INTRODUCTION:

Chronic energy deficiency is a problem of impaired nutrition fulfillment in pregnant women due to the inability to meet daily intake, especially in macronutrients for a long time. In addition to causing chronic energy deficiency, nutritional disorders during pregnancy can also cause anemia.¹There is an increase in red blood cells by 18–30% and haemoglobin around 19%, causing the need for iron to also increase during pregnancy.

The need for iron during pregnancy is 800mg, which is used for the needs of fetal growth and development (300 mg) and the formation of red blood cells (500mg).^2,3 The government mandates that every pregnant woman take iron tablets for a period of three months, but this does not reduce the incidence of anaemia in pregnant women.¹Even according to Basic Health Research data for 2018, the prevalence of anaemia in pregnant women in Indonesia was 48.9%, up 11.8% from the previous year, and WHO data shows that 40% of contributors to maternal mortality in developing countries are related to anaemia complications, specifically bleeding.^1,4,5 According to the findings of Lestari et al.⁶ 2018, the prevalence of anaemia in pregnancy in North Sumatra was higher than the national prevalence. The increasing prevalence of anaemia is due to poorer nutritional status, and Yulia 2017⁷ also found that poor nutritional status was caused by food intake that was not in accordance with the body's needs and impaired absorption of food consumed daily. Roosleyn 2016⁸ states that the nutritional status of pregnant women is often associated with the incidence of iron deficiency anemia and that other characteristic factors can also influence it. Fauzan and Kaseger 2022⁹ state that there is a relationship between BMI and the incidence of anaemia in pregnant women in the working area of the Motoboi Kecil Health Center (p = 0.000). However, unlike Akram et al. 2020,¹⁰ they explained that there was no statistically significant relationship between BMI and hemoglobin. Another study also stated that a lean BMI is not associated with anemia. Nutritional status is very important to achieve maternal and foetal health.¹¹ One method commonly used to determine a person's nutritional status is to calculate their BMI. Pregnant women's nutritional status is monitored in part by assessing their weight gain, which typically increases in the second and third trimesters, with a normal increase of 11 to 13kg during pregnancy¹²

Therefore, the fulfilment of iron during pregnancy needs to be supported through the consumption of foods that can increase the bioavailability of iron and its absorption in the body. Tariganet al. 2021⁵ stated that a diet that does not consume a variety of foods, especially foods that are sources of iron, can contribute to the occurrence of anemia. In this study, to increase the availability and absorption of ferrous sulphate supplements that pregnant women drink every day, the researchers provided an intervention by consuming infused okra water. Okra contains macronutrients and micronutrients that can help pregnant women's nutrition.^13,14,15Okra is said to be very useful against genitourinary disorders, blood glucose level, also working as an imbalance between antioxidants and reactive oxygen species (ROS) in the body results in oxidative stress which can cause premature aging, atherosclerosis, and cancer and have good radical inhibition properties.^16-21 As a result, it is critical to conduct a study that examines the nutritional status of pregnant women who have taken ferrous sulphate tablets along with okra-infused water and its impact on pregnant women's anaemia status.

MATERIALS AND METHODES:

This research is an experimental study with pre-test and post-test approaches. The intervention group in this study was given iron tablets and okra, while the control group was given ferrous sulfate tablets without okra. At the beginning of the study, both groups measured Hemoglobin (Hb) levels and Body Mass Index (BMI). After 90 days of intervention, Hb level and BMI were measured again.The population are all pregnant women with gestational age 16 - 32 weeks who are ANC visit at the Tanjung Midwife Clinicand Mariana Midwife Clinic with Hb levels < 11gr/dl and has received iron sulfate tablets 60mg per day taken regularly every day for 3 months. The number of samples is 50 people, with a sampling technique purposive sampling.

The intervention provided was 100grammes of fresh okra fruit, which had been made into infused okra water, which was then drunk by the respondents after consuming ferrous sulfatetablets. After completing the intervention, the researchers analysed nutritional status by measuring height and weight and then calculating the respondent's BMI. To determine anaemia status, researchers measured haemoglobin levels using an Hb test kit. This research has received approval from the ethical commission of the Faculty of Medicine, Muhammadiyah University of North Sumatra, Indonesia with a letter number 593/KEPK/FKUMSU/2021. After all the data was collected, data analysis was performed to analyse the relationship between BMI and anaemia status using the chi-square test.

RESULTS:

Table 1: The Relationship between BMI with Hb Levels in Pregnant Women at the Intervention Group

Body Mass Index	Hemoglobin Level				*p-value*
	Anemia (<11 g/dl)		Not Anemia (≥11 g/dl)
	n	%	n	%
Thin (<18,5 kg/m²)	5	10.0	0	0.0	0.478
Normal (18,5-25 kg/m²)	17	34.0	5	10.0
Overweight (>25 kg/m²)	5	10.0	0	0.0
Obesity (>27 kg/m²)	7	14.0	11	22.0
Total	34	68.0	16	32.0

Based on the table 1, it was found that pregnant women with underweight BMI and overweight BMI all have anemia as many as 5 people (10%), pregnant women with normal BMI and anemia as many as 17 people (34%) and who were not anemic there were 5 people (10%), while pregnant women with obese BMI who experienced anemia there were 7 people (14%) and who were not anemic there were 11 people (22%).The results of statistical tests using the chi-square test obtained p-value = 0.478 (p> 0.05), it can be concluded statistically that there is no relationship between increases in BMIand Hb levels in pregnant women in this study.

Table 2: The Relationship between BMI with Hb Levels in Pregnant Women at the Control Group

Body Mass Index	Hemoglobin Level				*p-value*
	Anaemia (<11 g/dl)		Not Anaemia (≥11 g/dl)
	n	%	n	%
Thin (<18,5 kg/m²)	0	0.0	0	0.0	0.793
Normal (18,5-25 kg/m²)	7	14.0	3	6.0
Overweight (>25 kg/m²)	8	16.0	6	12.0
Obesity (>27 kg/m²)	17	34.0	9	18.0
Total	32	64.0	18	36.0

Based on the table 2, it was found that pregnant women who are normal BMI haveanaemia were 7 people (14%) and those who were not anemic were 3 people (6%), pregnant women who are overweight have anaemia were 8 people (16%) and those who did not anaemia were 6 people (12%), while pregnant women who are obese haveanaemiaas many as 17 people (34%) and there were 9 people (18%) who were not anemia.The results of statistical tests using the chi-square test obtained p-value = 0.793(p>0.05), so statistically it can be concluded that there is no relationship between the increase in BMI and Hb levels in pregnant women in the group control.

DISCUSSION:

Pregnant women's nutritional status is monitored in part by assessing their weight gain, which increases in the second and third trimesters, with a normal increase of 11-13kg during pregnancy.²²In this study, all respondents were pregnant women with anemia, but the results obtained by the researchers showed there were 34% of respondents with normal BMI and 14% obesity. Pregnant women who were given okra water infused with ferrous sulfate statistically concluded that there was no relationship between increased BMI and Hb levels (table 1). Giving infused okra water to pregnant women in this study to increase iron absorption because pregnant women drink ferrous sulfatetablets every day. Okra contains nutrients such as vitamin C, vitamin A, folate, iron, calcium, and zinc, which can increase iron absorption. In addition, the carbohydrate content of okra, namely polysaccharides, is good for meeting calorie needs because it can help maintain body weight.¹⁴ It can be seen from the data that the majority of pregnant women's BMI is normal (34%), although they have not shown an optimal increase in Hb levels. Anemia in pregnant women in this study could not be treated but could be linked to other factors.

One of the most significant changes is the expansion of blood volume with a disproportionate increase in plasma volume so that the hematocrit usually decreases. This increase in plasma volume is the cause of the physiological anemia of pregnancy. The increase in plasma volume peaks at 24 weeks and continues to increase until the 37th week of gestation. Blood serum (blood volume) increases by 25-30% while red blood cells are only about 20% ^3,6,8so that even though given ferrous sulfate tablets as much as 60 mg per day with infused okra water in the intervention group in this study did not have a significant effect on increasing Hb levels. however, there was an increase in BMI due to increased body weight of pregnant women and an increase in the size of the fetus.

The results of this study are in line with Akram et al.'s 2020¹¹ explanation that there is no significant relationship between BMI and hemoglobin. Sal et al. 2018²³explained in their research that obesity is a disorder of energy metabolism that results in excessive fat storage. Similarly, the results of the research of Pasalina et al. 2019²⁴ explained that there was no relationship between BMI and the incidence of anemia. He further explained that obesity or being overweight will cause fat deposits in the liver, causing lipid peroxides and impacting iron metabolism. Obesity can also increase the risk of anaemia due to fat accumulation. This excess fat can cause an inflammatory reaction, thereby stimulating increased hepcidin expenditure and decreasing the absorption of iron in the intestine. Hepcidin is a peptide hormone produced by the liver and plays an important role in iron homeostasis. The mechanism is that hepcidin inhibits the function of ferroportin as an iron exporter from cells to the blood, which then inhibits iron absorption in enterocytes and iron release in the reticuloendothelial, resulting in iron metabolism disorder and iron deficiency. In addition, fat deposits in the liver will trigger the formation of lipid peroxidation, which damages red blood cell membranes and interferes with haemoglobin synthesis.^23,24

Wawer el at. 2021²⁵ explained the results of his study, which showed that obesity that occurs before pregnancy and obesity during pregnancy can carry a risk of iron deficiency anaemia in pregnant women as well as babies. The condition of being overweight will exacerbate the status of pregnant women because, during pregnancy, hemodilution has occurred, which causes anemia. In line with Jones et al. 2016²⁶, who explained the results of their study that there was a decrease in iron status in pregnant women whose BMI was higher in mid-pregnancy. Flynn et al. 2018²⁷ found a significant increase in CRP and IL-6 levels in obese pregnant women compared to pregnant women who were thin, but no difference in serum ferritin or serum hepcidin levels at 15-18 weeks of gestation in a study of 245 obese pregnant women and 245 pregnant women with normal weight.

Likewise in the control group, pregnant women who were only given ferrous sulfate tablets 60mg per day, there was no statistically significant change in hemoglobin levels (table 2). Adikariet al. 2016²⁸ showed a positive relationship between parity and excess nutrition (overweight and obesity) in pregnant women. This trend toward being overweight is due to the accumulation of residual fat during and after previous pregnancies. This condition causes the BMI to increase. Apart from this, the daily nutritional intake of pregnant women in this study was only energy, protein, and vitamin C, which met the RDA. Even protein goes beyond the daily requirement. Other types of nutrients, such as calcium, iron, folate, and vitamin A, from food do not meet the RDA criteria. Badriyahet al. 2021²⁹ stated repeated pregnancies in a short time cause iron reserves to decrease, and there is not enough time to restore the iron reserves that have been used in previous pregnancies. It is recommended that the gestation period be at least two years in order to restore iron reserves and restore the reproductive organs to their pre-pregnancy state.

Respondents with normal BMI status but anaemia may be due to pregnant women's inability to meet nutritional needs during pregnancy. Sal et al. 2018²³ explained that poor iron status can occur as a result of a daily food intake that is low in iron, so that the biological availability of iron does not meet the demand for iron during pregnancy. Although pregnant women in the intervention group were given ferrous sulphate at 60 mg/day and additional infused okra water, it was explained that anaemia is not only influenced by BMI factors, but the main factor is caused by a balanced diet and the sufficiency of macronutrients and micronutrients during pregnancy.

The results of this study are different from the results of the study by Mocking et al. 2018³⁰, which explained that the haemoglobin concentration increased significantly (0.03 and 0.08) with a higher BMI. Women with a higher BMI early in pregnancy tend to have higher haemoglobin levels. Pregnant women with underweight criteria are associated with insufficient needs for macronutrients and micronutrients. Generally, there is a protein deficiency in the daily food intake of pregnant women. Protein, as a macronutrient, plays a role in the metabolism of iron consumed by the mother. When protein intake is low, iron transport is disrupted.

Roosleyn, 2016⁸, explained that the daily food intake of pregnant women also affects iron absorption. Consumption of a wide variety of foods is very good for increasing iron absorption. Specifically, foods high in vitamin C (from fruits and vegetables), vitamin A, animal protein (eggs, red meat), folic acid, and zinc can help increase iron absorption. Similarly, Arman and Sumiaty 2021³¹ explained that folic acid, vitamin C, and animal protein in daily foods can increase iron absorption, particularly non-heme iron. This was reinforced by the results of a study by Diana et al. 2019³², which found that pregnant women with mild anaemia consumed more protein such as eggs, milk, and vegetable and fruit products compared to pregnant women with moderate anemia.Skolmowskaet al. 2019³³ described three strategies for managing anaemia by regulating the diet of pregnant women. The first strategy is to improve the types of foods that are high in iron intake, namely by choosing food products that contain iron, such as meat and fish, nuts, and green vegetables. The second strategy is to boost iron bioavailability by increasing iron absorption through foods like vitamin C and meat and decreasing intake of iron inhibitors like phytate. The third strategy is to provide education about nutrition because research results prove that nutrition counselling is effective in preventing and managing anemia.

LIMITATION OF THE STUDY:

The limitation in this study was that it did not inquire about food recall consumption for 24hours. However, researchers have observed respondents through interviews during visits only by asking the types of food that are often consumed daily, so the frequency of eating and unhealthy lifestyles are difficult for respondents to control, causing bias. Researchers also did not test serum ferritin and serum iron levels to determine the amount of reserves and body iron levels in pregnant women after the intervention.

CONCLUTIONS:

From the results of the study, it can be concluded that an increase in body mass index (BMI) in pregnant women who were given infused okra water and ferrous sulphate tablets did not have a positive effect on haemoglobin levels. Based on BMI, it appears that pregnant women are not malnourished.

ACKNOWLEDGMENTS:

The author would like to expresses deepest gratitude to Sari Mutiara Indonesia University for the moral and material support.

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Received on 10.01.2023 Modified on 15.05.2023

Research J. Pharm. and Tech 2024; 17(2):563-567.

DOI: 10.52711/0974-360X.2024.00087