Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11776 The effect of Dayak onion brewed water in reducing blood pressure and mean arterial pressure (MAP) in hypertensive patients Diah Setiani, Rahmawati Shoufiah, Hesti Prawita Widiastuti, Indah Nur Imamah, Rivan Firdaus, Frana Andrianur Department of Nursing, East Kalimantan Ministry of Health Polytechnic, Samarinda, Indonesia Abstract The World Health Organization (WHO) estimated that 1.28 billion adults aged 30-79 years worldwide suffered from hyperten- sion. Dayak onion is an herbal plant found in Indonesia, particu- larly in Kalimantan and traditionally used to treat hypertension. The purpose of this study was to determine the effect of Dayak onion steeping water on the reduction of systolic-diastolic blood pressure and mean arterial pressure (MAP) in hypertensive patients. This study employed a quasi-experimental research design with a time series approach, utilizing a pre-post-test design with a control group. The sample included two groups (interven- tion and control), totaling 30 participants. The independent vari- able was the steeping of Dayak onion bulbs, while the dependent variables were blood pressure values and MAP. The instruments used were Standard Operating Procedures (SPO) Dayak onion herb, SPO blood pressure measurement, SPO calculation of MAP, and a digital sphygmomanometer. Data analysis was performed using paired t-tests. The results of the paired t-test statistical anal- ysis of systolic-diastolic values and MAP in each group revealed significant findings. In the intervention group, a significant result was obtained in the pre-post test difference test, with a p<0.05 from day 1 to day 3 assessments. This suggests that Dayak onion steeping water had an effect on systolic-diastolic and MAP values in the intervention group. In contrast, the pre-post test in the con- trol group yielded a p<0.05 for systolic values on days 2 and 3, diastolic values on days 1 and 3, and MAP values on days 1, 2, and 3. This indicates differences in systolic-diastolic and MAP values in the pre-post assessments, although these differences were not even- ly distributed across every day. The study found that Dayak onion steeping water had an effect on systolic-diastolic and MAP values in the intervention group. Thus, the use of Dayak onion steeping water, containing allicin, can be considered an approach for control- ling hypertension in the realm of complementary and alternative medicine, utilizing natural ingredients for herbal therapy. Introduction An estimated 1.28 billion adults aged 30-79 years worldwide suffer from hypertension, with the majority (two-thirds) residing in low- and middle-income countries. Approximately 46% of adults with hypertension are unaware of their condition, and less than half (42%) receive a diagnosis and treatment. Only about 1 in 5 adults (21%) with hypertension have their blood pressure under control. Hypertension, often referred to as the silent killer, can wreak havoc if left uncontrolled, targeting vital organs and leading to heart attacks, strokes, kidney disorders, and even blindness.1 Hypertension induces endothelial dysfunction, exacerbates the atherosclerotic process, and contributes to the instability of Correspondence: Diah Setiani, Department of Nursing, East Kalimantan Ministry of Health Polytechnic, Samarinda, Indonesia. E-mail: diah.dee.oc@gmail.com Key words: allicin; blood pressure; Dayak onion; hypertension; MAP. Contributions: DS, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; final approval of the version to be published fund- ing acquisition. RS, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; HPW, con- ceptualization, methodology, formal analysis, validation, and writ- ing – original draft, review & editing; ini, methodology, visualiza- tion, writing – review & editing; SS resources, investigation, and writing –review & editing; RF, formal analysis, validation, writing – review & editing; FA, resources, investigation, and writing –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, Poltekkes Kemenkes Kalimantan Timur, based on ethical certificate No. LB.02.01/7.1/3320/2022. 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. Received: 12 September 2023. Accepted: 6 November 2023. Early access: 21 November 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; 11:11776 doi:10.4081/hls.2023.11776 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; 11:11776] [page 167] Non -co mmerc ial us e o nly atherosclerotic plaques. While hypertension is typically asymp- tomatic and can go unnoticed, some patients may report symptoms such as dizziness, headaches, nosebleeds, chest pain, and palpita- tions.2–4 Hypertension stands as the leading cause of premature death worldwide, and one of the global targets for non-communi- cable diseases is to reduce its prevalence by 33% between 2010 and 2030.5 Hypertension is more prevalent among men, older adults, and those who are overweight or obese. In Indonesia, the prevalence of hypertension rose from 25.8% in 2013 to 34.1% in 2018. In 2018, the number of individuals with hypertension in Indonesia reached 63.3 million, accounting for 34.11% of the pop- ulation. The hypertension rate in Indonesia reached 63.3 million, 34.11% of the population, in 2018.6 In East Kalimantan Province, the prevalence of hypertension per district, based on a doctor’s diagnosis in the population aged over 18 years, according to Riskesdas data from 2018, shows the following statistics for hyper- tension sufferers: Paser Regency 9.70%, West Kutai Regency 11.33%, Kutai Kartanegara Regency 10.14%, East Kutai Regency 8.12%, Berau Regency 9.75%, North Penajam Paser Regency 8.49%, Mahakam Ulu Regency 13.77%, Balikpapan City 12.66%, Samarinda City 11.19%, Bontang City 9.23%. West Kutai Regency, based on Riskesdas 2018 data, has the highest prevalence of hypertension per district in East Kalimantan. Notably, in Barong Tongkok District, the incidence of hypertension is relatively high, with data from the Barong Tongkok Health Center indicating that, as of October 2021, 561 people, comprising 190 men and 371 women in the age group of 15-59 years, have been diagnosed with hypertension.7 Hypertension, defined as persistent systolic blood pressure (SBP) of at least 130 mm Hg or diastolic blood pressure (DBP) of at least 80 mm Hg,8 affects approximately 116 million adults in the US and more than 1 billion adults worldwide. It is associated with an increased risk of cardiovascular disease (CVD) events, includ- ing coronary heart disease, heart failure, and stroke, as well as a higher risk of mortality.9,10 The global prevalence of hypertension poses a significant public health challenge due to the frequency of the condition and its associated risks of cardiovascular and kidney diseases. The treatment of hypertension includes both pharmaco- logical and non-pharmacological approaches. Pharmacological therapy involves various classes of drugs, such as angiotensin-con- verting enzyme inhibitors, calcium channel blockers, diuretics, beta-blockers, alpha-blockers, and angiotensin II and insulin receptor antagonists. Non-pharmacological therapy focuses on implementing a healthy lifestyle. Antihypertensive treatment aims to prevent the onset of related diseases by effectively controlling high blood pressure.11 Antihypertensive treatment aims to prevent these diseases by controlling high blood pressure.12 The availabili- ty, cost, and adverse effects of conventional hypertension medica- tions limit effective treatment. Due to these limitations, some patients, particularly in developing countries, turn to complemen- tary and alternative medicine for treatment.13 Effective manage- ment of hypertensive patients is a crucial strategy to prevent the increase in morbidity and mortalit.14 Unfortunately, there is a lack of recommendations for complementary therapy in hypertension treatment guidelines.15 It is well-known that many hypertensive patients seek complementary and alternative medicine.16 Complementary and alternative medicine therapies are typically divided into four main domains. They involve the utilization of natural compounds like probiotics, prebiotics, and dietary supple- ments to strengthen and promote healing in the human body. In this context,17 natural compounds contained in plants, such as herbs, play a significant role. Natural plant products have been employed throughout human history for various purposes. Today, herbal products are used to address a wide range of health issues and con- ditions, including allergies, arthritis, migraines, fatigue, wound healing, burns, digestive problems, skin infections, genetic disor- ders, and even cancer.18 Complementary and alternative medicine therapies are typical- ly divided into four main domains. They involve the utilization of natural compounds like probiotics, prebiotics, and dietary supple- ments to strengthen and promote healing in the human body. In this context, natural compounds contained in plants, such as herbs, play a significant role. Natural plant products have been employed throughout human history for various purposes. Today, herbal products are used to address a wide range of health issues and con- ditions, including allergies, arthritis, migraines, fatigue, wound healing, burns, digestive problems, skin infections, genetic disor- ders, and even cancer.19 Dayak onion plants are commonly found in Kalimantan, par- ticularly in East Kalimantan, within the West Kutai Regency. The most frequently used part of this plant is its tubers. This plant con- tains a wide array of phytochemical compounds, including alka- loids, glycosides, flavonoids, phenolics, and steroids. Through the isolation of compounds from Dayak onion bulbs, 15 compounds were identified, including (2S) dihydroeleuterinol-8-O-α-D-glu- copyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaA, (-)- hongkonin, eleuterin, isoeleuterin, (2S) dihydroeleuterinol-8-O-α- D-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaA, (-)-hongkonin, eleuterin, isoeleuterin, eleutocidaC, eleuterinosidaC, eleuterinosidaB, THE-7-acetyl-3,6- dihydroxy-8-methyltetralon, leutocideA, leutocideB, and eleuterinosideD. Among these compounds, eleuterol, eleuterin, and isoeleuterin have demonstrated potential as antihypertensive agents.20 According to a study conducted by Swandari & Nuryanto in 2018 on the anti-inflammatory activity of EC50 Results, E. Bulbosa extract exhibited potential anti-inflammatory properties, with effectiveness nearly equaling half the concentration of indomethacin. Other studies have supported this finding, indicat- ing that components in Dayak onion extract, specifically eleuther- ine and isoeleutherine, displayed anti-inflammatory activity by inhibiting carrageenan-induced leg edema. The mechanism of action for E. Bulbosa extract’s anti-inflammatory effects is believed to be related to its flavonoid content. One significant mechanism for anti-inflammatory activity involves the inhibition of enzymes that produce eicosanoids (phospholipase A2, cyclooxygenase, and lipoxygenase), leading to reduced levels of prostanoids and leukotrienes. Other potential anti-inflammatory mechanisms may include the inhibition of histamine release, phos- phodiesterase, protein kinase, and transcriptase activation.21 Based on several empirical reviews regarding the efficacy and compounds found in Dayak onions, researchers have become inter- ested in understanding the impact of steeping Dayak onions on reducing blood pressure and mean arterial pressure in hypertensive patients. This study serves as a means of exploring complementary therapies and alternative medicine, employing natural ingredients rooted in the local wisdom of Kalimantan for herbal therapy man- agement. The purpose of this study was to determine the effect of Dayak onion steeping water on the reduction of systolic-diastolic blood pressure and mean arterial pressure (MAP) in hypertensive patients. Materials and Methods The research design used was a Quasi-Experimental approach [page 168] [Healthcare in Low-resource Settings 2023; 11:11776] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly with a time series method and a pre-post-test design that included a control group. The sample consisted of two groups, the interven- tion and control groups, each comprising 30 participants. The inclusion criteria for the sample were respondents aged 35-59 years, not currently taking antihypertensive drugs, and not experi- encing crisis conditions or hypertensive emergencies. In this study, the independent variable was the steeping of Dayak onion bulbs, while the dependent variables were systolic, diastolic, and mean arterial pressure (MAP) values. The instruments utilized included standard operating procedures (SPO) for the preparation of Dayak onion ingredients in the intervention group, SPO for blood pres- sure measurements, and SPO for calculating MAP. Digital sphyg- momanometers were used for blood pressure measurements. Data analysis for this study was conducted using paired t-tests. The research received ethical approval from the Health Research Ethics Commission at Poltekkes Kemenkes Kalimantan Timur, based on ethical certificate No. LB.02.01/7.1/3320/2022. Throughout the research, the researcher adhered to ethical principles such as obtaining informed consent, respecting human rights, promoting beneficence, and ensuring non-maleficence. Results Characteristics of respondents Table 1 shows that in the intervention group, the majority of respondents were aged 36-45 years, comprising 8 people (53.3%), whereas in the control group, most fell into the 46-55 age range, totaling 12 people (66.7%). As for gender, the majority in both groups were women; in the intervention group, there were 10 peo- ple (66.7%), and in the control group, there were 8 people (44.4%). Concerning the history of hypertension drug usage, the majority in the intervention group took captopril, accounting for 9 people (60.0%), while in the control group, almost all used amlodipine, with 14 people (77.8%). Table 2. shows that systolic-diastolic blood pressure in the intervention group decreased. This is evident in the systolic mean of the intervention group on day 1, where the pre-post values were (163.33-154.27). After the administration of Dayak onion steeping water as an intervention, the systolic mean on day 3 also decreased, with pre-post values of (142.93-139.80). Similarly, the diastolic values of respondents decreased after they were given Dayak onion steeping water, with a mean pre-post change from (116.87- 101.73) on day 1, and on day 3, the change was from (89.93- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents. Characteristics of respondents Intervention group Control group Frequency % Frequency % Age 36-45 years 8 53.3 3 16.7 46-55 years old 7 38.9 12 66.7 Gender Man 5 33.3 7 38.9 Woman 10 66.7 8 44.4 History of antihypertensive drugs taken Amlodipine 6 40.0 14 77.8 Captopril 9 60.0 1 5.6 Total 15 100 15 100 Table 2. Blood pressure: systolic and diastolic, and MAP in both groups (intervention and control). Intervention group Control group Day Measurement Variable Min Max Mean SD Min Max Mean SD 1 Pre Systolic 153 173 163.33 5.108 155 173 164.07 4.773 Diastolic 104 127 116.87 7.661 102 124 112.93 6.552 MAP 211 236 221.77 6.695 207 235 220.53 7.267 Post Systolic 144 164 154.27 5.175 145 160 154.60 3.719 Diastolic 90 114 101.73 7.196 90 119 103.13 6.770 MAP 191 220 205.13 7.413 195 215 206.37 4.835 2 Pre Systolic 140 161 150.27 5.861 143 156 151.73 3.195 Diastolic 88 110 96.27 6.029 83 102 93.67 5.434 MAP 191 220 205.13 7.531 191 205 198.57 4.590 Post Systolic 138 153 145.47 4.207 139 150 145.07 3.615 Diastolic 85 103 92.00 4.472 80 92 85.80 3.448 MAP 185 213 198.40 5.377 181 195 187.97 4.704 3 Pre Systolic 137 150 142.93 3.936 137 146 142.13 3.067 Diastolic 84 99 89.93 3.788 81 88 83.73 2.120 MAP 180 196 187.90 4.789 179 189 184.00 3.665 Post Systolic 135 145 139.80 3.121 134 140 136.47 1.846 Diastolic 82 93 86.73 3.515 78 84 80.80 1.424 MAP 176 189 183.17 3.488 174 180 176.93 1.954 [Healthcare in Low-resource Settings 2023; 11:11776] [page 169] Non -co mmerc ial us e o nly 86.73). Regarding the MAP value, the intervention group also experienced a decrease after receiving the intervention of Dayak onion steeping water. The mean MAP on day 1 changed from (221.77-205.13) pre-post, and after the intervention, the mean MAP on day 3 changed from (187.90-183.17). It’s worth noting that systolic-diastolic blood pressure in the control group also decreased. This is evident in the systolic mean on day 1, where the pre-post values were (164.07-154.60), and on day 3, the values were (142.13-136.47). Similarly, the diastolic values changed, with the mean pre-post values being (112.93- 103.13) on day 1, and on day 3, the values were (83.73-80.80). The MAP values of respondents in the control group also showed a decrease. The mean MAP on day 1 had pre-post values of (220.53- 206.37), and on day 3, the values were (184.00-176.93). Table 3. Based the results of paired t-test statistical tests on systolic-diastolic values and MAP in the pre-post test intervention group. A p-value of 0.000 (α<0.05) was obtained, which was observed from day 1 to day 3. This indicates that there are signifi- cant differences in systolic-diastolic values and MAP before and after the intervention in the intervention group. Similarly, the paired t-test statistical test results for systolic, diastolic, and MAP values in the pre-post test control group yield- ed a p-value of < α (0.05) for systolic values on days 2 and 3, dias- tolic values on days 1 and 3, and MAP values on days 1, 2, and 3. This also indicates significant differences, reflecting a notable decrease in systolic-diastolic values and MAP in the control group. However, the decline in values was not evenly distributed on days 1, 2, or 3. In contrast to the intervention group, which experienced a consistent decrease in values on days 1, 2, and 3, it becomes evi- dent that there is an effect of Dayak onion steeping water (Eleutherine Palmifolia) on systolic-diastolic and MAP values in the intervention group. Discussion The results of paired t-tests on systolic-diastolic values and MAP for each group displayed significant outcomes. In the inter- vention group, a significant result was obtained in the pre-post test difference analysis, with a p-value of < 0.05 from day 1 to the day 3 assessment. This indicates that there was an effect of Dayak onion steeping water on systolic-diastolic and MAP values in the intervention group. In the pre-post test for the control group, significant p<0.05 were obtained for systolic values on days 2 and 3, diastolic values on days 1 and 3, and MAP values on days 1, 2, and 3. This indi- cates that there are differences in systolic-diastolic values and MAP in the pre-post values, although these differences are not evenly distributed every day. Dayak onion bulbs contain active compounds that are potent in combating various diseases, including their effectiveness as anti- hypertensive agents. These active compounds belong to the triter- penoid group, quinones, and naphthoquinones, along with the pres- ence of allicin and alkaloids.22 Allicin is believed to reduce blood viscosity, thereby leading to a reduction in blood pressure.23 This plant contains nearly all phytochemical content, including alka- loids, glycosides, flavonoids, phenolics, and steroids. Through the isolation of compounds from Dayak onion bulbs, 15 compounds were identified, namely (2S) dihydroeleuterinol-8-O-α-D-glu- copyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaA, (-)- hongkonin, eleuterin, isoeleuterin, (2S) dihydroeleuterinol-8-O-α- D-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaA, (-)-hongkonin, eleuterin, isoeleuterin, eleutocidaC, eleuterinosidaC, eleuterinosidaB, THE-7-acetyl-3,6- dihydroxy-8-methyltetralon, leutocideA, leutocideB, and eleuterinosideD.20 The activity of eleuterol, eleuterin, and isoeleu- terin has the potential to act as antihypertensive agents.24 Dayak onion tea has an effect on reducing blood pressure in hypertensive patients, with a p-value of 0.001 for systolic value and a p-value of 0.002 for diastolic value. In other words, Dayak onion tea has an impact on blood pressure.25 The administration of 100% Dayak onion tea resulted in a significant decrease in high blood pressure. The analysis yielded a p-value of 0.000 (p < 0.05) for the respon- dents’ blood pressure, indicating that Dayak onion tea has a notice- able effect on reducing blood pressure in the elderly.26 Particularly in allicin compounds, they exhibit vasodilator activity independent of nitric oxide synthesis, ATP-sensitive K(+) channels, activation of cyclooxygenase enzymes, or changes in bronchomotor tone in rat pulmonary blood vessels. Allicin is also believed to inhibit the renin-angiotensin system, which plays a cru- cial role in renovascular hypertension. This reduction in blood pressure occurs through the inhibition of angiotensin conversion enzyme (ACE) activity, while simultaneously enhancing the vasodilator effect. This decrease in ACE activity is observed in serum, aorta, heart, lungs, and kidneys. Treatment with allicin results in decreased hypertension, improved kidney function, and reduced heart dysfunction. Allicin compounds reduce vascular reactivity to angiotensin II, AT1R overexpression, and morphometric parameters. Allicin also down- regulates Keap1 and upregulates Nrf2 expression, leading to an increase in antioxidant enzymes and a reduction in oxidative stress. Therefore, allicin demonstrates antihypertensive, nephroprotec- tive, cardioprotective,27 and antioxidant effects through the down- regulation of AT1R and Keap1 expression.28 Simple extraction Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 3. Blood pressure difference test: systolic and diastolic, MAP in both groups (intervention and control). Intervention group Control group Day Measurement Variable Mean SD p Mean SD p 1 Pre -post Systolic 9.067 2.789 0.000 9.467 4.596 0.104 Diastolic 15.133 5.768 0.004 9.800 5.979 0.019 MAP 16.633 4.608 0.000 14.167 6.307 0.048 2 Pre -post Systolic 4.800 2.484 0.000 6.667 2.664 0.004 Diastolic 4.267 2.187 0.000 7.867 5.343 0.210 MAP 6.933 3.035 0.000 10.600 2.836 0.000 3 Pre -post Systolic 3.133 1.356 0.000 5.667 2.225 0.004 Diastolic 2.867 2.356 0.000 2.933 1.100 0.000 MAP 4.733 1.954 0.000 7.067 2.456 0.001 [page 170] [Healthcare in Low-resource Settings 2023; 11:11776] Non -co mmerc ial us e o nly methods of natural ingredients, such as onions containing allicin,29 can reduce systolic and diastolic blood pressure.30 Allicin has a potent antihypertensive effect, and this effect is associated with its vasodilatory properties and the H2S mecha- nism. The vasorelaxant activities of allicin are, in part, dependent on the endothelium. Endothelium-dependent vasorelaxation by allicin is mediated by the NO-sGC-cGMP, PGI2-AC-cAMP, and EDHF pathways, with H2S production playing a role in the first two pathways, rather than the third one. Meanwhile, endothelium- independent vasodilation is primarily attributed to H2S produc- tion. Therefore, the current study suggests that allicin might serve as an alternative agent for reducing the incidence of cardiovascular disorders in the hypertensive population.31 The effects of allicin, both direct and indirect through cytokine activation, can increase the quantity and proliferation of EPCs. This effect of allicin on EPC proliferation might explain the improvements in cardiovascu- lar disease.32 Garlic and Dayak onions both contain various active compo- nents. The biological functions of garlic include antioxidant activ- ity, anti-inflammatory activity, antimicrobial activity, immune sys- tem modulation, cardiovascular protection, antihypertensive activ- ity, anti-hyperlipidemia activity, heart protection, other cardiovas- cular protective effects, anticancer activity, hepatoprotective activ- ity, digestive system protection, anti-diabetic activity, anti-obesity activity, and renal protection.33 Providing hypertensive patients with Dayak onion bulb steep- ing water can reduce systolic-diastolic and MAP values. The sim- ple extraction of Dayak onion bulbs through steeping in hot water makes it easier for patients to consume the active compounds they contain. Specifically, allicin, the active compound in Dayak onions, has a vascular vasodilator effect that can inhibit the renin- angiotensin system, which plays a role in raising blood pressure. Therefore, the provision of Dayak onion steeping water to hyper- tensive patients can serve as a management approach in the domain of both complementary and alternative medicine for con- trolling hypertension through the use of natural ingredients in herbal therapy. Conclusions The results of statistical tests in the intervention group yielded significant values in the measurement of blood pressure values, including systolic-diastolic and MAP, on days 1 to 3. This indicates that there was an effect of Dayak onion steeping water on systolic- diastolic and MAP values in the intervention group. Therefore, providing Dayak onion steeping water to hypertensive patients can be employed as a management approach in the realm of both com- plementary and alternative medicine for ayakllingg hypertension through the use of natural ingredients as herbal therapies. References 1. Israfil I, Kusnanto K, Yusuf A, Efendi F. 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[page 172] [Healthcare in Low-resource Settings 2023; 11:11776] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly