Remaja ASIK and Optimized Food-based Recommendations
Condition: Anemia
MeSH terms: Anemia
Study type: Interventional

Summary: 
      Good nutritional status among adolescents is a window of opportunity to produce healthy
      adults or pregnant individuals. Modifying the dietary habits during adolescent girls may be a
      sustainable approach to ensure good nutritional status among population because those habits
      tend to stay for a life time. Over many years, there has much effort to overcome anemia. Iron
      supplementation and fortification have been the most popular and convenient strategies to
      combat anemia. However, there has not much success due to the high still prevalence of anemia
      among children and women reproductive age. Food-based approach has been defined as one of the
      most effective programs to combat or reduce the prevalence of anemia. In the meantime, food
      based recommendations (FBR) formulation through linear programming (LP) approach has been
      found to be more effective than the traditional method of developing FBRs called "trial and
      error". LP approach allows us to develop optimized diet for target population with addition
      to detect the nutrient problem in specific region. This study therefore aims to identify the
      nutrient problems in the community, to develop optimized FBR employing the LP approach and to
      assess effect of nutrition education using optimized FBR in order to improve the nutritional
      and hemoglobin status among adolescent schoolgirls in rural Malang City.

      This study was conducted in several phases: 1) cross-sectional study 2) intervention study.
      Cross-sectional study was aimed to formulate optimized food based recommendations using
      linear programming. Intervention study was performed during 20 weeks with Remaja ASIK as the
      tagline which means Active, Healthy, Smart, and Creative. Adolescent schoolgirls aged 14-18
      years was the subject of this study and 496 subjects were selected, including 152 for first
      phase and 344 for third phase. In addition, selected school based on inclusion criteria: 1)
      not boarding schools; and 2) having large number of students. In doing data collection, we
      collected socioecodemoghraphic data, anthropometry, biochemical data, dietary data, and
      cogitive performance.
    

Detailed description: 
      Nutrition among adolescent girls has been a concern in some settings throughout the world.
      Even in developed countries teenage girls were found to have inadequate intake of vitamins
      and minerals. Similarly, Indonesian adolescent girls might have suffered from similar
      micronutrient deficiency. Some small studies have shown that the prevalence of anemia was
      relatively high among adolescent girls. Over many years, there has much effort to overcome
      anemia. Iron supplementation and fortification have been the most popular and convenient
      strategies to combat anemia. However, study has shown that iron from the dietary
      fortification benefited the pathogens from the gut microbiota rather than increase the iron
      status of the host or it can cause gut inflammation among the target population.

      Modifying the dietary habits during adolescent girls may be a sustainable approach to ensure
      good nutritional status among population because those habits tend to stay for a life time.
      Food-based approach has been defined as one of the most effective programs to combat or
      reduce the prevalence of anemia. Linear programming (LP) approach allows us to develop
      optimized diet for target population with addition to detect the nutrient problem in specific
      region. This study therefore aims to identify the nutrient problems in the community, to
      develop optimized food based recommendations (FBR) employing the LP approach and to assess
      effect of nutrition education using optimized FBR in order to improve the nutritional and
      hemoglobin status among adolescent schoolgirls in rural Malang City.

      Eligible participants of this study were adolescent girls and meet all the inclusion
      criteria: 1) age: between 14-18 years 2) resident: live in rural areas of Malang district 3)
      willing to participate in the study 4) apparently healthy 5) already had menstruation. The
      list of adolescent girls from the selected high schools was obtained from each school
      principal. From the lists, adolescent girls was randomly selected using Random Number Apps.
      Those who meet the inclusion criteria was invited to participate and was given informed
      consent.

      In the beginning of data collection, the structured interview which captures the respondents'
      age, address, date of birth, parents' educational and occupation, food taboo, and morbidity.
      The body weight was measured using SECA weighing scale and Shorr Board for height
      measurement. Blood specimens was collected and analyzed for levels of hemoglobin (Hb),
      hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean
      corpuscular hemoglobin concentration (MCHC), red blood cell (RBC), WBC and genetic blood
      disorder (hemoglobinopathy), serum ferritin, serum tranferrin receptors (TfR), and
      subclinincal inflammations including C-reactive protein (CRP) and a1-acid-glycoprotein (AGP).
      CBC analyzer was used for complete blood count whereas enzyme-linked immunoassay (ELISA) will
      be used to measure iron status indicators and subclinical inflammations.

      Cross-sectional Study In the first phase, we conducted cross-sectional study to collect
      dietary data then analyzed using linear programming to obtain optimized food based
      recommendations. In order to develop optimized food based recommendations, we needed 152
      subjects to obtain their dietary data. This sample size calculation was based on 80% power,
      5% significance level, and 18.8% anemia prevalence among females and 10% absolute precision
      required. In the beginning of data collection, the structured interview was performed. Type
      of food commonly consumed and food frequency consumption per week was obtained through three
      days 24-hour dietary recall, 1 day weight diet record (WDR), and 3 days food records (FR).
      Anthropometry and biochemical measurement were assessed for each subject.

      Intervention Study TIPs (Trial for Improved Practices) was conducted to pretest optimized FBR
      which has been developed using LP. Adolescent girls (n=20) were assessed for their actual
      intake using 24-hour dietary recall and last 1-week food frequency questionnaire. Afterward,
      they were introduced on optimized FBR and asked to practice and to write the food that are
      consumed in seven days food records. After one week, 24-hour dietary recall and last 1-week
      food frequency questionnaire were performed and group interview was conducted to identify
      facilitating and barriers to practicing optimized FBR.

      Then, Intervention study was conducted as nutrition education in the school. As much as 144
      subjects per group were randomly selected to be intervention and control group. This minimum
      sample size was based on 90% power, dessign effect of 2, and 20% dropout allowance. After
      Trial for Improved Practices (TIPs), two teachers per school were invited to join Training of
      Trainers (ToT) for the purpose of delivering messages of weekly nutrition education.
      Intervention groups received "Remaja ASIK" which is the Indonesian tagline for nutrition
      education in intervention schools meant "adolescent girls who are active, healthy, smart, and
      creative". Nutrition education was performed in every Friday, particularly in "Keputrian
      Session" at least 30 minutes per session during 20 weeks. Trained teachers delivered the
      messages of nutrition education accompanied by supervisor team. Most of materials were
      delivered by teaching method and several topics were delivered by poster, file presentation,
      showing videos and doing activities such as canteen observation, BMI calculation, and food
      label identification.

      The effect of intervention was evaluated by nutrition knowledge, dietary intake, nutritional
      status, and cognitive performance. The nutrition knowledge questionnaire was generated by the
      team and was administered using close-ended format in baseline and endline. Dietary intake
      used food frequency questionnaire and three days non consecutive 24-H recall in baseline and
      endline. Nutritional status was determined by anthropometry and biochemical measurements.
      Cognitive test were administered by one well-trained enumerators who received training from
      psychologist to ensure standardization in the measurement and scoring procedures. Data
      analysis was performed using SPSS version 20. Socioeconomic status of the two groups were
      compared using mann-whitney test and chi-square test. The difference of changes in nutrition
      knowledge both of between group and within group were then analyzed by chi-square test and
      mcNemar test, respectively. Then, repeated measures general linear model was used to analyze
      the differences of dietary intake, nutritional status, and cognitive performance between
      group. Statistical significance was set at p<0.05.
    

Intervention name(s): Intervention group
Intervention type(s): Other
Intervention description(s): Training of Trainers (ToT) was conducted among teacher who would deliver the messages. "Remaja ASIK" is Indonesian tagline meant "girls who are active, healthy, smart, and creative". Nutrition education was performed in every Friday, at least 30 minutes during 20 weeks. In brief, this is the key messages of optimized food based recommendations: 1) 3 meals and 2 snack every day, 2) At least 2 portions of vegetables/day including at least 5 portions/week of green leafy vegetables, 3) At least 2 portions/day of animal protein including at least 2 portions/week of liver, 4) At least 1 portion/day of tempe or tofu, 5) At least 1 portion/day of fruit, 6) At least 3 portions/week of milk.Trained teachers delivered the messages accompanied by supervisor. The delivered topics were key messages, balance nutrition, anemia, menstruation, BMI, healthy and smart, strong bone, lunch box, safe snack, and food label.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Intervention group (4 schools) received nutrition education in the same time. Meanwhile, control group (4 schools) did not received anything except for baseline and endline data collection.
Masking: Single (Participant)
Primary purpose: Prevention
Keywords: Anemia; Linear programming; Optimized food based recommendations; Nutrition knowledge; Dietary intake; Dietary practices; Adolescent girls; Nutrition education; Indonesia