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Effects of Red Guava Juice on Hemoglobin and Hematocrit
Levels in Female Adolescent Students with Anemia
Mega1, Hidayat Wijayanegara1, Siti Sugih Hartiningsih1*, Menizibeya O Welcome2,
Senol Dane2
1Dharma Husada Institute of Health Sciences, Bandung, Indonesia
2Department of Physiology, College of Health Sciences, Nile University of Nigeria, Abuja, Nigeria
ABSTRACT
Background: Anemia is a major public health problem. Iron deficiency anemia is the most common form of anemia due to
malnutrition especially in developing countries. Adolescents are one of the major groups of risk for anemia. The condition
can lead to impaired brain functions resulting to a decrease in learning ability and academic performance. Medicinal foods,
in particular, red guava, have been used for decades to treat several ailments of humans. There is paucity of human data on
the effects of red guava on anemic conditions. The purpose of this study was to compare the effects of red guava juice on
hemoglobin and hematocrit levels with iron supplementation in adolescent female students with anemia.
Methods: The study was approved by the Ethical Committee of the Dharma Husada Institute of Health Sciences, Bandung,
Indonesia. The study was conducted among high school students of Tomo Secondary School, Sumedang, Bandung, Indonesia.
Out of 236 female adolescent students, a total of 32 (15-18 years, mean age ± standard deviation, 16.45 ± 3.12) had iron
deficiency anemia. The anemic students were randomized into two groups: red guava group (n=16) and iron
supplementation group (n=16).
Results: Both red guava and iron supplementations resulted in a significant increase in both hemoglobin and hematocrit
levels. The effectiveness of both was not different each other.
Conclusion: The results of this study suggest that red guava juice was effective as iron supplementation in increasing
hemoglobin and hematocrit levels.
Key words: Iron anemia, Hematocrit, Hemoglobin, Red guava juice
HOW TO CITE THIS ARTICLE: Mega, Hidayat Wijayanegara, Siti Sugih Hartiningsih, Menizibeya O Welcome, Senol Dane, Effects of Red Guava Juice on
Hemoglobin and Hematocrit Levels in Female Adolescent Students with Anemia, J Res Med Dent Sci, 2019, 7(3): 145-150
Corresponding author: Siti Sugih Hartiningsih
e-mail✉: sitisugih@stikesdhb.ac.id
Received: 01/05/2019
Accepted: 30/05/2019
INTRODUCTION
Anemia still attracts the attention of researchers and
policy makers worldwide due to the high prevalence and
the resulting menace posed by the condition [1,2]. Anemia
is a major public health problem with a global prevalence
of about 2 billion [3,4]. Adolescents are one of the major
risk groups for anemia. The incidence of anemia among
adolescents is higher in developing countries (27%),
compared to only 6% in developed countries [5]. The
prevalence of anemia in Indonesia is reported to be
around 16%-39% [2]. However, Barkley et al.
substantial changes in trends of anemia over time in
Indonesia, hence the need for continuous monitoring of
the prevalence of anemia [2]. Unfortunately, there is lack
of data on the prevalence of anemia in several regions of
Indonesia, including Tomo Secondary School, Sumedang,
Indonesia.
The most common type of anemia is iron
anemia, occurring mainly due to nutritional [6].
Iron anemia is the major type of anemia during
the adolescent period [4]. In addition to malnutrition and
accelerated growth, hormonal changes and onset of
menstruation, the condition is believed to be worse in
female adolescents [5]. Due to the importance of iron in
almost all organs and tissues of the body, of this
micronutrient may lead to impairment in perception,
learning and memory, consequently resulting to decrease
in academic performance among students [5].
The problem of iron anemia in students is
further worsened by the eating habits, hence the need to
monitor and where necessary carry out intervention to
tackle the problem [2]. Both iron supplementation and
medical plant products have been used to address the
problem of anemia in different settings [7]. Certain food
items as well as medicinal plant products contain
considerable amount of iron [8]. Red guava (Psidium
guajava Linn, family: Myrtaceae), popularly known as
guava, is a medicinal plant found in tropical and
subtropical countries [9,10]. Guava trees have been grown
Journal of Research in Medical and Dental Science
2019, Volume 7, Issue 3, Page No: 145-150
Copyright CC BY-NC 4.0
Available Online at: www.jrmds.in
eISSN No.2347-2367: pISSN No.2347-2545
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Journal of Research in Medical and Dental Science | Vol. 7 | Issue 3 | June 2019 145
by many other countries, thus allowing production
around the world [11]. Teas, infusions, and decoctions
prepared from the leaves, root, bark, seeds, fruits, and
are safe for oral and topical application and used
for treatment purposes [9,12]. The fruit serves as food
[9].
Though, traditionally, preparations of the leaves have
been used in folk medicine in several countries, mainly as
anti-diarrheal ant- dehydration remedy [13], over the
past decades, accumulating data have shown that red
guava is effective in addressing different infections,
including gastroenteritis and dysentery [9,14-17], act as
immunostimulant [18], anti-hyperglycemic [19], anti-
apoptotic [18,20], chemopreventive, chemotherapeutic
[21], hepatoprotective [22], antioxidant [23], anti-allergy,
cardioactive, and antinociceptive agent [24]. An animal
study conducted by Uboh et al. revealed that red guava
extract increased hemotocrit and
hemoglobin levels [25]. However, there is lack of human
data on the effects of red guava on hematocrit and
hemoglobin levels. No study has addressed
possible effects of red guava on the levels of hemoglobin
and hematocrit in patients with anemia.
The purpose of this study was to investigate the effects of
red guava juice on the levels of hemoglobin and
hematocrit in female students with iron
anemia.
MATERIALS AND METHODS
Ethical statement and clearance
The study was approved by the Ethical Committee of
Dharma Husada Institute of Health Sciences, Bandung,
Indonesia (ethical clearance number: 010/STIKes- DHB/
Sket/PSKBS2/X/2017).
Participants
Before the commencement of the study, 236 female
adolescent female students of Tomo Secondary School,
Sumedang, Bandung, Indonesia, were approached to
volunteer for the study after the aims and objectives,
study methodology, expected risks and had been
thoroughly explained to them.
Students were free to discontinue or withdraw from the
study at any given point. A total of 228 who volunteered
for the study were screened for anemia. Of them, 43
students who had positive signs of anemia on the basis of
preliminary assessment were selected for hematological
investigation. However, 33 volunteered for the
hematological investigation.
Based on the results of hematology, one of the 33
participants was excluded as the participant did not have
iron anemia and was referred to the nearest
Health Center further for diagnosis and treatment. A total
of 32 (range 15-18 years, mean age ± standard deviation,
16.45 ± 3.12; weight 42-56 Kg, average 47.38 ± 2.14 Kg)
had iron anemia according to hemoglobin,
hematocrit and serum ferritin levels.
The anemic students were randomized into two groups:
red guava group (n=16) and iron supplementation group
(n=16). Their age range was from 15 years to 18 years
(mean age ± standard deviation, 16.45 ± 3.12). There was
no age and body weight difference between the two
groups.
Inclusion criteria
1. Willingness to participate.
2. The presence of anemia
3. Absence of any other health problems based on
recent medical examination.
Exclusion criteria
1. Unwillingness to participate in the study.
2. Presence of other health problems other than
anemia such a metabolic, cardiac or renal disease,
which may affect hemoglobin or hematocrit based
on anamnesis.
Procedure
This study was conducted for 2 weeks i.e., from
December 2017-January 2018. After approval of the
experimental protocol, the aims and objectives of the
study were explicitly explained to the participants before
commencing the experiment.
All the volunteers signed an informed consent before
starting the experimental session. The phase of the
study was carried out by checking for conjunctiva pallor
and capillary Students who had pallor and a
delayed capillary (normal 1-2 seconds) were
brought to the local health laboratory for hemoglobin
and hematocrit analysis. The 32 students reported after
12 h overnight fast and 4 ml venous blood sample was
collected for analysis. All students were told to
completely abstain from iron rich foods such as cow milk,
meat, eggs, oranges, beans, peas, and strawberries. The
participants were randomized by assigning random
numbers generated using Excel sheet, the list of
participants was rearranged according to the random
numbers. 16 students each were assigned in each group.
For duration of 2 weeks, one group received red guava
juice and the other received iron tablet daily. They were
given a list of foods with high iron content (including
meat, liver and spinach) and advised not to consume the
stated foods.
Obtention and preparation of red guava juice
Fresh guava fruits without lesions induced mechanically
or by pathogens were purchased locally from Saluyu Jaya
village in Majalengka sub-district, Bandung, Indonesia.
The fruits were and authenticated by an
Agriculturist from the Food Crops and Horticulture
Services of West Java Province Government, and the
voucher specimen was deposited in the herbarium
(184/B. JmB. BR. IV/3.2017).
Siti Sugih Hartiningsih et al J Res Med Dent Sci, 2019, 7 (3):145-150
Journal of Research in Medical and Dental Science | Vol. 7 | Issue 3 | June 2019 146
The fruits were prepared according to the following
recommendations [12] with The fruits
were thoroughly washed in running water, kept in a 0.1%
sodium hypochlorite solution for 1 h, then washed in
distilled water. The fruits were ground in a blender
(Maspion group, Kembang Jepun 38-40, Surabaya 60162,
East Java, Indonesia) and subjected to manual
The resulting juice was stored in perfect condition under
refrigeration at -25°C before administration.
Supplementation of red guava juice
Sixteen participants included in group A were
supplemented with 100 ml of red guava juice everyday
under direct supervision for 2 weeks. The quantity of red
guava juice was based on the calculation that each 100 ml
contains about 0.69 mg of iron (the quantity required by
adolescent females is about 0.7 mg-0.9 mg of iron per day
at early adolescent stage to 2.2 mg iron per day or even
more in heavily menstruating adolescents [26].
Iron supplementation
All participants from the iron supplementation group
received a daily dose of ferrous sulfate 300mg, which is
equivalent to 60 mg of elemental iron (i.e., 300 × 0.2).
Identification of anemia
Determination of conjunctival pallor and capillary
refill time
Conjunctival pallor and capillary time were used as
measures for screening. Conjunctival pallor and capillary
time were determined as earlier reported [27].
Conjunctival pallor or capillary time is
recommended for anemia screening [27].
Collection of blood samples
A maximum of 4 ml of venous blood samples were
collected from the antecubital fossa by using aseptic
methods, and dispensed into EDTA tubes for hematology
for determination of hemoglobin and hematocrit. Sample
tubes were obtained from Becton Dickinson (Plymouth,
United Kingdom). Blood samples collected in EDTA tubes
were stored and transported in cold styrofoam boxes and
analyzed within 4 h of collection. Blood was allowed to
clot at room temperature (25°C) and was centrifuged at
3000 × g for 15 min [28].
Determination of hemoglobin, hematocrit and serum
ferritin levels
Hemoglobin, hematocrit, were measured by using
validated MSLAB07 plus Hematology Analyzer
(Guangzhou MeCan Medical Limited, Guangzhou,
Guangdong, China). Reagents, calibrators, and controls
were obtained from the instrument manufacturer.
Analysis of samples was performed within 8 h of blood
draw. Automated determination of hemoglobin,
hematocrit levels were performed according to the
manufacturer’s
The hemoglobin cut-off point indicating anemia was
done according the World Health Organization. A value
less than 12 g/dl or 120 g/l for females (aged 12
years-18 years) was considered as anemia according
[25]. Hematocrit was considered to be abnormal at
values <0.36 for females [28].
Serum samples for measurement of ferritin were stored
at -70°C until they were sent to the Biochemical
Laboratory of the Health Center at Sumedang, Bandung,
Indonesia for analysis. Ferritin concentration was
measured by ELISA technique as previously described
[29]. Iron was as ferritin levels <12
µg/l [30]. All participants with iron had serum
ferritin levels lower than <12 µg/l.
Statistical analysis
The SPSS software (version 18.0 for Windows) was used
for statistical data analysis. Results are expressed as
mean ± standard deviation (SD) as well as in percentages
(%). The pattern of data distribution was evaluated by
Kolmogorov Smirnov test. Repeated Measures Test in
General Linear Model was used for comparison of results
of hemoglobin and hematocrit before and after (two
measures: 7th and 14th days) therapy. Differences were
considered statistically at p˂0.05.
RESULTS
There were no statistically differences in the
pretest values of hemoglobin and hematocrit levels
between the red guava group and iron supplementation
group. Both red guava and iron supplementation in the
female students led to increase in both hemoglobin and
hematocrit levels (p=0.00) (Figures 1-4). However, there
was no statistically differences in the values of
posttest hematocrit and hemoglobin values between the
red guava group and iron supplementation group
(F=2.57, p=0.1).
Figure 1: Hemoglobin levels (g/dl) before (7th day) and after (14th
day) treatment with red guava juice
Siti Sugih Hartiningsih et al J Res Med Dent Sci, 2019, 7 (3):145-150
Journal of Research in Medical and Dental Science | Vol. 7 | Issue 3 | June 2019 147
Figure 2: Hematocrit levels (%) before (7th day) and after (14th
day) treatment with red guava juice
Figure 3: Hemoglobin levels (g/dl) before (7th day) and after (14th
day) of iron supplementation
Figure 4: Hematocrit levels (%) before (7th day) and after (14th
day) of iron supplementation
DISCUSSION
The use of medical plants for food and treatment is an
integral part of the cultures in many parts of the world
[31]. These cultures promote health and quality of life
with therapies based on the use of natural products [32].
Given that plants have been widely used as herbal
medicines, several approaches are now being carried out
to discover new bioactive compounds from natural
sources [33]. The results of this study suggest that a 2-
week supplementation with red guava juice can be
effective is treating iron anemia, which
accounts for about 50% of all anemias. Iron
anemia is worse in tropical and subtropical countries due
to endemicity of malaria and other parasitic infections
[25]. Interestingly, the effects of red guava juice were
comparative with those of iron supplementation group.
Consequently, red guava juice can be used in place of iron
supplementation because it is easier to produce and
cheaper. Red guava contains a substantial quantity of
iron. The iron content of this medicinal plant is estimated
to be about 6.91 mg/kg or equal to 0.69 mg/100 g, which
is greater than the iron content in meat (2 mg/kg or
equal to 0.2 mg/100 g of iron), liver (5 mg/kg or equal to
0.5 mg/100 g of iron) [34-36]. Although different parts of
this plant have been used traditionally to treat many
diseases including bleeding gums [25], no empirical
investigation has been conducted in humans on the
effects of red guava on hematological indices of anemia.
The fact that no difference was observed
between the iron supplementation group who took 300
mg of ferrous sulfate (60 mg of elemental iron) and the
red guava group possibly, suggests some differences in
intestinal absorption of iron in different sources. Though
60 mg of elemental iron is relatively high, there are
currently many recommendations on oral iron dosage,
which vary with age, gender, and physiological states, and
may range from 8 mg to 60 mg per day [37-42]. Ingestion
of iron within a period of two weeks successfully treated
the observed anemia in the volunteers. Indeed iron is
absorbed within 24 h-48 h following ingestion [43].
Incorporation of elemental iron into hemoglobin occurs
within 4-7 days, but may be as early as 2-3 days,
depending on dietary and other factors [44,45]. Iron
absorption may even occur within a shorter period of 1
h-6 h depending on the time after food ingestion or
fasting [46]. However, Goodnough et al. noted that in
patients with iron about 50% of “intravenous
iron” is incorporated into hemoglobin in 3-4 weeks [47].
The reasons for these discrepancies in data are not
exactly clear. But it may be due to differences in
methodological approaches and peculiarities in intestinal
absorption, transport and turnover rate of iron/
hemoglobin in different individuals as well as the
presence of diseases that affect iron metabolism and
turnover.
The majority of works on the medicinal importance of
red guava has been focused on the leaves, which is
traditionally used in folk medicine to treat a couple of
human diseases including diabetes mellitus,
hypertension, infections (gastrointestinal, respiratory,
dental, cutaneous), cancer, menstrual problems, pain,
hepatic problems among others [48,49].
However, the fruit is the most palatable portion of red
guava. Thus the fruit is the most important part of red
guava [12]. From the above, the plant has substantial
economic importance, in addition to its taste and
[12]. Apart from our study, the effects of guava on indices
of anemia have not been explored empirically in humans.
Though the mechanisms of action of red guava is not
exactly clear, several studies performed around the globe
have shown that the medicinal plant contains tens of
molecules including over 60 types of compounds:
alkaloids, glycosides, polyphenols, saponins
Siti Sugih Hartiningsih et al J Res Med Dent Sci, 2019, 7 (3):145-150
Journal of Research in Medical and Dental Science | Vol. 7 | Issue 3 | June 2019 148
[25], anthocyanins, carotenoids, essential oils, fatty acids,
lectins, tannins, triterpenes, vitamin C [25], ellagitannins,
proanthocyanidins, dihydrochalcones, anthocyanidins,
stilbenes, acetophenones, benzophenones, phlorizin,
nothofagin, astringin, chrysin-C-glucoside, valoneic acid,
bilactone, cinnamoyl-glucoside, dimethoxycinnamoyl-
hexosides [50], gallic acid, epigallocatechin gallate,
syringic acid, o-coumaric acid, resveratrol, quercetin,
catechin [13], gallic acid, caffeic acid, guaijaverin,
carotenoids, triterpenoids [13,24], and quercetin [25].
The role of red guava juice in mediating increase in
hemoglobin and hematocrit levels may in part be due to
its pleiotropic activities including its antioxidant action.
Red guava was shown to suppress
molecules such as iNOS and NF-κB through activation of
PPARγ [10,50].
CONCLUSION
Red guava juice was effective in increasing hemoglobin
and hematocrit levels of female students with anemia.
The effects of red guava on hemoglobin and hematocrit
levels were comparable to the effects achieved upon
administration of iron supplementation. Red guava is a
very cheap fruit that even the less privileged people can
acquire it easily. Therefore, this fruit juice can be effective
not only in managing oxidative states, but
also, treat iron anemia.
ACKNOWLEDGEMENT
We acknowledge Dr. HJ. Suryani Soepardan, Chairman of
Dharma Husada, Bandung; Principal of Tomo Secondary
School, Sumedang, Indonesia, and their co-workers who
helped at one or more phases of the study.
CONFLICT OF INTEREST
The authors declare that there is no of interest
regarding the publication of this manuscript.
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