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Indrayani, Agus Rahmadi, Dava Alpha Rakhim
1750 P J M H S Vol. 12, NO. 4, OCT – DEC 2018
Can date fruits and 7dates replace iron tablets in increasing
hemoglobin levels?
INDRAYANI1, AGUS RAHMADI2,3, DAVA ALPHA RAKHIM2
ABSTRACT
Background. Iron suplement programs, as an approach to overcoming anemia, indicate positive impact
although many studies have also noted varying levels of success or even a failure. The known and commonly
acknowledged side effect of iron supplements, such as constipation, causes a tendency for patients to stop
consuming these supplements.
Aim: To examine hemoglobin level and bowel movement differences resulting from an iron suplement
program of the government program as well as consumption of the date fruits, and two common products
freely available to the Indonesian consumers.
Method. This study is a pilot randomized controlled trial with four groups consist of three treatment groups
and one control group. Respondents were anemia adolescent girls with inclusive but not exclusive criteria. 40
respondents were selected using random permutated blocks. Intervention was done for 30 days with weekly
assessments. Data analysis used Friedman Test, Wilcoxon Signed Rank and Multiple Linear Regression test.
Results. There is a significant hemoglobin difference before and after intervention on the four groups. The
differences seen in week 1, 2, 3, then tends to decline. Strong, significant correlation is found in treatment
with hemoglobin and defecation duration (week 4) and bowel problems (week 2, 3, 4); feeding frequency and
menstruation with hemoglobin (week 1); feeding frequency and defecation duration (week 2); water intake
and defecation duration (week 4). Multiple linear regression analysis results in regression equation and
participants’ prediction towards dependent variables. There is a positive, significant relationship between
treatment (week 2, 3) and bowel problems, water intake (week 4) and defecation duration.
Conclusion. Dates can be used instead of iron tablets and 7dates can be used as a companion iron tablets.
Keywords: Iron tablets, ferrous sulfate, ferrous gluconate, date fruits, 7dates, anemic, hemoglobin, bowel
movements, dietary fiber, water intake, bowel problems
INTRODUCTION
Obstetric haemorrhage is the main cause of maternal
mortality1 and it has been estimated to cause 25% of all
maternal mortality in the world and over 30% in Asia2, 3.
In fact, the real number of deaths is beyond the
estimation since many death cases caused by
postpartum haemorrhage are unreported. However, the
absolute risk of death is lower in high-income countries
with a ratio estimation of 1: 100,000 childbirths compared
to the ratio estimation of 1: 1,000 childbirths in low-
income countries4. Anemia is an advanced problem that
occurs as a result of hemorrhage, but it can also be the
indirect cause of hemorrhage5. To date, anemia
particularly iron deficiency is a serious public health
problem in developing countries6. Anemia in pregnancy
can lead to fetal growth disorders, preterm labor, low
birth weight, and haemorrhage7, 8, 9, 10, 11. Approximately
16-55% of women have suffered from anemia since early
pregnancy12. Iron supplementation is the most widely
used approach to treat anemia13. The iron tablet
administration program starting after the first trimester of
pregnancy has been applied in many developing
countries. Several studies have reported the positive
-----------------------------------------------------------------------------------------
1Akademi Kebidanan Bina Husada, Tangerang
2Akademi Kebidanan Bunda Auni, Bogor
3Klinik Sehat Indonesia
Correspondence to Indrayani, Akademi Kebidanan Bina Husada, Tangerang.
Kutai Raya No.1, Bencongan Kelapa Dua, Tangerang, Banten, Indonesia.
Zip Code 15811 Ph. +62-21-55655372 Fax. +62-21-55655372. Email:
indrayani_akbid@yahoo.co.id
effects of this effort14, 15, 16, 17 yet the impact is still far from
the expectations12 and it is considered an unsuccessful
program18 due to low adherence of women in
consumption of iron tablets. Some studies have reported
that gastrointestinal side-effects generally have dropped
women compliance in consuming iron tablets18, 19. The
most common complaints after taking iron tablets are
nausea and constipation. This condition is further
exacerbated if they are consumed by pregnant women
as the body adapts towards pregnancy hormone20, 21, 22.
Other studies also reported that iron supplementation
may cause constipation23, 24, 25. Women without a history
of bowel problems may experience constipation in the
early pregnancy, while women with previous constipation
history will experience worse complaints during their
pregnancy20. The prevalence of constipation reported in
pregnancy is 11-38%26, 27, 28. Other factors which
aggravate constipation are less dietary fiber21, 29 and low
water intake21. Moreover, a pregnancy period is a short
time period to deal with pre-existing anemia12. Therefore,
iron deficiency correction should have been done from
teenage years or before pregnancy30.
Iron is a crucial substance for biological function
including respiration, energy production, deoxy-
ribonucleic acid (DNA) synthesis, and cell proliferation31
as well as an essential element needed to produce red
blood cells which carry all of the nutrients to cells
throughout the body32. Iron can be acquired from food
and beverage. Dates are an example of iron-containing
ORIGINAL ARTICLE
Indrayani, Agus Rahmadi, Dava Alpha Rakhim
P J M H S Vol. 12, NO. 4, OCT – DEC 2018 1751
nutrients often consumed and favored by the Muslim
community33. Mariyam et al. reported that Ajwa dates
contain the least iron (0.85 mg/100 gr) while the Tunisian
dates contain the most iron (7.2 mg/100 g)34. In addition
to iron, 100 gr of dates also contain 5.2% crude fiber and
minerals such as calcium (Ca) 65 mg, phosphorus (P) 72
mg, potassium (K) 521 mg, magnesium (Mg) 20 mg, and
selenium (Se) 0.34 mg. Furthermore, the contents of
vitamins in dates include vitamin A (0.04 mg), B1 (0.08
mg), B2 (0.05 mg) and nicotinic acid (2.20 mg). All these
vitamins have different functions that can help the body
to be healthy through carbohydrate metabolism,
maintaining blood glucose levels, fatty acids for energy,
and assisting in the formation of hemoglobin, leukocytes
and red blood cells32. Some studies have proven that
dates consumption can escalate hemoglobin levels35, 36.
This study was aimed to examine the divergences of
hemoglobin levels and bowel movements among iron
supplementation supplied by the government, as
opposed to the supplements circulated in the open
market and nutritional sources of iron often consumed by
the community and to identify an alternative solution to
solve anemia.
METHOD OF STUDY
This study is a pilot randomized controlled trial. The
independent variables of this study were consumption of
ferrous sulfate, ferrous gluconate, date fruits and 7dates
while the dependent variables were hemoglobin levels,
duration of defecation and bowel problems. Confounding
variables for hemoglobin levels were mean of feeding
frequency per week and menstruation, whereas for
duration of defecation and bowel problems were mean of
feeding frequency, dietary fiber and water intake per
week. There were four groups, each selected randomly,
included three intervention groups (ferrous gluconate,
date fruits and 7dates) and one control group (ferrous
sulfate).
The control group was iron tablet subsidized by the
Bogor District Health Office containing ferrous sulfate
excitation 200 mg, while the first treatment group was
Sangobion tablet which is an iron tablet commonly
consumed by Indonesian people and sold freely over the
counter in drugstores containing 250 mg ferrous
gluconate. The second treatment group consumed a
popular date sold in the Indonesian market, Sayer
dates37. The third treatment group consumed a
commonly available date drink packaged as 7dates. The
7dates election was based on its staple ingredients using
dates and water only and it has been certified as a viable
product certification from The Assessment Institute for
Food, Drugs, and Cosmetics of Indonesian Ulema
Council (figure 1).
Respondents in this study were anemic teenage
girls in the Bunda Auni community (age 18 to 25 years
old) who met the inclusion criteria and were excluded
from exclusion criteria. The inclusion criteria were
nulligravida and nullipara, having hemoglobin levels 7 to
12 gr/dL (see table 1), having one or more symptoms of
anemia, not consuming any iron supplements, and a
willingness to consume either iron tablets, dates or
7dates. The exclusion criteria were girls with excess iron
(hemocromatosis, hemosiderosis), anemia due to red-
cell fragmentation (hemolytic anemia), disorders of red
blood cells (porphyria, thalassemia), stomach ulceration
(peptic ulceration) and colon ulceration (ulcerative
colitis), alcohol drinkers and recipients of routine blood
transfusions.
Figure 1. Sayer dates and 7dates
Table 1. Diagnosis of anemia according to WHO
Group
Hb levels (g/dL)
Children aged 6 months to 6 years old
<11.0
Children aged 6-14 years old
<12.0
Adult men
<13.0
Adult women who are not pregnant
<12.0
Pregnant women
<11.0
Source: AlDallal38
Before data collection, 6 persons were recruited and
trained including 2 officers to measure hemoglobin levels
and 4 officers to observe the compliance of respondents
in consumption of ferrous sulfate 200 mg (1 tablet per
day), ferrous gluconate 250 mg (1 tablet per day), date
fruits 70-75 gr (2x35-37.5 gr per day)39 which contain
iron around 2.4 mg/75 gr dates40 and 7dates (3 bottles
per day) for 30 days. Determination of dates doses were
based on the recommended consumption of 7 dates per
day where Muslims believe that by eating 7 dates each
day, a person will be spared from poison and sorcery
(Hadith narrated Bukhari no. 356)41 and considerations
of safety aspect where lethal dose (LD) of 50 extract
dates are more than 5000 mg/kg42 whereas the LD of
Ferrous Sulfate for adults is 200-250 mg/kg body
weight43, 44. Data was collected from January to April
2018 in Bojong Kulur village, Gunung Putri district, Bogor
regency, West Java province, Indonesia. Data collection
method in this study was using primary data taken
directly from respondents through observation, interview,
and examination.
The selection of research sites was based on
considerations of access and technical observation of
respondents as most of the girls of the Bunda Auni
community reside in dormitories and some live in groups
in boardinghouses. Determining the number of samples
per group was based on the sample calculation using
Federer’s formula and 10% addition to anticipate the
drop out sample, that was 10 respondents per group or
40 respondents overall. Each member of the groups
Can date fruits and 7dates replace iron tablets in increasing hemoglobin levels?
1752 P J M H S Vol. 12, NO. 4, OCT – DEC 2018
were chosen by random permutated blocks. A total of 46
anemic girls met the inclusion criteria and were not
included in the exclusion criteria and were willing to be
involved in the study. However, as many as 6 people
dropped out in the first week, 4 of them were unable to
tolerate the side-effects of iron supplements and 2 of
them moved out, while 40 others remained in the study
until the end of the study.
Anamnesis, physical examination and hemoglobin
estimation were performed before intervention for
screening respondents. Every day the officer reviewed
food intake, dietary fiber and water intake, menstruation,
bowel movements and bowel problems experienced by
respondents followed by weekly examinations including
anamnesis, physical examination and hemoglobin
estimation that was done by Sahli’s method and digital
hemoglobin test (hemoglobin testing system quick-
check) Easytouch with one prick. The main reason for
using Sahli’s method is because it is recommended by
Indonesian government while digital hemoglobin test is
most frequent used by Indonesian midwives. Data
analysis was done by using statistical procedure and
service solution (SPSS) 19 software. Univariate analysis
was performed to describe each variable studied
separately. The two-way repeated Anova test could not
be done since the data normality and homogeneity were
not eligible so the Friedman test was chosen as an
alternative test followed by advanced test or post hoc
with Wilcoxon signed rank test to identify which group is
mutually meaningful. Further, a multiple linear regression
was performed to examine the size of the influence
between variables.
This study has been submitted to the Ethics of
Health Study Committee, The Faculty of Medicine of
Universitas Padjadjaran Bandung and obtained approval
from the Ethics of Health Study Committee, The Faculty
of Medicine of Universitas Padjadjaran number
29/UN6.C10/PN/2018.
RESULT
Friedman test results showed significant differences
in hemoglobin levels in all four groups (ferrous sulfate,
ferrous gluconate, dates and 7dates) between, before
and after intervention (1, 2, 3 and 4 weeks) both using
Sahli’s method and digital hemoglobin test (table 2).
Table 2. Changes in hemoglobin levels (gr/dL)
FS*
FG
DF
7D
Shali’s method
Initial
9.7+0.85
10.3+0.83
9.7+1.31
10.7+0.61
1 week
10.5+1.19
11.1+0.86
10.7+0.88
10.8+1.36
2 weeks
11.7+0.92
11.7+0.78
11.4+1.06
12.1+1.10
3 weeks
12.2+0.75
12.3+0.48
12.3+0.61
12.3+0.43
4 weeks
12.4+0.66
11.7+1.52
12.3+0.83
11.9+1.46
P
.000***
.001**
.000***
.002**
Digital hemoglobin test
Initial
9.8+0.95
10.5+0.60
9.7+1.35
10.6+0.56
1 week
11.2+1.34
12.9+1.22
11.5+1.02
11.3+1.83
2 weeks
13.1+1.63
13.0+1.86
13.1+1.02
12.0+1.81
3 weeks
13.8+1.97
13.5+1.45
13.4+1.38
13.0+0.96
4 weeks
13.2+1.27
13.0+1.91
12.5+1.25
12.1+1.51
P
.000***
.001**
.000***
.008**
Note: Mean+standard deviation; Ferrous Sulfate supplied by
local government (FS); Ferrous Gluconate (FG); Date
Fruits (DF); 7dates (7D); Friedman test (*p< .05 **< .01
***p< .001 are significant)
An exponential surge in hemoglobin levels occured
in the 1st week to 3rd week while in the 4th week the
overall hemoglobin levels tended to decline where the
increase was seen only in the ferrous sulfate and dates
group by Sahli’s method (figures 2 and 3).
The Wilcoxon test result provided a more detail
description of the research findings in figure 2 and 3.
There were significant differences in hemoglobin levels
between before and after treatment (weeks 1, 2, 3 and 4)
and between week 1 and in the following weeks (week 2,
3 and 4) that were found in almost all four groups both by
Sahli’s method and digital test. Furthermore, a significant
difference in hemoglobin levels between week 2 and
after week 3 and 4 was found only in ferrous sulfate and
dates groups by Sahli’s method (table 3).
All respondents reported consuming less dietary
fiber each week which in the 7dates group reporting the
least fiber intake (table 4).
Indrayani, Agus Rahmadi, Dava Alpha Rakhim
P J M H S Vol. 12, NO. 4, OCT – DEC 2018 1753
Table 3. The result of Wilcoxon signed rank test in hemoglobin levels and bowel movements
Sahli’s method
Digital hemoglobin test
FS
FG
DF
7D
FS
FG
DF
7D
Z
p
Z
p
Z
p
Z
p
Z
p
Z
p
Z
p
Z
p
1 week-initial
-1.632a
.103*
-2.092a
.036*
-2.196a
.028*
-.416a
.677
-2.659a
.008*
-2.807a
.005*
-2.142a
.032*
-1.479a
.139
2 weeks-initial
-2.805a
.005*
-2.654a
.008*
-2.652a
.008*
-2.805a
.005*
-2.803a
.005*
-2.599a
.009*
-2.803a
.005*
-1.683a
.092
3 weeks-initial
-2.805a
.005*
-2.805a
.005*
-2.805a
.005*
-2.810a
.005*
-2.803a
.005*
-2.803a
.005*
-2.807a
.005*
-2.810a
.005*
4 weeks-initial
-2.805a
.005*
-2.397a
.017*
-2.805a
.005*
-1.887a
.059
-2.803a
.005*
-2.666a
.008*
-2.805a
.005*
-2.295a
.022*
2 weeks-1 week
-2.703a
.007*
-2.045a
.041*
-1.843a
.065
-2.807a
.005*
-2.347a
.019*
-.051b
.959
-2.501a
.012*
-.816a
.414
3 weeks-1 week
-2.803a
.005*
-2.807a
.005*
-2.668a
.008*
-2.547a
.011*
-2.666a
.008*
-.663a
.507
-2.397a
.017*
-2.244a
.025*
4 weeks-1 week
-2.805a
.005*
-1.173a
.241
-2.814a
.005*
-1.277a
.201
-2.599a
.009*
-.102a
.919
-2.134a
.033*
-1.172a
.241
3 weeks-2 weeks
-1.231a
.218
-1.897a
.058
-2.075a
.038*
-.534a
.593
-1.599a
.110
-.867a
.386
-.306a
.759
-1.172a
.241
4 weeks-2 weeks
-2.462a
.014*
-.204b
.838
-2.296a
.022*
-.051a
.959
-.204a
.838
-.306a
.759
-1.186b
.236
-.297a
.767
4 weeks-3 weeks
-1.245a
.213
-1.122b
.262
-.102a
.919
-.408b
.683
-.867b
.386
-1.073b
.283
-1.276b
.202
-.970b
.332
Note: Ferrous Sulfate supplied by local government (FS); Ferrous Gluconate (FG); Date Fruits (DF); 7dates (7D); *Indicates statistically significant change
(p<0.05); a. Based on negative ranks; b. Based on positive ranks; c. Wilcoxon Signed Ranks Test
Table 4. Consumption of fiber and water weekly by number of respondents
1 week
2 weeks
3 weeks
4 weeks
FS
FG
DF
7D
FS
FG
DF
7D
FS
FG
DF
7D
FS
FG
DF
7D
Mean consumption of fiber in a week
No fiber consumption
0
2
0
0
1
1
2
2
0
3
1
1
0
0
1
4
Just 1 day
2
0
0
1
1
1
1
3
2
0
0
1
4
3
1
1
2 days
1
0
1
3
1
4
1
2
2
2
3
4
0
0
2
1
3 days
1
3
2
1
1
1
4
1
3
3
3
3
2
4
3
2
4 days
2
2
2
3
3
1
0
1
1
1
1
1
2
2
2
2
5 days
1
1
2
2
3
1
1
1
2
0
1
0
2
1
0
0
Almost every day
3
2
3
0
0
1
1
0
0
1
1
0
0
0
1
0
Every day
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mean intake of water per week
<1000 mL
1
1
1
2
3
1
4
4
4
3
2
3
5
3
3
4
>1000-1500 mL
6
5
2
3
4
6
2
4
1
6
5
5
3
5
5
4
>1500-2000 mL
2
2
4
3
2
3
2
1
4
1
1
2
2
2
1
2
>2000-2500 mL
1
2
3
1
1
0
1
1
1
0
1
0
0
0
0
0
>2500 mL
0
0
0
1
0
0
1
0
0
0
1
0
0
0
1
0
Note: Ferrous sulfate supplied by local government (FS); Ferrous gluconate (FG); Date fruits (DF); 7dates (7D)
The prominent finding of this study concerns the
duration of defecation and bowel problems each week.
Even though, the hemoglobin levels of ferrous sulfate and
dates groups showed higher levels compare to other groups
but there were differences in bowel movements. It can be
seen clearly from the table 4 and 5 that even the 7dates
group consumed less dietary fiber, but its bowel movements
was the smoothest and had the least complaints, followed
by the dates group. Meanwhile, many respondents of
ferrous sulfate and ferrous gluconate experienced bowel
problems. The complaints included inability to defecate,
hard stool and diarrhea. Inability to defecate was the most
problem complained by respondents of ferrous sulfate and
ferrous gluconate groups weekly (table 5).
Table 5. Description of bowel movements experienced by respondents
1 week
2 weeks
3 weeks
4 weeks
FS
FG
DF
7D
FS
FG
DF
7D
FS
FG
DF
7D
FS
FG
DF
7D
Mean duration of defecation per week
ND for 8 days
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
ND for 7 days
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
0
ND for 6 days
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ND for 5 days
0
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
ND for 4 days
1
1
0
0
0
2
0
0
0
0
0
1
1
0
0
0
ND for 3 days
2
3
0
1
2
0
1
1
1
0
0
0
1
1
1
0
ND for 2 days
1
1
2
1
2
1
0
1
1
4
0
1
0
2
0
0
Routine each 2 days
0
0
0
0
0
0
0
0
0
1
0
0
0
2
0
1
Almost every day
2
0
2
3
1
3
2
1
0
2
2
2
1
0
2
1
Every day
4
4
5
5
5
4
7
7
7
3
8
6
6
4
7
8
Respondents faced bowel problems
Inability to defecate
4
2
1
0
4
2
1
0
4
2
0
0
4
2
0
0
Hard stool
2
0
2
4
0
0
2
0
0
0
0
0
0
0
2
1
Diarrhea
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
No complaints
3
8
7
6
6
8
7
10
6
8
10
10
6
8
8
9
Note: No Defecation (ND); Ferrous sulfate supplied by local government (FS); Ferrous gluconate (FG); Date fruits (DF); 7dates (7D)
Can date fruits and 7dates replace iron tablets in increasing hemoglobin levels?
1754 P J M H S Vol. 12, NO. 4, OCT – DEC 2018
Table 6. Correlation: intake factors, menstruation, hemoglobin levels and bowel movements
1 week
2 weeks
3 weeks
4 weeks
1 week
2 weeks
3 weeks
4 weeks
r
p
r
p
r
p
r
p
r
p
r
p
r
p
r
p
Hemoglobin levels
Sahli’s method
Digital hemoglobin test
Treatment
.043
.396
.095
.279
.075
.323
-.087
.296
-.085
.301
-.213
.093
-.207
.099
-.284
.038*
Feeding frequency
-.269
.046*
-.074
.325
-.125
.220
-.165
.154
-.243
.066
.048
.384
-.037
.410
-.124
.223
Menstruation
.276
.043*
.209
.098
.124
.223
-.086
.299
.004
.491
.243
.066
.179
.134
.192
.118
Bowel problems
Duration of defecation
Bowel problems
Treatment
.203
.105
.213
.094
.193
.117
.339
.016*
.238
.070
.333
.018*
.438
.002*
.315
.024*
Feeding frequency
-.034
.418
-.293
.033*
-.003
.492
.163
.157
-.206
.102
-.261
.052
-.193
.117
.188
.122
Fiber consumption
.096
.277
-.128
.216
.012
.470
-.178
.136
-.005
.488
-.135
.202
-.018
.456
-.005
.487
Water intake
.123
.225
.04
.403
.243
.065
.399
.005*
-.085
.301
-.019
.455
.106
.258
.202
.106
Note: Pearson’s correlation coefficient (r) and the one-tailed p-values (p); *Significant at .05 level
Table 7. Regression equation and prediction of hemoglobin levels and bowel movements
Hemoglobin levels
Sahli’s method
Digital hemoglobin test
1 week
Regression equation
Prediction
R2 = .155, F(3,36)= 2.207, p > .05
Y = 10.652 + 0.022X1 – 0.564X2 + 0.727X3
R2 = .068, F(3,36)= .880, p > .05
Y = 13.449 - 0.128X1 – 0.698X2 + 0.057X3
2 weeks
Regression equation
Prediction
R2 = .052, F(3,36)= .658, p > .05
Y = 10.703 + 0.069X1 – 0.065X2 + 0.526X3
R2 = .118, F(3,36)= 1.600, p > .05
Y = 10.957 - 0.325X1 + 0.220X + 1.207X3
3 weeks
Regression equation
Prediction
R2 = .029, F(3,36)= .361, p > .05
Y = 12.182 + 0.025X1 – 0.131X2 + 0.138X3
R2 = .082, F(3,36)= 1.067, p > .05
Y = 13.317 – 0.291X1 – 0.171X + 0.625X3
4 weeks
Regression equation
Prediction
R2 = .042, F(3,36)= .524, p > .05
Y = 13.651 - 0.111X1 – 0.350X2 – 0.330X3
R2 = .095, F(3,36)= 1.258, p > .05
Y = 13.324 – 0.298X1 – 0.294X + 0.391X3
Note: df (regression, residual); Y= constant, treatment (X1), feeding frequency (X2), menstruation (X3); a. Predictors: (Constant), menstruation, treatment,
feeding frequency; b. Dependent Variable: hemoglogin estimation by Sahli’s method and digital hemoglobin test; *p<0.05 **<0.01 ***p<0.001
Bowel movements
Duration of defecation
Bowel problems
1 week
Regression equation
Prediction
R2 = .068, F(4,35)= .634, p > .05
Y = 6.568 + .360X1 – .270X2 + .170X3 + .219X4
R2 = .118, F(4,35)= 1.165, p > .05
Y = 3.674 + .274X1 – .535X2 + .053X3 – .159X4
2 weeks
Regression equation
Prediction
R2 = .142, F(4,35)= 1.443, p > .05
Y = 9.262 + .319X1 – .904X2 + .040X3 + .203X4
R2 = .178, F(4,35)= 1.893, p > .05
Y = 3.291 + .357X1 – .559X2 + .034X3 + .074X4
3 weeks
Regression equation
Prediction
R2 = .105, F(4,35)= 1.023, p > .05
Y = 7.698 + .311X1 – .307X2 – .028X3 + .545X4
R2 = .237, F(4,35)= 2.716, p < .05*
Y = 3.047 + .394X1 – .495X2 + .017X3 + .209X4
4 weeks
Regression equation
Prediction
R2 = .287, F(4,35)= 3.516, p < .05*
Y = 7.015 + .535X1 – .498X2 – .132X3 + 1.017X4
R2 = .135, F(4,35)= 1.363, p > .05
Y = 2.022 + .317X1 + .030X2 + .031X3 + .223X4
Note: df (regression, residual); Y= constant, treatment (X1), feeding frequency (X2), fiber consumption (X3), water intake (X4); a. Predictors: (Constant),
water intake, feeding frequency, treatment, fiber consumption; b. Dependent Variable: duration of defecation and bowel problems; *p<0.05 **<0.01
***p<0.001
The analysis result on hemoglobin levels shows a strong
and significant correlation between treatment (r=-.284,
p=.038) and hemoglobin levels by digital hemoglobin test
at week 4; and between feeding frequency (r=-.269,
p=.046), menstruation (r=.276, p=.043) and hemoglobin
levels by Sahli’s method at week 1. While, the result
analysis on bowel movements shows a strong and
significant correlation between treatment and duration of
defecation at week 4 (r=.339, p=.016) and bowel
problems at week 2 (r=.333, p=.018), week 3 (r=.438,
p=.002) and week 4 (r=.315, p=.024); between feeding
frequency and duration of defecation at week 2 (r=-.293,
p=.033); and between water intake and duration of
defecation at week 4 (r=.399, p=.005) (table 6).
A multiple linear regression analysis was performed
to predict hemoglobin levels and bowel movements
based on its predictors that produced regression
equations and participants’ predicted towards dependent
variables (table 7).
Based on multiple regression analysis, it was
discovered that there is no correlation between
hemoglobin levels (both by Sahli’s method and digital
test) and major confounders (treatment, feeding
frequency and menstruation) (table 8).
Table 8. Multiple linear regression analysis using hemoglobin levels as the dependent variable in both estimation
Sahli’s method
Digital hemoglobin test
Variables
ꞵ value
P value
95% CI
ꞵ value
P value
95% CI
Lower
Upper
Lower
Upper
1 week
Treatment
.154
.878
-.273
.318
-.596
.555
-.561
.306
Feeding frequency
-1.824
.077
-1.191
.063
-1.536
.133
-1.619
.224
Menstruation
1.866
.070
-.063
1.518
.100
.921
-1.104
1.219
2 weeks
Treatment
.501
.620
-.211
.350
-1.446
.157
-.780
.131
Feeding frequency
-.245
.808
-.602
.472
.512
.612
-.652
1.093
Menstruation
1.201
.238
-.362
1.414
1.697
.098
-.235
2.649
3 weeks
Treatment
.304
.763
-.143
.193
-1.393
.172
-.716
.133
Feeding frequency
-.583
.564
-.585
.324
-.302
.765
-1.321
.979
Menstruation
.632
.532
-.305
.581
1.131
.266
-.496
1.747
Indrayani, Agus Rahmadi, Dava Alpha Rakhim
P J M H S Vol. 12, NO. 4, OCT – DEC 2018 1755
Sahli’s method
Digital hemoglobin test
Variables
ꞵ value
P value
95% CI
ꞵ value
P value
95% CI
Lower
Upper
Lower
Upper
4 weeks
Treatment
-.586
.562
-.497
.274
-1.243
.222
-.784
.188
Feeding frequency
-.796
.431
-1.241
.541
-.531
.598
-1.417
.828
Menstruation
-.659
.514
-1.344
.685
.621
.539
-.887
1.669
Note: Dependent variables, Hb levels by Sahli’s method and digital hemoglobin test; CI: confidence interval; *p<0.05 **<0.01 ***p<0.001
However, there is a significant positive correlation
between treatment week 2 and 3 and bowel problems
after adjusting the effects of major confounders (feeding
frequency, fiber consumption, water intake) and between
water intake week 4 and duration of defecation after
adjusting the effects of major confounders (treatment,
feeding frequency, fiber consumption) (table 9).
Table 9. Multiple linear regression analysis using duration of defecation and bowel problems as the
dependent variables
Duration of defecation
Bowel problems
Variables
ꞵ value
P value
95% CI
ꞵ value
P value
95% CI
Lower
Upper
Lower
Upper
1 week
Treatment
1.163
.253
-.268
.988
1.560
.128
-.083
.631
Feeding frequency
-.389
.699
-1.678
1.138
-1.357
.183
-1.335
.265
Fiber consumption
.804
.427
-.259
.599
.444
.660
-.190
.297
Water intake
.630
.533
-.488
.927
-.804
.427
-.561
.243
2 weeks
Treatment
1.340
.189
-.165
.803
2.123
.041*
.016
.699
Feeding frequency
-1.901
.066
-1.870
.062
-1.663
.105
-1.241
.123
Fiber consumption
.252
.803
-.283
.363
.304
.763
-.194
.262
Water intake
.774
.444
-.330
.737
.399
.692
-.303
.451
3 weeks
Treatment
1.148
.259
-.239
.861
2.728
.010*
.101
.687
Feeding frequency
-.387
.701
-1.915
1.302
-1.172
.249
-1.353
.362
Fiber consumption
-.139
.890
-.438
.382
.160
.874
-.202
.236
Water intake
1.603
.118
-.145
1.236
1.152
.257
-.159
.577
4 weeks
Treatment
1.969
.057
-.017
1.088
1.813
.078
-.038
.671
Feeding frequency
-.567
.574
-2.279
1.284
.054
.957
-1.113
1.174
Fiber consumption
-.652
.519
-.542
.279
.240
.812
-.233
.295
Water intake
2.578
.014*
.216
1.817
.880
.385
-.291
.737
Note: Dependent variables, duration of defecation and bowel problems; CI: confidence interval; *p<0.05 **<0.01 ***p<0.001
DISCUSSION
The Friedman test result has detected a significant
difference in the hemoglobin levels in all four groups
between before and after treatment. It is undeniable that
iron consumption can improve hemoglobin levels13, 45, 46,
47 through increasing the serum retinol48. Similarly, the
consumption of dates can elevate hemoglobin levels36
through serum iron, serum ferritin, transferrin saturation
and total iron binding capacity49. This is interesting
considering that based on the composition, iron content
in 75 gr dates and 3 bottle 7dates are not equivalent to
200 mg ferrous sulfate and 250 mg ferrous gluconate.
Some studies reported that the average iron content
in 100 gr dates is approximately 0.24 mg50, 51, 52 while
100 gr Sayer dates contain 3.21 mg iron (around 2.4
mg/75 gr)40. With such a small amount of iron, dates
group can elevate hemoglobin levels almost as much as
ferrous sulfate group. Ferrous sulfate and ferrous
gluconate rely solely on iron for hemoglobin
enhancement, in contrast to dates and 7dates which use
multiple micronutrients to increase hemoglobin levels
since other micronutrient deficiencies will limit the
response of hemoglobin to iron supplements13. There are
some substances in dates contributing to hemoglobin
enhancement including iron, vitamin A, vitamin C, zinc,
and riboflavin. 100 gr of dates contain vitamins and
minerals (the percentage of each minerals in dried dates
varies from 0.1 to 916 mg)53, 54. The average vitamin
content in dates are vitamin A (23.85 μg), B1 (78.61 μg),
B2 or riboflavin (116.5 μg), B3 or niacin (1442 μg), B6
(207 μg), B9 (53.75 μg) and vitamin C (3900 μg)50.
Based on human and animal studies, Hodges et al.
concluded that vitamin A is essential for normal
hematopoiesis55. Experiments in mice show that iron
deficiency can decline serum retinol and affect on
accumulation of vitamin A in the liver as retinyl esters.
This may be related to impaired hepatic acid retinyl ester
hydrolase (iron-dependent enzymes)56. In case of
vitamin A deficiency, iron mobilization from the body’s
reserve to the circulation and tissues of hematopoietic
will be destroyed and cause disorders of erythropoiesis
(red cell production)57. Supplementation of vitamin A may
increase the response of hemoglobin to iron
supplementation13 and increase iron absorption
associated with iron concentrations in tissue57.
Therefore, a combination of iron and vitamin A
supplements may further improve iron status58, 59. Similar
to vitamin A, zinc supplement has also been proven to
elevate hemoglobin levels. Allen’s study reported that
supplement of zinc only or iron only can increase plasma
retinol. However, combination of zinc plus iron can
Can date fruits and 7dates replace iron tablets in increasing hemoglobin levels?
1756 P J M H S Vol. 12, NO. 4, OCT – DEC 2018
enhance plasma retinol more than iron alone13. The next
micronutrient is riboflavin. Riboflavin deficiency can limit
the efficacy of iron supplement, increase iron loss in
intestine and interfere iron absorption and intracellular
iron mobilization60, 61, 62. This condition may also interfere
with globin sythesis and activity of NADH-FMN
oxidoreductase so that the iron is trapped in ferritin and
becomes unavailable for erythropoiesis. NADH is
nicotinamide adenine dinucleotide (reduced form) which
is an active coenzyme form of vitamin B3 (‘niacin’) and
flavin mononucleotide (FMN) or riboflavin-5’-phosphate
is a biomolecule produced from B2 ('riboflavin') by the
enzyme riboflavin kinase. NADH-FMN reductase is an
enzyme involved in releasing iron from ferritin. Riboflavin
supplement may enhance hemoglobin response towards
iron supplementation63 and iron absorption through
enhanced gastrointestinal function64. Apart from that,
riboflavin is also prominent for the synthesis of the globin
component of hemoglobin65. Hence, riboflavin plus iron
supplements can increase hematologic status better than
iron alone66, 67. The same effect was also reported by
other studies that iron supplements or iron-rich foods
combined with micronutrients are more effective in
increasing hemoglobin levels than iron alone63, 68. The
combination of substances in dates may trigger activity
of phenol compounds which can stimulate erythropoietin
production by the liver which has an impact on
increasing hemoglobin enhancement35, 36. 100 gr fresh
dates contains phenolics (134-280 mg of ferulic acid
equiv), free phenolic acids (2.61-12.27 mg), and bound
phenolic acids (6.84-30.25 mg)69. While Biglari et al.
reported total phenolic level in 100 gr dates is in range
2.89-4.82 for soft date, 4.37-6.64 for semi-dry date and
for dry date at 141.35 milligrammes of gallic acid
equivalent per 100 grammes of dry weight (mg
GAE/100g dw)70. One further matter of interest is that in
addition to containing micronutrients, dates also contain
macronutrients that can inhibit iron absorption, namely
calcium and magnesium71, 72. On average, 100 gr dates
contains 56-150 mg magnesium50, 51, 52, 73 and 123-187
mg calcium73. In spite of macronutrients contents that
can inhibit iron absorption, dates remain capable to raise
hemoglobin levels. This is caused by other substances in
dates which are able to inhibit the inhibitory effect of iron
absorption as reported by Layrisse who stated that
vitamin A may reduce the inhibitory effect of polifenol
and phytates on iron absorption74.
Hemoglobin estimation by digital test shows that the
four groups tended to experience a downward trend in
the fourth week. This is more likely to relate to the body’s
defense system in which the hemoglobin levels of
respondents in four groups had reached a normal level
at around 12.0 g/dL to 13.0 g/dL (see table 2). Human
body has evolved to keep iron from breakage in various
ways including recycling iron after the damage of red
blood cells and iron retention if there is no dispense
mechanism. However, iron excess can be toxic so that
its absorption is limited to 1-2 mg per day and the most
iron needed by the body (about 25 mg per day) is
provided through recycling by macrophaging agitated
erythematic phagocytosis. The two mechanisms are
controlled by hormone Hepcidin, which keeps total body
iron in the normal range (no deficiency or excess)75.
Iron supplements have been proven to increase
hemoglobin levels. However, high doses of iron
consumption (more than 120 mg) significantly increase
the risk of constipation, gastric pain, diarrhea,19, 76
heartburn, nausea and vomiting19. This report is in line
with the findings that the ferrous sulfate and ferrous
gluconates groups experienced more problems in
defecation. Constipation is the most frequent chronic
gastrointestinal complaint77. Patients may report
constipation even though they defecate daily. Criteria for
constipation diagnosis includes less frequent bowel
movements (less than 3 times per week), hard stool
and/or difficulty to expel feces,20, 78 and straining78. These
complaints are often ignored because these complaints
are considered taboo to be discussed and left without
treatment until constipation becomes a severe problem
for the patient79. If constipation persists and the patient
does not obtain appropriate treatment, complications will
become severe, including feacal impaction (obstruction
due to hard stool), further causing faecal incontinence80.
Straining defecation may also increase the risk of
prolapse uterovaginal81 and cause permanent damage in
the form of pudendal nerve damage and impair the
supporting function of the pelvic floor muscles82. It is not
surprising that patients with constipation have a lower
quality of life compared to inflammatory bowel disease or
gastroesophageal reflux disease83. In extreme and rare
cases, complication is caused by untreated constipation,
such as movement from thrombus vena into vena
pulmonary, or sudden cardiac death as a result of
straining and cardiac abnormalities84, 85.
On the other hand, the 7dates and dates groups had
fewer bowel complaints than ferrous sulfate and ferrous
gluconates groups. This is because dates are the best
source of dietary fiber. High fiber consumption decreases
the risk of constipation86 and obesity,87 increases the
amount and frequency of bowel movements, and
decreases the average transit time88. Recommended
daily intake (RDI) of dietary fiber for healthy adults (>20
years) is 25-35 gram per day85. Some studies reported
that 100 gr dates contains 6.4% to 11.5% dietary fiber,54,
89 including 0.84 gr soluble dietary fibre, 5.76 gr insoluble
dietary fiber and 8 gr total of dietary fiber69, 90, 91, 92.
Insoluble dietary fiber plays a very significant role in
human body. It can protect the body from many
diseases, such as diverticular disease and bowel cancer
through the increase of fecal weight, and also has a
laxative effect93. The findings in this study are also
supported by Al-Shahib et al. which stated that the
consumption of six or seven dates can meet 50-100% of
RDI of dietary fiber90. The fiber content in dates can help
to relieve bowel movements and overcome constipation.
It can be used as a natural laxative for patients with
constipation54.
Indrayani, Agus Rahmadi, Dava Alpha Rakhim
P J M H S Vol. 12, NO. 4, OCT – DEC 2018 1757
In addition to fiber, the body also needs water.
Derbyshire et al. found that water intake significantly
decreases the incidence of constipation in women21.
Given the side-effects of iron consumption and people’s
habit of consuming less fiber and water, the optimization
of natural nutrients can be the recommended as a sound
strategy. In many cases, dates and its processed
products can be considered as the most ideal food54
because dates contain many other essential nutrients
needed by the human body90.
CONCLUSION
In the final analysis, dates can be used instead of iron
tablets and 7dates can be used as a companion iron
tablets. Although ferrous sulfate, ferrous gluconate,
dates and 7dates can elevate the hemoglobin levels,
both ferrous sulfate and ferrous gluconate have negative
side effects while dates and 7dates give positive effects
in bowel movements so that both dates and its
processed products should be considered as an
alternative solution for handling and preventing anemia.
Acknowledgement: We would like to present our gratitude to
the Overseas Seminar Assistance Program of Directorate
General of Research and Development Reinforcement,
Kemristekdikti that has facilitated researchers to present the
research findings at 5th World Congress on Midwifery and
Women's Health in Frankfurt, Germany. We would also like to
thank to Ms. Jayanti Chess Ruti, Ms. Tri Widiawati, Ms. Silpha
Shetty, Ms. Amatulloh Shoolihah, Ms. Windi Suparwati, Ms.
Dera Ayu Ardiana who has helped in the process of data
collection.
Conflict of interest: All authors state that there is no conflict of
interest in this study.
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