Red spinach-containing snack food improved hemoglobin and hematocrit levels of girl adolescents in Riau Archipelago

Backgrounds : Anemia often occurs in adolescents, characterized by a decrease in hemoglobin and blood hematocrit levels. Red spinach (Alternanthera amoena Voss.) as a food high in iron has the potential to be studied for its eﬀect in treating anemia. Objectives : To evaluate the eﬀect of red spinach-containing snack foods on the hemoglobin and hematocrit levels of anemic adolescent girls at SMP Negeri 2 Bintan Timur, Riau Archipelago. Methods : It was a quasi experimental study with a pretest-posttest control group design with 36 subjects, divided


INTRODUCTION
levels of anemic adolescent girls in the Riau Archipelago.This product can be used as an alternative food to overcome anemia.

KEYWORDS: alternanthera amoena voss.; anemia; adolescent; iron; food
In 2013, anemia was a significant health problem in Indonesia, with a prevalence rate of 21.7% (1).This means that a substantial portion of the adolescent population in Indonesia was affected by anemia.The prevalence of anemia was notably higher among girls aged 15 to 18 years.This age group was particularly affected by anemia.Anemia's incidence was e v e n m o r e p r o n o u n c e d i n t h e R i a u Archipelago, where the prevalence was exceptionally high at 38.1% (2).Inadequate iron intake is identified as a major cause of anemia among adolescents (3).This is often reflected in low levels of blood hemoglobin and hematocrit, which are important indicators of anemia.Untreated or severe a n e m i a m a y c o n t r i b u t e t o l a t e r l i f e development, particularly physical and academic performance, and decreased immunity (2)(4).

Red spinach (Alternanthera amoena
Voss) is a famous type of leafy vegetable that is high in iron.It contains a total iron of 7 mg/100 g, higher than green spinach (3.3 mg/100 g) (5).Red spinach also has good n u t r i t i o n a l v a l u e , l i k e p r o t e i n , f a t , carbohydrates, fiber, mineral (phosphorus, manganese, calcium), vitamins (A, B, and C), and niacin (6).Carotenoid, flavonoid, and alkaloid is also good as immunity enhancer (6).The previous study reported that hemoglobin levels increased after the intervention of single red spinach juice in pregnant mothers of trimesters 1 and 2 (7) and its combination with beetroot juice (8).
The girl given boiled red spinach also proved to have higher hemoglobin levels (9).
The acceptance of spinach is usually limited due to its taste.Therefore, it needs to be developed a snack food to increase the intake of red spinach-containing food.So far, there has been a modification of red spinach products to become pudding, but it must be combined with orange juice that is high in vitamin C to enhance the absorption of iron in the body.The consumption during seven days could enhance hemoglobin levels to 2.04 ± 0.2 g/dL (10).However, it has not been studied for other modifications without combination with vitamin C.This study aimed to evaluate the effect of red spinachcontaining snack foods on the hemoglobin and hematocrit levels of anemic adolescent girls at SMP Negeri 2 Bintan Timur, Riau Archipelago.

MATERIALS AND METHODS
The research was approved by The Institutional Review Board of Alma Ata

Characteristics of subjects
In this study, there were 36 anemic adolescent girls who were selected as subjects and divided into two groups, that was a control group and a treatment group.
However, there was one subject in the control group who dropped out because she did not attend the invitation several times during the study.
Characteristics of adolescent girls at SMP Negeri 2 Bintan based on age and anemia symptoms can be seen in Table 1.
Most of the subjects were 13 years old, both in the control (52.9%) and the treatment group (44.4%).As we know that adolescence is more vulnerable to anemia due to the increasing need for nutrients during the growth period, especially iron needs.
Moreover, menstruation and parasitic infestation also affected blood loss in young girls (15).The most incidence occurs in young girls who had imbalance consumption of micronutrients, such as iron, folic acid, zinc, vitamins B6, B12, and C ( 16) and may had low levels of knowledge about the role of iron in the body (17).The previous study proved that girl aged 16-18 years old were sensitive to malnutrition related to iron deficiency anemia (18), but another studies reported that the age between 12-15 years old was the highest prevalence due to the peak requirement at this period (15).The characteristics of subjects in this study were also observed from the symptoms of anemia.The data were collected from the interview.All subjects (100%) felt sleepy, but only 74.3% of subjects complained of difficulty in concentrating, and 45.7% felt weak, tired, lethargic, tired, and negligent (Table 1).It is noted that other studies have also found clinical symptoms of anemia in girl adolescents, such as pale conjunctiva, angular stomatitis, swollen and bleeding gums, loss of luster, dry brittle hair, dermatitis, dry nails, and dental caries (18).These symptoms are attributed to the lack of iron in the cells, leading to various physiological disruptions, including problems with oxygen binding, nutrition transport and storage, enzymatic reactions, and immunity function (15).

The effect of red spinach-containing snack food on hemoglobin levels of adolescent girls
Table 2 shows the results of a T-testdependent analysis to know the effect of red spinach-containing snack food on hemoglobin levels of anemic adolescent girls.This study shows that there was a significant difference in hemoglobin levels in the treatment group (p<0.05),but there was not in the control group (p>0.05).Specifically, the average increase of hemoglobin levels after 14 days of consumption of red spinach-containing food was 0.4 ±0.05 g/dL in anemic adolescent girls.
Besides the content of high iron, in red spinach, there were also vitamin C, vitamin A, and antioxidants like anthocyanins and saponins (10,19).The presence of vitamin A and vitamin C increased the absorption of non-heme iron that is usually found in plants (4) (8).Moreover, the antioxidants had a role in maintaining body stability and immunity that overcome iron deficiency anemia (9).This result was in line with other research that used boiled red spinach for the girl adolescents at SMK Al-Islam Kudus (13) and red spinach juice for pregnant women in the second trimester in Bandar Klippa Village, Percut Sei Tuan District, Deli Serdang Regency (20).However, the increase in hemoglobin levels was not as high as in other studies that used green spinach and millet (4) (21).This may be influenced by the high oxalate contents in spinach that may inhibit iron absorption (22).

The effect of red spinach-containing snack food on hematocrit levels of adolescent girls
The effect of red spinach-containing snack food on the hematocrit levels of anemic adolescent girls is shown in Table 3.This result proved that the consumption of red spinach-containing snack food could significantly increase the hematocrit levels of anemic adolescent girls (p<0.05), while it could not happen in the control group (p>0.05).The increase in hematocrit levels was closely related to hemoglobin levels, as the formation of both hemoglobin and hematocrit was influenced by the adequate requirement of iron in the body (23) .
Hemoglobin reflects a protein that is combined with red blood cells, while hematocrit is calculated as the volume ratio between red blood cells and total blood.The other r e s e a r c h a l s o u s e d h e m o g l o b i n a n d hematocrit levels to reflect the iron levels in the body during pregnancy and maternal in Japan (24).subjects categorized as non-anemic.The intervention of red spinach-containing snack food had an impact on anemia treatment.This study also indicated that the processing of red spinach becoming snack food that involved heating did not increase the bioavailability of iron in the body.This was shown by the increase in hemoglobin levels after 14 days of treatment, which could not be as high as the previous study that used fresh spinach or juice (8).Theoretically, heating and cooking may have both negative and positive effects.

Group
On one side, it may increase the bioavailability of protein, iron, and also decrease the oxalate or phytate content that inhibits the iron absorption (25) (22) (18), on the other hand, high-temperature processing during cooking may decrease the antioxidant that has a role in body immunity (9).

CONCLUSION AND RECOMMENDATIONS
Red spinach-containing snack food could increase hemoglobin and hematocrit levels of adolescent girls at SMP Negeri Bintan Timur Riau Archipelago after 14 days of treatment.This snack food can be an alternative snack food to overcome anemia.
Further studies may be needed to develop the product and evaluate its organoleptic and nutritional content.
Red spinach-containing snack food improved hemoglobin and hematocrit levels of girl ... 153 University Yogyakarta with the number of KE/AA/VI/10802/EC/2022 on June 9, 2022.This study was quasy experimental with a pretest-posttest control group design.This research was conducted in June 2022 at the junior high school of SMP Negeri 2 Bintan Timur, Riau Archipelago.The population of this study was 53 anemic adolescent girls aged 12-15 years old at SMP Negeri 2 Bintan.The subjects were screened based on blood evaluation of hemoglobin levels of <12 g/dL and hematocrit levels of <36 (11), and willingness to participate in this study.They were excluded if they were menstruation, received iron s u p p l e m e n t t a b l e t s , s u ff e r e d f r o m thalassemia, chronic illness, gastrointestinal disorder, or died during the study.The sample size was 18 for each of the control and treatment groups.It was calculated by Lemeshow equation for one population (12), considering the mean difference of (X1-X2) 2.04 g/dL and standard deviation (S) of 1.26 from a previous study (13), the power of 90% (β=0,10), an alpha level of 0.05 (14), and Zα = 1,96; Zβ = 1,28.The Lemeshow equation was shown below.The treatment group received red spinach-containing snack food in the form of a fried stick, but the control group received a fried stick without red spinach.All of them received 100 g of snack food for 14 days.The estimation of Fe contained in red spinach was 7 mg/100 g (5).Blood was taken twice using Hemoglobin Hematocrit Testing Fora 6 at the beginning and the end of the study.Data were analyzed by a dependent T-test analysis to know the differences in hemoglobin and hematocrit levels before and after the intervention.

Table 1 . Characteristics of adolescent girls at SMP Negeri Bintan Timur Riau Archipelago
Red spinach-containing snack food improved hemoglobin and hematocrit levels of girl ... 155

Table 3 . The effect of red spinach-containing snack food on hematocrit levels of adolescent girls at SMP Negeri Bintan Timur Riau ArchipelagoTable 2 . The effect of red spinach-containing snack food on hemoglobin levels of adolescent girls at SMP Negeri Bintan Timur Riau Archipelago The effect of red spinach-containing snack food on the anemia prevalence
Based on Table4, the prevalence of anemia in the control group was almost the same before and after the intervention period (p>0.05),while in the treatment group, there was a decrease in anemia prevalence after treatment.In addition, there were seven