KONSUMSI TEH DAN ANEMIA DEFISIENSI BESI PADA WANITA HAMIL DI KABUPATEN BOGOR, INDONESIA Tea Consumption and Iron-Deficiency Anemia among Pregnant Woman in Bogor District, Indonesia

Background. Anemia in pregnancy is an essential problem due to affect to not only the mother’s life but also to baby’s life. An iron deficiency causes about 75 percent of anemia during pregnancy. Objective. This study aimed to identify risk factors for iron deficiency among pregnant women and determine the possible link between iron status and tannin levels associated with tea consumption. Method. The population-based cross-sectional studies were conducted from secondary data of previous thesis-research in 2013, “Pengaruh Kadar Tanin pada Teh Celup terhadap Anemia Gizi Besi (AGB) pada Ibu Hamil di UPT Puskesmas Citeureup Kabupaten Bogor Tahun 2012”. The study population consisted of 94 randomly selected pregnant women. The inclusion criteria were pregnant women who participated in the previous study and have a complete antenatal care record. Demographic data were collected, including data on age, working status, gestational stage, time since last pregnancy, and parity. The information included nutritional variables, such as iron supplements, nutritional status, and iron intake. Also, data for tannin level grouped as low, medium, and high based on the frequency of daily tea consumption and tea-making habits. The linear model analysis was used to determine the influence of tea consumption on serum ferritin levels. Results. The results showed that time since last pregnancy (<2 years), parity (more than two children), reduced consumption of foods containing heme, and levels of tannin consumption (low, medium, or high) were predictors of iron-deficiency anemia. The results also suggested that tannin levels were inversely proportional to serum ferritin levels. Conclusion. Pregnant women who consumed tea with a low tannin level had the highest serum ferritin levels, whereas those who drank tea with medium and high tannin levels had the lowest serum ferritin levels.

Kata kunci: anemia, feritin, kehamilan, tanin, teh inadequate nutrient absorption, insufficient nutrient intake to fulfill increased nutritional needs during pregnancy, and insufficient intake of hematopoietic nutrients. 4,5 About 75 percent of anemia during pregnancy is caused by iron deficiency. 5 A previous study conducted in West Java concluded physiological changes due to pregnancy exacerbated pre-existing malnutrition and vitamin B12, folic acid, and vitamin C deficiencies, thereby contributing to anemia. 5 High parity, short birth spacing, inadequate antenatal care or pregnancy care, and a low socioeconomic level were also reported to be risk factors for anemia among pregnant women. [6][7][8] According to the literature, tea consumption may contribute to anemia by absorbing minerals as a form of iron. 9 Tea contains various substances, such as phytate and tannin, that can inhibit iron absorption. 9 Mineral in iron reacts with tannin to form a complex bond, which is not broken down in the gastrointestinal system.
Thus, the minerals no longer function and are released from the body in the form of feces. As tannins can bind proteins, they have the ability to absorb nutrients. 10  According to studies, an estimated 20 percent of deaths are associated with low levels of hemoglobin during pregnancy that related to bleeding, eclampsia, and infection. 4 In pregnancy, the most common cause of anemia is a nutrient deficiency. The underlying causes of nutritional anemia include inadequate nutritional intake, of anemia on pregnant women and low birth weight or prematurity and mortality. 11 Although laws exist to ensure the safety of various foods and beverages, information on safe levels of consumption, including safe levels of tea consumption, is lacking among communities. 12 A lack of awareness and knowledge impede programs aimed at improving maternal and child health and reducing maternal and infant mortality and morbidity. 10 This study aimed to identify risk factors for iron deficiency among pregnant women and determine the potential link between iron status and tannin levels associated with tea consumption. Information was also collected on the frequency of daily tea (black tea) consumption and tea-making habits. The following tea-making habits were recorded: type of water used (i.e., boiled water vs. non-boiled [hot] water) and duration (1 min, 5 min, and 8 min) of tea bag dipping when making tea.

METHODS
The tannin contents of six samples of tea were tested in the laboratory. For each sample, the tea bag was dipped in boiled water and hot water for 1 min, 5 min, and 8 min ( Table 1).
The tannin content was then tested using the titrimetric method (permanganate). Tannin levels were classified as low, medium, or high based on the frequency of daily tea consumption by using quartile as a cut-off point.    According to the linear model analysis adjusted for serum ferritin levels, time since last pregnancy <2 years, parity (more than two children), reduced consumption of foods containing heme, and level of tannin consumption were predictors of irondeficiency anemia (Table 4). Based on this model, this study developed an equation, which source from the effect size (coefficient):

Figure 1. Predicted Serum Ferritin Related to Tannin Consumption according the Linier Model
Predicted SF (µg/l) = 28.923 (intercept) -10.308*Time since last pregnancy (more than two-years) a + 5.102*Parity (more than two children) b -0.043*Consumption of food containing heme (gram/day) + 7.325*Tannin low (mg/mL/day) c -1.165*Tannin medium (mg/mL/day) c -1.835*Tannin high (mg/mL/day) c a As opposed to less than two years b As opposed to less than two children c As opposed to not consumption of tea The results suggested that the tannin level was inversely proportional to the serum ferritin level.
Pregnant women who consumed tea with a low tannin level had the highest serum ferritin level as compared with pregnant women who consumed tea with medium and high tannin levels.

DISCUSSION
In this study, 94 of 104 pregnant women (participant rate 90.4%) were included in the final analysis. There are six of whom consumed tea made from loose leaves rather than tea bags and two who never drank tea were excluded from this study. The other two respondents could not take part in the interview due to health reasons.
According to the findings of the present study, time since last pregnancy, parity, protein consumption, and tea consumption (inhibit factor) predicted iron deficiency. A previous review also concluded that a short recovery between pregnancies had a strong impact on iron-deficiency anemia. 4 A number of studies reported that parity was a strong predictor of irondeficiency anemia among pregnant women. 6,15,16 A study conducted in Oman reported a hazard ratio of 3.7 (95% confidence interval [CI] = 3.80-4.91) for a high-parity group as compared with that of a low-parity groups. 6 A study results of a multivariable analysis revealing that the likelihood of anemia was increased among highparity women as compared with a low parity group. 7 In this study, heme consumption seemed to confer a protective effect against anemia or iron deficiency in pregnant women. A previous study found a similar result, reporting that heme iron absorption derived from animal products (meat, fish, poultry, and eggs) conferred more protection against anemia than nonheme obtained from plant products. 17 The same study reported that tea consumption inhibited iron absorption only when it was consumed simultaneously with foods containing nonheme iron. 17 Protein compounds can increase iron absorption in the body, which the animal-based products provide a good quality of protein material and aid iron absorption. 18 In the present study, plant-based products, such as tofu and tempeh, were the most common types of food Previous research demonstrated that tea consumption decreased iron absorption in the gastrointestinal tract. 17 The authors attributed this finding to polyphenols in tea forming insoluble complexes with iron, therefore making iron unavailable for absorption. 8 A previous study reported that drinking tea without milk inhibited the absorption of iron from solutions of Iron Chloride (t = 2.68, p < 0.05) and Ferous Sulfate containing ascorbic acid (t = 4.46, p < 0.01). 12 A case study conducted in Italy showed that a young woman with hypermenorrhea and iron-deficiency anemia failed to respond to oral iron treatment until cessation of a long-established habit of consuming large quantities of tea. 9 Another study reported a significant reduction in iron absorption when a test meal was accompanied by tea instead of water. 19 A previous research found that there was no association between serum ferritin concentrations of various groups (men, premenopausal women, and postmenopausal women) and the type of tea (e.g., black, green, or herbal) consumed. 15 The same study found were predictors of anemia. 11 Some studies also found that gestational age, ethnicity, residence, and income were significantly associated with hemoglobin concentrations and the prevalence of anemia. 10,11,17,24,25 They also reported that hemoglobin concentrations of pregnant women decreased with increased gestational age. 10,21 Socioeconomic status and breastfeeding were reported to influence the onset of anemia. 21 Women from minority groups had higher odds of anemia as compared with those from nonminority groups. 22,23 In addition, women with high parity, long duration of breastfeeding, and high socioeconomic levels had low rates of anemia. 22,23 Previous research suggested that the association of tea consumption with iron status did not hold true in Western populations, where most people had adequate iron stores, as determined by serum ferritin concentrations. 21,23 We attempted to minimize the existence of selection bias or information bias in this study. We used a structured questionnaire to prevent diagnostic bias during the interviews and also confirm the iron status through the results of laboratory tests of serum ferritin concentrations. There was a potential recall bias in this study related to nutritional data information although this study already use the Food Frequency Questionnaire (FFQ) for assess the consumption, which included questions about daily tea consumption and tea-making habits, based on 24-h recall. Measurement bias may have been introduced by assuming that the tea bag soaking times, hot water sources, and daily tea consumption frequencies remained unchanged.

CONCLUSIONS
According to the findings of the present study, four factors appeared to affect serum ferritin levels of pregnant women: time since last pregnancy (<2 years), parity (more than two children), reduced consumption of foods containing heme, and level of tannin consumption.
The tannin level was inversely proportional to serum ferritin levels. Thus, pregnant women who consumed tea with a low tannin level had the highest serum ferritin levels, whereas those who consumed tea with medium and high tannin levels had the lowest serum ferritin levels.

SUGGESTION
Pregnant women should not consume tea combined with meals due to the negative effects of tannin that affected iron binding in food.

ACKNOWLEDGEMENT
The author would like to thank to Bogor District Health Office for taking research data.