enough 7 30.4 16 69.6 23 100

Famil

Income

Less 23 65.7 12 34.3 35 100 3.311

(

1.196 -9.173

)

0.019

Enou

h 11 36.7 19 63.3 30 100

Amount 34 52.3 31 47.7 65 100

ICSDH 2023 - The International Conference on Social Determinants of Health

106

nutritional status of young women was obtained,

namely nutritional status in the normal category

(0.056 SD). Based on the interview results, this can

occur due to young women who prefer snacks rather

than eating home-cooked meals where young women

tend to consume snack foods such as batagor,

dumplings, cilok, fried foods, the majority of which

are foods high in fat and carbohydrates. in addition,

lack of consumption of vegetables and fruit, tend to

consume tea and coffee drinks as a companion to

meals, and disobedience in taking iron tablets. In line

with research conducted by Anjaya et al (2020) which

states that anemia can occur as a result of an

unhealthy diet.

Based on table 3.2, young women who have a

nutritional status of less than 100% have anemia,

while young women with more than 50% nutritional

status have anemia, so it can be concluded that there

is a significant relationship between nutritional status

and the incidence of anemia in young women at SMA

Muhammadiyah 15 Jakarta with p-value 0.048. One

of the risk factors for anemia is young women with

poor nutritional status. Research conducted by

Indrawatiningsih (2021) states that young women

with poor nutritional status have a 15,000 times

chance of developing anemia compared to young

women with good nutritional status. His research

concluded that there was a significant relationship

between nutritional status and anemia in young

women (Indrawatiningsih et al., 2021). Other

research states that undernutrition in young women

results in an increase in glycolytic enzymes such as

hexokinase, pyruvate kinase and G6PD (glucose 6-

phosphate dehydrogenase) changing membrane

permeability resulting in the breakdown of red blood

cells which is characterized by low serum ferritin

levels (Arima et al., 2019). This research is in line

with research conducted by Muhayati & Ratnawati

(2019) which found that the results of a study of

young women with a thin BMI as much as 67.7%

experienced anemia, so it was concluded that there

was a significant relationship between nutritional

status and the incidence of anemia in young women

at SMA Negeri 97 Jakarta (Muhayati & Ratnawati,

2019). Other research states that this can occur

because young women who have a thin nutritional

status can experience anemia due to overly adjusting

their diet to maintain body shape (body image)

resulting in malnutrition (Sari, 2019).

3.2.3 Protein Intake

Based on table 3.1, 49.2% of female adolescents

lacked protein intake, 43.1% of female adolescents

had sufficient protein intake and 7.7% of female

adolescents had excess protein intake. From these

results, it was found that the average protein intake

for young women was 58.3 grams/day, which could

meet around 89.6% of the needs of young women.

Based on the results of the Semi Quantitative Food

Frequency Questionnaire (SQ-FFQ) interview, the

type of protein most often consumed by young

women is animal protein, namely chicken, eggs and

fish. Adolescent girls with less protein intake most

often consume vegetable protein sources compared to

animal protein sources because the price is relatively

cheaper. In addition, the lack of protein intake is

because young women often consume inhibitory

substances such as iced tea and coffee at mealtimes

and rarely eat fruits and vegetables which can help

absorb protein, this causes the total protein needs of

young women cannot be met. In line with this, the

results of a study conducted by Marlenywati et al

(2020) stated that as many as 73.3% of female

students lacked protein intake because protein

consumption was dominated by vegetable protein

rather than animal protein, which should be balanced.

Other studies have suggested that protein intake is not

fulfilled, possibly due to the poor quality and quality

of the protein consumed, where the quality of the

protein is determined by the composition and number

of essential amino acids (Pratama et al., 2020).

Based on table 3.2, 78.1% of female adolescents

who lacked protein intake experienced anemia, while

female adolescents who had excess protein intake of

60% experienced anemia, so it can be concluded that

there was a significant relationship between protein

intake and the incidence of anemia in female

adolescents at SMA Muhammadiyah 15 Jakarta with

p-value 0.000. This research is in line with research

conducted by Solichah et al (2019) which stated that

the lower the protein intake, the lower the hemoglobin

level. The results of his research concluded that there

was a significant relationship between protein intake

and hemoglobin levels in female adolescents

(Sholicha & Muniroh, 2019). Another study stated

that as many as 68.3% of the proportion of young

women in the protein-deficient category experienced

anemia, meaning that there was a significant

relationship between protein intake and the incidence

of anemia in young women at SMU 98 Jakarta

(Junengsih & Yuliasari, 2017).

Relationship Between Nutritional Status, Food Intake, Nutritional Knowledge, and Family Income with the Incidence of Anemia

107

3.2.4 Iron Intake

Based on 3.1, 78.5% of female adolescents lacked

iron intake, 15.4% of female adolescents had

sufficient iron intake and 6.2% of female adolescents

had excess iron intake. From these results the average

intake of iron in female adolescents was 9.3 mg/day.

Based on the results of the Semi Quantitative Food

Frequency Questionnaire (SQ-FFQ) interview,

female adolescents tend to consume foods high in

protein but low in iron, such as vegetable protein. In

addition, this is evidenced by the decreased

absorption of iron consumed by the high iron needs

of young women who are not balanced. Young

women tend to consume light snacks, sweetened and

carbonated drinks, consume coffee and tea as a

companion to the main meal, and low fruit and

vegetable consumption causes low iron intake in

female adolescents, causing female adolescents to

experience anemia. For this reason, female

adolescents are provided with iron supplements given

by the school to help meet their iron needs. However,

female adolescents do not adhere to taking iron

tablets. In line with this, a study conducted by Warda

et al (2021) stated that young women with low iron

bioavailability have 9,927 times the risk of

experiencing anemia. Her research concluded that

young women with low iron consumption had a

15,812 chance of experiencing anemia (Warda &

Fayasari, 2021). Other research states that lack of iron

intake in female adolescents is influenced by the type,

amount and frequency of intake of heme iron

consumed in small amounts (Arima et al., 2019).

Based on table 3.2, as many as 62.7% of female

adolescents who lack iron intake experience anemia,

while female adolescents who have an excess of

100% iron intake do not experience anemia, so it can

be interpreted that there is a significant relationship

between iron intake and the incidence of anemia in

female adolescents in SMA Muhammadiyah 15

Jakarta with a p value of 0.003. In line with this, a

study conducted by Marlenywati et al (2020) stated

that a lack of iron intake could result in a decrease in

the number of erythrocytes resulting in iron

deficiency anemia. His research concluded that there

was a significant relationship between respondents'

iron intake and hemoglobin levels (Marlenywati &

Kurniasih, 2020). Another study conducted by Akib

& Sumarmi (2017) states that the main cause of iron

deficiency is reduced iron absorption, female

adolescents prefer to consume vegetable protein

compared to animal protein which has a higher iron

content and is more physiological for the body (Akib

& Sumarmi, 2017). The same study stated that the

occurrence of anemia is influenced by the level of

absorption and bioavailability of iron so that

sufficient iron intake may not necessarily be able to

meet the needs of iron in the body (Arima et al.,

2019).

3.2.5 Nutritional Knowledge

Based on table 3.1, 64.6% of female adolescents had

insufficient nutritional knowledge, 20% of female

adolescents had adequate nutritional knowledge and

15.4% of female adolescents had good nutritional

knowledge. From these results a knowledge score

was obtained with a median value of 50 with the

lowest knowledge score being 20 and the highest

knowledge score being 100. Based on the results of

the interviews the lack of knowledge of nutrition in

young women was due to the fact that most young

women had never received special education or

counseling regarding anemia. In addition, most of the

health information obtained by young women

through social media such as tiktok, YouTube,

Instagram, Twitter and Facebook. However, the truth

of health information circulating on social media

cannot be validated, this causes misinformation by

young women. In line with this, according research

by Rusdi et al (2021) states that social media is a place

that is often accessed by adolescents to seek

information, especially health information and

platforms that can reach many targets that are not

limited in space and time. In his research, he stated

that education through social media had an impact on

increasing knowledge and changing behavior so that

it could be concluded that misinformation caused

inappropriate behavior changes (Rusdi et al., 2021).

Other research states that the level of knowledge

affects the tendency of young women to choose foods

with good nutritional value, so it can be concluded

that if young women have good nutritional

knowledge they can avoid consuming foods that

hinder the absorption of nutrients (Anggoro, 2020).

In the bivariate analysis, nutritional knowledge

was divided into two categories, namely knowledge

of poor nutrition and knowledge of adequate nutrition

(knowledge of adequate nutrition and knowledge of

good nutrition). Based on table 3.2, as many as 64.6%

of female adolescents at SMA Muhammadiyah 15

Jakarta have poor nutritional knowledge. In addition,

as many as 64.3% of young women who have poor

nutritional knowledge experience anemia, so it can be

concluded that there is a significant relationship

between nutritional knowledge and the incidence of

anemia in SMA Muhammadiyah 15 Jakarta students

with a p value of 0.009. Adolescent girls with poor

ICSDH 2023 - The International Conference on Social Determinants of Health

108

nutritional knowledge are at risk of experiencing

anemia 4 times compared to female adolescents with

sufficient nutritional knowledge. In line with this,

research conducted by Anggoro (2020) states that the

higher the level of knowledge of young women, the

lower the risk of young women experiencing anemia,

the results of his research show that there is a

significant relationship between knowledge and the

incidence of anemia in young women (Anggoro,

2020). Other research states that young women who

have less knowledge of nutrition lead to a lack of

intake of hemoglobin-forming nutrients such as

sources of protein and iron so that hemoglobin levels

become low (Suryani et al., 2020).

3.2.6 Family Income

Based on table 3.1 as many as 61.5% of young women

with low per capita family income and as many as

38.5% of young women with sufficient per capita

family income. From these results obtained a median

value of Rp. 950,000 per capita income for a family

of young women with the lowest per capita income of

Rp. 300,000 and the highest per capita income is Rp.

5,000,000. Based on the results of the interview, the

low family income was due to the young women's

family economy which had not fully recovered after

the outbreak of COVID-19. The low per capita

income of the family of young women is influenced

by the number of family members, meaning that the

more the number of family members, the lower the

per capita income of the family, this causes the

nutritional adequacy of young women to prevent

anemia. In line with this, research conducted by

Alexander (2020) states that the greater the income

the family earns, the more nutritional adequacy of

adolescent girls is fulfilled (Alexander, 2020).

Based on table 3.2 as many as 65.7% of young

women who have low family income experience

anemia, it can be concluded that there is a significant

relationship between family income and the incidence

of anemia in SMA Muhammadiyah 15 Jakarta

students with a p value of 0.019. The category of

family income can be seen from the size of per capita

income in the household. Young women with low

family income are 3 times at risk of experiencing

anemia compared to young women with sufficient

family income. Based on the results of interviews

with young women with low family income, they tend

to eat cheap and tasty food, such as instant noodles,

fried dumplings, batagor, cilok, and so on, compared

to nutritious foods. This situation causes low

consumption of quality food resulting in nutritional

deficiencies such as anemia. This research is in line

with research conducted by Anggoro (2020) which

states that young women with sufficient family

income can influence the diversity of nutrients

prepared by their parents. The low intake of iron in

young women is obtained from the food consumed

daily (Anggoro, 2020). Other research states that the

higher the level of family income affects the type of

food consumed so that someone with a high income

will change their diet from traditional to practical

food, this has an impact on the anemia status of young

women (Warda & Fayasari, 2021). Other research

also states that family income can affect access to

meet nutritional needs. his research concluded that

there was a significant relationship between family

income and the incidence of anemia in young women

(Misroh mulianingsih, 2021).

4 CONCLUSIONS

Based on the results of research on the relationship

between nutritional status, protein intake, iron intake,

nutritional knowledge and family income with the

incidence of anemia in female adolescents at SMA

Muhammadiyah 15 Jakarta, it can be concluded that

most young women are 16 years old, namely 49.2%,

more than half of female adolescent experience

anemia, namely as many as 52.3%, teenage girls who

have more nutritional status as much as 27.7% and

less nutritional status as much as 9.2%, almost a small

proportion of young women lack protein intake,

namely as much as 49.2%, most young women lack

iron intake, namely as much as 78.5%, more than half

of young women have less knowledge, namely as

many as 64.6%, young women who have a low family

per capita income of 61.5%.

the results of the study showed that there was a

relationship between nutritional status, food intake

including protein and iron intake, nutritional

knowledge and family income with the incidence of

anemia in SMA Muhammadiyah 15 Jakarta students.

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