Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11733 Bay leaf decoction water and low-impact aerobic exercise impact on blood cholesterol levels Ismansyah Ismansyah,1 Arifin Hidayat,1 Rini Ernawati2 1Nursing Department, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda; 2Nursing Department, Universitas Muhammadiyah Kalimantan Timur, Samarinda, Indonesia Abstract Hypercholesterolemia is a global health concern, including in Indonesia, potentially leading to coronary artery disease, heart failure, and stroke if left untreated. This study aimed to assess the effectiveness of bay leaf decoction and low-impact aerobic exer- cise on reducing blood cholesterol levels in patients. Used a quasi- experimental design with 120 participants, randomly assigned to two groups, the first group consumed bay leaf decoction (100 ml, twice daily for 7 days), while the second group underwent low- impact aerobic exercise (3 times a week for 7 days). Blood choles- terol levels were measured, and paired t-tests were employed for statistical analysis. Results revealed that both interventions signif- icantly lowered cholesterol levels after 7 days (p<0.001 for bay leaf decoction and p=0.001 for low-impact aerobics). The bay leaf decoction group achieved the highest reduction at 25.3 mg/dl. In conclusion, this study highlights the potential of bay leaf decoc- tion and low-impact aerobic exercise as non-pharmacological approaches to manage blood cholesterol levels. It reinforces the notion that these interventions can be valuable in addressing hypercholesterolemia. Introduction Cholesterol is a fatty substance that circulates in the blood, pro- duced by the liver, and essential for the body’s functioning. Approximately 80% of the cholesterol in the blood is produced by the body itself, while the remaining 20% comes from dietary sources.1 However, excessive consumption of cholesterol-rich foods can lead to elevated blood cholesterol levels, a condition known as hypercholesterolemia.2 Various factors contribute to hypercholesterolemia, including dietary choices, physical inactivi- ty, obesity, and age.3,4 This condition can lead to serious cardiovas- cular complications such as coronary heart disease, heart attacks, heart failure, deep vein thrombosis, stroke, and even death.5–7 Global data from the World Heart Report indicates that over 160 million people worldwide have hypercholesterolemia, with total cholesterol levels exceeding 200 mg/dl, which is considered high. Furthermore, more than 34 million American adults have total cholesterol levels exceeding 240 mg/dl, which requires ther- apeutic intervention.8,9 In Indonesia, national data from the Basic Health Research shows a prevalence of high cholesterol among individuals aged 15 and above to be 15.8%, with 5.4% in men and 9.9% in women. Elevated cholesterol levels increase the risk of coronary heart disease, stroke, and compromised blood circula- tion.10–12 While hypercholesterolemia is not listed among the top 10 major diseases in Samarinda according to the Samarinda City Health Office’s 2022 data, the Sempaja Samarinda Health Center has reported the highest number of hypercholesterolemia cases in the Health Office records.13 Correspondence: Ismansyah Ismansyah, Nursing Department, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia. E-mail: ismanamin18@gmail.com Key words: bay leaf decoction; hypercholesterolemia; low impact aerobics. Contributions: ISM Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft, Review & Editing; AH Conceptualization, Investigation, Methodology, Validation, and Writing – Original Draft, Review & Editing; RE Conceptualization, Methodology, Formal Analysis, Validation, and Writing – Original Draft, Review & Editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Commission, [NO. DP.04.03/7.1/07744/2023]. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: we would like to thankful to Poltekkes Kemenkes Kalimantan Timur, Universitas Muhammadiyah Kalimantan Timur for their valuable insights and contributions to this study. Received: 9 September 2023. Accepted: 6 October 2023. Early access: 10 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11733 doi:10.4081/hls.2023.11733 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2023; 11:11733] [page 21] Non -co mmerc ial us e o nly Cardiovascular diseases, as described by Hidayat et al. (2021),14 often result from disruptions in lipid metabolism caused by hyperlipidemia or elevated lipid fractions in the bloodstream. The primary lipid fraction disorder is elevated triglycerides, while high levels of Low-Density Lipoprotein (LDL) and cholesterol are major contributors to atherosclerosis.12,15,16 Control of hyperlipi- demia can be achieved through various means, including non-phar- macological methods such as physical activity and dietary changes, as well as pharmacological interventions.17,18 When lifestyle modifications alone cannot adequately control hyperc- holesterolemia, pharmacotherapy with chemically synthesized drugs such as niacin and fibrates becomes an alternative. However, these drugs often have side effects like liver toxicity, nausea, abdominal pain, and indigestion.19,20,21 Non-pharmacological approaches, such as natural ingredients and physical activities like yoga and aerobic exercises, offer alter- native means to manage hypercholesterolemia.22,23–26 Utilizing readily available natural ingredients and engaging in physical activities can help reduce hyperlipidemia and hypercholes- terolemia, as demonstrated by the effects of basil extract and bay leaves.14,27 Bay leaves, or Syzygium polyanthum, commonly used as a food flavoring spice in Indonesian kitchens, have demonstrat- ed potential in reducing cholesterol levels.28 The use of herbal remedies and natural ingredients has gained popularity worldwide as a means to manage cholesterol levels. This growing interest in herbal medicine aligns with the abundant potential of medicinal plants in Indonesia. Previous studies have explored bay leaves, often in the form of tea, for their cholesterol-reducing properties.29 Research conducted by Batool (2020)30 highlighted the phyto- chemical content of bay leaves, including flavonoids, tannins, eugenol, citric acid, carbohydrates, steroids, alkaloids, triter- penoids, and essential oils. These compounds can function as antioxidants, alleviate stomach discomfort, clear lung mucus, and exhibit antidiabetic properties.30,31 While studies on the reduction of total cholesterol levels remain limited, the phytochemical con- tent of bay leaves suggests potential cholesterol-lowering effects. In this study, researchers explored a different preparation method – bay leaf decoction – as a cost-effective alternative. Additionally, physical activity, particularly low-impact aerobic exercise, was chosen as an intervention to impact blood cholesterol levels positively. Engaging in aerobic exercise for 50 minutes, three times a week, has been shown to help control blood pressure and lipid levels.32,33 Aerobic exercise induces muscle contractions, requiring energy in the form of Adenosine Triphosphate (ATP). The metabolism of ATP in mitochondria converts consumed food into energy rather than cholesterol, thereby reducing overall cholesterol levels.34–36 Through this study, researchers aimed to investigate the effects of bay leaf decoction and low-impact aero- bic exercise on blood cholesterol levels. Materials and Methods Research design This study employed a quantitative quasi-experimental design with a pre-test and post-test group design. The research was con- ducted from March 14 to June 6, 2023. Population and sample The study’s population comprised patients with hypercholes- terolemia residing within the service area of Sempaja Health Center, Samarinda City, Indonesia. The sample consisted of 120 individuals, selected using simple random sampling, and evenly allocated into two groups. Inclusion criteria encompassed hyperc- holesterolemia patients aged 20-50 years, having blood cholesterol levels greater than or equal to 200 mg/dl, the ability to engage in physical activity without assistance, and a willingness to partici- pate as respondents. Exclusion criteria included patients with comorbid conditions like stroke and respondents unable to attend or complete the intervention. Data collection methods The first group comprised 60 individuals who received an intervention involving the consumption of bay leaf decoction. For this decoction, 10 large dried bay leaves were washed under run- ning water. After washing, the bay leaves were placed in a pot and boiled with 300 ml of water. The mixture was allowed to simmer until it reduced to 150 ml, becoming cloudy and yellow in color. Subsequently, the boiled water was strained and measured using a measuring cup, ensuring it amounted to 150 ml before packaging. The resulting decoction was consumed daily, 75 ml in the morning (06:00-07:00) and 75 ml in the afternoon (16:00-17:00), over the course of 1 week. The second group comprised 60 individuals who underwent a low-impact aerobic exercise intervention. This exercise involved light-intensity movements that combined hand, shoulder, and foot movements, such as walking in place and forward-and-backward walking with clapping. The low-impact aerobic exercise routine consisted of warm-up exercises (5 movements), core exercises (11 movements), and cool-down exercises (2 movements). The exer- cise sessions lasted for 45 minutes, divided into a 10-minute warm- up, a 20-minute core exercise, and a 15-minute cool-down. These exercises were performed three times in the morning at 07:00 over the course of 1 week. Blood cholesterol levels were measured using blood drawn from the fingertips. Measurements were conducted using the GCU Meter Device (Glucose, Cholesterol, Uric Acid), lancet needles, cholesterol test strips, alcohol swabs, hand scoons, and an observa- tion sheet to record the results of blood cholesterol levels. In this study, blood cholesterol levels were measured before the interven- tion (bay leaf decoction and low-impact aerobic exercise) and again after 7 days of intervention (post-test). Data analysis Data analysis was performed using the dependent t-test with data processing software. The normality of variables was assessed through a normality test. For pre-test and post-test blood cholesterol levels of bay leaf decoction and low-impact aerobic exercise, paired t-tests were employed, with a significance level set at α=0.05. Results A total of 120 participants with hypercholesterolemia were included in the study and divided into two groups, as shown in Table 1. The table presents the characteristics of respondents based on age, gender, occupation, education, and duration of hyperc- holesterolemia at Sempaja Samarinda Health Center in 2023. Table 1 illustrates the characteristics of the respondents based on age, gender, occupation, education, and duration of hyperc- holesterolemia. The majority of respondents in both intervention groups were aged 41-50 years, with 63.3% in the bay leaf decoc- tion water group and 50% in the low-impact aerobic exercise group. Female respondents predominated in both groups, with 83.3% in the bay leaf decoction water group and 73.3% in the low- [page 22] [Healthcare in Low-resource Settings 2023; 11:11733] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly impact aerobic exercise group. Furthermore, respondents who were not working constituted a significant portion in both groups, with 60% in the bay leaf decoction water group and 43.3% in the low-impact aerobic exercise group. Regarding education, the high school level was predominant in both groups, accounting for 43.3% in the bay leaf decoction water group and 40% in the low- impact aerobic exercise group. In terms of the duration of suffering from hypercholesterolemia, those with less than 1 year of duration comprised the majority in both groups, with 50% in the bay leaf decoction water group and 23.3% in the low-impact aerobic exer- cise group. Table 2 shows that, in the bay leaf decoction group, mean pre- test cholesterol was 269.3 mg/dl (SD 37.3), decreasing to 255.8 mg/dl (SD 37.03) post-test. In the Low Impact Aerobic group, mean pre-test cholesterol was 269.3 mg/dl (SD 35.51), decreasing to 244 mg/dl (SD 35.4) post-test. Table 3 illustrates the impact of bay leaf decoction water and low-impact aerobics. Significant differences in cholesterol levels were observed for both groups (p<0.001 for bay leaf and p=0.001 for aerobics), with the highest reduction in the bay leaf group at 25.3 mg/dl. Discussion This study revealed a significant impact of bay leaf decoction water and low-impact exercise on blood cholesterol levels. These findings indicate a substantial reduction in cholesterol levels in both intervention groups. This study aligns with research conduct- ed by Emilia (2023),37 which also demonstrated a significant decrease in cholesterol levels before and after the administration of Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents with hypercholesterolemia. Characteristics Bay leaf intervention group Low impact aerobic exercise intervention group n % n % Age 20-30 years 6 10.0 20 33.3 31-40 years old 16 26.7 10 16.7 41-50 years old 38 63.3 30 50.0 Gender Male 10 16.7 16 26.7 Female 50 83.3 44 73.3 Jobs Work 24 40.0 34 56.7 Not working 36 60.0 26 43.3 Education Primary school 20 33.3 6 10.0 Junior high 8 13.3 6 10.0 High school 26 43.4 24 40.0 Higher education 6 10.0 24 40.0 Duration of hypercholesterolemia <1 year 1-3 years 30 50.0 14 23.3 4-7 years 18 30.0 18 30.0 >7 years 10 16.7 22 36.7 2 3.3 6 10.0 Total 60 100.0 60 100.0 Table 2. Blood cholesterol levels before and after bay leaf and aerobic interventions. Blood cholesterol levels Mean ± SD Bay leaf decoction water Pre test 269.3 37.30 Post test 255.8 37.03 Low impact aerobic exercise Pre test 269.3 35.51 Post test 244 35.40 Table 3. Paired t-test results for blood cholesterol levels in bay leaf and aerobic exercise groups (pre-test and post-test) Pre Post Difference Paired t-test Mean ± SD Mean ± SD p Bay leaf decoction water 269.3±37.30 255.8±37.03 25.30 0.000 Low impact aerobics exercise 269.3±35.51 244±35.40 12.00 0.001 [Healthcare in Low-resource Settings 2023; 11:11733] [page 23] Non -co mmerc ial us e o nly bay leaf cooking water (p=0.000<α=0.05). The observed reduction in cholesterol levels can be attributed to the active compounds pre- sent in bay leaf cooking water, including flavonoids, saponins, tan- nins, vitamin C, and fiber. These compounds have the potential to lower cholesterol content in the bloodstream.31,38 Flavonoids act as antioxidants, preventing lipid peroxidation, while tannins con- tribute to improved lipid profiles. According to Laka (2022),39 saponins found in bay leaves function as hypocholesterolemics by binding cholesterol with bile acids, effectively reducing choles- terol levels. Flavonoids and tannins inhibit pancreatic cholesterol esterase, bind to bile acids, and reduce cholesterol solubility in cell membranes, inhibiting cholesterol absorption and ultimately lead- ing to reduced blood cholesterol levels. Additionally, other studies, such as the one conducted by Mubarak et al.,40 have shown that light and moderate-intensity aerobic exercises have a significant impact on total cholesterol levels (p=0.01 <α=0.05). This effect is attributed to the utilization of fat oxidation as a source of energy when glycogen stores in muscles are depleted. Furthermore, the reduction in cholesterol levels observed in the low-impact aerobic exercise group can be explained by the nature of aerobic exercise, which combines specific rhythmic movements. This type of exercise requires energy derived from ATP stored in muscles, which is converted into energy during physical activity. Aerobic exercise contributes to the reduction of fat deposits in various parts of the body.41,42 According to Hwang C, aerobic exercise is an effective method for weight loss and sig- nificantly reduces body fat percentage and body weight.43 Low- impact aerobic exercise specifically converts fatty acids into ener- gy, minimizing the potential for excessive sterol core synthesis and, consequently, preventing excessive cholesterol formation.44 Continuous-intensity exercise actively affects fat degradation, mainly due to the release of epinephrine and norepinephrine from the adrenal medulla during physical activity, as well as increased lipoprotein lipase enzyme activity. Lipoprotein lipase helps trans- port LDL cholesterol from the bloodstream to the liver, where it is either converted into bile or secreted, resulting in decreased LDL levels.45 This study has several limitations. Firstly, it employs a quasi-experimental design, which may have inherent biases and limitations compared to randomized controlled trials. Secondly, the variables measured are limited to total blood cholesterol levels, and the study does not include the assessment of High-Density Lipoprotein (HDL) and LDL levels, which could provide a more comprehensive understanding of lipid profiles. Conclusions The intervention involving bay leaf boiled water and low- impact aerobic exercise offers a cost-effective non-pharmacologi- cal therapy option for individuals with hypercholesterolemia, pro- moting a healthier lifestyle. Both interventions have demonstrated their effectiveness in reducing blood cholesterol levels, albeit through different mechanisms. The presence of active compounds in bay leaf cooking water, including saponins, catechins (flavonoids), tannins, vitamin C, and fiber, plays a crucial role in lowering cholesterol levels. 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Effects of a 12-week walking intervention on circulating lipid profiles and adipokines in nor- mal weight and abdominal obese female college students. J Exerc Sci Fit 2023;21:253-9. Healthcare in Low-resource Settings 2023; 11:11733] [page 25] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly