The Relationship between Intakes of Iron, Folic Acid, Vitamin C, Age at Menarche, Hemoglobin Status and Physical Activity with Menstrual Cycles in Female Students at Smait Al-Ichwan Cikarang Utara-Indonesia

Background: Adolescence is the period of transition from children becoming adults that is marked by the occurrence of puberty, namely menstruation. At that time there was a change in the reproductive system that allows the occurrence of disturbances, one of which is menstrual cycle disorders.

Aim: Based on data from RISKESDAS (basic health survei) (2013), it shows that the percentage of menstrual cycle irregularities at the age of 10-29 years is 16.4% (RISKESDAS (basic health survei). Irregular menstrual cycles in adolescent girls aged 15-19 years are 11.7% and as many as 14.9% women who live in urban areas in Indonesia.

Methods: Samples were taken by using purposive sampling technique; it is obtained a sample of 35 students from grade 11 and 12 aged 16-18 years at SMAIT-Al-Ichwan Cikarang Utara. Data on the age at menarche and menstrual cycle with the method of interview used a questionnaire, food intake was obtained from 2x24 hours food recall form that is not in a row and hemoglobin status used Easy Touch Blood Hb tool conducted by nurses. Physical activity data was obtained by filling out a form and the results were calculated by using the PAR/PAL method. Statistical analysis used a chi-square test and used a fisher exact test value.

Results: The results of the reserach showed that there is no significant relationship between the intake of iron, folic acid, vitamin C and physical activity on menstrual cycle (p > 0.05).

Conclusion: This conclusion constitues there is a significant relationship between hemoglobin status on menstrual cycle (p = 0.005).

Menstrual cycle is the time from the first day of menstruation until the arrival of menstruation in the next period. According to Proverawati [1], menstrual cycle in women normally ranges from 21-35 days, with a menstrual period of 3-8 days, and then there are 1-2 days followed by a little blood. After that, menstrual cycle is said to be abnormal if <21 days or >35 days. In Indonesia, there is a prevalence of menstrual cycle irregularities in women aged 10-29 years. In RISKESDAS (basic health survey) 2010 data was 15.2%, while in RISKESDAS 2013 data was 16.4%. From those data there is an increase of 1.2% [2]. Menarche is the first menstruation in a woman as a sign of sexual maturity. Menarche also indicates that hormone has been actively produced by uterus as a feedback from hypothalamus [3]. Based on RISKESDAS data in 2010 as many as 37.5% of adolescent girls experienced menarche at the age of 13-14 years [4].

According to Wahab [5], the age at menarche is divided into three groups based on the age of group, namely early menarche <11 years, normal menarche 11-15 years and late menarche >15 years. Women with early or normal menarche show regular menstrual cycles compared to women with late menarche). In contrast to next research which stated that long and irregular menstrual cycles often occur in subjects who experienced menarche over the age of 14 years [6]. According to Sukarni [7], the impact that arises from irregular menstrual cycles that are not handled immediately and properly can cause fertility problems. In addition, the body can lose a lot of blood so it causes anemia which is characterized by fatigue, paleness, lack of concentration, and other signs of anemia. In women there is a specific fat that arises at puberty which is a sign of secondary sex that is usually deposited in breasts, upper arms, forearms, lower abdomen, genitals and thighs. Body fat percentage is the percentage of comparison of fat and non-fat tissue mass in a person's body [8]. According to the theory of Frisch and Revelle, the percentage of body fat that causes menarche is 17%. The percentage of fat as many as 22% in adolescents can maintain regular menstrual cycles [9].

Women of fertility age 15-49 years are considered to be anemia if the hemoglobin level is below normal, namely 12.0 g/dL [10]. A person's hemoglobin level can be influenced by various factors including age, gender, infectious diseases, physical activity, and food intake [11]. In Indonesia, the prevalence of anemia according to age groups based on RISKESDAS in 2013 at the age of 15-24 years was 18.4%, in adolescent girls aged 13-18 years and women of fertility age 15-49 years each of them is 22.7% [12]. While, according to RISKESDAS data in 2018, the prevalence of anemia increased by 48.9%. Menstrual cycle irregularities can also be affected by the level of physical activity. In which high and low level of physical activity can affect menstrual cycle, and if it is not balanced with a balanced food intake [13]. Micronutrient intake plays a role in the formation of red blood cells.

Several micronutrient intakes that play a role in the formation of red blood cells are iron, folic acid and vitamin C. The needs of iron in the body that is not sufficient result in the blood cannot conduct its function optimally to carry oxygen to all members of the body and to produce energy [14]. Folic acid is required for the formation of hemoglobin. Indirectly, folic acid deficiency will affect iron metabolism [15]. In addition, the lack of vitamin C intake can also inhibit the formation of hemoglobin, where vitamin C is an essential element that is needed by the body for the formation of red blood cells.

Frequency distribution

Iron in the body has a role as the main transportation in distributing oxygen throughout the body. In addition, iron also plays a role in the production of hemoglobin and supports the immune system [16]. Iron adequacy rate for adolescent girls is based on the RDA in 2019 that is 11 mg/day for the age of 16-19 years. Folic acid is needed for the formation of red blood cells and white blood cells in the bone marrow. Folic acid deficiency can inhibit growth and cause megaloblastic anemia. The number of folic acid adequacy for adolescent girls based on the RDA in 2019 is 400 mcg/day for the age of 16-19 years.

Vitamin C really helps the absorption of iron. Vitamin C adequacy rate for adolescent girls based on the RDA in 2019 is 90 mg/day for the age of 16-19 years. Menarche is the occurrence of first menstruation experienced by women. Hemoglobin status is one of the ways to determine whether a woman is anemia or not. The normal level of hemoglobin in adolescent girls is ≥ 12 g/dl. Physical activity is physical movement conducted by the body's muscles and their supports in one day. This activity is calculated by the PAR/PAL method. Menstrual cycle is the cycle of time between the start of last menstrual period until the start of next menstruation. Here is the frequency distribution table of the intake of iron, folic acid, vitamin C, age at menarche, hemoglobin status and physical activity with menstrual cycles.

Based on table 1 shown that 22 subjects (62.9%) have sufficient iron intake (>70% of RDA adequacy) and as many as 13 people (37.1%) have insufficient iron intake (≤ 70% of RDA adequacy). From this 35 subjects, it was found that the lowest daily iron intake of subjects is 5 mg, the highest is 18 mg with the average iron intake is 9.6 mg + 3.56 mg. The most consumed iron sources of subjects are derived from legumes and animal source namely chicken.

It is also known that folic acid intake in subjects is 20 people (57.1%) have insufficient folic acid intake (≤ 70% of RDA adequacy) and as many as 15 people (42.9%) have sufficient folic acid intake (> 70% of RDA adequacy). From 35 subjects, it was found that the lowest daily folic acid intake of subjects is 110 mcg, the highest folic acid intake is 487 mcg and the average folic acid intake of subjects is 274.8 mcg + 121.2 mcg. The most consumed folic acid sources of subjects came from fruit and vegetable, namely banana and spinach.

Based on table 1 known that vitamin C intake in subjects is 23 people (65.7%) have insufficient vitamin C intake (≤ 70% of RDA adequacy) and 12 people (34.2%) have sufficient vitamin C intake (> 70% of RDA adequacy). From 35 subjects, it was found that the lowest daily vitamin C intake is 37 mg, the highest vitamin C intake is 114 mg with the average vitamin C intake 70.1 mg + 20.2 mg. The most consumed Vitamin C sources came from fruits.

Based on table 1 known that subject who had a normal age at menarche is 29 people (82.9%) namely,11-15 years; and as many as 6 people (17.1%) experience abnormal age at menarche (< 11 years or > 15 years). From 35 subjects, it was found that the lowest age at menarche is 9 years, the highest age at menarche is 15 years and the average age at menarche is 12.3 + 1.58 years. These data show the same results in the research in Jakarta, showing the average age of adolescent menarche (9-15 years) is 12.3 years 66). According to Wahab [5], the age at menarche is divided into three groups based on age groups, namely early menarche < 11 years, normal menarche 11-15 years and late menarche > 15 years. In addition, according to RISKESDAS (basic health survey) (2018) in Indonesia, it is known that 37.5% of women experience the first menstruation (menarche) at the age of 9-13 years. The average age of menarche at the age of 10-19 years is 12.7% with 1.23 + experience menarche during elementary school.

Based on table 1 known that hemoglobin status in subjects is 20 people (57.1%) have anemia with Hb level < 12 g/dL and as many as 15 people (42.9%) do not experience anemia or normal with Hb level ≥ 12 g/dl. From 35 subjects, it was found that the lowest hemoglobin level of subjects is 8 g/dl, the highest hemoglobin level of subjects is 19 g/dl and the average hemoglobin level of subjects is 11.7 g/dl 2.07 + g/dl. Based on data from RISKESDAS (basic health survey) results (2018), the prevalence of anemia in Indonesia is 48.9% with the proportion of anemia in the age group of 15-24 years and 25-34 years.

Based on table 1 known that physical activity in subjects is 20 people (57.1%) with light physical activity (PAL ≤ 1.69) and 15 people (42.9%) with moderate physical activity (PAL > 1.70 – 1.99). From 35 subjects, it was found that the lowest PAL score of subjects is 1 score, the highest PAL score of subjects is 2 scores and the average PAL score of subjects is 1.64 scores with a standard deviation of 0.16 scores. From the data obtained, the subjects conducted more activities in the house such as playing mobile phones, watching TV and sleeping.

Based on table 1 known that menstrual cycle in subjects is 23 people (65.7%) experience regular menstrual cycles (21-35 days) and as many as 12 people (34.3%) experience irregular menstrual cycles (< 21 days or > 35 days). From 35 subjects, it was found that the lowest menstrual cycle of subjects is 10 days, the highest menstrual cycle of subjects is 35 days and the average menstrual cycle of subjects is 22 days with a standard deviation of 4.71 days. Based on data from RISKESDAS (basic health survey) (2010) the percentage of menstrual cycle irregularities at the age of 10-29 years is 15.2%. While, RISKESDAS (basic health survey) showed that the percentage of menstrual cycle irregularities at the age of 10-29 years is 16.4% (RISKESDAS (basic health survey). A disturbed menstrual cycle can be influenced by several factors such as age, weight, physical activity, stress and nutritional status.

Analysis of the relationship between two variables

In this research, menstrual cycle category consists of two categories, namely regular and irregular. Menstrual cycle is categorized as regular if students experience menstrual cycle for 21-35 days, while menstrual cycle is categorized as irregular if students experience menstrual cycle for < 21 days or > 35 days. Intakes of iron, folic acid and vitamin C is categorized into two based on the level of adequacy (% RDA) that is < 70% insufficient and ≥ 70% sufficient. In this research, the age at menarche is categorized into two, namely abnormal and normal. Menarche is categorized as abnormal if the age of subject’s menarche is early and late, while menarche is categorized as normal if the age of subject’s menarche is 11-15 years. In this research, hemoglobin status is categorized into two, namely anemia and normal. Subject is categorized as anemia if the hemoglobin level is < 12 g/dl, while subject is categorized as normal if the hemoglobin level is ≥ 12 g/dl. In this research, physical activity is categorized into two categories, namely light and moderate. Subject is categorized as mild if the PAL value is ≤ 1.69 while the subject is categorized as moderate if the PAL value is 1.70-1.99. Here is the table of relationship between intake of iron, folic acid, vitamin C, age at menarche, hemoglobin status and physical activity with menstrual cycle.

Based on table 2 showed that subjects who experience regular menstrual cycles are more commonly found in those with sufficient iron intake (50%) and subjects who experience irregular menstrual cycles are more commonly found in those with insufficient iron intake (61.6%). Based on table 2, it can be seen that from the results of the chi-square test show a p-value = 0.508, namely (p > 0.05), it can be concluded that there is no significant relationship between iron intake and menstrual cycle. Thus, subjects with irregular menstrual cycles tend to have an iron intake deficiency although there is no relationship. This is in line with research conducted by Mita concerning the relationship between nutrient intake, on menstrual cycle of adolescent girls at SMAN 32 Jakarta with p > 0.05 that there is no significant relationship between iron intake and menstrual cycles in adolescent girls. In addition, iron deficiency will result in anemia which is characterized by easily fatigue, dizziness, and lack of concentration. The results of this research were not in line with research conducted by Annisa [17] in Jakarta which showed that there is a relationship between iron intake and menstrual cycles in female students with p = 0.012. The results of this research were not in line with research conducted by Annisa [17] because there are differences in the number of subjects and the age.

Based on table 2, it showed that subjects who experience regular menstrual cycles are more commonly found in those with sufficient folic acid intake (46.7%) and subjects who experience irregular menstrual cycles are more commonly found in those with insufficient folic acid intake (55.0%). Based on table 2, it can be concluded that there is no significant relationship between folic acid intake and menstrual cycle. Therefore, subjects with irregular menstrual cycles tend to have folic acid intake deficiency although there is no relationship. This was in line with research conducted by Catrine [18] concerning the relationship between folic acid intake and menstrual cycle of badminton athletes that there is no significant relationship with (p > 0.05) [18]. Menstrual cycle is not only influenced by nutritional intake but it can be influenced by several factors, one of the factors is nutritional status. Krisna's [19] research showed that the results of analysis obtain a p-value = 0.003 it can be concluded that there is a relationship between BMI and menstrual cycle. Judging from the research conducted by Asniya [20] showed that there is a relationship between nutritional status and menstrual cycle p = 0.037 indicating that subjects who experience obesity have a 1.89 times chance of experiencing menstrual cycle irregularities compared to subjects with normal nutritional status.

Based on table 2 showed that subjects who experience regular menstrual cycles are more commonly found in those with sufficient vitamin C intake (50.0%) and subjects who experience irregular menstrual cycles are more commonly found in those with insufficient vitamin C intake (56.5%). Based on table 2 it can also be seen that the results of chi-square statistical test show a p-value = 0.713 that is (p > 0.05), it can be concluded that there is no significant relationship between vitamin C intake and menstrual cycle. Thus, subjects with irregular menstrual cycles tend to have a lack of vitamin C intake although there is no relationship. This was in line with research conducted by Catrine [18] on badminton athletes with (p > 0.05) that there is no significant relationship between vitamin C intake and menstrual cycle. The results of this research were not in line with research conducted by Yulia and Ratna [21] in Jakarta which show that there is a relationship between vitamin C intake and menstrual cycle in adolescent girls with p = 0.003. The results of this research were not in line with research conducted by Yulia and Ratna because there are differences in the subjects investigated, the number of subjects, and the age of subjects. According to Isnaeni (2010), mentioned that menstrual cycle is not only influenced by vitamin C intake but it is influenced by many other factors, one of which is stress. In this research the stress factor was not investigated. However, this is supported by a journal review conducted by Sugma [22], from various theories written that there is an influence between stress and menstrual cycle.

Based on table 2 above, it showed that subjects who experience regular menstrual cycles are more commonly found in those with normal menarche age (55.2%) and subjects who experience irregular menstrual cycles are found in those with abnormal menarche age (100.0%). It can be seen that irregular menstrual cycles have a tendency to experience an abnormal age at menarche, but the average of subjects experience a normal age at menarche. In this research, the chi-square test could not conduct although the table was simplified to 2x2 because there are no subjects with regular menstrual cycles who experienced abnormal menarche age (0.0%).

Based on table 2 above, it showed that subjects who experience regular menstrual cycles are more commonly found in those who have normal Hb (73.3%) and subjects who experience irregular menstrual cycles are more commonly found in those who experience anemia (75%). Thus, almost all subjects with irregular menstrual cycles experience anemia. Based on the table above, it can be seen that the results of chi-square statistical test showed a p-value=0.005 (p <0.05), it can be concluded that there is a significant relationship between hemoglobin status and menstrual cycle. This was also in line with research conducted by Septi, et al. [23] by adolescent girls at SMA Negeri 1 Imogiri Bantul Yogyakarta (2013) that there is a significant relationship between anemia and menstrual cycle with a p-value = 0.018 (p <0.05). Another research conducted by Sabilla [24], concerning the relationship between menstrual cycle and anemia status in adolescent girls at the Minhaajurrosyidiin Islamic Boarding School in Jakarta, stated that there is a significant relationship between menstrual cycle and anemia status in adolescent girls with a p-value=0.001 (p < 0.05). Adolescent girls who experience anemia or lack of hemoglobin levels in the body can affect menstrual cycle. Hemoglobin in red blood cells itself serves to bind oxygen throughout the body. If the level of hemoglobin in red blood cells is low, then the supply of oxygen throughout the body is reduced so that it affects the work of estrogen, progesterone hormones, Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH).

Based on table 2 above, it showed that subjects who experience regular menstrual cycles are more commonly found in those with moderate physical activity (53.3%) and subjects who experience irregular menstrual cycles are more commonly found in those with light physical activity (60%). Based on table 2 above, the results of chi-square statistical test showed a p-value = 0.433 (p > 0.05), it can be concluded that there is no significant relationship between physical activity and menstrual cycle.

This was because physical activity conducted by subjects do not vary during the COVID-19 pandemic, besides that the frequency of online schools in subjects is more frequent than offline schools, namely 2x offline and 3x online every week and there are no extracurricular activities or sports during the COVID-19 pandemic, and more subjects conduct light physical activity at home, namely watching television, using cellphones, studying, and sleeping. The majority of physical activity conducted was no difference between subjects. The results of this research were in line with research conducted by Dewi [16], regarding the relationship between physical activity and menstrual cycle disorders, it was obtained p = 0.47 (p > 0.05), namely there is no relationship between physical activity and the incidence of menstrual cycles in adolescent girls [25]. In another research conducted by Putri [18] on students regarding the relationship between physical activity and menstrual cycle, it was found that a p-value = 0.846 (p > 0.05), namely there is no relationship between physical activity and menstrual cycle [26]. The results of this research were not in line with the results of research conducted by Mahitala [27], regarding the relationship between physical activity and menstrual cycle disorders in a woman in Magelang, namely there is a relationship between physical activity and menstrual cycle disorders in a woman (p < 0.05). The results of this research were not in line with research conducted by Mahitala [27] because there are differences in age and number of subjects.

Regular or irregular menstrual cycles can be influenced by several factors, namely nutrient intake, age at menarche, hemoglobin status and physical activity. However, in this research that has a significant relationship is hemoglobin status and menstrual cycle with a value (p value=0.005). Where there is a tendency for subjects who experience irregular menstrual cycles experiencing anemia by 75%, with the number of subjects who are anemic by 57.1% and 65.7% of subjects experiencing irregular menstrual cycles.

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