Analysis of the Variables Affecting Chronic Energy Deficiency (CED) in Adolescent Girls: a Systematic Review

: Chronic Energy Deficiency (CED) can have a negative impact on health. Individuals who experience CED will have underweight or have low body weight, and their daily productivity will be disrupted due to malnutrition. Chronic Energy Deficiency occurs in Women of Reproductive Age (WRA) so it will have an impact in the future when they will experience the process of pregnancy, and childbirth and the baby's weight will also be affected. Chronic Energy Deficiency includes being underweight, undernourished, undernutrition, and stunting. Therefore the authors want to analyze the causes that can influence the incidence of chronic energy deficiency in late adolescent girls. The author performs an article search method through electronic databases originating from Google Scholar, PubMed, Science Direct, and the Garuda portal. Journal references used amounted to 18 articles. The results of the search found that food intake behavior of macro and micro substances, nutritional knowledge, nutritional attitudes, beliefs about ideal body image, sociodemographics, socioeconomic factors, family members, knowledge, attitude, and many other causes can influence the occurrence of Chronic Energy Deficiency.

Nutritional needs increase during adolescence when these nutrients are used to meet the growing demands of puberty.Adolescence is an age when growth and development proceed rapidly after infancy.Adolescents gain up to 50% of their adult body Fifty percent of adult body weight comes from adolescence, and twenty percent of adult height, and fifty percent of bone mass during adolescence.A variety of factors can influence adolescent eating habits and behavior, such as understanding and brain development can influence health and the wider family, sociocultural, and economic environment in which adolescents live, eat, learn, and play.Malnutrition occurs when people do not consume the nutrients to be processed to meet their daily energy needs and to maintain the immune system (Tafasa et al., 2022).In addition, both mental and physical health in young women is an investment for the future because healthy female students will become healthy workers in the future (Ribeiro et al., 2018).
Adolescent girls are classified into early and late young women.Early adolescent girls aged 10-13 years, middle adolescents aged 14-17 years, and ending at ages of 18-22 years (Lukman et al., 2022).In the final group of young women aged 18-22 years, body image is an aspect that is of sufficient concern (Widhiyanti et al., 2020a).At present, social media is increasingly in demand, especially tik tok, Instagram, Facebook, Twitter, and other social media which are very much loved by adolescent girls, including late adolescent girls (Clark et al., 2021).Social media presents images of slender and fairly thin models as ideal body shape figures, this can cause late young women to feel often dissatisfied and even insecure about their own body condition (Vall-Roqué et al., 2021).
Malnutrition including CED, underweight, undernutrition, undernourished, and thinness directly affected by inadequate food intake and disease and indirectly linked to many factors, including poor water, sanitation and hygiene (WASH) (Chattopadhyay et al., 2019).CED among adolescents is often associated with poverty, poor maternal health so that child nutrition becomes poor also due to improper feeding and child care when infants and children are early in life.A study in various parts of the world says sociodemographic factors, environment, type of diet, and pubertal characteristics are the main factors associated with adolescent malnutrition (Tafasa et al., 2022).
Large family members, country residence, unprotected sources of drinking water, lack of latrines, low-scoring diet diversity, illiterate mothers, and food insecure households are identified as factors causing undernourished adolescents in the literature (Negash et al., 2022).Adolescent nutrition is very important to help improve the nutritional status of adolescents, which will have an impact on future economic development, as well as break the chain of malnutrition (Tafasa et al., 2022).
Stojcic (2020) said that the theory generally used to explain the development of body image is the tripartite influence model, namely parents, peers, and social media.Teenagers tend to compare themselves with their peers on social media.Comparisons made by adolescents can be in the form of comparing physical forms with their peers or with public figures seen on social media (Frederick et al., 2022).
Therefore, researchers are interested in knowing the causes of chronic energy deficiency and all types of malnutrition such as underweight, undernutrition, and unnourished in adolescent girls.

METHOD
Article search uses four databases, namely PubMed, Google Scholar, Garuda Portal, and ScienceDirect.The search keywords for the article were "chronic energy deficiency", "malnutrition in adolescent girls", "chronic lack of energy in adolescent girls", "causes of chronic energy deficiency", "underweight in adolescent girls", "undernourished in adolescent girls", and "mid upper arm circumference".The inclusion criteria for this study were articles published in 2017-2022, full text, and on adolescent girls.The exclusion criteria were pregnant women, paid articles, textbooks, and articles using languages other than English and Indonesian.
A literature search through four databases resulted in 5.727 articles that match the keywords used by the researchers.There are 97 similar articles (duplication) and 4.779 articles that are irrelevant and do not use Indonesian or English, so the entire contents of the article are obtained for selection.From the selection results, 851 articles were found that matched the research objectives, inclusion critera and exclusion criteria.After going through various stages in the systematic review, 18 articles were found to be discussed in this study.

RESULTS
From the search selection results from the articles described in the method above.There were 18 articles obtained regarding various variables that can affect chronic energy deficiency or underweight in late adolescent girls, which can be seen in the table below.The prevalence of undernourished is 25.6% (95%CI: 24.5-26.9).There was a significant relationship between undernourished adolescent girls and young women aged 15-19 years (AOR: 1.53), individual media exposure (AOR: 0.82), and unprotected drinking water source (AOR: 1.24).

DISCUSSION
Adolescence is the age of transition from childhood to adulthood (Nair et al., 2017).According to Santrock (2007) adolescence begins around 10-13 years and ends at 18-22 years (Vransisca, 2022).When a adolescence will experience a lot of changes.For example, in physical and body changes to increase muscle mass, and increase in fat tissue in the body, as well as hormonal changes also occur.These changes impact the nutritional needs of their food.The Imbalance between intake needs and adequacy will cause nutritional problems, both in the form of problems of excess nutrition and malnutrition (Purba et al., 2022).This period requires nutritional needs that contain lots of macronutrients and micronutrients to supply rapid growth spurts and increased physical activity (Ahmad et al., 2018).
The prevalence of undernutrition is still high.Chronic energy deficiency (CED) is defined as a chronic condition in which a person is in an energy imbalance, even though they live not from a poor family (Dagne et al., 2021).CED occurs due to lower energy consumption compared to the amount of energy needed by the body, which lasts for years.CED can be known from the value of the mid-upper arm circumference (MUAC) ≤ 23,5 cm (Astuti et al., 2022;Purba et al., 2022;Wardhani et al., 2020) and BMI < 18,5kg/m 2 (WHO, 2013).
The way to measure MUAC is to measure the circumference of the middle arm between the tip of the elbow and the tip of the shoulder, this method is a simple way of assessing nutritional status in the adolescent population.In contrast to BMI measurements which can be influenced by factors that affect overall body mass, such as trunk edema due to protein energy malnutrition.MUAC is not affected by this factor (TFNC, 2016).MUAC is more usable for measuring adolescents and children, from the age of five years and over concurrent with the WHO references (Destaw et al., 2021).BMI also requires adequate equipment, namely a stadiometer and functional scales.Meanwhile, MUAC uses only simple equipment (standard tape in millimeters specially made for MUAC measurement) and can be used by clinicians and non-clinics in both clinical and non-clinical settings, more efficiently and economically.(Lillie et al., 2019).
Mid-upper arm circumference is an illustration of the availability of nutrients in the subcutaneous fat and muscles.Energy reserves can be stored in the form of adipose tissue, which is fat under the skin (Telisa & Eliza, 2020).The level of energy and protein adequacy affects muscle mass but the decrease in muscle mass is caused by the level of energy and protein adequacy.This is in accordance with the theory that nutritional intake can affect a person's nutritional status.If protein intake is sufficient, the nutritional status will be appropriate, including the MUAC size.
Protein is a macro-nutrient that functions as a bodybuilder and also as a source of energy in the body (Telisa & Eliza, 2020).It is known that protein can function as a reserve of the last energy after fat and carbohydrates are used.It can be interpreted that protein is used as compensation for energy deficits to reduce the incidence of CED (Widhiyanti et al., 2020).Carbohydrates are a source of energy for the body, these substances are found in foodstuffs derived from plants such as rice, corn, cassava, sago, wheat, Generally, adolescent girls reported frequent intake of locally available indigenous street food (Ahmad et al., 2018) and do not pay attention to the amount of energy intake needed in a day to carry out activities (Widhiyanti et al., 2020).The increased consumption of processed foods that lack nutritional value, but have a lot of calories, such as consuming junk food, is the cause adolescents being very vulnerable to certain nutritional deficiencies even though their nutritional status is normal (Telisa & Eliza, 2020).Changes in nutrition in adolescents if not made improvements that are well sought after, will affect the quality of society in the future (Dagne et al., 2021).When food intake in adolescents is good, it will produce good energy and can be used for growth and development in adolescence.The worse the food intake of an adolescent, the higher the risk of CED occurring in that person (Purba et al., 2022).
Based on the selected articles, it is known that several variables can affect CED in adolescent girls.It was found from several articles that food intake behavior of macro and micro substances, both energy intake, carbohydrate intake, protein, fat, and iron intake (Telisa & Eliza, 2020; Widhiyanti et al., 2020b), although there are also articles that say that protein intake has no effect on CED (Purba et al., 2022).One of the behaviors of food intake is the type of diet (Ramya et  School is a factor that can influence knowledge to reduce malnutrition.Religion, information, and motivation can influence attitudes toward reducing malnutrition.Schools, fathers' education, information, and behavioral skills can reduce malnutrition.In this study it was stated that young women had poor knowledge about malnutrition, regarding definitions, types, causes, effects, and prevention, both micronutrient deficiencies such as iron, vitamin A, calcium, and iodine, or macronutrients such as energy, carbohydrates, fat.and proteins.Lack of knowledge about malnutrition can be caused by a lack of education in young women regarding knowledge and nutrition health education (Shapu et al., 2020).
In contrast to the research by Saha et al (2021), which stated that educational status did not have a relationship with being underweight among adolescent girls.In this study, only age, the number of family members, knowledge, and use of the toilet were statistically associated with the BMI category among young women.Although there are several other factors that do not cause statistically, their impact on nutritional status cannot be avoided.So it is true that nutrition in adolescents, especially young women, must be prioritized by improving adequate living standards and good health education.
Socioeconomic can affect nutritional status, if he comes from the upper class, of course the teenager will not be malnourished, but if the teenager comes from the lower class or the economy is down, it is likely that the teenager will experience malnutrition.This can be seen from the Nutritional status can also be caused by WASH.It was explained in one of the selected articles, that water facilities outside the household have a significant relationship with stunting and low BMI.Adolescent girls who get water from outside the home are more likely to be short and thin.Significant results are also seen in open defecation which can cause stunting and low MUAC.Adolescent girls who do not use soap after defecating tend to have a lower MUAC.Not attending health services organized by the health department is also a factor that causes malnutrition (Chattopadhyay et al., 2019).
It was explained that thinness can be influenced by teenage age, grade level, eating snacks, marital status, menarche, and dietary diversity.It is better to do a better way by improving the standard of living of the family better by looking for activities that can generate money, nutrition education, and personal and environmental hygiene practices.Interventions should also be carried out to improve the nutritional status of young women through regular nutrition counseling at health facilities, community strata, and schools (Hadush et al., 2021).

Fig 1 .
Fig 1. Research flowchart others.Carbohydrates function as a provider of energy or calories to meet the needs of the body's activities and also to maintain body temperature(Telisa & Eliza, 2020).
al., 2017; Wardhani et al., 2020b) and the number of meals per day (Tafasa et al., 2022).Usually, adolescent girls go on a diet because they want to maintain their body shape, in order to create an ideal body image.It is explained in the article that body image is like Appearance Orientation, Appearance Evaluation, Overweight Preoccupation, Body Area Satisfaction, and Self-Classified Weight has a major impact on CED (Wardhani et al., 2020).Therefore, body image can indirectly affect chronic energy deficiency (Ramya et al., 2017; Syati, 2017b; Wardhani et al., 2020b; Widhiyanti et al., 2020b), or malnutrition such as underweight and thinness.When adolescent girls are on a strict diet and do not manage their diet properly, malnutrition will happen.
research Ahmad et al (2018).In line with research Alemu et al (2021) and Hadush et al (2021) rural areas that have no latrine, lower wealth class can affect nutritional status.It is said in the article that it can cause thinness and stunting.