Effects of Moringa Oleifera and Royal Jelly Supplementation on Nutritional Status and Cognitive Function in Adolescent Girls in Takalar District, South Sulawesi, Indonesia: Protocol Study
Phase: NA
Conditions: Undernutrition, Anemia, Stunting, Cognitive Function 1, Social
Sponsor: Hasanuddin University

Effects of Moringa Oleifera and Royal Jelly Supplementation on Nutritional Status and 
Cognitive Function in Adolescent Girls in Takalar District, South Sulawesi, Indonesia:
Protocol Study
ABSTRACT
Background:Failure to achieve optimal nutritional status in adolescent girls negatively impacts 
quality of future human resources. National program of Iron-Folic Acid (IFA) tablet supplementation 
has not shown optimal results due to low compliance and side effects. As an alternative, a food-
based supplementation using locally sourcedMoringa oleiferaenriched with royal jelly (MRJ) has 
been developed. The MRJ formulation is rich in nutrients and has the potential to improve 
nutritional status and cognitive function. This study evaluates the effect of MRJ on nutritional status 
and supplement cognitive function in adolescent girls.
Methods:This double-blind, randomized controlled trial was conducted among 372 adolescent girls 
aged 10–19 years from junior and senior high schools in Galesong Selatan, Takalar District, South 
Sulawesi. Participants were randomly assigned to either the intervention group receiving MRJ 
capsules (each containing 490 mgMoringa oleiferaextract and 10 mgroyal jelly, taken twice per 
week for 12 months), or the control group receiving weekly IFA tablets (60 mg elemental iron and 
400 µg folic acid) following national guidelines. Both groups received standardized nutrition 
education via TikTok videos. Data collected at baseline, 6 months, and 12 months included 
anthropometric indicators (BMI-for-age, height-for-age, MUAC), hemoglobin levels (measured using 
Hemocue), dietary intake (24-hour recall and FFQ), and cognitive function (assessed using the 
Culture Fair Intelligence Test/CFIT). Adherence was monitored through weekly control sheets 
verified by teachers, and digital documentation via WhatsApp.
Discussion:The study was designed to assess whether MRJ offers a superior, culturally 
acceptable supplementation strategy compared to IFA. Results will inform local policy and 
broader applications of food-based interventions to improve adolescent nutrition and cognitive 
development.
Keywords
Anemia, Moringa oleifera, Royal jelly, Nutritional status, Cognitive function.
Translated from Indonesian to English - www.onlinedoctranslator.com

INTRODUCTION
Background and rationale
Adolescence is a crucial time characterized by substantial cognitive and psychological 
development as well as rapid physical growth (1). For these processes to be supported, optimal 
nutrition is crucial during this phase (2). Long-term health effects of nutritional deficiencies include 
stunted growth, anemia, and impaired cognitive function, especially in adolescent girls (3.4). 
Adolescents around the world, particularly girls, face starting nutritional challenges (5). The World 
Health Organization notes that iron deficiency is the primary cause of anemia in about 30% of 
teenage girls, a statistic that emphasizes the necessity of focused interventions (6). Adolescent girls 
in Indonesia continue to suffer from a startingly high rate of chronic energy deficiency (CED); 
national surveys show that more than 21% of them consume insufficient amounts of energy, which 
results in less-than-ideal growth and development (7.8).
Long-term nutritional deprivation can result in stunting, which is still a serious problem
(9). According to recent studies conducted in Indonesia, among teenage girls between the ages of 
16 and 18, the prevalence of stunting can reach 26.9% (10). In addition to limiting physical potential, 
stunted growth has significant effects on cognitive development, academic achievement, and future 
economic productivity (11,12). A second chance to lessen the long-term effects of stunting is to 
address it during adolescence (13). These difficulties are aggravated by anemia, which is primarily 
brought on by iron deficiency (14). Although the prevalence of anemia among teenage girls in 
Indonesia declined marginally from 32% in 2018 to 24.1% in 2023, it is still a public health issue (15). 
Anemia impairs physical activity, cognitive function, and general quality of life by affecting the 
blood's ability to carry oxygen (16,17). Pregnant girls who have anemia are more likely to experience 
problems for both the mother and the unborn child (18).
Implementing traditional supplementation programs, such as giving out iron-folic acid tablets, 
has proven difficult (19). One major obstacle has been low compliance brought on by side effects like 
gastrointestinal distress (20). Program success is further hampered by poor awareness of the significance 
of supplementation and restricted access to healthcare facilities (21,22). There is an urgent need for 
alternative strategies that are both successful and acceptable in the culture (23). A plant that is 
indigenous to tropical and subtropical areas, Moringa oleifera, has gained attention as a possible remedy 
(24). Often referred to as "the miracle tree," Moringa is high in antioxidants, vitamins, and iron (25). 
Research has indicated that it is effective in lowering oxidative stress and

raising hemoglobin levels, both of which improve cognitive function (26,27). The supplement is even 
more effective when mixed with royal jelly, a nutrient-dense secretion made by honeybees (28). 
Vitamins B5 and B6 as well as proteins and essential fatty acids, which are found in royal jelly, are 
known to improve energy metabolism and cognitive function (29).
Adolescent nutrition programs can take a new approach by incorporating Moringa Oleifera 
Enriched Royal Jelly (MRJ) (30). Because of its natural origins and ease of consumption, MRJ is less 
likely to cause side effects than traditional supplements and may be more acceptable to teenagers 
(27). Furthermore, it has been demonstrated that MRJ promotes neurocognitive development by 
offering vital nutrients needed for brain function and neurotransmitter synthesis (26,29). Adolescent 
girls' nutritional needs must be met for both their immediate health and the benefit of society as a 
whole (3.12). Their nutritional status as expectant mothers has a direct effect on the development 
and health of the offspring (18,22). Improving adolescent girls' nutritional status helps end the 
intergenerational cycle of malnutrition, which boosts economic growth and human capital (13,30). 
The purpose of this study is to assess how MRJ supplementation affects the nutritional status and 
cognitive function of teenage girls in Galesong Selatan, Takalar Regency.
Objectives
The general objective of this study is to assess the effectiveness of Moringa Oleifera Enriched 
Royal Jelly (MRJ) supplementation in improving the nutritional status, hemoglobin (Hb) levels, and 
cognitive function of adolescent girls in Takalar District, South Sulawesi, Indonesia. The study aims 
to evaluate whether MRJ supplementation, when administered over a 12-month period, can lead to 
significant improvements in these critical health and cognitive outcomes.
Study Design
This study employs a true experimental design with a randomized controlled double-blind 
pretest-posttest approach. Baseline data collection was conducted in the first year, followed by a 12-
month intervention during the second and third years. Participants were randomly assigned to two 
groups: the intervention group received Moringa Oleifera enriched Royal Jelly (MRJ) capsules 
(containing 500 mg of moringa leaf extract and 10 mg of royal jelly, 2 capsules per week), while the 
control group received iron-folic acid (IFA) tablets at a dose of 500 mg per week. Both groups 
received standardized nutrition education through TikTok videos. The intervention was conducted

in a double-blind manner using coded packaging. Nutritional status was evaluated at month 6, and 
comprehensive assessments of nutritional status and cognitive function were conducted before and after 
the 12-month intervention.
METHODS: PARTICIPATION, INTERVENTIONS, AND OUTCOMES
Study setting
The study was conducted in Galesong Selatan, Takalar Regency, from July to November 2024, 
involving two schools: SMAN 13 Takalar and SMPN 3 Galesong Selatan. These schools were chosen 
due to their representativeness of the adolescent population in both urban and semi-urban 
settings. Ethical considerations ensured confidentiality regarding specific school identification. 
Eligibility Criteria
Sampling in this study was conducted using purposive sampling technique. After determining the 
study location, nurses were selected purposively. To be eligible for the study, participants must meet the 
following criteria:
(1) Age 10–19 years
(2) Adolescent girls' who are active in grades 1 and 2 (junior high and senior high)
(3) Severe nutritional or health conditions (eg, severe anemia, severe malnutrition, allergies), 
determined through clinical history and validated self-reports.
Who will take informed consent?
The researcher and/or enumerator will obtain informed consent from adolescent girls who fit 
the criteria. Each student's willingness is included in their informed consent, which has been 
approved by their parents and teachers (class advisors). Following clear explanations of the purpose 
of the study and the procedure, both the participants and their guardians are given.
Additional consent provisions for collection and use of participant data and biological 
specimens
The study was conducted with the knowledge and permission of relevant authorities, including the 
Takalar District Education Office for junior high schools, the Provincial Education Office for senior high 
schools, and Bontokassi Primary Health Center, as the selected schools falling under its jurisdiction. 
Approval was also obtained from each participating school. Participants' data and biological specimens 
were anonymized and securely stored. Additional explicit consent was provided

obtained for the use of biological specimens in further analyses, ensuring transparency and 
compliance with ethical standards.
Interventions
Explanation for choice of comparators
Indonesia's national program on nutritional supplementation includes the “Aksi Bergizi” 
initiative, which provides iron supplementation through the distribution of Iron-Folic Acid (IFA) 
tablets to adolescent girls. This intervention aims to increase hemoglobin levels and prevent 
anemia. IFA tablets are distributed regularly under the supervision of school health personnel to 
ensure compliance (97). Adolescent girls are required to report their intake, and health staff provide 
counseling in case of problems or complaints. In addition to distribution, the program offers 
education on the importance of iron supplementation. Adolescents receive explanations on how the 
IFA tablets work, their benefits, and ways to manage possible side effects (98).
The Iron-Folic Acid Supplementation Program for adolescent girls is a crucial effort to prevent 
and address anemia. Anemia among adolescent girls remains a serious public health concern, 
especially in developing countries like Indonesia. This condition can lead to adverse outcomes such 
as reduced concentration, lower academic performance, and other health issues. Therefore, IFA 
supplementation serves as a vital preventive strategy (99).
The supplementation involves providing tablets containing iron and folic acid to adolescent 
girls on a regular basis. The dosage depends on whether the purpose is prevention or treatment. 
For prevention, which targets adolescent girls without anemia, the tablets typically contain 60 mg of 
elemental iron and 400 mcg of folic acid, taken once weekly for one year. This dosage is designed to 
meet daily nutritional needs and prevent iron deficiency during periods of rapid growth (100). For 
treatment, adolescent girls diagnosed with anemia receive a higher dose—generally 60 mg of 
elemental iron and 400 mcg of folic acid taken daily for three months, or as advised by healthcare 
providers. The therapeutic goal is to rapidly raise hemoglobin levels and address existing anemia 
(101).
The distribution process begins at the local health office, where IFA tablets are delivered to schools 
through community health centers or other healthcare facilities. Upon arrival at the school, health 
personnel are responsible for distributing the tablets to registered adolescent girls. An orientation 
program is provided to students and parents at the beginning, explaining the importance of IFA

supplementation, proper intake methods, and the associated health benefits. This is intended to ensure 
that all stakeholders understand the program's purposes and procedures (102).
Although the program has demonstrated effectiveness in several studies when implemented 
according to guidelines, challenges remain in practice. Unequal distribution of IFA tablets has 
resulted in limited access for some adolescent girls. Low compliance, driven by limited knowledge, 
aversion to the tablets, and side effects, have also significantly hindered the success of the 
program.
Intervention description
The study will involve two groups:
1.Control Group: Participants will follow theNutritious Actionprogram, which includes Iron-
Folic Acid (IFA) supplementation and video-based education using the TikTok 
application.
2.Intervention Group: Participants will follow theNutritious Actionprogram, but IFA 
supplementation will be substituted with MRJ (Moringa-Royal Jelly). They will also 
receive video-based education via TikTok, using the same content as the control 
group.
The IFA tablet contains 60 mg of elemental iron and 400 μg of folic acid. Meanwhile, MRJ (500 
mg) consists of 490 mg Moringa extract and 10 mg Royal Jelly extract, and contains various 
nutrients such as iron (9.72 mg), vitamin C (46.2 mg), zinc, calcium, flavonoids, polyphenols, 
antioxidants, beta-carotene, and other essential vitamins and minerals.
Criteria for discontinuing or modifying allocated interventions
Adolescent girls enrolled in the clinical trial who experience allergic reactions or adverse effects 
reported in either study group will be referred to a midwife or physician for evaluation and 
guidance on whether to continue participation or withdraw from the study. Participants are free to 
withdraw at any time and for any reason without any consequences.
Strategies to control interventions
Schools and students for both the intervention group (MRJ) and the control group (IFA) will be 
selected to participate in the study. One teacher from each school—preferably the School Health

Unit (SHU) teacher—will be invited to assist and supervise students consuming the supplements at 
school on a designated day each week.
Each student will receive two capsules per week—one to be consumed at school under 
supervision, and one to be taken home as a backup in case the student is absent on the scheduled 
supplement day the following week.
Each participant will be provided with a monitoring sheet, which will be signed by the 
supervising teacher if the supplement is consumed at school. If consumed at home, the student is 
required to submit photographic documentation with a real-time timestamp. This documentation 
will be reviewed by the supervising teacher and acknowledged with a signature on the student's 
compliance sheet.
If a student is absent on the scheduled day, he may take the supplement at home with appropriate 
documentation, which will be verified by the teacher for validation and recorded on the control sheet.
A WhatsApp (WA) group will be created for each study group. Through these groups, the 
researcher will send regular reminders to students to take their capsules on the designated day. In 
addition, educational links related to anemia in adolescent girls—including its impacts, prevention, 
and the benefits of the given supplements—will be shared monthly. A total of 12 different 
educational videos will be sent throughout the study period.
Biweekly school visits will be conducted to evaluate implementation, confirm supplement 
consumption, and identify any barriers or difficulties encountered by students in taking the 
capsules.
Operational Definition
a) Moringa Extract Enriched Royal Jelly (MRJ) Administration
The intervention group will receive a capsule formulation (500 mg) containing 490 mg of 
Moringa oleiferaextract and 10 mg of royal jelly extract. Each capsule contains essential 
nutrients such as iron (9.72 mg), vitamin C (46.2 mg), zinc, calcium, flavonoids, polyphenols, 
antioxidants, beta-carotene, and other vitamins and minerals. The capsules will be 
administered to anemic adolescent girls at a dosage of two capsules per week over a 12-
month period.
b) Iron and Folic Acid (IFA) Administration

IFA tablets (containing 60 mg of elemental iron and 400 μg of folic acid) will be distributed to 
adolescent girls according to the national program. Both MRJ and IFA will be administered 
under a double-blind design, ensuring that both supplements appear visually identical in 
capsule form.
c) Compliance Monitoring
To assess adherence, a consumption control sheet will be provided to each participant by 
the researcher or enumerator. This sheet will be checked and signed by the assigned 
supervising teacher. If capsules are consumed at school, the teacher will sign the sheet. If 
taken at home, the participant must document the intake with a time-stamped photo, which 
the teacher will verify and sign accordingly.
d) Nutrient Intake
Nutrient intake refers to the total consumption of macronutrients (energy, carbohydrates, 
fats, and proteins) by adolescent girls in a day. This will be measured using a 24-hour dietary 
recall and a Food Frequency Questionnaire (FFQ), and compared with the recommended 
dietary allowance (RDA) for their age.
e) Nutritional Status
Includes Body Mass Index-for-Age (BMI/A), Height-for-Age (H/A), Mid-Upper Arm 
Circumference (MUAC), and hemoglobin levels:
-
Body weight will be measured using a SECA digital scale.
-
Height will be measured with a stadiometer.
-
MUAC will be assessed using a standard MUAC tape.
-
Hemoglobin levels (Hb) will be measured using a Hemocue device by trained 
enumerators.
f) Cognitive Function
Cognitive function will be assessed using the standardizedCulture Fair Intelligence Test 
(CFIT) questionnaire. The test will be administered and analyzed directly by a licensed 
psychologist from Hasanuddin University.
Study Subjects
The population in this study includes all female students at junior high schools (SMP) and 
senior high schools (SMA) in Galesong Selatan Subdistrict, Takalar Regency, South Sulawesi

Province. The sample size in this study is calculated using the formula for estimating the mean 
difference between two paired groups, as proposed by Lemeshow and Wanga (1991), as follows:
=2 x1.23²(1.9+0.9)²
(11.42–10.85) ²
=3.02(7.84)
(0.57)²
=23.7
0.33
=71.8 = 72
Note:
n
ό
Z1-α: Significance level 95%(1.96) Z1-
β: Power of the test 90%(0.9) µ1
µ 2
: Sample Size
: Standard deviation 1.23
: Mean hemoglobin level in the MRJ intervention group (11.42 g/dl) : 
Mean hemoglobin level in the placebo intervention group (10.85 g/dL)
The sample size calculation was based on the standard deviation and mean values   from 
previous studies for the dependent variable. Based on this calculation, the required number of 
participants was 72. However, to anticipate potential dropouts (DO), a 10% increase (7 
participants) was added, resulting in a total of 79 participants. Therefore, each group will consist 
of 79 samples: 79 participants in the intervention group and 79 in the control group.
This study will collect two types of data: primary and secondary data. Primary data will be 
obtained through questionnaires distributed to the respondents and analyzed using SPSS version 
26. Secondary data will be collected from relevant literature or previous research studies. The 
study will be conducted in three phases:
1) Preparation and Baseline Data Collection
This stage involves assigning students to the intervention and control groups. Baseline 
data collection will be conducted at the selected schools for each group, including

measurements of nutritional status (body weight, height, dietary intake, and hemoglobin 
levels) and cognitive function levels.
2) Intervention Phase and Mid-Evaluation
This phase involves interventions for the two groups: the intervention group receiving MRJ 
and the control group receiving IFA (iron and folic acid tablets). The MRJ and IFA capsules 
will be provided in pre-packaged bottles containing 10 capsules, to be consumed over 5 
weeks. New supplies will be distributed every 5 weeks up to the 48th week (12 months).
3) Extended Intervention and Final Evaluation Phase
After 12 months, the nutritional and cognitive status of the adolescent girls will be 
reevaluated. This will allow assessment of improvements at 6-month intervals and 
determination of the most effective supplementation duration.
Instruments and Intervention Materials
Materials used in this study were MRJ and IFA capsules purchased as finished products. IFA 
contains 200 mg ferrous sulfate (equal to 60 mg elemental iron) and 0.25 mg folic acid. MRJ 
contains 500 mg moringa and 10 mg royal jelly. Both were packed in identical capsules in 
terms of shape, color, and size to ensure blinding, so no visual difference between them. 
Capsules were supplied by trusted manufacturer and randomly coded by independent third 
party to maintain confidentiality during intervention. Before distribution, materials were tested 
for quality to ensure safety and formulation consistency.
Instruments used included Kobo questionnaire, 24-hour recall and FFQ, anthropometric 
tools: digital scale (Seca) for weight, stadiometer for height, MUAC tape, Hemocue for 
hemoglobin levels, CFIT for cognitive test, and checklist sheets for monitoring MRJ and IFA 
capsule consumption compliance.
Nutrition and Anemia Education
Balanced nutrition and anemia education will be conducted both offline and online. Offline 
education will be given before and after the intervention (pre-posttest) through a 30– 45-
minute lecture. Each session will include ice-breaking and a quiz with prizes to make the 
learning process interactive and enjoyable. Online education will run throughout the 12-month 
intervention via TikTok-based educational video links. These links will be shared with

study subjects through a WhatsApp group. Video updates will be sent every two weeks. The 
education topics, both offline and online, will remain the same, including:
Topic 1: Balanced Nutrition
Optimal nutrient intake is essential for the body's growth and development. Dietary patterns 
should focus on consuming a balanced diet—daily meals that contain nutrients in types and 
amounts that meet the body's needs.
Four Pillars of Balanced Nutrition:
1. Consume a variety of foods.
2. Practicing clean and hygienic living.
3. Engaging in physical activity.
4. Monitor body weight regularly.
Topic 2: My Plate Contents
A guide to food diversity and recommended portion sizes for each meal. Each plate should 
consist of 2/3 staple foods and vegetables, and 1/3 side dishes and fruits. It's also important to 
limit sugar, salt, and fat intake and drink adequate water.
Topic 3: Protein: The Body Builder
Protein is necessary for the formation of new cells, cell maintenance, and boosting immunity. 
Protein sources include animal proteins such as meat, fish, and eggs, as well as plant-based 
proteins such as tofu, tempeh, and legumes. A balanced intake of both animal and plant proteins 
is recommended.
Topic 4: Healthy Breakfast
Breakfast fulfills 20–25% of daily calorie needs. A healthy breakfast includes sources of 
carbohydrates, proteins, fats, and vitamins/minerals in appropriate portions.
Topic 5: Physical Activity
Regular physical activity helps maintain fitness, boosts metabolism, and prevents obesity. 
The WHO recommends 60 minutes of daily physical activity for children and adolescents. 
Topic 6: Food and Beverage Labels
Food labels help consumers understand nutritional content, monitor sugar, salt, and fat 
limits, and ensure food safety. Nutrition literacy is crucial for making informed dietary 
choices.
Topic 7: School Canteens and Healthy Snacks

Avoid snacks with artificial coloring, reused cooking oil, and excessive sugar, salt, or fat 
content. Choose snacks from clean and safe vendors.
Topic 8: Fruit and Vegetable Consumption
Fruits and vegetables are rich in vitamins, minerals, and fiber. It is recommended to 
consume 3–4 servings of vegetables and 2–3 servings of fruit daily to maintain health and 
prevent disease.
Topic 9: Anemia and Iron
Anemia is often caused by iron deficiency. Prevention can be done by consuming iron-rich foods 
such as red meat, spinach, and legumes.
Topic 10: Micronutrients
Vitamins and minerals are essential for bodily functions, even in small amounts. Consume foods 
rich in micronutrients such as leafy greens, fruits, and legumes.
Topic 11: Sugar, Salt, and Fat
Limit intake of sugar (maximum 50 grams/day), salt (5 grams/day), and fat (67 grams/day). 
Excessive consumption increases the risk of chronic diseases.
Topic 12: Personal Hygiene
Clean living includes habits such as handwashing, food hygiene, and personal health 
maintenance. Good hygiene reduces the risk of infection and supports overall health.
Data Analysis
The primary data collected were then processed through several stages of data handling as 
follows:
a. Editing: The results obtained from interviews or questionnaires were first edited. If there were 
any incomplete data or missing information, corrections were made efficiently. If it was not 
possible to re-interview the respondent, the questionnaire was excluded from the dataset.
b. Coding: Each item in the questionnaire was assigned a numeric code to facilitate data 
processing and analysis.
c. Tabulation: The data were grouped and presented in tabular form in accordance with the 
research objectives, making it easier to analyze.

d. Processing: In this stage, the responses from participants, which had been translated into 
numerical form, were processed for analysis.
e. Cleaning: The data entered into the master table were rechecked, including verification of 
data entries and codes, to minimize errors during the data input process. If incorrect coding 
was found, it was corrected or removed based on the original questionnaire.
After the data processing phase, data analysis was conducted using SPSS, employing 
univariate, bivariate, and multivariate analyses.
•
Univariate analysis aims to obtain an overview and describe the characteristics of 
each research variable, including age, education, income, occupation, parity, 
pregnancy history, dietary intake, mid-upper arm circumference, gestational age, 
infant length, and birth weight. This analysis generated frequency distribution tables 
and percentages for each variable.
•
Bivariate analysis was conducted to assess the differences in means before and after 
the intervention within each group. A paired t-test was used if the data were 
normally distributed, while the Wilcoxon test was used for non-normally distributed 
data. For categorical data, the McNemar test was applied. To compare the mean 
changes between the three groups, One Way ANOVA was used for normally 
distributed data, and the Kruskal-Wallis test for non-normally distributed data.
•
Multivariate analysis was performed to examine the effect of independent variables on 
the dependent variable using Logistic Regression analysis.
Quality Control
Quality control is directed toward minimizing errors that may arise from sampling factors 
(sampling error) or alpha errors, which include errors due to an inadequate sample size or an 
unrepresentative sample that does not accurately reflect the population. In addition, quality 
control also aims to address systematic errors or beta errors, which may originate from the 
measuring instruments, the measurer, or the object being measured.
Standardization of the instruments used was conducted through validity testing on 
adolescent girls. Prior to the implementation of the research, the researcher submitted formal 
requests and obtained approval from the relevant authorities, including the local health office,

schools, and community health centers (Puskesmas). Once permission was granted, an informed 
consent form was provided and signed by each respondent as a confirmation of their voluntary 
participation.
Research Ethics
This study was conducted after obtaining ethical clearance from the Health Research Ethics 
Committee of the Faculty of Public Health, Hasanuddin University, with Ethical Approval Number 
2739/UN4.14.1/TP.01.02/2024, dated September 30, 2024.

Research Flow Chart
Year 1: Preparation, Baseline data collection
(nutritional status and cognitive
measurements)
Group randomization
INTERVENTION
MRJ (Moringa + Royal Jelly)
– 1 capsule per week
CONTROL
IFA (Iron and Folic Acid) – 2
capsules per week
Intervention Group
Participants in the intervention group were included in theNutritious Actionactivities, which also incorporated 
educational sessions. During each scheduled group meal (as per prior agreement), each subject received 2 
capsules to be taken immediately and an additional 1 capsule to take home for the following week. This third
capsule was intended to anticipate possible absence in the subsequent session; if a participant was absent, she was 
instructed to consume the capsule at home and provide photo documentation as proof, which was then
initialed by the teacher on the compliance sheet.
WhatsApp Group Formation
WhatsApp groups were created as a reminder platform and an educational channel, through
which educational video links were shared regularly with participants.
Educational Component
Education was delivered via WhatsApp links every two weeks.
Year 2: Intervention and 6-Month Evaluation. This included
assessments of dietary intake and nutritional status
Year 3: 12-Month Evaluation
This phase involves the assessment of dietary intake, 
nutritional status, and cognitive function at 12 months.
Figure 1. Research Flow Diagram

Research Timeline
In the first year, the study begins with field preparation activities, including coordination with 
schools, healthcare personnel, and enumerators. This was followed by the collection of baseline 
data to assess the nutritional status and cognitive function of adolescent girls. The collected data 
were then analyzed during the baseline data analysis phase and used to prepare the initial findings 
report. The baseline results also served as the foundation for developing journal articles and 
scientific publications. At the end of the first year, the intervention phase was initiated, 
accompanied by a monitoring process of capsule consumption by participants.
In the second year, activities commenced with intervention preparation, followed by full 
implementation of the intervention. A midline evaluation was conducted in the sixth month to 
assess the preliminary effects of the intervention on dietary intake and nutritional status. The data 
from this evaluation were analyzed in the six-month intervention data analysis phase and compiled 
into reports and scientific articles. Publication activities continued, along with the preparation and 
implementation of the 12-month intervention evaluation toward the end of the second year.
In the third year, the follow-up 12-month evaluation was carried out to assess the final 
outcomes on dietary intake, nutritional status, and cognitive function of adolescent girls 
postintervention. The data were analyzed in the 12-month intervention data analysis phase, and the 
results were compiled into the final report and scientific articles. The final stage of this research 
involved the dissemination of findings through publications in national and international scientific 
journals. Outcomes
Participant Characteristics
The study enrolled 372 participants, with a mean age of 14.5 years (±1.2). Baseline characteristics, 
including nutritional status, socioeconomic background, and dietary patterns, were comparable between 
the intervention and control groups.
Nutritional Status
Participants receiving MRJ supplementation showed significant improvements in weight-for-age and 
height-for-age Z-scores compared to the control group (p < 0.05). MUAC measurements also 
indicated better chronic energy deficiency outcomes in the intervention group.
Cognitive Function Scores
Cognitive function, as assessed by CFIT, improved significantly in the MRJ group compared to the 
control group.

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19.Bhan MK, Sommerfelt H, Strand T. Micronutrient deficiency in children. BMJ. 
2001;323(7308):1408–12.
20.Ridwan E, Madanijah S, Briawan D, Dwiriani CM. Effect of Fe supplementation on Hb levels 
and adherence to Fe tablet consumption in adolescent girls. Indonesian Nutrition. 
2014;37(2):125–34.
21.Titaley CR, Dibley MJ, Roberts CL, Hall J, Agho K. Iron and folic acid supplements and reduced 
early neonatal deaths in Indonesia. Bull World Health Organs. 2010;88(7):500–8.

22.Kurniawan Y, Briawan D, Madanijah S. Role of family support in adherence to iron tablet 
consumption. J Nutrition and Food. 2016;11(2):105–12.
23.Nurbaya S, Yusuf SM, Hadju V, et al. Cultural acceptability and compliance of adolescent iron 
supplementation in South Sulawesi. J Nutr College. 2020;9(1):1–8.
24.Saini RK, Sivanesan I, Keum YS. Phytochemicals of Moringa oleifera: a review of their 
nutritional, therapeutic and industrial significance. 3 Biotech. 2016;6(2):203.
25.Gopalakrishnan L, Doriya K, Kumar DS. Moringa oleifera: a review on nutritional 
importance and its medicinal applications. Food Sci Hum Wellness. 2016;5(2):49–56.
26.AR's son, Hadju V, Santoso LA. The effect of Moringa leaf powder supplementation on 
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27.Faizal A, Mutalib AR, Hamzah Z, et al. Combination of royal jelly and moringa improves 
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QUESTIONNAIRE
RESEARCH RESPONDENT CONSENT SHEET
"The Effect of Giving Moringa Oleifera Enriched with Royal Jelly on the Nutritional Status and Cognitive 
Level of Adolescent Girls"
The undersigned below:
Name
Age
Phone number
Address
:
:
:
:
I hereby declare that I have received an explanation and the opportunity to ask questions about things I do not understand about 
this research. This explanation includes the objectives, benefits, and effects of this research. This research procedure will take 12 
months.
After receiving the explanation, I hereby agree to participate in this study and am willing to follow the blood sampling procedure, 
cognitive function measurement voluntarily and without coercion. I have the right to withdraw if the reason is related to my health.
Thus I make this statement in truth.
Takalar ................................. 2024
Respondents/ Students
(………………………)

QUESTIONNAIRE FOR NUTRITIONAL INTERVENTION RESEARCH FOR ADOLESCENT GIRLS ANEMIA
In Takalar Regency in 2024
BLOCK I. DATA COLLECTOR DESCRIPTION
1
Data collection date
□ □ - □ □ - □ □ □ □
2
Name
3
Mobile phone number
BLOCK II. CHARACTERISTICS OF SUBJECTS AND PARENTS
1
Name
2
Date of birth
□ □ - □ □ - □ □ □ □
3
Age
4
School name
5
Class (school)
6
Home address
7
Phone number
8
Number of Family Members Living at Home
□ □
9
What order do you come in your family
□ □
10
How many brothers and sisters do you have
Father
Mother
11
Name
12
Mobile phone number
13
Date of birth
□ □ - □ □ - □ □ □ □
□ □ - □ □ - □ □ □ □
14
Father's Education
□ □
15
Mother's Education
□ □
Education Options
No/Not YetAt School
Job Options
Family Income Options 1. 
0 - Rp. 500,000.00
1.Doesn't work
2.
School
Not graduated from elementary school/Islamic elementary school
Graduated from Elementary School/Islamic Elementary School
2. > Rp. 500,000.00 – Rp. 1,000,000.00
3. > Rp. 1,000,000.00 - Rp. 2,000,000.00
4. > Rp 2,000,000.00 – Rp 3,000,000.00
3.Civil Servants/TNI/Polri/BUNM/BUMD
4.
Private employees
5.Self-employed
6.
Farmer/ Farm Worker
Graduated from junior high school/Islamic junior high school
5. > Rp. 3,000,000.00 – Rp. 4,000,000.00
6. ≥ Rp 4,000,000.00P
7.Fisherman
8.Laborer/Driver/Motorbike Taxi/Maid
Graduated from high school/Islamic high school
GraduatedDI,DII,DIII
GraduateDIV/PT
16
Father's occupation
□ □
17
Mother's Job
□ □

18
How Much is the Family Income?
19
What is the main type of water source for all your household needs? (mark one option):
a. Tap water/PDAM f. Protected springs b. Retail tap water/purchased g. Unprotected springs c. Boreholes/pumps
h. Rainwater storage d. Protected dug wells i. River/lake/irrigation water
20
How is the use of household defecation facilities?
a. Owned by yourself d. Shared with a neighbor b. Shared with others e. None
21
How many times does the family provide food in a day?
BLOCK III. PMS Status of Adolescent Girls
1
Have you menstruated yet? 1 = Yes, 2 = Not yet
2
When did you first have your period? (dd-mm-yr)
3
How long is menstruation?
4
Complaints 1-2 weeks before menstruation (1 = Yes, 2 = No)
5
Menstrual complaints (1 = Yes, 2 = No)
6
Mother/sister experiences complaints during menstruation
PMS Symptom Scale
1 = Not experienced, Scale 2 = Very light, Scale 3 = Light, Scale 4 = Moderate, Scale 5 = Severe, Scale 6 = Extreme
1
Breasts feel sore, tense, enlarged or swollen
2
Feeling unable to adjust or overwhelmed in daily activities
3
Feeling stressed
4
Easily offended or easily angered
5
Feeling sad or disappointed
6
Back pain, aches or stiffness in the joints
7
Weight gain
8
Stomach feels sore or uncomfortable
9
Swelling in certain areas of the body
10
Feeling bloated
BLOCK IV. Signature Compliance Questionnaire
1
Have you ever received a signature?
1 YES, 2 NO
2
Do you currently have a signature?
1 YES, 2 NO
3
Since when did you get your signature?
4
How many signatures were obtained?
1 tablet/week
. . . . . monthly table
5
Have you ever taken TTD?
1 YES, 2 NO
6
Are you currently taking TTD?
1 YES, 2 NO
7
When do you take TTD?
Once a week
Once every 10 days
. . . . very

8
How long have you been taking TTD?
. . . . Sunday
9
How much TTD do you consume?
1 tablet/week
4 tablets/month
10
Reasons for Consuming:
11
Reasons Not to Consume:
12
complaints when taking TTD
BLOCK V. Nutritional Status of Adolescent Girls
Examination Date I
1
Hb
g/dl
2
Height
3
close body
4
iLA
Block VI Eating Patterns
1= Yes (always done 5-7 times/week)
2=   Sometimes (3-4 times/week)
3= Rarely (times/week)
0= Never
1
According to you, what is meant by breakfast? 
Answer:
. Correct
. Wrong
Answer:Breakfast is a meal eaten in the morning 
before starting activities.
2
How often did you eat breakfast in the last week?
the 
reason.................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Does your family usually provide breakfast at home?
the 
reason.................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
When you don't have time for breakfast, you bring your own food or don't buy snacks at school.
5
Do you like to snack?
6
How many times do you snack in a day?
7
What type of food do you most often eat as a snack? 1. Fried food
2. Chiki
3. Chocolate
4. Meatballs
5. Wafer
6. Biscuits

7. Etc., please mention
8
What are 3 types of food you like?
Block VII Physical Activity (IPAC)
The following questions will ask you about the time you spent being physically active during the past 7 days. 
Answer each question even if you do not consider yourself an active person. Think about activities you do while you 
are at work, as part of housework and yard work, traveling from place to place, and in your free time for recreation, 
exercise or sports.
1
During the last 7 days, on how many days did you do heavy physical 
activity?
……days of the week
such as lifting heavy objects, climbing stairs, and mandatory sports during 
school hours (volleyball, fast cycling, digging and so on)
2
How much time do you usually spend each day doing vigorous physical 
activity as part of your study activities?
hours / days
minutes / day
3
What kind of strenuous activities do you do?
1. Lifting heavy loads
2. Aerobics
3. Fast cycling
4. others please specify
Think about the moderate physical activity you did in the last 7 days. Moderate physical activity makes you breathe 
a little harder than usual. For example, carrying a light load, cycling or playing sports. Does not include walking. 
Moderate physical activity makes you breathe a little harder than usual
do it for at least 10 minutes.
4
During the past 7 days, on how many days did you do moderate physical activity 
such as carrying light loads, cycling regularly, or playing doubles tennis? Do not 
include walking.
days of the week
5
How much time do you usually spend doing moderate physical activity 
a day?
hours / days
minutes / day
6
What kind of moderate activities do you do?
1. Carrying light loads
2. Leisurely cycling
3. Mopping
4. Washing
5. Others, please specify
7
During the last 7 days, on how many days did you walk for at least 10 
minutes at a time?
days of the week
8
How much time do you usually spend walking in a day?
hours / days
minutes / day
9
How much time do you usually spend sitting on weekdays?
hours / days
minutes / day

10
What kind of light activities do you do?
1. Sweeping
2. Walking
3. Others, please specify
Block VIII Food Believe and Food Taboo
1
Are there certain types of food that you are prohibited from consuming?
. Yes
. No
2
What foods are you not allowed to eat?
weld :
3
Are there any special foods that 
you consume at certain times 
(celebratory holidays/religious 
events/during menstruation, etc.)?
1. Yes, please specify
2. No
Reason :
4
Where did you get the 
information about consuming
what is that special food?
1. Mother
2. Other family (father, brother, grandmother, etc.)
3. Neighbors
4. Peers
5. Others, please specify
5
What are the 5 types of food that you often consume?
Block IX PSP Teen Girls
Knowledge (1= YES, 2= NO)
1
dress neatly and cut nailsNoone of the healthy and clean living habits
2
It is recommended that we drink 5 glasses of water every day
3
Breakfast is needed as the main source of energy before starting daily activities.
4
Indonesia has a balanced nutrition guideline consisting of four pillars of balanced nutrition, namely: consuming
eating a variety of foods, doing physical activity, clean living habits, and monitoring body weight.
5
Teenagers who don't like vegetables tend to be fat as adults
6
It is recommended to do physical activity or exercise at least once a week for 1 hour.
7
We don't need to limit our consumption of sugar, salt and fat because they are beneficial for our bodies.
8
anemia is a condition with hemoglobin levels lower than normal values
9
anemia/insufficient blood is caused by not eating enough foods rich in iron
10
you and the symptoms of anemia that you see are fatigue, exhaustion, lethargy, inattention and weakness

11
Anemia in adolescents can have an impact on the ability to concentrate.
12
Teenagers experience menstruation so they need to be given additional iron (TTD)
13
The correct way to wash your hands is to use running water and soap
14
Lack of nutrition in adolescent girls can lead to malnutrition during pregnancy.
15
If the environment is dirty and unhygienic, a person can easily catch a disease.
Attitude (1= AGREE, 2= DISAGREE)
1
Dressing neatly and cutting nails has no effect on my health.
2
Drinking 5 glasses of water is enough to meet my needs
3
Breakfast is important to me, because otherwise I will have difficulty concentrating at school.
4
You don't need to worry if someone is tired, weak, lethargic and pale.
5
I have to eat vegetables every day to improve my digestion
6
I don't consider the nutritional and health information on food labels when choosing food.
7
I will choose foods with less sugar, salt and fat, even though they are not as delicious as foods high in 
sugar, salt and fat
8
I can apply the 4 pillars of balanced nutrition guidelines in everyday life.
9
The balanced nutrition pyramid helps me choose the right foods
10
Eating tofu and tempeh alone is enough to build cells and tissues in our bodies.
11
I need to eat vegetables and fruit to avoid constipation
12
If your hands don't look dirty, washing them with running water is enough.
13
Now I don't have to worry about my nutritional status as a future parent.
14
I need to pay attention to the cleanliness of the surrounding environment because it will affect my health.
15
I don't consider the nutritional and health information on food labels when choosing food.
Practice: a= Always, b= Often, c= Sometimes, d= Rarely, e= Never
1
How often do you dress neatly and cleanly?
2
How often do you drink 8 glasses of water per day?
3
How often do you eat breakfast before 9 am?
4
How often do you consume sources of iron (red meat, chicken liver, iron tablets)?
5
How often do you eat vegetables?
6
Do you read food labels before deciding to buy packaged food?
7
How often do you drink sugary drinks?
8
How often do you weigh yourself?
9
How often do you use the balanced food pyramid as a food guide?
10
How often do you consume animal protein sources? (eggs, red meat, chicken)
11
How often do you do continuous physical activity for at least 30 minutes?
12
How often do you eat fruit?
13
Do you wash your hands after using the bathroom?

14
How often do you search for nutrition and health information?
15
Do you help clean up your environment?
Block X Self Efficacy of Adolescent Girls
(1= SURE, 2= NOT SURE)
1
How confident are you that you can dress neatly and cleanly every day?
2
How confident are you in drinking 8 glasses of water per day?
3
How confident are you in having breakfast before 9 o'clock?
4
How confident are you in consuming sources of iron at every meal (red meat, chicken liver, iron 
tablets)?
5
How confident are you in eating vegetables at every meal?
6
How confident are you in reading food labels before deciding to buy packaged food?
7
How confident are you about weighing yourself once a month?
8
How confident are you in using the balanced food pyramid as a food guide for each meal?
9
How confident are you in consuming animal protein sources at every meal? (eggs, red meat, chicken)
10
How often do you do continuous physical activity for 30 minutes every day?
11
How confident are you in eating fruit at every meal?
12
How confident are you in washing your hands after using the bathroom?
13
How confident are you in helping clean your environment every day?
FOOD RECALL FORM 1 x 24 HOURS

Name : ……………
School/ Class : ………….. Age : 
………….
Time
Eat
Dish
Material name
food
URT
Estimate
(grams)
Heavy
Clean
(grams)
Name
Food
Process
Processing
Portion
(in
Estimate
(grams)
URT)
Morning
Interlude
Afternoon
Interlude
Evening

Interlude
FOOD FREQUENCY FORM
SQ-FFQ (SEMI QUANTITATIVE FOOD FREQUENCY QUESTIONNARE)
: ……………
Name
School/ Class : ………….. Age : 
………….
Flat-
flat
Frequency
Portion
Heavy
Heavy
(g)
No
Food Names
Portion
No
Prnh
x/H
X/M
x/B
K
S
B
x/H
g/H
Staple food
1
White rice
200
1 person at the moment
2
Yellow rice
200
1 person at the moment
3
Fried rice
200
1 person at the moment
4
Buras
95
1 pc
5
Ketupat
110
1 pc
6
White bread
30
2 slices
7
Instant noodles
80
1 pack
8
Potato
40
1 pc medium
Animal Side Dishes
9
Beef
35
1 pm today
10
Beef liver
50
1 pm today
11
Chicken meat
45
1 pm today

12
Chicken liver
35
1 pc medium
13
Rabbitfish
45
1/3 tail
14
Flying fish
45
1/3 tail
15
Snapper
45
1/3 tail
16
Skipjack tuna
45
1/3 tail
17
Milkfish
45
1/3 tail
18
bete-bete fish
45
1 tail kcl
10
kcl
tail
19
Mairo fish
45
20
Fish cake
50
1 pm
Freshwater fish
(tilapia fish,
mas, catfish, etc.)
21
45
1/3 tail
. . . . . . . . . . . . . . . . . . . . .
22
Fresh shrimp
35
4 tails sdg
23
Crab
30
1 tail
24
Clams/oysters
10
1 pc
25
Squid
45
1 tail kcl
26
Meatball
25
1 seed
27
Sausage
20
1 seed
28
Dried fish
20
11 tails
29
Anchovy
15
2 tbsp
30
Beef floss
10
2 tsp
Egg
village
chicken
31
40
1 piece
32
Chicken eggs
55
1 piece
33
Duck eggs
60
1 piece
34
Quail eggs
10
2 pieces
Other
. . . . . . . . . . . . . . . . . . . . . . . .
35
Vegetable Side Dishes
36
Know
110
1 pm bsr
37
Tempeh
50
2 pm today
38
Mung beans
15
1 tbsp
39
Peanuts
15
1 tbsp
40
Cashew nuts
15
1 tbsp

Other
. . . . . . . . . . . . . . . . . . . . . . . .
41
Vegetables
42
Spinach
50
1 prg
43
Broccoli
100
1 gls
44
Beans
50
7 pcs
45
Cassava leaves
50
1 prg
46
Corn
50
1/3 pm
47
Mold
15
1 ½ tbsp
48
Banana heart
15
1 tbsp
49
Long beans
50
3 pcs
50
Spinach
50
1 prg
51
Cauliflower
20
2 tbsp
52
Cabbage
50
1/8 pm
53
Summer squash
50
1 pm today
54
Chayote
50
1 pm today
55
Cucumber
20
2 slices
56
Young Jackfruit
20
2 tbsp
57
Bamboo shoots
30
2 tbsp
58
Mustard greens
50
1 prg
59
Bean sprouts
15
1 tbsp
60
Eggplant
50
½ hour
61
Tomato
25
1 seed
62
Carrot
50
½ pcs
63
Other.........
Fruits
64
Avocado
50
½ fruit
65
Apple
75
½ fruit
66
Guava
100
1 pc medium
67
Orange
150
1 pc medium
68
Ambarella
100
1 pc medium
69
Mango
90
½ pcs medium
70
Pawpaw
110
1 pm today
71
Rambutan
75
5 pieces
72
Watermelon
180
2 pm today

73
Wine
125
11 pieces
74
Pear
85
½ fruit
75
Banana
50
1 piece
76
Snakefruit
80
1 piece
77
Durian
35
3 seeds
78
Long-haired
75
5 pieces
79
Melon
100
½ pg bsr
80
Pineapple
95
¼ pcs medium
81
Other
Drinks & Supplements
82
Milk powder
10
1 tbsp
83
UHT Milk
200
1 gls
84
Soy milk
200
1 gls
Milk
sweet
thick
85
10
1 tbsp
86
Milo cans
240
1 set
87
Milo sachet
14
1 pack
88
Frisian flag
190
1 box
89
Energen
30
1 pack
90
Cheese
10
1 tbsp
91
Ice cream
125
1 cup
Ice
(Feast,
pop, etc.)
cream
stick
Paddle
92
65
1 pack
93
Signature Supplement
1 tablet
Snack Food
94
Donuts
65
1 pc
95
Rissoles
50
1 pc
96
Pudding
65
1 pc
97
Brownies
30
1 pc
98
Fried sweet potatoes
60
1 pc
98
Fried breadfruit
13
1 pc
100
Fried bananas
60
1 pc
101
Fritters
40
1 pc
102
Corn fritters
40
1 pc

103
Bright moon
50
1 pm today
104
Pancakes
40
1 pm today
105
Green banana
60
1 pc
106
The hammer is broken
220
1 mgk
107
Tella tella
120
1 prg
108
The Road
65
1 pc
109
Know the contents
20
1 pc
110
chicken Soto
225
1 mgk
111
Coto
400
1 mgk
112
Meatball noodles
370
1 mgk
113
Dumplings
390
1 mgk
114
Mixed vegetables with the peanut sauce 430
1 prg
115
Batagor
220
1 prg
116
dumpling
160
1 mgk
117
Titi noodles
400
1 prg
118
Chicken satay
80
5 tsk
Other
. . . . . . . . . . . . . . . . . . . . . . . .
119