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Resumen: Efectos de la incorporación de la Moringa oleifera en las bebidas de frutas sobre parámetros clínicos que miden la deficiencia de hierro y anemia en niños. La anemia ferropénica (AF) es una de las carencias nutricionales más significativas a nivel mundial, especialmente en los países de bajos y medios ingresos, debido principalmente a la morbilidad asociada, las implicaciones en el sistema de salud y el estado de bienestar. Una de las causas más frecuentes de esta deficiencia en los niños es la ingesta insuficiente, que tiene una evidente conexión con el entorno social. La principal estrategia en el manejo de esta afección es contrarrestar esta deficiencia a través de la mejora de la nutrición y la educación familiar. Con el objetivo de explorar enfoques asequibles, novedosos y directos para el tratamiento de esta enfermedad, se desarrolló un estudio descriptivo asociado a la incorporación de la Moringa oleifera en bebidas de frutas caseras que se suministraron a 32 niños de familias de bajos ingresos para hacerle seguimiento a la evolución de la anemia por deficiencia de hierro, evaluando parámetros clínicos específicos como el volumen de células rojas y los niveles de hemoglobina, ferritina y hierro sérico en un lapso de dos meses. Se observó un aumento estadísticamente significativo en los niveles de todos los parámetros evaluados una vez finalizado el período de intervención. Al final del ensayo, observamos un aumento estadístico significativo en los niveles de todos los parámetros evaluados, encontrando un aumento de aproximadamente 1.3 veces en los niveles de hemoglobina y ferritina y en el volumen de los glóbulos rojos; el hierro sérico fue 1.1 veces mayor. Estos hallazgos son una demostración del amplio espectro de las características medicinales de la Moringa y establecen una estrategia prometedora y accesible, fácil de incorporar a la dieta de las familias de los niños que sufren esta patología. ALAN, 2019; 69(1): 2-11. Palabras clave: Anemia ferropénica, Moringa oleifera, nutrición, escolares, alimentos funcionales, hierro sérico.
Effect of the addition of Moringa oleifera to fruit drinks on clinical parameters
associated with iron deficiency anaemia in schoolchildren
Karen Piedad Martínez Marciales,1,2^ Javier Andrés Soto,1,3^ Jhoalmis Sierra Castrillo,1,
Jonathan Gonzalo Olivieri Moncada,^1 Jaizul Carolina Galeano Arias,^1 Lyz Jenny Gómez Rave.^4
(^1) University of Santander (UDES), Cúcuta, Bacteriology Program and Clinical Laboratory, 2 Crisalida Research Group. 3 Biogen Research Group. 4 University Institution of the Higher School of Antioquia (IUCMA), Faculty of Health Sciences, Biosciences Research Group, Medellín, Colombia. Autor para la correspondencia: Jhoalmis Sierra Castrillo, Email: jhosica1988@hotmail.com Summary: Effect of the addition of Moringa oleifera to fruit drinks on clinical parameters associated with iron deficiency anaemia in schoolchildren. Worldwide, iron deficiency anaemia (IDA) is one the most significant nutritional maladies, especially in low and middle-income countries. This is mainly due to the associated morbidity, economic implications on the health system and the welfare state. One of the most prevalent causes of IDA in children is insufficient food intake, which has an obvious connection with the social environment. The main strategy in the management of this condition is counteracting such deficiency through the improvement of nutrition and family upbringing. Aiming to explore affordable, novel and straightforward approaches to treat this nutritional condition, we developed a descriptive study associated with the incorporation of Moringa oleifera in homemade fruit beverages delivered to 32 children from low-income families, in order to assess the evolution of IDA, evaluating specific clinical parameters such as red blood cells volume, as well as hemoglobin, ferritin and serum iron levels, within a two months lapse. At the end of this period, we observed a significant statistical rise in the levels of all the assessed parameters, finding about a 1.3-fold increase in hemoglobin and ferritin levels and in red blood cells volume; serum iron was 1.1 times higher. These findings are demonstrative of the wide spectrum of the medicinal features of Moringa and establish a promising and accessible strategy easy to incorporate into the diet of families of children suffering this pathology. ALAN, 2019; 69(1): 2-11. Key words: Iron deficiency anaemia, Moringa Oleifera , nutrition, schoolchildren, functional food, serum iron. ARCHIVOS LATINOAMERICANOS DE NUTRICIÓN Órgano Oficial de la Sociedad Latinoamericana de Nutrición Vol. 69 N° 1, 2019 Introduction According to World Health Organization WHO (1), nutrition is the intake of food in relation to the dietary needs of the body, and a deficient nutrient uptake can affect immunity, increase vulnerability to disease, alter physical and mental development, and reduce cognitive productivity. Nutrition and feeding are complementary
Moringa oleífera-anaemia for iron deficiency processes that are extremely significant at all stages of human development and biologically critical in childhood. A balanced diet is necessary in the early stages on the growth of an individual to consolidate his or her development and thus establish a solid biological basis for the following phases. An imbalance in the feeding-nutrition process could lead to the onset of a plethora of negative physiological outcomes, including the well-known iron deficiency anaemia (IDA). A quarter of the world’s population is affected by anaemia and half of these individuals suffer from IDA. Iron is an inorganic mineral found in a variety of food that plays a main role in the physiology of living beings, as it is crucial for tissue development, synthesis of hormones and enzymes as well as oxygen intake in red blood cells. Twenty years ago, the International Nutritional Anaemia Consultative Group (INACG) estimated that about 80% of the world’s population could be iron-deficient (2), whereas in Colombia the prevalence of iron- deficiency anaemia is 47% among schoolchildren (3). It is well known that critical social conditions are intimately linked with the appearance of IDA. There are geographic regions in Colombia that reach malnutrition rates similar to those observed in child population of Southern Sudan. Intense efforts are being made to develop social and experimental IDA control strategies based on the use of iron supplements, the intake of fortified food and drinks and the improvement of food safety. Based on this background, there was the need to develop a study whose main objective was to determine the effect of the addition of Moringa oleifera in daily household beverages to assess the evolution of anaemia in the population under study. This plant has a strong precedent in studies concerning traditional medicine and has been shown to play role as a an anti-pyretic, anti-oxidant, anti-cancer, anti-inflammatory, anti- obesity, hepatic and gastric-protector, anti-diabetic, immunomodulator, analgesic, among others (4), due to its phytochemical and pharmacological properties. Based on the generous empirical literature, we provided homemade beverages supplemented with Moringa oleifera to school students from low- income families in order to assess the condition of anaemia through various clinical parameters during two months of treatment. Materials and Methods Population and type of study. This research was constructed as a prospective field study based on repeated measurements where every single individual was her/his control. A sample of 32 schoolchild from the Juan Bautista Scalabrini Institution located in Cucuta city was evaluated, according to the guidelines required for human research and under the approval of the Research Committee of Bacteriology and Clinical Laboratory program of the University of Santander, Cucuta campus. This study lasted two months The inclusion criteria applied for selection of individuals were: students between 4 to 8 years old, hemoglobin levels (Hb) lower than 12 g/dl, volume of red cells lower than 33%, according to the criteria of the World Health Organization (WHO) for the diagnosis of anaemia in relation to hemoglobin levels and red blood cell volume in children from 5 to 11 years of age, (5). Children should be free of immunohematological diseases and cancer diagnosis. For children to be included in the study, the representative figure had to sign an informed consent beforehand. A family survey was conducted to assess the level of knowledge about anaemia status and assiduity in children’s consumption of vegetables, fruit and protein. This study followed the guidelines established in the Declaration of Helsinki for research in human groups, pointing out that this research was carried out by individuals with adequate scientific preparation and under the supervision of health professionals. On the other hand, the willingness of each individual to decide whether or not to participate in this study was respected, always safeguarding their personal integrity. (Council of International Organizations of the Medical Sciences 1993). Survey We performed a survey looking to support the descriptive investigation in order to collect data through a previously designed questionnaire, without modifying the environment or the phenomenon. We collected this information in the form of a table. Data was obtained by performing a set of standardized questions addressed to the parents of the children selected for the study. We applied the conventional pencil and paper method for the physical filling of the questionnaire and we implemented open and closed response questions related to the lifestyle and specific topics on the nutrition of their children and the state of health, as well as related to the condition of anaemia.
Figure 1. Questions addressed to parents of the 32 schoolchildren under study. In these pie charts are represented the most significant data obtained from the survey applied to the parents in order describe plausible descriptive associations with further assessment of the clinical parameters. Do you know what anaemia is? Do you know the physical consequences of having anaemia? Weekly intake of fruits Do you know the ways to prevent anaemia? Weekly intake of vegetables Weekly intake of chicken/meat Do you children eat grains weekly? Which of the following symptoms you see most frequently in your children Sleepiness 12% Unwilling to do anything 16% Weakness 6% Educational underachievement 66% NO 38% YES 62% Once at week 64% Once at week 36% (^) Once at week 62% Once at week 38% NO 94% YES 6% Once at week 76% Never 24% NO 13% YES 87% NO 59% YES 41% Moringa oleífera-anaemia for iron deficiency Adding Moringa oleifera to homemade beverages has positive effects on IDA. Seeking to test our hypothesis on the biological effect that Moringa could promote in children suffering from IDA, we assessed a series of clinical parameters, which are the most appropriate for a clinical follow-up of this condition. Tables 1 y 2 represents all the measures of everyone analyzed. The collected data was submitted for statistical analysis, specifically comparison of variables by significant minimum difference of Turkey due to the nature of the assessed variables and the design of our work. Although no obvious difference was observed for absolute values, once the statistical tools were applied a significant difference was observed for all parameters. The mean values increased for the volume of red blood cells, hemoglobin, ferritin and serum iron in the population under study at the end of treatment in a significant trend, so the statistical evaluation gives a p-value < 0.01 for each intervention. The Mauchly sphericity test determined that the data met the homogeneity requirement except for the red cells volume (6). In order to present our findings in a more descriptive way, we present the output data through a graphical representation in which it is possible to observe the increasing trends of each parameter over time in a statistically significant way (Figure 2). These positive observations derived from the study were also identified in the proportion of children influenced by the effects of treatment. According to the histogram depicted in Figure 3, it is possible to observe a clear trend in the intervention time with respect to the increasing number of children who showed an improvement in the measurement of the biological parameters evaluated. Due to the design of the study, all individuals exhibited measurements below the normal cutoff in all the parameters at the beginning of the treatment, but this appreciation began to revert throughout the intervention, showing an increasing number of children who eventually began to recover normal values in the volume of red cells, hemoglobin, ferritin and serum iron.
Karen Piedad Martínez Marciales et al. Table 1. Measurements in boys participants in the study. In this table are depicted every value for every parameter in every time lapse of intervention according to sex RED VOLUME CELLS ≤ 32% HEMOGLOBIN ≤ 12,5 Gr/L FERRITIN Male ≤ 29 μg/L ; Female ≤ 19 μg/L SERUM IRON Male ≤ 64 μg/dL ; Female ≤ 49 μg/dL Code 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx NUES001 28 30 32 9,8 11,4 12,1 21 23 28 48 49 55 NUES002 21 28 31 8,1 9,2 11,2 25 26 29 37 38 43 NUES006 28 29 31 9,9 9,8 11,2 23 24 27 55 57 60 NUES011 30 32 33 11,2 11,1 11,9 24 26 29 41 45 46 NUES012 26 28 32 9,1 9,6 11,1 26 29 33 39 40 47 NUES022 14 19 30 5,6 6,7 10,1 26 28 31 54 55 59 NUES026 28 30 34 9,5 10,9 12,4 21 27 30 51 54 61 NUES027 24 31 35 8,3 11,1 12,6 25 27 31 39 41 49 NUES032 29 30 33 10,5 11,1 11,9 21 25 29 53 55 62 NUES036 26 30 32 9 10,7 11,1 27 28 31 45 46 57 NUES038 23 32 34 8,1 11,7 12,5 23 24 30 39 40 48 NUES039 27 33 36 10,1 11,9 12,6 24 25 29 45 48 55 NUES047 30 41 42 10,7 12,9 13,2 24 29 32 54 59 65 NUES048 29 36 41 10,1 11,9 12,9 26 30 31 61 68 69 NUES050 18 29 33 7,4 9,3 10,6 25 26 30 60 67 67 NUES054 27 28 32 9,5 9,3 10,1 27 28 31 54 56 64 NUES055 25 28 34 8,4 8,9 11,2 20 23 28 45 48 55 NUES057 23 25 30 7,9 8,1 10,6 25 26 26 39 41 47 NUES062 30 33 34 10,5 10,5 10,9 23 26 31 53 55 63 NUES066 23 34 34 7,6 8,1 10,6 25 23 28 56 57 61 NUES067 20 29 31 6,9 8,9 10,1 21 21 27 61 64 67 NUES070 19 25 30 6,7 8,3 10,3 19 23 29 52 55 64 NUES072 21 29 33 8 9,8 10,7 22 25 31 48 50 57 RED VOLUME CELLS ≤ 32% HEMOGLOBIN ≤ 12,5 g/L FERRITIN Male ≤ 29 μg/L ; Female ≤ 19 μg/L SERUM IRON Male ≤ 64 μg/dL ; Female ≤ 49 μg/dL Code 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx 1 Mx 2 Mx 3 Mx NUES003 23 25 30 8,2 8,6 10,9 14 19 23 29 31 40 NUES013 21 26 30 7,5 8,4 10,9 16 18 24 28 32 40 NUES021 19 23 29 7,2 7,5 10,6 14 17 24 31 35 42 NUES031 21 28 32 7,4 8,9 12,1 15 17 25 28 29 38 NUES046 21 27 30 8,2 10,1 10,9 16 17 26 38 36 40 NUES051 27 30 32 8,7 8,9 10,9 17 17 24 47 55 61 NUES060 21 31 32 7,5 9,8 10,1 15 16 21 42 46 54 NUES064 21 27 31 8,1 9,2 11,1 15 16 24 40 42 49 NUES065 26 30 32 8,2 10,9 11,2 18 18 23 33 35 44 Table 2. Measurements in girls’ participants in the study. In this table are depicted every value for every parameter in every time lapse of intervention according to sex.
Discussion In terms of diet, it is essential to bear in mind that nutrition in the first stage of human life, i.e. in childhood, implies a commitment to the provision of enough elements to the body to carry out the necessary biological functions at this important stage of development. Assuming a balanced diet in children is key to avoiding the appearance of possible disorders such as obesity, anorexia, malnutrition, poor cognitive development, predisposition to cancer, among others. In addition to this panorama, it is common to identify inappropriate lifestyles, many of them associated with poor socioeconomic conditions. Mahan and Scote (2001) (7) state that nutrition is the intake of food in relation to the dietary Karen Piedad Martínez Marciales et al. Figure 3. Proportion of individuals influenced by treatment. This histogram allows to identify a gradual increase in the number of children that start to recover the normal values in all the parameters during the time of the intervention. needs of the body. A good nutrition (a balanced diet combined with regular physical exercise) is a key element of good health. Essential nutrients include vitamins, amino acids, fatty acids and a certain amount of carbohydrates as energy sources. The amounts needed for these nutrients differ with age and physiological status. Conditionally nutrients are those that can be synthesized in the body, such some amino acids and puric bases, in quantities that may be insufficient in certain states, so they should be provided to immature infants and individuals who do not synthesize them enough due to genetic defects or pathological conditions.
The FAO definition of undernourishment refers to the proportion of the population whose dietary energy consumption is low than a predetermined threshold. This threshold is country specific and is measured in terms of the number of kilocalories required to conduct sedentary or light activities (8). Undernourished is also referred to as suffering from food deprivation and it has a straight relation with social economic environment of a country. Colombia is one of the four countries that have managed to reduce malnutrition since 2014, however, malnutrition is a problem that affects all regions of the country. (9) Each federal agency dedicated to addressing this problem has taken steps to counteract it. Colombia’s Family Welfare Institute warns that 13.2% of the country’s children suffer from chronic malnutrition and ensures that strategies are already being implemented to fight this situation. (10). Thus, the government and the food companies have developed strategies that seek to confront this gloomy panorama. These alternatives include fortified public food delivery interventions such as Bienestarina, which is distributed to all children, or the free breakfast program for disadvantaged children, which distributes milk, biscuits and other cereals fortified with folic acid, iron and zinc. Among other examples in Latin America of these approaches is the work performed by Alvarez et al (2012), where they carried out a study regarding delivering of instant rice porridge fortified with micronutrients for children from 12 to 36 months, showing that this strategy is a potential alternative for infant feeding in a straightforward way (11). Hijar et al (2015) developed a systematic review of the literature related with the efficacy of fortified rice consumption in relation to increase of iron and other micronutrients levels in children from 6 to 59 months of age, and found that rice fortification represented an effective intervention strategy to correct iron deficiency in this population (12). Rojas et al (2011) compared the efficacy of aminoquelate iron versus ferrous sulphate as a fortifying dietary supplement in iron-deficient preschool children. Fifty-six preschool children with iron deficiency were analyzed and after two months the levels of hemoglobin, volume of red cells and serum ferritin were measured, the two compounds being found to increase ferritin levels, but milk enriched with aminoquelated iron does so in a statistically significant way (13). The food industry contributes through fortified children’s foods and preparations, but the disadvantage is that they are expensive and unavailable to the families that need them most. That is why these approaches should be focused on using as raw material items that are easy to consume and with a low production cost, as it could be Moringa oleifera. Moringa is a genus of shrub whose leaves, roots and unripe pods are eaten as a vegetable. All its parts (bark, pods, leaves, seeds, tubers, roots and flowers) are edible and its use dates back to 2000 BC. (14) The potential uses of this plant are several and can be applied in the nutritional field, to the treatment of water or soil and even in industry, so it is evident the importance of this plant for the future (15). Sanchez et al (2016) developed a study in order to assess the impact generated by the use of the plant in in the breeding of chickens, identifying that the animals that consumed the food and water mixed with Moringa presented blood analyses of total proteins, albumin, leukocytes and hematocrit superior to those of the control group (16). In 2013, Castro developed a study to propose that the Moringa tree could be implemented as a renewable source for the production of biodiesel with high yield and productivity in Colombia, as well as an instrument to the decontamination of surface water (17). The widest and most varied studies focus on the biomedical uses of the plant. Moringa Oleifera is a small tree that has great nutritional qualities, which can contribute to the supply of nutrients needed in the diet of children (18). The leaves have outstanding nutritional qualities, which are among the best of all vegetables (19). The protein content of the leaves is 27% and contains significant amounts of calcium, iron and phosphorus, as well as vitamin A and C. This nutritional value is particularly important in areas where food security may be threatened by periods of drought, as Moringa leaves can be harvested during dry periods when no other fresh vegetables are available (20). The most important micronutrients are iodine, iron and vitamin A, which are essential for physical growth, development of cognitive and physiological functions and resistance to infections, and it is well known the association between iron deficiency and onset of IDA. Several in vitro and in vivo approaches have been developed to evaluate the potential role of this plant in the treatment of anaemia. Mun’im et al (2016) conducted a study to assess the effect of ethanolic extract of Moringa leaves through the evaluation of hematological parameters in female rats, finding an increase in hemoglobin, red blood cells count and total iron Moringa oleífera-anaemia for iron deficiency
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