October – December, 2023
AcTion:
Aceh Nutrition Journal
Original Article Pages: 635 - 641 p-issn 2527-3310; e-issn 2548-5741
DOI: http://dx.doi.org/10.30867/action.v8i4.1310

Aceh. Nutri. J. 2023; 8(4) http://ejournal.poltekkesaceh.ac.id/index.php/an

The relationship between menarche and nutritional status in Junior
High School students in Aceh Besar. A study from 30 years of armed
conflict area, Aceh, Indonesia
Hubungan usia menarche dengan status gizi pada siswa SMP di
Aceh Besar. Studi dari daerah post konflik senjata di Aceh, Indonesia

Muhammad Yani
1*, Azhari
2, Agus Hendra Al Rahmad
3, Farid Bastian
4,
Teuku Muhammad Ilzana
5, Cut Rizka Rahmi
6, Andriaty, S. Nora
7, Adithia
Chanda
8,
Syahnaz Salsabila
9

1
Department of Public Health, Faculty of
Medicine, Universitas Syiah Kuala, Aceh,
Indonesia. E-mail: [email protected]
2
Department of Nutrition, Aceh Provincial
Health Office, Aceh, Indonesia.
E-mail: [email protected]
3
Department of Nutrition, Poltekkes
Kemenkes Aceh, Aceh, Indonesia.
E-mail: [email protected]
4
Department of Public Health, Faculty of
Medicine, Abulyatama University, Aceh,
Indonesia. E-mail: [email protected]
5
Faculty of Public Health, Muhammadiyah
University, Aceh, Indonesia.
E-mail: [email protected]
6
Department of Public Nutrition, Faculty of
Medicine, Universitas Syiah Kuala, Aceh,
Indonesia. E-mail: [email protected]
7
Department of Public Health, Faculty of Medicine,
Abulyatama University, Aceh, Indonesia.
E-mail: [email protected]
8
Medical Student of Faculty of Medicine,
Universitas Syiah Kuala, Aceh, Indonesia.
E-mail: [email protected]
9
Department of Public Health, Faculty of
Medicine, Abulyatama University, Aceh,
Indonesia.
E-mail: [email protected]

*Correspondence Author:
Department Public Health, School of
Medicine, University of Syiah Kuala, Teuku
Nyak Arief Street 441st, Syiah Kuala
District, Banda Aceh City 23126, Aceh,
Indonesia. E-mail: [email protected]


Article History:
Received: July 5, 2023; Revised:
September 6, 2023; Accepted: September
24, 2023; Published: December 8, 2023.


Publisher:



© The Author(s). 2023 Open Access
This article has been distributed under the
terms of the License Internasional Creative
Commons Attribution 4.0


Abstract
Age at menarche is strongly associated with adolescents' nutritional
status. Food insecurity is one of the factors that cause nutritional
disorders. Communities living in areas of armed conflict often experience
food insecurity and low levels of parental knowledge, leading to being
underweight and stunting. Aceh had been plagued by armed conflict for
almost three decades, which ended 23 years ago. This study aimed to
measure the relationship between menarche and the nutritional status of
adolescents in Aceh Besar, Aceh Province. This analytical research
method used a cross-sectional survey approach. The sample consisted of
278 Junior High School (JHS) students, taken by stratified random
sampling at ten of the JHS in Aceh Besar in 2021-2022. Data were
collected through interviews, using questionnaires, anthropometric
measurements (Weight and Height), and observations. Statistical analysis
used the Chi-square test at CI 95%. 79,1% of the students' menarche was
normal, and 64,7% had normal nutritional status. There was a significant
relationship between age at menarche and nutritional status (p<0,05). In
conclusion, menarche's age is related to adolescent girls' nutritional
status at Junior High School in Aceh Besar.
Keywords: Adolescent, menarche, nutritional status

Abstrak
Usia menarche berhubungan kuat dengan status gizi remaja. kerawanan
pangan merupakan salah satu faktor penyebabkan gangguan gizi.
Masyarakat yang tinggal didaerah konflik bersenjata sering mengalami
kerawanan pangan, tingkat pengetahuan orang tuanya yang rendah,
hingga menyebabkan underweight dan stunting. Aceh dilanda konflik
bersenjata hampir 3 dekade dan berakhir pada 23 tahun lalu. Penelitian
bertujuan untuk mengukur hubungan menarche dengan status gizi
remaja di Aceh Besar, Provinsi Aceh. Metode penelitian analitik ini
menggunakan pendekatan Cross-sectional survey. Sampel sebanyak 278
siswi SMP, diambil secara stratified random sampling pada 10 SMP di
Aceh Besar pada tahun 2021-2022. Data dikumpulkan melalui
wawancara menggunakan kuesioner, pengukuran antropometri (Berat
Badan dan Tinggi Badan), serta observasi. Analisis statistik menggunakan
uji Chi-square pada CI 95%. Sebanyak 79,1% menarche siswa adalah
normal, dan sebanyak 64,7% mempunyai status gizi normal. Terdapat
hubungan antara usia menarche dengan status gizi (p<0,05). Kesimpulan,
usia menarche memiliki hubungan dengan status gizi pada remaja putri di
SMP Aceh Besar.
Kata Kunci: Menarche, status gizi, remaja putri

636 The relationship between menarche and nutritional status … Yani et al.

Introduction
Adolescence or puberty is a transitional period
from childhood to adulthood. One of the
significant events in the life cycle of adolescent
girls is their first menstruation, called menarche,
which is a sign of their entry into the
reproductive period. Menarche is an essential
indicator of pubertal development, physical
maturity, nutritional status, and reproductive
health in young women (Ibitoye et al., 2017).
The age at menarche is a symbol that the woman
is healthy (fertile), ready to have sex, and ready
for marriage; this is a picture found in several
regions in Asian and African countries
(Nandi et
al., 2020; Sommer, 2013).
Basic Health Research in 2018 shows that
the average age of menarche in Indonesia is 13
years (20,0%), with an earlier occurrence at the
age of less than nine years and some later up to
20 years (Indonesian Ministry of Health, 2018).
The age at menarche is influenced by multiple
factors such as genetics, ethnicity, psychology,
nutritional status, diet and exercise habits, living
environment, and economy (Carlson & Shaw,
2019). The diversity of food consumption and
genetic factors play an essential role in
triggering the release of gonadotropin-releasing
hormone (GnRH), which determines the age of
menarche in adolescent girls (Rahimi et al.,
2019; Thifal et al., 2023).
Age at menarche can influence the risk
factors for developing diseases in adulthood,
such as increased risk of cardiovascular disease,
gestational diabetes mellitus, asthma, non-
alcoholic fatty liver disease, infertility, and
postmenopausal depression. Age at menarche
can also be related to the use of alcohol and
drugs or dropping out of school (Carlson &
Shaw, 2019; Rahimi et al., 2019). Adolescent
girls experiencing early menarche are closely
related to early sexual activity (Dars et al., 2014;
Juul et al., 2017). In addition, menstrual patterns
also affect BMI.
Research on menarche has been widely
conducted in developed countries. However, it is
rarely found in developing countries, including
Indonesia, especially Aceh, as a post-conflict and
Islamic Syariah law area (Ibitoye et al., 2017;
Karim et al., 2021; Zhang et al., 2019).
Young women's problems related to
menstruation and menarche are rarely. Even
unusual cases to be discussed in the community,
even though the case itself is not revealed in
their own family, and comprehensive health
intervention programs, especially in terms of
reproductive health, nutrition, and social
aspects, for young women are also minimal (Abi-
esber, 2017).
The experience of armed conflict is
strongly related to food and nutrition insecurity.
Communities affected by conflict or stress were
significantly associated with malnutrition (being
underweight and stunting). Children affected by
conflict face multiple burdens, malnutrition, and
poor health outcomes (Burris & Wiley, 2021;
Carroll et al., 2017; Ghattas et al., 2014;
Loewenberg, 2015). The results also showed
that stunted girls had a delayed age at menarche,
similar to the reports of studies in Senegal and
Kenya, which indicated that post-menarcheal
girls had better nutritional status than pre-
menarcheal girls (Hadush et al., 2021;
Tumilowicz et al., 2019).
In addition, Aceh has experienced three
decades of armed conflict that has affected its
economic and social status. Conflict affects the
decrease in maternal and paternal education
and food insecurity and increases the number
of stunts in Aceh (Yani et al., 2022). This study
is part of a significant effort to obtain
information on the determinants of stunting in
Aceh and identify appropriate interventions to
solve the problem of nutritional disorders in
Aceh.


Methods
Design
This cross-sectional survey aimed to measure
the relationship between nutritional status and
age at menarche in junior high school students
in Aceh Besar District. There are 10 Junior High
Schools (JHS) in Aceh Besar District. In total, 278
respondents were obtained. Samples were
obtained by conducting a stratified random
sampling of schools and selecting random
respondents from each school. The research
period was 6 months (September 2021 -
February 2022).

Study Instrument and Variables
The independent variable was age at menarche,
which was divided into early, normal, and late
menarche
(Leone & Brown, 2020).
The

Aceh. Nutri. J. Vol: 8, No: 4, 2023 637

dependent variable. Based on the CDC-2000
graph, nutritional status was divided into thin,
normal, overweight, and obese (Kemenkes RI,
2020). The enumerators were medical students
who had been trained to ensure the validity of
the research instruments used.

Data analysis
Univariate analysis was used to analyze patient
characteristics, age at menarche, and nutritional
status. Bivariate analysis was performed to
assess the association between the age at
menarche and nutritional status. All analyses
were performed using SPSS software.


Result and Discussion
Characteristics of respondents.
Of the 278 respondents, the age range is
between 10-14 years, and the average age of
menarche was 13,77 + 1,121).
Most respondents had a normal menarche
age (79,1%), and it was interesting that only
6,5% of the respondents had experienced early
menarche and 14,4% had late menarche. Most
respondents had a normal nutritional status; 25
(9%) were thin (underweight), and 11% were
obese.

Table 1. Characteristics respondents (n= 278)
Characteristics Age n %
Age
Ten years 18 6,5
11 years old 58 20,9
12 years old 52 28,7
13 years old 110 39,6
14 years 40 14,4
Age of Menarche
Early Menarche 18 6,5
Normal Menarche 220 79,1
Late Menarche 40 14,4
Nutritional status
Thinness 25 9
Normal 180 64,7
Over Weight 42 25,1
Obesity 31 11,2

As shown (Table 2), 278 respondents
(67,3%) were of normal age at menarche and
had normal nutritional status. Interestingly, late
menarche occurs in 14,4% of the respondents,
and overweight and obesity accounted for
36,3%.

Table 2. The relationship between nutritional status and age of menarche in Junior High School in
Aceh Besar District
Age of
menarche
Nutritional status
Total p-value
Thinness Normal Overweight Obesity
n % n % n % n % n %
Early 1 5,6 5 27,8 5 27,8 7 38,88 18 100 0,000
Normal 14 6,4 148 67,3 36 16,4 22 10,0 220 100
Late 10 25 27 67,5 2 5,0 1 2,5 40 100
Total 25 9,0 180 64,7 43 15,1 30 11,2 278 100

As shown in Table 2, 278 respondents (67,3%)
were of normal age at menarche and had normal
nutritional status. Interestingly, early menarche
mainly occurred in the obese (38,88%). Late
menarche was found in most patients with a normal
nutritional status (67,5%), but it was also often found
in large numbers in the thin group (25%). The analysis
revealed significant differences in the age at menarche
and nutritional status (p= 0,000). Late menarche was
associated with obese respondents, while late
menarche was associated with thinness.

Nutritional Status
The results of this study indicate that most of the
respondents had normal nutritional status (148
respondents, 67,3%), but 9% were thin (poor
nutritional status), and 5% were obese, according
to the research conducted by Juliyatmi and
Handayani (2015) in Yogyakarta, where most of
the students had a normal nutritional status of
47,9%.
However, the percentage of students with
nutritional disorders was more significant than or
equal to that of students in Aceh (28,5%). The
results of these two studies were better than those
of the National Health Survey in Indonesia
(RISKESDAS 2018). It possibly due to parents'
relatively low knowledge of and behavior toward
providing nutritious food and a balanced menu for
children.

638 The relationship between menarche and nutritional status … Yani et al.

Studies conducted in India and Pakistan
have reported significantly higher rates of
thinness. Mohanty and Panda (2022) reported
that among 160 adolescent girls, the rate of
nutritional disorders was 61,3%, of which
90% suffered from anemia. According to the
researcher, this was due to the lack of
awareness among young women related to
limited government programs. Another study
by Hassan et al. (2017) found that adolescent
malnutrition was related to a lack of food
security at the household level. Its study was
found that 140 young women in urban
communities are malnourished. Other possible
causes include menstruation status and the
availability of latrines, lifestyle changes, and
eating habits that can also affect the amount of
food and nutrients consumed, such as fear of
being fat so that they do not eat breakfast and
only eat once a day, the habit of not eating
breakfast, and higher physical activity.
Although the proportion of adolescents with
malnutrition is only 9% if this condition is not
corrected, it can have negative consequences;
for the children themselves, even when they
are married and pregnant, they will also tend
to become pregnant with nutritional disorders.
It contributes to the high prevalence of
stunting in Aceh (Al Rahmad et al., 2020;
Telisa & Eliza, 2020). Pregnant women with
malnutrition can carry the risk of children
being born with low weight or disabilities due
to a lack of minerals, and stunting can even
cause death to the mother.

Another nutritional disorder found in a
study of junior high school students in Aceh
Besar District was obesity. Obesity in children is
a predisposing factor for future cardiovascular
diseases. In this study, obesity was found in
11,2% of junior high school students; this figure
is lower than the national obesity prevalence
and from findings in America and China
(Jacobson et al., 2019; Jiang et al., 2022; Wang et
al., 2021). The 2018 National Health Survey in
Indonesia (RISKESDAS 2018) reported that the
prevalence of obesity in adolescents aged 13-15
years was 16,0%, and in adolescents aged 16-18
years, 13,5% (Kemenkes RI, 2018). While a
study conducted on American adolescents by
Hedley in 2000 found a prevalence of 16%,
research in China reported obesity to be 17% in
adolescent girls and 25% (Jiang et al., 2022;
Wang et al., 2021).
No statistical analysis was performed on
the causal factors in this study. However, in
several studies, such as the Avon longitudinal
study, there was a relationship between obesity
and genetic, neuroendocrine, metabolic,
psychological, and socioeconomic factors, as
well as comorbid factors such as cardiovascular,
kidney, and liver disorders. It will have an
impact on public health in the future (Jacobson
et al., 2019; Jiang et al., 2022).

The rapid flow of information, especially
from the Western world, has also brought about
changes in the lifestyle of teenagers, including in
Indonesia, where most teenagers use their free
time for inactive activities and eating factory-
made snacks or processed food. It includes being
more independent of choice. These choices are
often inaccurate, which can lead to nutritional
problems.

The Age of Menarche
This study found that the age of menarche in
junior high school students in Aceh Besar
District varied. Most were aged 13 years (39 %).
The results of this study are consistent with
those of 2018 Basic Health Research.
This study was in accordance with the
research conducted by Siwi & Fitriahadi (2015)
with a sample of 49 respondents, which included
four students who were fast at menarche (8,2%)
and five students (10,2%) who were slow at
menarche, as many as 40 students (81,6%). The
age at menarche varied widely, from 10 to 16
years, with an average of 12,5 years.

Relationship between Nutritional Status and
Age of Menarche
This study, conducted in the Aceh Besar district,
showed a significant relationship between the
age (time) of menarche of female students and
nutritional status (p < 0,005). Those who
experienced early menarche were mostly obese
(6,5%), while normal menarche age and late
menarche were more common in normal and
poor nutritional status (41,2%) and (8,9%,
respectively). The results of this study did not
differ from those previously reported (Jiang et
al., 2022; Singh et al., 2019).
The relationship between age at menarche
and nutritional status is still a matter of debate
as to whether early menarche causes an increase
in BMI or nutritional status, which encourages
menarche to occur at an earlier age. Leptin

Aceh. Nutri. J. Vol: 8, No: 4, 2023 639

secreted by adipose glands affects the levels of
neuropeptide Y, which in turn affects GnRH.
Changes in the levels of GnRH can alter LH
secretion. Leptin also affects oocyte maturation,
which stimulates the maturation of the ovum
produced by the ovaries (Barabás et al., 2020).
Adolescent girls who have a high BMI
(overnutrition) are caused by earlier puberty
(menarche) rather than excessive fat (Singh et
al., 2019). The same result was reported by Jiang
et al. (2022), who found that girls who received
early menarche at the age of 13-14 years were
higher and had a higher BMI than girls of the
same age but had not yet received menarche.
Very few studies have been conducted on
menarche and nutritional status, particularly in
conflict areas. Our study was in accordance with
the results of other studies; late-age menarche
was found predominantly in the thin or
underweight groups, while early menarche was
found to be overweight (Hadush et al., 2021;
Tumilowicz et al., 2019). Information on the age
of menarche is essential from a public health
perspective because it is associated with a high
BMI incidence and even obesity in adolescence,
which has an impact on morbidity rates, such as
cardiovascular risk and diabetes mellitus at an
early age. The relationship between early
menarche and a tendency to increase BMI and
obesity has received little attention from public
health experts, including clinics. It is often
forgotten, even though its impact will be quite
significant in the future (Alam et al., 2015;
Barabás et al., 2020; Kurnia et al., 2020). This
finding is beneficial for decision-makers.


Conclusion
A significant relationship was observed between
nutritional status and the age at menarche. This
study showed that early menarche was
associated with obesity among respondents
(seven out of 18 students).
Considering that Aceh is mainly Muslim
and menarche or menstruation is still a closed
issue, a reproductive health Communication,
Information, and Education (CIE) program
related to reproductive organs and personal
hygiene, child marriage age (early marriage),
pregnancy process, and prevention not intended
to free sex is needed. In contrast, the promotion
of nutrition topics is very much needed: a
balanced food menu, Benefits of Macro and
Micronutrients for adolescents, especially young
women, obesity, and their risk of cardiovascular
and metabolic diseases. The CIE was also
provided to the student's parents.


Acknowledgments
We want to thank the principals of Junior High
School in Aceh Besar District, Aceh, Indonesia.


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