Comparing intake adequacy and dietary diversity between adolescent schoolgirls with normal nutritional status (NG) and undernutrition (UG) based on BMI-for- age (BAZ) living in urban slums in Central Jakarta

Abstract

Introduction: Undernutrition among adolescent girls is an important concern due to their rapid growth velocity that requires adequate intake of energy and nutrients. This study compared intake adequacy and dietary diversity between adolescent public schoolgirls from slum areas in Central Jakarta who had normal and poor nutritional status. Methods: A total of 220 eligible girls aged 14-18 years were recruited, with an equal proportion in the normal group (NG) [-1 to +1 SD body mass index-for-age z-score (BAZ)], and undernutrition group (UG) (BAZ < -1SD). Dietary intake was assessed using two non-consecutive 24-hour recalls. Dietary diversity scores (DDS) were determined with reference to the intake of 13 food groups with a minimum daily intake of 15 gram/food group. Receiver operating curve analysis was performed to obtain the DDS cut-off. The Mann-Whitney test was performed to compare DDS between the NG and UG. Logistic regression analysis was conducted to examine the likelihood of potential factors in predicting nutritional status outcome. Results: Overall, almost half of the girls' daily food intake showed low dietary diversity based on DDS cut-off < 5, with no significant difference between NG and UG adolescents. Protein intake inadequacy showed significant unlikelihood of a NG outcome (OR=0.4; 95% CI: 0.2-0.8), while low socioeconomic status (SES) showed a strong likelihood of an UG (OR=2.7; 95% CI: 1.3-5.5) compared to high SES. Conclusions: Low dietary intake and DDS were common among adolescent schoolgirls in slum areas in Jakarta. Nutrition interventions promoting appropriate dietary intake among adolescent girls are recommended.

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Mal J Nutr 25 (Supplement): 19-32, 2019
Comparing intake adequacy and dietary diversity
between adolescent schoolgirls with normal nutritional
status (NG) and undernutrition (UG) based on BMI-for-
age (BAZ) living in urban slums in Central Jakarta
Rika Rachmalina1,2, Helda Khusun3*, Luluk Basri Salim2, Luh Ade Ari
Wiradnyani3 & Drupadi HS Dillon2,3
1Center for Public Health Research and Development, National Institute of Health
Research and Development, Indonesian Ministry of Health, Jakarta; 2Community
Nutrition Study Program, Faculty of Medicine Universitas Indonesia; 3SEAMEO
Regional Center for Food and Nutrition (RECFON)–PKGR Universitas Indonesia,
Jakarta
ABSTRACT
Introduction: Undernutrition among adolescent girls is an important concern due
to their rapid growth velocity that requires adequate intake of energy and nutrients.
This study compared intake adequacy and dietary diversity between adolescent
public schoolgirls from slum areas in Central Jakarta who had normal and poor
nutritional status. Methods: A total of 220 eligible girls aged 14–18 years were
recruited, with an equal proportion in the normal group (NG) [-1 to +1 SD body
mass index-for-age z-score (BAZ)], and undernutrition group (UG) (BAZ < -1SD).
Dietary intake was assessed using two non-consecutive 24-hour recalls. Dietary
diversity scores (DDS) were determined with reference to the intake of 13 food
groups with a minimum daily intake of 15 gram/food group. Receiver operating
curve analysis was performed to obtain the DDS cut-off. The Mann–Whitney test was
performed to compare DDS between the NG and UG. Logistic regression analysis
was conducted to examine the likelihood of potential factors in predicting nutritional
status outcome. Results: Overall, almost half of the girls’ daily food intake showed
low dietary diversity based on DDS cut-off <5, with no signicant difference between
NG and UG adolescents. Protein intake inadequacy showed signicant unlikelihood
of a NG outcome (OR=0.4; 95% CI: 0.2-0.8), while low socioeconomic status (SES)
showed a strong likelihood of an UG (OR=2.7; 95% CI: 1.3-5.5) compared to high
SES. Conclusions: Low dietary intake and DDS were common among adolescent
schoolgirls in slum areas in Jakarta. Nutrition interventions promoting appropriate
dietary intake among adolescent girls are recommended.
Keywords: Adolescent girls, dietary diversity, nutrient adequacy, undernutrition,
Jakarta slums
__________________________
*Corresponding author: Helda Khusun
SEAMEO Regional Center for Food and Nutrition (RECFON)–PKGR Universitas Indonesia,
Jakarta, SEAMEO RECFON Building, Jl. Salemba Raya No. 4, Jakarta
Telephone no.: +622131930205; Fax no.: +62213913933
E-mail: hkhusun@seameo-recfon.org; hkhusun@gmail.com

Rachmalina R, Khusun H, Salim LB et al.S20
INTRODUCTION
Adolescence is a critical period of
physical growth and development.
Undernutrition among adolescents is a
public health concern in Asian countries
with prevalence of > 20% underweight
(Cappa et al., 2012). In Jakarta, the
prevalence of undernutrition in the
form of thinness among adolescents
was approximately 11.2% in 2010
(MOH Indonesia, 2013), indicating
that adolescent undernutrition is at an
unsatisfactory level (WHO, 2010).
Undernutrition during adolescence
is of signicance given that 50% of the
adult weight and skeletal mass and 20%
of the adult height are gained during
this period. As the rapid growth velocity
requires adequate intake of energy
and nutrients, adolescents become
vulnerable to nutrient deciencies
(Stang & Story, 2005). Adolescent girls
in low and middle income countries
(LMIC) are often reported to have a
monotonous cereal based diet consisting
of low nutrient-dense foods, resulting
in an inadequate intake of energy and
nutrients (USAID & SPRING, 2015). As
a consequence, poor nutrition during
adolescence affects the ability to learn,
reduces work productivity, results in
a failure to attain potential height and
gain optimal bone mass in adulthood,
and delays the onset and progression of
puberty.
Several factors are known to lead to
undernutrition. These include household
food insecurity, intra-household
allocation of food that does not meet
dietary needs, livelihood insecurity,
and poor knowledge of nutrition (WHO,
2005). Poor diet quality could be due
to a lack of dietary diversity, which
indicates consumption of a low variety
of food. This condition has been shown
to be associated with micronutrient
inadequacy among children and
adolescents (Korkalo et al., 2017; Zhao
et al., 2017). A higher household dietary
diversity was reported to be associated
with a lower likelihood of child stunting
(Lee & Ryu, 2018; Mahmudiono,
Sumarmi & Rosenkranz, 2017).
Studies determining dietary diversity
among Indonesian adolescents in
relation to undernutrition are few. This
study was aimed at comparing the
dietary intake adequacy and dietary
diversity between adolescent schoolgirls
with normal and poor nutritional status
living in urban slum areas in Central
Jakarta, Indonesia.
MATERIALS AND METHODS
Study design and subjects
This cross-sectional study was conducted
in Central Jakarta. A list of schools was
obtained from the Education Ofce of
Central Jakarta, from which ve high
schools located in slum areas were
randomly selected.
Sample size
As studies on dietary diversity of
Indonesian adolescent girls are lacking,
the sample size for this study was
computed based on the results reported
by Jayawardena et al. (2013), that
underweight female (BMI≤18.5 kg/
m2) had lower mean dietary diversity
(5.69±1.52) than those whose nutritional
status was normal (BMI >18.5 - ≤22.9kg/
m2) (6.52±1.47). Based on 80% power and
a 95% condence interval, a minimum
sample size of 220 was estimated with
an equal number for each group, that
is 110 for the undernutrition group and
another 110 for the normal nutritional
status group.
The study inclusion criteria for
selecting the participants were girls aged
14-18 years, who were post menarche
and apparently healthy. A total of 1,073
schoolgirls from the public schools who

Low dietary diversity among adolescent schoolgirls S21
had met the study criteria were selected,
and were invited for anthropometric
screening.
Nutritional status
Anthropometric measurements were
conducted following standard
procedures (Gibson, 2005). Height was
measured using the ShorrBoard (Weigh
and Measure, LLC, USA), and weight
was measured using an electronic SECA
no. 876 weighing scale (Seca, Germany).
The average of two consecutive
measurements was used to calculate the
body mass index-for-age z-score (BAZ)
using WHO AnthroPlus software (WHO,
2009). The girls were classied into two
groups based nutritional status. These
were the normal group (NG) (BAZ: –1SD
≤ BAZ ≤ +1SD) and the undernutrition
group (UG) (BAZ < -1SD) (Thomaz, et
al., 2010). The 110 schoolgirls whose
BAZ status was (BAZ < -1SD) agreed,
on a voluntary basis to participate, and
were classied to the UG. The other 110
schoolgirls with BAZ status (-1SD ≤ BAZ
≤ +1SD) were placed in the NG.
Data collection
All the eligible participants were
interviewed by ve trained enumerators,
to collect data on dietary diversity, food
consumption, morbidity (history of
diarrhoea and upper respiratory tract
infection in the previous one month),
physical activity (PA), household food
security, working and education status
of mother, and household socioeconomic
status (SES). The questionnaires on
food consumption and dietary diversity
were pre-tested on several adolescent
girls from a public high school located
in the study area. After pretesting, the
questionnaires were revised to improve
clarity.
Food consumption
Dietary intake was assessed using two
non-consecutive 24-hour (24-h) food
recall periods, comprising one weekday
and one day of a weekend. A four-stage
multiple-pass interviewing technique
was used in the 24-h recall method
(Gibson & Ferguson, 2008). The national
standardised food photograph book
was used for the estimation of portion
size (MOH Indonesia, 2014a). The daily
nutrient intake was determined using the
Indonesian food composition database
and calculated by NutriSurvey for
Windows, version 2007 (Erhardt, 2007).
Energy and protein requirements were
calculated by using an estimated energy
requirement and protein requirement to
specic body weight (FAO, WHO & UNU,
2001; WHO, FAO & UNU, 2007). Fat and
carbohydrate adequacy were taken as
meeting at least 77% of the Indonesian
recommended dietary allowance (RDA)
(MOH Decree, 2013). The estimated
average requirement was used to
evaluate micronutrient adequacy (WHO
& FAO, 2006). A dietary intake that was
above these requirements was classied
as energy and nutrient adequacy.
Dietary diversity
A standardised individual dietary
diversity questionnaire was used
to obtain the dietary diversity score
(DDS) (Arimond et al., 2008). The DDS
consisted of 13 food groups, namely
starchy staples, legumes and nuts, dairy
products, organ meats, eggs, small sh
eaten with bone, meat (“esh foods”)
and animal protein, vitamin A-rich deep
yellow/orange/red vegetables, vitamin
A-rich deep green leafy vegetables,
vitamin A-rich fruits, vitamin C-rich
fruits, vitamin C-rich vegetables, and
lastly other fruits and vegetables.
Morbidity (upper respiratory tract
infection and diarrhoea)
Participants with upper respiratory
tract infection were identied based on
medical diagnosis or reports of fever, sore
throat, and cough in the previous one

Rachmalina R, Khusun H, Salim LB et al.S22
month. Participants with diarrhoea were
identied based on doctor’s diagnosis
or had experienced passing liquid or
loose stools three or more times in the
previous one month.
Physical activity
A short form of the international PA
questionnaire (IPAQ) was used to
determine PA during the past seven days
(IPAQ, 2005).
Household food security
Household food security status was
determined by using the food security
survey module for children aged ≥ 12
years. The nine questions in the module
about food situation at home during
the past one month were answered by
participants. Response to the questions
were assumed to be an indication of the
food security status of the children, as
perceived by the family (Connell et al.,
2004).
Socioeconomic status
The SES of the household was determined
based on ownership of assets consisting
of the sources of drinking water,
electricity and cooking fuel, ownership
of toilet, type of latrine, nal faecal
disposal, ownership of a motorcycle,
television, air-conditioner, water heater,
12 kg cooking gas cylinder, refrigerator,
and car (MOH Indonesia, 2013).
Data analysis
The DDS was computed by assigning a
score of one (1) for the consumption of
at least 15g/day of a food group, and
zero (0) score for intake < 15g/day. The
total score for the entire food groups
ranged from 0-13. The receiver operating
characteristic (ROC) curve was plotted to
obtain the DDS cut-off corresponding to
the nutritional status of the schoolgirls.
For this purpose, we contrasted the
DDS with the composite score for the
intake adequacy of energy and protein.
The procedure yielded a DDS of 5 as
the cut-off for dietary diversity with the
area under the curve (AUC) of 0.65,
sensitivity of 60%, and specicity of 64%
(p= 0.002). This cut-off was also used in
examining the relationship between the
DDS and nutritional status.
PA was analysed according to the
IPAQ guidelines. The subjects were
requested to recall the duration of usual
their PA in a week. The duration of
these activities was then converted into
metabolic equivalent (MET) – minutes
per week and categorised into high,
moderate, and low PA based on the IPAQ
guidelines (IPAQ, 2005).
Household food security status was
categorised as food-secure or food-
insecure, based on the responses to
the nine questions in the module. We
examined under- and over - reporting of
energy intake to check for potential bias
in participant’s dietary intake (McCrory
et al., 2002).
SES was constructed based on 13
variables that were used to indicate the
wealth index (MOH Indonesia, 2013).
By using principal component analysis
(PCA), a reliability analysis was rst
conducted, yielding ten variables, which
were screened providing a Cronbach’s
alpha of 0.686. The PCA yielded a
correlation score of > 0.6 for the SES
variables. The scores were then ranked
into tertiles, where tertile one was the
lowest and tertile three the highest SES.
The independent t-test was used to
compare the differences in height and
body weight between the two nutritional
status groups (NG vs UG). The Mann–
Whitney test was used to compare the
differences in dietary intake and DDS
between these two groups. The chi-
square test was used to examine the
independence between DDS (cut-off <
5 and ≥ 5 food groups) and nutritional
status (NG vs UG). Logistic regression

Low dietary diversity among adolescent schoolgirls S23
analysis was undertaken to assess the
relationship between the categorical
potential predictive factors: DDS,
intake adequacy (energy and protein
adequacy), morbidity status (history of
diarrhoea and upper respiratory tract
infection in the previous one month),
household food security status, and
SES, in predicting the categorical
outcome: normal nutritional status
versus undernutrition. The potential
predictors were selected according to
the conceptual framework of nutritional
problems and causal factors during
adolescence; dietary inadequacies
and infectious diseases are immediate
cause of undernutrition in adolescence
(WHO, 2005). The results of the logistic
regression were expressed as the odds
ratio and 95% condence interval.
Statistical analyses were performed
using SPSS (version 20). P values <0.05
were considered statistically signicant.
Ethical approval
The study protocol was approved by
the Research Ethics Committee of the
Medical Faculty of Universitas Indonesia
in Jakarta (reference number 206/
UN.2.F1/ETIK/2015, dated 16 March
2015). The subjects provided written
consent prior to data collection.
RESULTS
The study was conducted from March
to April in 2015. Out of a total of 220
eligible participants who were selected,
25 were excluded from data analysis due
to under- or over -reporting of energy
intake. The nal analysis was performed
on 195 participants, consisting of 100
adolescents in the UG and 95 in the NG.
The mean body weight and height
were signicantly different between the
NG and UG. The mean body weight of
the NG (49.3±5.1kg) was signicantly
higher than that of the UG (40.8±4.0kg)
(Table 1). However, the mean height of
the NG at 1.53±0.06m was signicantly
less than that of the UG at 1.56±0.06m.
This indicates that on average, the UG
was thinner but somewhat taller than
the NG. In line with this, the proportion
of stunting was signicantly higher in
the NG compared to the UG (24.4% vs
12.0%, respectively; p=0.029).
The SES of the UG was worse off than
that of the NG, with the former having
a signicantly higher proportion with
low SES (50.0% vs 31.6%, respectively)
(Table 1). Overall (i.e. NG and UG),
more than half of the adolescent
schoolgirls (55.4%) reported having
upper respiratory tract infection while a
lower proportion (12.3%) had diarrhoea
in the previous month. There were no
statistically signicant differences in
the morbidity status between the NG
and UG. There was also no signicant
difference between the two groups in
terms of the prevalence of household
food insecurity (UG 60.0% vs NG 50.5%),
and the proportion of working mothers
(UG 25.5% vs 37.6% NG).
The median daily intake of energy,
protein, and fat were approximately
1,500 kcal, 49 g, and 62g, respectively;
these gures were 72.0%, 83.0% and
87.0%, respectively, of the Indonesian
RDA (Table 2). There were no statistically
signicant differences in the intake of
energy, macro- and micro- nutrients
between the UG and NG.
Table 3 shows that, overall, <10.0%
of the adolescents had adequate energy
intake and >60.0% of them attained
adequate intake of protein, fat, vitamin
A and vitamin B6. Nonetheless, very
low proportions of the adolescents had
adequate intakes of folate, calcium
and zinc. There were no signicant
differences in energy and nutrient intake
adequacy between the UG and NG,
except for protein intake adequacy at
83.0% vs 65.3%, respectively.

Rachmalina R, Khusun H, Salim LB et al.S24
Table 1. Anthropometric measurements, morbidity, household food security, and socioeconomic status of the adolescent schoolgirls
according to nutritional status
All (n=195)
Nutritional status
p†
Undernutrition
(BAZ<-1SD)
(n=100)
Normal
(-1SD ≤ BAZ ≤ 1SD)
(n=95)
Height, m (mean±SD) 1.55±0.06 1.56±0.06 1.53±0.06 0.06*
Weight, kg (mean±SD) 44.9±5.8 40.8±4.0 49.3±5.1 <0.001***
Stunting (Height-for-age z-score <-2.0) (%) 17.9 12.0 24.2 0.029*
Had upper respiratory tract infection in the previous month (%) 55.4 56.0 54.7 0.859
Had diarrhoea in the previous month (%) 12.3 10.0 14.7 0.317
Physical activity level‡ (%)
Low 33.3 32.0 34.7 0.976
Moderate 64.6 66.0 63.2
High 2.1 2.0 2.1
Household food security status§ (%)
Food secure 44.6 40.0 49.5 0.184
Food insecure 55.4 60.0 50.5
Adolescent girls with working mother (n=191) (%) 31.3 25.5 37.6 0.073
Mother educational level (n=191) (%)
Lower education (graduated from junior high school or less) 26.7 26.5 26.9 0.956
Higher education (attending high school or more) 73.3 73.5 73.1
Socioeconomic status¶ (%)
Low 41.0 50.0 31.6 0.005**
Middle 24.6 24.0 25.3
High 34.4 26.0 43.2
†T-test for continuous variables and chi-square test for discrete variable
‡Based on average MET-minutes per week (IPAQ, 2005)
§The sum of afrmative responses to the nine questions in the food security module for children aged ≥12 years (Connell et al., 2004)
¶SES was dened based on tertiles of wealth index score (household ownership of assets) (MOH Indonesia, 2013)
*p<0.05, **p<0.01, ***p<0.001

Low dietary diversity among adolescent schoolgirls S25
Table 2. Energy and nutrient intake among the adolescent schoolgirls according to nutritional status
All (n=195)
Nutritional status
p†
Undernutrition
(BAZ<-1SD)
(n=100)
Normal
(-1SD ≤ BAZ ≤ 1SD)
(n=95)
Median (IQR‡)
Energy (kcal/day) 1531.3 (1265.3–1865.1) 1556.6 (1281.2–1853.9) 1478.7 (1260.9–1883.9) 0.594
Protein (g/day) 48.9 (38.3–62.5) 49.0 (37.8–63.3) 48.8 (38.7–62.2) 0.744
Fat (g/day) 61.9 (47.5–79.1) 62.3 (50.6–80.8) 59.6 (46.1–77.6) 0.455
Carbohydrate (g/day) 198.4 (158.0–252.5) 205.2 (162.4–253.2) 197.5 (153.9–247.9) 0.385
Vitamin A (µg/day) 1068.1 (723.6–1627.2) 1059.3 (739.9–1615.9) 1082.5 (684.7–1627.2) 0.823
Thiamine (mg/day) 0.6 (0.4–0.9) 0.7 (0.5–0.9) 0.6 (0.4–0.9) 0.366
Riboavin (mg/day) 0.8 (0.6–1) 0.8 (0.6–1.0) 0.8 (0.5–1.0) 0.359
Niacin (mg/day) 9.1 (6.9–12.5) 8.9 (6.4–12.6) 9.1 (7.1–12.4) 0.657
Vitamin B6 (mg/day) 1.2 (0.8–1.8) 1.2 (0.8–1.7) 1.1 (0.8–1.8) 0.539
Folate (µg/day) 124.0 (83.0–181.0) 130.0 (88.0–191.0) 118.0 (77.0–174.0) 0.080
Vitamin B12 (µg/day) 1.9 (1.3–3.5) 2.0 (1.4–3.5) 1.9 (1.2–3.5) 0.732
Vitamin C (mg/day) 24.1 (13.1–44.6) 24.9 (13.8–48.7) 21.9 (11.2–44.5) 0.339
Calcium (mg/day) 294.4 (219.5–421.2) 307.1 (229.3–420.3) 281.8 (190.7–426.6) 0.335
Zinc (mg/day) 6.5 (5.2–8.2) 6.3 (5.3–8.3) 6.6 (5.2–8.1) 0.114
Iron (mg/day) 7.7 (5.4–8.2) 8.0 (6.0–10.2) 7.2 (4.9–9.9) 0.971
†Mann–Whitney test
‡IQR=Interquartile range

Rachmalina R, Khusun H, Salim LB et al.S26
Based on a DDS cut-off of <5,
almost half of all the girls (46.2%) daily
consumed a low diversity of foods,
with no signicant difference between
the NG and UG (Table 4). The food
groups consumed by the majority of all
the adolescents on a daily basis were
starchy staples (100%), esh foods and
animal protein (85.1%), legumes and
nuts (55.9%) and egg (54.4%). They
consumed a low percentage of fruits,
only about one-third reported taking
vegetables, on a daily basis. Signicant
differences were observed for the daily
intake of legumes and nuts (NG 42.1%
vs UG 69.0%), and vitamin C-rich
vegetables (NG 14.7% vs UG 28.0%).
Higher intake of legumes and nuts by the
UG may explain the nding of signicant
difference of protein intake adequacy
between this group and the NG, as
shown in Table 3. Daily consumption
of the other food groups did not show
signicant differences between the NG
and UG girls.
The logistic regression analysis
showed that among the factors studied,
two were found to have signicant
inuence on the nutritional status
outcome of the adolescent schoolgirls
living in the slum areas of Jakarta.
Household SES and protein intake
adequacy were signicantly associated
with the nutritional status of the
schoolgirls (Table 5). Protein intake
inadequacy was associated with a less
likelihood of attaining normal nutritional
status (OR=0.4; 95% CI: 0.2-0.8;
Table 3. Percentage of the adolescent schoolgirls according to nutritional status meeting
energy and nutrient intake adequacy†
All
(n=195)
Nutritional status
p‡
Undernutrition
(BAZ<-1SD)
(n=100)
Normal
(-1SD ≤ BAZ ≤ 1SD)
(n=95)
Energy 9.7 12.0 7.4 0.276
Protein 74.4 83.0 65.3 0.005**
Fat 63.1 66.0 60.0 0.386
Carbohydrate 34.9 38.0 31.6 0.347
Vitamin A 92.8 95.0 90.5 0.226
Thiamine 22.6 25.0 20.0 0.404
Riboavin 17.4 20.0 14.7 0.333
Niacin 47.7 47.0 48.4 0.843
Vitamin B661.0 63.0 58.9 0.562
Folate 6.2 7.0 5.3 0.614
Vitamin B12 49.2 50.0 48.4 0.826
Vitamin C 19.0 20.0 17.9 0.708
Calcium 0.5 1.0 0.0 0.328
Zinc 4.6 6.0 3.2 0.344
†Energy and protein requirements were calculated by using estimated energy requirement and
protein requirement to specic body weight (FAO, WHO & UNU, 2001; WHO, FAO & UNU,
2007). Fat and carbohydrate adequacy were taken as meeting at least 77% of the Indonesian
RDA (MOH Decree, 2013). Estimated average requirement was used to evaluate micronutrient
adequacy (WHO & FAO, 2006). Dietary intake above these requirements was classied as
energy and nutrient adequacy.
‡Chi-square test
**p<0.01

Low dietary diversity among adolescent schoolgirls S27
Table 4. Distribution (%) of dietary diversity scores (DDS) and food groups consumed by the adolescent schoolgirls according to
nutritional status
All
(n=195)
Nutritional status
p†
Undernutrition
(BAZ<-1SD)
(n=100)
Normal
(-1SD≤BAZ≤1SD)
(n=95)
Dietary diversity score, median (IQR) 5.0
(4.0–6.0)
5.0
(3.0–6.0)
5.0
(4.0–6.0) 0.113
DDS <5 (%) 46.2 43.0 49.5 0.365
DDS ≥5 (%) 53.8 57.0 50.5
Food groups (%)
Starchy staples 100.0 100.0 100.0 1.000
Legumes and nuts 55.9 69.0 42.1 <0.01**
Dairy products 42.1 41.0 43.2 0.761
Organ meats 5.1 6.0 4.2 0.572
Eggs 54.4 57.0 51.6 0.449
Small sh eaten with bone 4.6 3.0 6.3 0.271
Flesh foods and animal protein 85.1 81.0 89.5 0.097
Vitamin A-rich deep yellow/orange/red vegetables 33.8 33.0 34.7 0.798
Vitamin A-rich deep green leafy vegetables 23.1 22.0 24.2 0.715
Vitamin A-rich fruits 6.2 5.0 7.4 0.493
Vitamin C-rich vegetables 21.5 28.0 14.7 0.025*
Vitamin C-rich fruits 15.4 58.0 63.2 0.152
Other fruits and vegetables 39.5 42.0 36.8 0.463
†Chi-square test; Mann–Whitney test for dietary diversity score
*p<0.05
**p<0.01

Rachmalina R, Khusun H, Salim LB et al.S28
p=0.006). Schoolgirls from households
with low SES were 2.7 times more likely
to be undernourished than those from
households with high SES (OR=2.7; 95%
CI: 1.3-5.5; p=0.006). The other factors
that were studied including DDS, energy
intake, morbidity status, and household
food security were not found to exert a
signicant inuence on the nutritional
status outcome of the adolescent
schoolgirls.
DISCUSSION
Data on dietary intake and dietary
diversity among adolescents are limited
in Indonesia. Interventions to improve
the dietary intake of adolescents are also
lacking. The results of this study provide
some insights into the quality and
variety of food consumed by adolescent
schoolgirls from slum areas in Central
Jakarta.
On the average, Indonesian
adolescents showed a lower DDS (less
than ve food groups) than some other
countries. By comparison, Iranian
adolescent girls consumed an average
of approximately six food groups (range
5–14 food groups) (Akbari & Azadbakht,
2014). and the mean DDS was 5.76 for
Table 5. Logistic regression analysis in predicting nutritional status of the adolescent girls
(n=195) according to potential factors
Normal nutritional status vs
undernutrition†
Potential factors OR 95% CI p
Dietary diversity score (DDS)
DDS ≥5 (reference)
DDS <5
Dietary intake
1.1 0.6-2.0 0.805
Energy intake adequacy (reference)
Energy intake inadequacy
0.7 0.3-1.9 0.494
Protein intake adequacy (reference)
Protein intake inadequacy
Morbidity status
0.4 0.2-0.8 0.006**
Had upper respiratory tract infection
Without upper respiratory tract infection (reference) 1.0 0.6-1.9 0.899
Had diarrhoea
Without diarrhoea (reference) 0.6 0.3-1.6 0.328
Household food security
Food secure (reference)
Food insecure
Socioeconomic status
1.3 0.7-2.4 0.405
High SES (reference)
Middle SES 1.5 0.7-3.2 0.323
Low SES 2.7 1.3-5.5 0.006**
†Normal BMI-for-age score or BAZ: (–1SD ≤ BAZ ≤ +1SD) as reference vs undernutrition (BAZ
< -1SD)
**p<0.01

Low dietary diversity among adolescent schoolgirls S29
urban adolescent schoolgirls in Ethiopia
with 76% of them having adequate
dietary diversity (Birru, Tariku & Belew,
2018).
The diet of the adolescent schoolgirls
in this study was predominantly based
on starchy staples. More than half
of the girls reported taking animal
protein foods and legumes and nuts.
A low percentage of them consumed
fruit and vegetables on a daily basis,
when compared to the nding of the
national survey in Indonesia, which
reported vegetable consumption among
Indonesian adolescents aged 13–18 years
at 94.7% (Hermina & Prihartini, 2016).
In studies on adolescents conducted
in Africa and Canada, low energy and
nutrient intake were generally found in
adolescents from households with low
SES and food insecurity (Kirkpatrick &
Tarasuk, 2008; Dapi et al., 2010). In low
income households, common barriers
to low fruit and vegetable intake were
the unavailability and poor access to
affordable types of fruit and vegetables,
a lack of knowledge about healthy
foods, the poor quality of the produce,
and budgetary constraints (Huang,
Edirisinghe & Burton-Freeman, 2016).
A poor knowledge of nutrition among
adolescent school girls was reported
by a study conducted in 12 districts of
Indonesia, which showed that less than
half of adolescents aged 10-19 years were
aware of health benets of fruits (43.7%)
and vegetables (36.2%) (Sudirman &
Jahari, 2012). Therefore, disseminating
knowledge of the health benets of fruits
and vegetables is essential. The public
sector should enable people to have better
access to reduce retail prices so that a
wider variety of foods is affordable to all
socioeconomic strata in a community
(Nair, Augustine & Konapur, 2016).
Several studies have revealed
that dietary diversity is consistently
associated with micronutrient adequacy
in children and adolescents (Korkalo
et al., 2017; Zhao et al., 2017). Women
of reproductive age in ve developing
countries reported that dietary diversity
consistently predicts micronutrient
adequacy (Arimond et al., 2010).
This study showed that the
adolescents had low nutrient intake,
particularly of vitamin B1, vitamin B2,
folate, vitamin C, calcium, and zinc.
Macronutrient intake, except for fat,
was below the national requirements
for Indonesian adolescents aged 14–18
(MOH Indonesia, 2014b). The latest
Indonesian dietary survey revealed
that the highest proportion of energy
inadequacy was among adolescents aged
13–18 (MOH Indonesia, 2014b). This is
consistent with the literature regarding
dietary intake among adolescents
in developing countries, which has
highlighted the poor diet quality in this
age group (Ochola & Masibo, 2014).
Their diets are known to be limited in
diversity, particularly in the fruit and
vegetable food groups (Zhao et al., 2017).
Further, energy and micronutrient
intake were found to be inadequate in
the majority of adolescents in developing
countries (Ochola & Masibo, 2014).
These ndings indicate that nutrition
policies and programmes are important
to improve the food intake of adolescents
for growth, cognition, and educational
achievements (Ochola & Masibo, 2014).
This study found that low household
SES had a strong inuence on the
nutritional status of the adolescents.
This is consistent with ndings
elsewhere in other groups such as that
of a study of pregnant women in Kenya,
which reported that socioeconomic
factors including employment status,
household assets, and land ownership
inuenced dietary diversity in pregnant
women (Kiboi, Kimiywe & Chege, 2017).

Rachmalina R, Khusun H, Salim LB et al.S30
CONCLUSION
The diet of adolescent schoolgirls living
in slum areas in Jakarta was inadequate
in terms of dietary adequacy and
diversity. The Indonesian Ministry of
Health issued dietary guidelines in the
2014 on principles of a balanced diet.
However, these guidelines may not be
well disseminated, and key elements of
it, including “consume a variety of foods”,
are not widely known or understood.
Interventions directed at promoting good
diets through dietary diversication
among adolescent schoolgirls, are
recommended for schools and the
community at large.
Acknowledgements
The authors are grateful to all the investigators
and adolescent schoolgirls who took part in this
study.
Authors’ contributions
RR, designed research, carried out data collection,
analysed and interpreted the data, and developed
manuscript; HK, designed research, interpreted
the data and critically reviewed the manuscript;
LBS, carried out data collection; LAAW, critically
reviewed the manuscript; DHSD, designed research
and critically reviewed the manuscript. All authors
have seen and approved the nal manuscript.
Conict of interest
The authors declare no conict of interest.
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