INTRODUCTION
Hibiscus sabdariffa L. has been widely explored in both healthy participants and patients with metabolic disorders. Hibiscus sabdariffa has indicated a good effect on hypertensive patients (Herrera-Arellano et al., 2007; McKay et al., 2010), as proven by a randomized double-blind clinical study of H. sabdariffa L. (containing 250 mg of total anthocyanins/dose) administered for 4 weeks. This study resulted in a decrease in blood pressure (BP) (Herrera-Arellano et al., 2007). Another randomized double-blind clinical study on 65 participants with pre- and mild hypertension treated with brewed H. sabdariffa L. tea reported a significantly lower systolic BP, but not significantly lower diastolic BP (McKay et al., 2010). A study on type II Diabetes mellitus patients with mild hypertension consuming H. sabdariffa L. infusion demonstrated positive effects on their BP (Mozaffari-Khosravi et al., 2009). In a randomized control trial, patients with nonalcoholic fatty liver disease treated with a 450 mg capsule of H. sabdariffa or a placebo capsule daily for 8 weeks experienced a decrease in serum triglyceride, alanine aminotransferase, and aspartate aminotransferase levels compared with the placebo. A significant decrease in systolic BP and diastolic BP and a significant elevation in total antioxidant capacity had also been described (Izadi et al., 2021). Moreover, a rise in high-density lipoprotein cholesterol and a significant decrement in BP of healthy participants treated with H. sabdariffa tea for 30 days were also reported (Diantini et al., 2021).
The ethanol and water extracts of H. sabdariffa calyces have been proclaimed for their antioxidant activity (Adusei, 2020; Anokwuru et al., 2011; D’Heureux–Calix and Badrie, 2004; Hamrita et al., 2022; Pozos et al., 2020; Purbowati and Maksum, 2019) and various other pharmacology activities tested in animal models, for example, antidyslipidemia (Ajay et al., 2007; Ekor et al., 2010; Hirunpanich et al., 2006). These activities were predicted due to the plant’s total phenol compound (Anokwuru et al., 2011; D’Heureux–Calix and Badrie, 2004; Purbowati and Maksum, 2019) and anthocyanins (D’Heureux–Calix and Badrie, 2004; Guardiola and Mach, 2014; Purbowati and Maksum, 2019). Anthocyanins could remarkably reduce the oxidation of low-density lipoprotein, inhibit adipogenesis, and alter the expression of a particular gene (Guardiola and Mach, 2014). An in vitro study on cultured hematopoietic stem cells demonstrated the effect of H. sabdariffa on rising the glutathione level and superoxide dismutase activity but the amount of reactive oxygen species (ROS) was unchanged (Lin et al., 2014).
The physical practice is believed to be the foundation of good health; however, this activity may escalate the production of ROS, which eventually results in cell damage. Moreover, physical practice results in increasing the levels of malondialdehyde in the blood which works as an indirect indicator of lipid peroxidation (Clarkson and Thompson, 2000). The physical practice is believed to be able to stimulate inflammation and muscle fatigue (Simioni et al., 2018). Also, during heavy physical practice, the oxygen flux to active skeletal muscles is significantly elevated (Atalay et al., 2015; Radak et al., 2013). The demand for O2 in skeletal muscle during physical workups leads to a remarkable change in blood flow (Kawamura and Muraoka, 2018). Previous studies announced that treatment with antioxidants might decrease oxidative stress caused by heavy physical practice (Clarkson and Thompson, 2000). Participants supplemented with vitamin E had shown a decrease in creatine kinase and lactic dehydrogenase levels which confirmed the protective effect of vitamin E against oxidative stress (Itoh et al., 2000).
Considering this, it is interesting to explore the effect of H. sabdariffa, which has been reported for its ability to increase the activity of antioxidant enzymes, on normotensive participants’ post-physical practice in terms of cardiovascular fitness. Thus, our work assessed the effect of 30 days of daily intake of H. sabdariffa tea on the VO2max and BP in healthy participants. VO2max equals the maximal O2 consumption during exercise to approximately the depletion of physical strength. It is one of the best methods of predicting cardiorespiratory endurance and is related to body weight (Blair et al., 2001).
MATERIALS AND METHODS
Study design
This study was a quasi-experiment with a pre-post design for 32 adult males (59.4%) and females (40.6%), aged 21–55 years. The participants were affirmed to be healthy by a physician. Participants diagnosed with hypertension, peptic ulcers, knee arthritis, and/or musculoskeletal disorders were excluded. The protocol of this study was approved by the Research Ethics Committee of Universitas Padjadjaran (approval no. 35/UN6.C.10/PN/2018). The participants had agreed to sign the informed consent in compliance with the Ethical Principles for Medical Research Involving Human Subjects of the WMA Declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/) with the knowledge that they could withdraw at any time.
The general characteristics of the participants based on their age and body mass index (BMI) are shown in Tables 1 and 2, respectively. The participants were given 200 ml of H. sabdariffa tea, twice daily for 30 successive days. The H. sabdariffa tea was prepared by boiling 100 g of dried calyces and 500 g of sugar in 10 l of potable water for 15 minutes; thus, the daily dose of the H. sabdariffa tea (2 × 200 ml) contains approximately 4 g of dried calyces and 20 g of sugar.
 | Table 1. Characteristics of the participants based on their ages. [Click here to view] |
 | Table 2. Characteristics of the participants based on their BMI. [Click here to view] |
Measurement of VO2max and BP before and after treatment with H. sabdariffa tea
Before the intervention and every Friday during the treatment, the participants were required to undertake cardiovascular fitness by precisely obeying the Young Men’s Christian Association (YMCA) step test (Beutner et al., 2015; Diantini et al., 2021; Morrow et al., 2005; Teren et al., 2016). The participants were prepared to avoid taking meals, cigarettes, and caffeine for at least 2 hours before the test. The test was conducted as follows.
The BP of participants was measured before the step test. The participants were told to sit for 5 minutes on an upright chair in a position with their feet flat on the floor. BP was measured using a sphygmomanometer and stethoscope (Muntner et al., 2019) with three replicates per reading.
Afterward, the participants were directed to stand facing a bench (about 30 cm in height/Harvard bench). A sensor plate connected to a computer was equipped on their chest to record the heart rate. The operator set the metronome to 96 beats per minute (24 steps per minute). The participants started stepping on and off (right foot up, left foot up, right foot down, and left foot down) the bench with a regular rhythm for 3 minutes. After 3 minutes, the participants stopped and sat on the bench for 1 minute. The VO2max was determined by adopting the table described by the American Heart Association Cardiorespiratory Fitness Chart published in 1972. The classification is presented in Table 3 (Herdy and Caixeta, 2016; Morrow et al., 2005).
Statistical analysis
Data were analyzed using the Wilcoxon test in IBM Statistical Package for the Social Sciences Statistics version 20.0 for Windows with a p-value <0.05 indicating a statistical significance.
RESULTS
Figure 1 presents the cardiovascular fitness of the participants based on BP and VO2max. A decrease in systolic and diastolic BP (p = 0.036 and p = 0.03, respectively) compared to baseline was observed in week 4 (Fig. 1a). A decline in the number of participants with very poor VO2max (from 23 participants before intervention to 6 participants at week 4 of intervention) was also observed. However, six participants with very poor VO2max status have not changed. Inversely, an increase in the number of participants with average VO2max (from 4 participants before intervention to 14 participants at week 3 of intervention) was confirmed. Detailed information on the VO2max of all participants from the baseline (before intervention with H. sabdariffa tea) to week 4 is presented in Table 4.
 | Table 3. VO2max (ml/kg/minute) based on the American Heart Association cardiorespiratory fitness chart. [Click here to view] |
 | Figure 1. BP (a) and VO2max (b) of the participants before and after intervention with H. sabdariffa. Stars indicate a significant difference compared to the baseline (p < 0.05). [Click here to view] |
 | Table 4. VO2max status of the participants (measured every week). [Click here to view] |
Statistical analysis revealed a significant difference in the number of participants with very poor and average VO2max after intervention with H. sabdariffa tea (p < 0.05) compared to baseline (Fig. 1b). Therefore, the intervention with H. sabdariffa tea might influence cardiovascular fitness, in terms of the BP and VO2max parameters.
DISCUSSION
In our study, H. sabdariffa tea was administered twice daily to 32 healthy normotensive Indonesian participants and its effect on cardiovascular fitness was observed in terms of BP and VO2max every week until 4 weeks. Both the systolic and diastolic BP of the participants reduced significantly. Our study is in accordance with previous studies reported elsewhere (Al-Shafei and El-Gendy, 2013; Diantini et al., 2021; Herrera-Arellano et al., 2007; Izadi et al., 2021; McKay et al., 2010; Mozaffari-Khosravi et al., 2009). Moreover, a non-randomized quasi-experimental study in Egypt reported a significant decrement in pulse pressure and BP of the normotensive and hypertensive participants compared to their baseline values by the end of week 4 (Al-Shafei and El-Gendy, 2013).
However, apparently, no human studies on the H. sabdariffa effect on cardiovascular fitness were reported. Our study is the first report on the effect of H. sabdariffa tea on the VO2max of normotensive participants. The intake of H. sabdariffa tea twice daily for 30 days could significantly reduce the number of participants with very poor cardiovascular fitness and increase the number of participants with average cardiovascular fitness. Based on these data, H. sabdariffa tea could improve the VO2max and BP in normotensive participants.
The calyces of H. sabdariffa have been proven to contain abundant anthocyanins, which is indicated by the dark red color. We predict that these anthocyanins may play important role in improving the cardiovascular fitness of the participants. In fact, several epidemiological studies have described the correlation between anthocyanins and cardiovascular diseases. An earlier cohort study reported that the intake of 0.2 mg/day of anthocyanins (strawberries and blueberries) was associated with a decreased risk of cardiovascular diseases in elderly females (Mink et al., 2007). Anthocyanins intake was also reported to have the ability to prevent chronic inflammatory diseases in men and women (aged 40–74 years) (Karlsen et al., 2007).
Generally, VO2max is being used as the marker of cardiovascular health status. It is considered an important physiological measure in healthy adults (Bennett et al., 2016). A previous study on Korean women (aged 30–59 years), with more than 30% body fat, reported that systolic and diastolic BP was significantly correlated with VO2max (Shin and Ha, 2016). Moreover, in a study on 24 Sweden athletes and 5 healthy non-athletes, no significant correlation between VO2max and the systolic BP/VO2 slope was found, but a significant correlation between VO2max and systolic BP in males was observed (Eklund, 2021).
CONCLUSION
Our study assessed the effect of 30 days of H. sabdariffa tea consumption on the VO2max and BP in healthy male and female normotensive participants. We declared that this is the first study on normotensive humans assessing the effect of H. sabdariffa tea on their cardiovascular fitness. Hibiscus sabdariffa tea intake could significantly reduce the systolic and diastolic BP of the participants. Moreover, H. sabdariffa tea significantly reduced the number of participants with very poor VO2max status and significantly increased the number of participants with average VO2max status. Although this study was applied to a limited number of participants (n = 32), we concluded that H. sabdariffa tea could improve the VO2max and BP in normotensive participants.
AUTHORS’ CONTRIBUTIONS
Ajeng Diantini contributed to conceptualization, methodology, funding acquisition, and supervision. Leonardo Lubis contributed to methodology and data curation. Sri Adi Sumiwi contributed to supervision. Syamsul Rahmat contributed to participant recruitment and clinical investigation. Annisa Alpiani contributed to participant recruitment and clinical investigation. Jutti Levita contributed to writing the original draft, reviewing, editing, and supervision. All the authors have read and approved the final article.
FINANCIAL SUPPORT
This research was funded by Academic Leadership Grant (no. 1373i/UN6.O/LT/2019). The publication fee is funded by Universitas Padjadjaran via the Directorate of Research and Community Engagement.
CONFLICTS OF INTEREST
All the authors declared no potential conflicts of interest.
ETHICAL APPROVALS
The protocol of this study has been approved by The Ethical Committee of Padjadjaran University (document no. 35/UN6.C.10/PN/2018). Data availability can be accessed from the first author upon request.
DATA AVAILABILITY
All data generated and analyzed are included in this research article.
PUBLISHER’S NOTE
This journal remains neutral with regard to jurisdictional claims in published institutional affiliation
REFERENCES
Adusei S. Bioactive compounds and antioxidant evaluation of methanolic extract of Hibiscus sabdariffa. J Tech Sci, 2020; 31(2):139–47.
Ajay M, Chai HJ, Mustafa AM, Gilani AH, Mustafa MR. Mechanisms of the anti-hypertensive effect of Hibiscus sabdariffa L. calyces. J Ethnopharmacol, 2007; 109(3):388–93.
Al-Shafei AI, El-Gendy OA. Effects of Roselle on arterial pulse pressure and left ventricular hypertrophy in hypertensive patients. Saudi Med J, 2013; 34(12):1248–54.
Anokwuru CP, Esiaba I, Ajibaye O, Adesuyi AO. Polyphenolic content and antioxidant activity of Hibiscus sabdariffa calyx. Res J Med Plants, 2011; 5:557–66.
Atalay M, Lappalainen J, Korkmaz A, Sen CK. Physical exercise. In: Zampelas A, Micha R (Eds.). Antioxidants in health and disease. 1st edition, CRC Press, Boca Raton, FL, 2015.
Bennett H, Parfitt G, Davison K, Eston R. Validity of submaximal step tests to estimate maximal oxygen uptake in healthy adults. Sports Med (Auckland NZ), 2016; 46(5):737–50.
Beutner F, Ubrich R, Zachariae S, Engel C, Sandri M, Teren A, Gielen S. Validation of a brief step-test protocol for estimation of peak oxygen uptake. Eur J Prev Cardiol, 2015; 22(4):503–12.
Blair SN, Cheng Y, Holder JS. Is physical activity or physical fitness more important in defining health benefits? Med Sci Sports Exerc, 2001; 33:S379–99.
Clarkson PM, Thompson HS. Antioxidants: what role do they play in physical activity and health? Am J Clin Nutr, 2000; 72(2 Suppl):637S–46S.
D’Heureux–Calix F, Badrie N. Consumer acceptance and physicochemical quality of processed red sorrel/roselle (Hibiscus sabdariffa L.) sauces from enzymatic extracted calyces. Food Serv Technol, 2004; 4:141–8.
Diantini A, Rahmat S, Alpiani A, Sumiwi SA, Lubis L, Levita J. Effect of the roselle (Hibiscus sabdariffa L.) calyces drink on the physiological parameters of healthy adult subjects. Biomed Rep, 2021; 15(5):89.
Eklund G. Systolic blood pressure response to exercise in relation to oxygen uptake in endurance athletes. Thesis, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden, 2021.
Ekor M, Adesanoye OA, Udo IE, Adegoke OA, Raji J, Farombi EO. Hibiscus sabdariffa ethanolic extract protects against dyslipidemia and oxidative stress induced by chronic cholesterol administration in rabbits. Afr J Med Med Sci, 2010; 39(Suppl):161–70.
Guardiola S, Mach N. Potencial terapéutico del Hibiscus sabdariffa: una revisión de las evidencias científicas [Therapeutic potential of Hibiscus sabdariffa: a review of the scientific evidence]. Endocrinol Nutr, 2014; 61(5):274–95 [Spanish].
Hamrita B, Emira N, Papetti A, Badraoui R, Bouslama L, Tekfa MB, Hamdi A, Patel M, Elasbali AM, Adnan M, Ashraf SA, Snoussi M. Phytochemical analysis, antioxidant, antimicrobial, and anti-swarming properties of Hibiscus sabdariffa L. calyx extracts: in vitro and in silico modelling approaches. Evid Based Complement Alternat Med, 2022; 2022:Article ID 1252672.
Herdy AH, Caixeta A. Brazilian cardiorespiratory fitness classification based on maximum oxygen consumption. Arq Bras Cardiol, 2016; 106(5):389–95.
Herrera-Arellano A, Miranda-Sanchez J, Avila-Castro P, Herrera-Alvarez S, Jimenez-Ferrer JE, Zamilpa A, Roman-Ramos R, Ponce-Monter H, Tortoriello J. Clinical effects produced by a standardized herbal medicinal product of Hibiscus sabdariffa L. on patients with hypertension. A randomized, double-blind, lisinopril-controlled clinical trial. Planta Med, 2007; 73(1):6–12.
Hirunpanich V, Utaipat A, Morales NP, Bunyapraphatsara N, Sato H, Herunsale A, Suthisisang C. Hypocholesterolemic and antioxidant effects of aqueous extracts from the dried calyx of Hibiscus sabdariffa L. in hypercholesterolemic rats. J Ethnopharmacol, 2006; 103(2):252–60.
Itoh H, Ohkuwa T, Yamazaki Y, Shimoda T, Wakayama A, Tamura S, Yamamoto T, Sato Y, Miyamura M. Vitamin E supplementation attenuates leakage of enzymes following 6 successive days of running training. Int J Sports Med, 2000; 21(5):369–74.
Izadi F, Farrokhzad A, Tamizifar B, Tarrahi MJ, Entezari MH. Effect of sour tea supplementation on liver enzymes, lipid profile, blood pressure, and antioxidant status in patients with non-alcoholic fatty liver disease: a double-blind randomized controlled clinical trial. Phytother Res, 2021; 35(1):477–85.
Karlsen A, Retterstøl L, Laake P, Paur I, Bøhn SK, Sandvik L, Blomhoff R. Anthocyanins inhibit nuclear factor-kappaB activation in monocytes and reduce plasma concentrations of pro-inflammatory mediators in healthy adults. J Nutr, 2007; 137(8):1951–4.
Kawamura T, Muraoka I. Exercise-induced oxidative stress and the effects of antioxidant intake from a physiological viewpoint. Antioxid (Basel), 2018; 7(9):119.
Lin WHL, Abdalla BJ, Yuen OB, Latif ES, Mohamed J, Rajab NF, Wah CP, Harto MKAW, Budin SB. The role of Hibiscus sabdariffa L. (Roselle) in maintenance of ex vivo murine bone marrow-derived hematopoietic stem cells. Sci World J, 2014; 2014:Article ID 258192.
McKay DL, Chen CY, Saltzman E, Blumberg JB. Hibiscus sabdariffa L. tea (tisane) lowers blood pressure in prehypertensive and mildly hypertensive adults. J Nutr, 2010; 140(2):298–303.
Mink PJ, Scrafford CG, Barraj LM, Harnack L, Hong CP, Nettleton JA, Jacobs DR Jr. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr, 2007; 85(3):895–909.
Morrow JR, Jackson A, Disch J, Mood D. Measurement and evolution in human performance. 3rd edition, Human Kinetics, Champaign, IL, p 234, 2005.
Mozaffari-Khosravi H, Jalali-Khanabadi BA, Afkhami-Ardekani M, Fatehi F, Noori-Shadkam M. The effects of sour tea (Hibiscus sabdariffa) on hypertension in patients with type II diabetes. J Hum Hypertens, 2009; 23(1):48–54.
Muntner P, Shimbo D, Carey RM, Charleston JB, Gaillard T, Misra S, Myers MG, Ogedegbe G, Schwartz JE, Townsend RR, Urbina EM, Viera AJ, White WB, Wright JT Jr. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension, 2019; 73(5):e35–66.
Pozos GIP, Ruiz-López MA, Nátera JFZ, Moya CA, Ramírez LB, Silva MR, Macías RR, García-López PM, Cruz RG, Pérez ES, Radillo JJV. Antioxidant capacity and antigenotoxic effect of Hibiscus sabdariffa L. extracts obtained with ultrasound-assisted extraction process. Appl Sci, 2020; 10(2):560.
Purbowati ISM, Maksum A. The antioxidant activity of Roselle (Hibiscus sabdariffa Linii) phenolic compounds in different variations microwave-assisted extraction time and power. IOP Conf Ser Earth Environ Sci, 2019; 406:012005.
Radak Z, Zhao Z, Koltai E, Ohno H, Atalay M. Oxygen consumption and usage during physical exercise: The balance between oxidative stress and ROS-dependent adaptive signaling. Antioxid Redox Signal, 2013; 18:1208–46.
Shin JY, Ha CH. Relationships between blood pressure and health and fitness-related variables in obese women. J Phys Ther Sci, 2016; 28(10):2933–7.
Simioni C, Zauli G, Martelli AM, Vitale M, Sacchetti G, Gonelli A, Neri LM. Oxidative stress: role of physical exercise and antioxidant nutraceuticals in adulthood and aging. Oncotarget, 2018; 9(24):17181–98.
Teren A, Zachariae S, Beutner F, Ubrich R, Sandri M, Engel C, Löffler M, Gielen S. Incremental value of veterans specific activity questionnaire and the YMCA-step test for the assessment of cardiorespiratory fitness in population-based studies. Eur J Prevent Cardiol, 2016; 23(11):1221–7.