Jamu formula could reduce plasma cholesterol patients with mild Hyper cholesterolemia

Background: Treatment of hypercholesterolemia often lasts a lifetime, therefore patients leave chemical drugs and choose herbal medicines. The aim of this clinical study is to evaluate the efficacy of antihiperkolesterol jamu formula consists of Guazuma ulmifolia leaves, Cassia senna leaves, Sonchus arvensis leaves, Camellia sinensis leaves, Curcuma xanthorrhiza rhizomes, Curcuma longa rhizomes and Phyllanthus niruri herbs to lowering cholesterol plasma level as part of Saintifikasi Jamu program. Methods: This study was a quasi-experimental with pre and post test design. The total subjects were 50 patients with mild hypercholesterolemia who met the inclusion criteria. The research took place at RRJ ‘Hortus Medicus’ Tawangmangu between September to December 2014. The data were analyzed using a paired t-test with SPSS 16 software. Results: Results showed jamu anticholesterol formula which is taken every day for 28 days lowered the mean of cholesterol plasma level of 212.42 mg / dl to 196.6 mg / dl. Paired t test at 95% confidence level acquired p value <0.05, showed that there is significant differences in the mean cholesterol level subjects before and after the study. Conclusion: The administration of jamu antihypercholesterol formula for 28 days could reduce plasma cholesterol level in subjects with mild hypercholesterolemia. (Health Science Journal of Indonesia 2018;9(2):87-92)

Hypercholesterolemia is a medical condition characterized by increased of cholesterol level in the blood exceeds the normal limit. 1 Cholesterol has a soft structure, such as a candle, consisting of fat that can be produced by the body or derived from food. 2 Cholesterol is produced in the liver, and has a function to build cell walls as well as a precursor of steroid hormones. 3Normally cholesterol plasma level is below 200 mg/dL, while the cholesterol level more than or equal to 200 mg/dL indicates hiperkolesterolemia (Table 1). 1 Table 1.Classification of Plasma Cholesterol Level. 1 Total Cholesterol (mg/dl) Classification <200 Normal 200-239 Borderline high ≥240 High Hypercholesterolemia increases the risk of coronary heart diseases, cardiovascular diseases, and stroke through atherosclerosis process. 1,2The high blood cholesterol levels are giving rise to a low-grade systemic inflammatory response in multiple vascular beds.Inflammation increases Reactive Oxygen Species (ROS) production that may damage cellular defence mechanisms leading to atherogenesis, protein damage and enzyme inactivation, with the final result of vascular dysfunction. 4,5e cardiovascular disease (CVD) is the number one killer in the world especially in developing country. 6orld Health Organization reported about 1,7 million people died each year from CVD's.It is estimated 31% of all deaths world wide and more than 75% of CVD deaths occur in low income and middle income countries. 7Along with advancement of technology and change in modern lifestyles, an estimated number of patients with hypercholesterolemia will increase.
According to Riset Kesehatan Dasar (RISKESDAS) in 2013 the prevalence of hypercholesterolemia in the Indonesian population aged 15 years and over was 35,9%. 8Hypercholesterolemia treatment becomes very important in order to reduce the risk of complications.The priority treatment for mild/ borderline high of hypercholesterolemia (cholesterol values 200-239 mg/dl) is the lifestyle changes such as regular exercise, reducing intake of fatty foods, and last step is using drugs/ herbs that can lower cholesterol plasma level. 2,9percholesterolemia is a matabolic disorder that often require lifelong treatment.These conditions often make patients leave conventional treatment and chose herbal treatment.Sub-chronic toxicity test showed that administration of jamu formula for 3 months did not resulting toxic effect or death in the rats.Neither of damage was found on the organ examination, so the jamu formula in the safe category were used. 11,12e aim of this study is to evaluate the efficacy of the jamu anticholesterol formula in lowering cholesterol plasma level, in term of Saintifikasi Jamu program.

Plants Materials
The Sample size was determined using the following formula : 13 Sample size was 47,25 with an estimated 5% dropout, the total sample was 50 subjects.
The primary end point of this study was the decrease of average plasma cholesterol level below 200mg / dl and the secondary end point which expected was a reduced risk of atherosclerosis.
All subjects were examined on plasma cholesterol.After diagnosis of hypercholesterolemia was confirmed, each subject was given 7 packs of jamu anticholesterol formula for 7 days.Subjects should return once a week and drank jamu for 28 days.At the end of day 28, all subjects had a plasma cholesterol examined again.

Jamu Formula
All subjects were instructed to boil 1L of water every morning for 28 days, one pack of jamu formula was put into boiling water, wait 15 minutes and stop the boiling process.Filtered the water after it is cooling down, and take it each a glass two times a day after breakfast and dinner.

Statistical analysis
Data were analyzed using paired t test with the Statistical Product and Service Solutions (SPSS) program for window version 16.

RESULTS
All fifty subjects completed the research for 28 days.More than 50% subjects are women, aged between 41-60 and overweight.(table 2).Education and Age had correlations with cholesterol level (p<0,05) while gender, occupation, hypercholesterolemia history, Body Mass Index (BMI) and smoke habit had no correlation.
There are significant differences in reduction mean of subjects plasma cholesterol level before and after the study (p <0.05) (tabel 3).
A total of 35 subjects experienced a decrease in plasma cholesterol level, whereas 13 subjects experienced an increase in plasma cholesterol level, and 2 subjects of study experience no change in plasma cholesterol level.The increase in the level of cholesterol at the end of the study can be caused by several factors: heredity, high-fat diet and lack of exercise.Hereditary factors play an important role in the occurrence of hypercholesterolemia.The hereditary hypercholesterolemia is more difficult to treat than lifestyle hypercholesterolemia.In this study there were no restrictions on diet for the subjects, only suggestion to reduce high fatty foods, so that the increase in the level of cholesterol in 13 study subjects may occur due to excessive intake of fatty foods. 14In addition, lack of physical activity can also lead to increased cholesterol level of 13 study subjects. 15is the sample size, Z is the level of confidence (75%), P is expected prevalence ( 30%) and d is presicion (5%)  Cholesterol plasma level of 28 subjects at the end of the 4th week became normal (<200 mg/dl), while 22 subjects still had cholesterol level above 200 mg/ dl.There were 9 subjects that although experience decrease in cholesterol level but still above the normal level, the limited 28 days intervention could become the reason.
Administration of antikolesterol jamu formula for 28 consecutive days was relatively safe for the liver and kidneys of the subjects, indicated by the absence of significant changes in the levels of Serum Glutamic Piruvic Transaminase (SGPT), Serum Glutamic Oxaloacetic Transaminase, Ureum and Creatinine.A full report on the safety of this jamu formula will be written in another article.

DISCUSSIONS
The prevalence of hypercholesterolemia in Indonesia is indeed higher in women, namely 14.5% while in men 8.6%. 14,16Subject ages were in the range of 30-60 years, none of subjects under 30 years old.This is consistent with the theory that increasing age is one of the risk factors for hypercholesterolemia. 17 The majority of subject education is secondary and high education.This plays a role in treatment behavior.Higher education encourages a person to be more curious about his health condition.Usually mild hypercholesterolemia is asymptomatic and often be found incidentally on routine health checks.The BMI 28 subjects were in the category of overweight and obese.As we all know being overweight is a predisposing factor for hypercholesterolemia. 17 According to our knowledge, there are no similar study to this clinical study ever published.However, the scientific articles related to the safety and efficacy of each constituent plant in lowering plasma cholesterol invivo have been widely found.
Aqueous extract of Guazuma ulmifolia leaves contains tannin, flavonoids and saponin. 18Aqueous extract at a dose of 50 mg/kg bw can lower total cholesterol and Low Density Lipid (LDL) level significantly compared control. 19Mucilage in Jati belanda can swell in the stomach so that pressing appetite.Alkaloids in Jati belanda has the activity in inhibiting pancreatic lipase enzyme that hydrolyze fat. 10 Dried extract of Jati belanda leaves doses of 2, 4, and 8 g/kgbw that administered in male mice once a day for 3 months did not increase the level of creatine and plasma urea and an average diameter size of the rat kidney glomerulus. 18,19This suggests that long-term administration Jati belanda leaves does not disturb the function of kidney. 20,21ssia senna is a medicinal plant that has been known throughout the world.Society of India and the Middle East since long ago use Cassia senna to treat hemorrhoids, as a laxative, colon cleansing, helps get rid of all the toxins in the body, and to reduce body weight. 22In Indonesia Cassia senna leaves commercially sold in the form of tea bags or dried leaves with claims of efficacy to reduce body weight, laxative and lowering plasma cholesterol.Cassia sennae leaves contain hydroxyanthracene glycosides, with the derivate are sennosides (BO-linked glycosides) has the effect of laxative.Sennosides are not absorbed in the upper intestine, and will be changed by bacteria in the large intestine becomes metabolically active rheinanthrone.Rheinanthrone would increase the motility of the colon, so shortening the transit time of food in the colon. 23assia sennae leaves also contain flavonoids that can inhibit pancreatic lipase enzyme. 22Dose of sennosides up to 500mg/kgbw given to dogs for 4 weeks showed no toxic effects, as well as the dose to 100 mg/kg in rats during administration of 6 months. 23mellia sinensis leaves contain polyphenols (catechins and flavonoids), alkaloids, volatile oil, polysaccharides and amino acid. 24,25Catechins in tea can lowering total cholesterol and Low Density Lipid level in blood plasma.This is associated with the increasing of body metabolism.Epigallocathecin-3gallate (EGCG) in green tea stimulate thermogenesis and fat oxidation which has implications for body weight loss EGCG inhibits the activity of acetyl CoA carboxylase in fatty acid biosynthesis cycle, hence reducing the accumulation of triacylglycerol (triglycerides) in fat tissue. 24,26,27nchus arvensis leaves contain kaempferol, quercetin, orientin, rutin, catechin and miristisin. 28ndonesia community since long ago have been using tempuyung to treat kidney stones and lowering plasma cholesterol. 29It is rich in polyphenols, which have antioksidan activity. 28Empirically tempuyung leaf infusion has used to lower plasma cholesterol level. 21Studies in mice, showed the ethanol extract of Sonchus arvensis leaves with doses up to 1.000 mg/kg proved to be safe and efficacious to lowering plasma cholesterol. 30rcuma xanthorhizza rhizomes well known as temulawak and Curcuma longa rhizomes or turmeric or kunyit in bahasa has been used by local community in Indonesia as traditional remedy since centuries.Temulawak contains curcuminoid fraction which had been proven can reduce cholesterol in hypercholesterol rats through inhibition of 4 gene related oxidative stress expression CD44, ICAM-1, iNOS, and LOX-1.31 Based on the invivo study, supplementation of turmeric extract in rats fed with high-cholesterol diet significantly increased the expression of cholesterol 7 α-hydroxylase, hemeoxygenase 1, and low-density lipoprotein receptors as well as decreased in 3-hydroxy-3-methyl-glutarylCoA reductase level when compared with rats fed a normal or high-cholesterol diet, showing that turmeric could prevents hypercholesterolemia and fatty liver formation by the modulation of expressions of enzymes that are important to cholesterol metabolism.32 Hydro-alcoholic extract of leaves of Phyllanthus niruri in India known as Phyllanthus amarus Schumach possessed significant hypolipidemic activity at doses 300 and 500 mg/kg in cholesterol diet induced hyperlipidemia rats.The extract contain of alkaloids, flavonoids, saponins and tannins.Saponin was known to elicit serum cholesterol lowering activity.33 In conclusion, administration of antikolesterol Jamu formula for 28 days significantly lowered plasma cholesterol levels in study subjects with mild hypercholesterolemia.
10Based on data from the Rumah Riset Jamu 'Hortus Medicus' there are about 500 new cases of hypercholesterolemia during 2013.Indonesia has some Jamu formulas that have empirically been used to lower blood cholesterol level.
2. The characteristics of Subjects *Chi Square test at the confidence level 95%

Table 3 .
The averages of plasma cholesterol levels before and after ....