Penyakit Mikro Dan Makrovaskular

International Summit on Science Technology and Humanity (ISETH2019) p-ISSN: 2477-3328
Advancing Scientific Thought for Future Sustainable Development e-ISSN: 2615-1588
The Effect of Rosella (Hibiscus sabdariffa Linn) on Insulin

Resistance in Patients with Type 2 Diabetes Mellitus: A Randomized
Clinical Trial
Dwi Sarbini1, Emy Huriyati2, Hamim Sadewa3, Mae Sri Hartati Wahyuningsih4
1
Nutrition Departement Faculty of Health Sciences Universitas Muhammadiyah Surakarta
2
Nutrition Departement Faculty of Medical Science Public Health And Nursing Universitas Gadjah Mada
3
Biochemistry Departement Faculty of Medical Science Public Health And Nursing Universitas Gadjah Mada
4
Pharmacology Departement Faculty of Medical Science Public Health And Nursing Universitas Gadjah Mada
*) Correspodence1 : Dwi.Sarbini@ums.ac.id/Dwi.Sarbini@mail.ugm.ac.id
Abstract
Insulin resistance in Type 2 Diabetes Mellitus (T2DM) is indicated with high fasting blood glucose level,
fasting insulin and HOMA-IR. The long-time consume of diabetes drugs would bring harm. Rosella
can be used as a complementary drug to improve insulin resistance and prevent T2DM complications.
This study seeks the effect of consuming Rosella on fasting blood glucose, fasting insulin and HOMA-
IR in T2DM patients.
The study design used double-blinded & placebo-controlled randomized clinical trial with intervention
(placebo and Rosella) for 8 weeks. The sample consisted of 52 T2DM outpatients at Health Office
Yogyakarta City. Measurement of fasting blood glucose was conducted through GOD-PAP method,
fasting insulin was measured by MEIA, HOMA-IR was calculated with HOMA Calculator 2.2.3
Version. Analysis of the influence of Rosella on fasting blood glucose, fasting insulin and HOMA-IR
level in one group were tested with the Wilcoxon Signed Test and the effect between groups were tested
through Mann Whitney with a significance level of 95%.
Rosella consumption can reduce fasting blood glucose, fasting insulin and HOMA-IR levels. There
was a significant effect of Rosella administration on decreasing fasting blood glucose level in T2DM
patients (p=0.001) but there were no significant effect on decreasing fasting plasma insulin level and
HOMA-IR levels (p=0.932 and p=0.368). Rosella can improve insulin resistance by reducing fasting
blood glucose levels, fasting insulin levels and HOMA-IR values.
Keywords: type 2 diabetes mellitus, glucose, Hibiscus sabdariffa Linn, HOMA-IR, insulin, Rosella
INTRODUCTION
The International Diabetes Federation states that the number of people with diabetes in the
world has reached 415 million and is expected to continuously increase in 2040 to around 642
million (55%). The prevalence rate of Diabetes Mellitus (DM) in Indonesia in 2013 was 2.1%
which experienced an increase of 1.1% compared to 2007 from total population of 250 million
(National Institute of Health Research and Development, 2013). Nearly 80-90% of the prevalence
of diabetes mellitus is T2DM with world’s prevalence rate of 90-95%. Indonesia ranks third country
with the highest number of people with T2DM in the world behind India, China and the United
States (World Health Organization, 2016).
The causes of T2DM are insufficiency of insulin secretion, insulin resistance, or both (ADA,
2018). T2DM is a chronic disease that has not been cured yet due to a disruption in the mechanism
of blood sugar regulation in which the pancreas is unable to produce insulin. In addition, DM T2
may occur because the target cell is unable to respond to the insulin so hyperglycemia emerges or
insulin resistance presents (Whiting et.al., 2011).
ISETH 572 International Summit on Science Technology and Humanity

p-ISSN: 2477-3328 International Summit on Science Technology and Humanity (ISETH2019)
e-ISSN: 2615-1588 Advancing Scientific Thought for Future Sustainable Development
Insulin resistance is resistance to the effects of insulin on glucose uptake, metabolism, and
storage. Clinical manifestations of insulin resistance, glucose intolerance and hyperinsulinemia are
consequences of the inability of insulin to stimulate glucose absorption in insulin target tissues,
such as muscle and fat. Insulin resistance interferes with glucose uptake in peripheral tissues and
results in excessive glucose production by the liver. This affects the occurrence of hyperglycemia in
T2DM. In addition, insulin resistance causes impaired insulin secretion by sensitive tissues and an
increase in liver glucose secretion which is distinguished by an increase in fasting blood sugar. The
disruption may also occur in the formation of glycogen (Tangvarasittichai, 2015).
Studies on insulin resistance in T2DM have been widely conducted. In North Indian, the
prevalence is 37.8% where 58.46% happens in men & 41.53% in women (Kumar et.al., 2005).
About 17% of children are obese in the US, 50% have insulin resistance and 10-25% have glucose
abnormalities (Mizokami et al., 2015). Whereas in Peshawar is 78% where 77% is in men &
79% in women over the age of 30 years (Shah, et al., 2008). Another study in Korea shows that
the prevalence of insulin resistance is 70.6%, whereas the number is higher in impaired insulin
secretion patients with 59.5% vs. 22.0% (Kim & Lee, 2016). A cross-sectional study in Kenya
shows 82.6% out of 167 T2DM patients suffer insulin resistance (Gulam, et al., 2017). In general,
the prevalence of insulin resistance in T2DM is 18%, with ratio of 4:1. Research in Indonesia
shows a strong correlation (r = 0.939; p-value <0.001) between insulin resistance and HOMA-IR
index and T2DM in Indonesia (Srihardyastutie et al., 2014).
Impaired insulin secretion and insulin resistance in T2DM are shown by higher of fasting blood
glucose, fasting insulin and HOMA-IR value compared
to normal individuals. (Vimaleswaran et
al., 2011). Shah et al., (2008) observed in T2DM patients with insulin resistance that indicated
by 60% uncontrolled glucose level. Hyperglycemia due to insulin resistance in T2DM may cause
complications such as microvascular complications (retinopathy, nephropathy, neuropathy) &
macrovascular (cardiovascular & cerebrovascular).
Due to expensive DM treatment costs and clinical complications, herbal medicines as
complementary therapy (adjuvant) is required for treatment and prevention of T2DM complications.
Herbal medicines that contain antioxidants are proven to boost and prevent the progression of
T2DM. Treatment with herbal ingredients has several advantages, for instance, patients feel more
comfortable because of the relatively fewer side effects compared to synthetic drugs. The use of oral
diabetes drugs (OAD) for a long time causes resistance (Atiqoh et al., 2011; Lin et al., 2016). One
of the tropical plants consumed to prevent complications and as T2DM adjuvant drugs is Rosella
(Hibiscus sabdariffa Linn). Rosella is proven as an antidiabetic by reducing blood glucose levels,
boosting insulin secretion and improving insulin resistance (Andraini & Yolanda, 2014).
The Rosella polyphenols content, especially the anthocyanin group (delphinidin 3-sambubioside,
delphinidin 3-glucoside, cyanidin 3-sambubosyde, cyanidin 3 glucoside), alkaloids (quercetin,
protocatechuic acid), and some organic acids (vitamin C) have antioxidant activities that can
suppress oxidative stress from free radical effects on insulin resistance in T2DM (Zarrabal et al.,
2012). Studies in experimental animals have shown that Rosella extract boosts insulin resistance
by reducing blood glucose level, plasma insulin level, visceral fat tissue weight & HOMA-IR value
and increasing adiponectin secretion (Chuenta et.al., 2011; Bunbupha et.al., 2012; Huaysrichan et
al., 2016; Singh & Pannangpetch, 2017). Rosella has antihyperinsulinemia effect on T2DM with
insulin resistance (Belwal et al., 2017).
The content of anthocyanin Rosella has been shown to reduce systolic and diastolic blood
pressure in T2DM patients with in vitro, in vivo and clinical hypertension and can reduce blood
glucose level and increase plasma insulin level in diabetic rats (Lin et al., 2016; Ardalani, 2016). The
International Summit on Science Technology and Humanity 573 ISETH

inhibition mechanism of Rosella for T2DM through inhibiting the key enzymes of carbohydrate
digestion forming glucose is α-glucosidase and α-amylase enzymes with in vitro by polyphenol
compounds (flavonoids, phenolic acids, and tannins) (Ademiluyi & Oboh, 2013). Another study
also shows that phenolic compounds are able to regulate postprandial glucose levels and inhibit
glucose intolerance due to insulin response and decrease glucose secretion caused by glucagon
insulinotropic polypeptide (GIP) and glucagon like polypeptide-1 (GLP-1). Protocatechuic acid
content acts as antidiabetic by reducing plasma glucose level and increasing insulin level in diabetic
rats and has the potential to prevent complications in reducing triglyceride level, anticoagglucosation,
antioxidant and anti-inflammatory (Lin et al., 2016; Farombi, 2007).
There is a significant effect of various concentrations in Rosella petals infusion on decreasing
blood glucose level in glucose-induced mice (Atiqoh et al., 2011) and reinforced by Rosemary
et al. (2014) and Mardiah et al. (2015) in streptozotocin-induced mice, besides able to increase
MDA level and maintain bodyweight of alloxan-induced mice and reduce blood glucose level
insignificantly (Ojewumi & Kadiri, 2013). Rosella can reduce blood glucose level 1.6±26 mg/dl
in T2DM (Mozaffari-Khosravi et al., 2014) and 22.5 mg/dl in pre-diabetes women in Yogyakarta
(Rohmah et al., 2018). Andraini & Yolanda (2014) prove that Rosella can reduce or prevent insulin
resistance in high-fructose dietary-induced rats, in which decrease in fasting blood glucose level,
fasting blood insulin level and HOMA-IR are found. Nerdy (2015) proves that Rosella bioactive
compounds (quercetin, hibiscetin, gossypetin, protocatechuic acid) have better potential as PEPCK
enzyme inhibitors than metformin. The ability of Rosella phenolic acid in glucose uptake is similar
to the absorption of metformin & thiazolidinedione.
Besides as a good antioxidant, Rosella is also considered safe. The prescription of Rosella
extracts 150 to 180 milligram/kg BW/day orally shows no signs of additional effects (LD50 between
2000-5000 mg/kg/day) (Hopkins et al., 2013). It is also reported that consumption of Rosella tea
has no side effects on the liver and kidneys (except consumption> 5000 mg/kg/day). Rosella can
capture ROS and free radicals, reduce reactive O2, metabolize fat peroxidation into non-radical
products, and prevent the generation of free radicals by neutralizing free radicals by 44% (Wang et
al., 2000). High vitamin C content can reduce blood glucose and HbA1c levels (Wu et al., 2014).
Many studies that prove the effectiveness of Rosella for antidiabetic have been conducted both in
vitro and in vivo. Mozzafari-Khosravi et al. (2009) prove that consumption of 2 gram Rosella calyx
tea dissolved in 240 ml of boiling water with 2 times per day consumption (morning and evening)
between main meals for a month can significantly reduce systolic blood pressure.
Based on the backgrounds above, further research is required to analyze the effect of Rosella
therapy on insulin resistance in T2DM, fasting blood glucose level, fasting insulin level and HOMA-
IR with a randomized controlled clinical trial model in T2DM patients.
PATIENTS AND METHODS

Study Design and Participants
This study used experimental design with a double-blinded & placebo-controlled randomized
clinical trial (RCT) design conducted in 2018-2019 with total participants of 60 T2DM outpatients.
The population was 5 (five) Public Health Center in the Yogyakarta City which was randomly
selected. The chosen public health center was determined by choosing those with T2DM prevalence
above the national prevalence (2.6%) from January 2018-June 2018, those were Puskesmas Tegalrejo,
Jetis, Gedongtengen, Kotagede 1 and Gondokusuman 1. The inclusion criteria were determined by
T2DM patients with fasting blood glucose levels ≥126 mg.dL or random blood glucose level 2JPP

≥ 200 mg/dL, willing to be sample by signing informed consent, able to communicate well, T2DM
patients without kidney complication and heart disease, T2DM patients ranged between 35-65
years, and consuming the same drugs with the type, dose/amount and frequency until the study was
completed. Exclusion criteria were pregnant & nursing patients. Samples were not included in the
data processing and analysis (withdrawn criteria) if mortality occurred during the study, patients
withdrawing during data collection, patient compliance consuming Rosella capsules <20% during
the study, suffering from infections and abscesses, increasing in diabetes medications (dosage &
frequency) during the study, consuming herbal tea or herbal medicine, and the patient defying the
study protocols.
After obtaining samples based on inclusion and exclusion criteria of the study, the aims and
objectives of the research were explained. Subjects agreed with the research by signing informed
consent to become a respondent. Samples were randomly divided based on permuted block
randomization by computer using 4 random numbers consisting of 2 (two) groups, the group
that received Rosella capsules and the group with no Rosella prescription but received placebo
capsules (500 mg lactose). The samples were selected by convenience sampling technique from
affordable population by dividing it into 2 groups (control and Rosella groups) and then drawing
for each group division. Randomization was performed by PT Liza Herbal International and the
randomization team.
Researchers, samples and laboratory analysts of the study outcomes were completely unaware
of the interventions provided. Rosella and placebo capsules were made in an identical shape, size,
color, taste, and bottle package. Rosella and placebo capsules were secured by PT Liza Herbal
International with quality standards certificate based on National Food and Drug Agency with
number of POM TR: 073 371 151. Rosella and placebo packages were labeled using 1-52
numbering, the composition of contents was only recognized by the manufacturer of Rosella
capsules. Both study groups consumed the same amount of capsules and direction with 2 capsules
a day after meals (morning and evening) for 8 weeks.
Prior to the intervention of Rosella and placebo capsules, the samples were given nutrition
counseling or nutrition education by a nutritionist to regulate samples’ dietary so the food intake
factor did not become a confounding factor in study. During the study, samples were not permitted
to take supplements or other herbal medicines. All participants were followed up every 1 week
(8 times during the study) to ensure their compliance with capsules consumption through home
visits by enumerators. Each participant was given a diary containing a record of compliance with
capsule consumption, the remaining capsules, reasons for not consuming capsules and a record of
complaints during the capsules consumption that written every day. Participants who experienced
digestive & kidney disorders during the study were excluded from the study. PT Liza Herbal
International or capsules manufacturer delivered the composition of the capsules when the study
was completed.
Measurements
Subject characteristics (sex, age, supplement consumption, herbal/tea consumption, family
history, drug consumption, smoking status, infection and abscess presence, occupation, DM
duration) were collected through interviews with patients conducted by enumerators using
characteristic questionnaires for research subjects. The physical activities of the samples were
measured by interviews using International Physical Activity Questionnaire (IPAQ). Food intakes
(energy, carbohydrate, protein, and fat) were obtained through interviews by enumerators using
Semi Quantitative Food Frequency Questionnaire (SQFFQ) method with the assistance of food

photo books from the Ministry of Health Republic of Indonesia in 2014. Compliance with the
intervention capsule consumption can be seen from the record of the remaining capsules in the
compliance book capsule consumption using the formula:
Remaining capsules
× 100
Total capsules
Nutritional status was measured using body mass index (BMI). Nutritional status is determined
by anthropometric measurements including measurement of weight (kg) and height (cm) in units
of kg/m2 using the formula:
Weight (kg )
Height squared (m 2 )
Weight was measured using a digital body scale (Camry brand) with a minimum clothing
capacity of 200 kg and accuracy level of 100 g. Weight measurements were taken before and after
the intervention. Height was measured by microtoice with a length of 200 cm and level of accuracy
of 1 mm. During measuring height, the participants were asked to take off shoes and stand upright
straight forward. The nutritional status of the participants was measured using body mass index
(BMI).
Blood pressure value is three times the average value of systolic and diastolic blood pressure
measurements measured using a stethoscope and mercury sphygmomanometer (Omron brand)
before and after the interventions.
Blood samples were used to obtain serum for examination of fasting blood glucose level and
fasting insulin level. Before blood draw, patients were asked to fast for 8-10 hours to subsequently
be taken for blood samples. Fasting is a condition of no-calorie intake but drinking water is
allowed. Blood was drawn through the cubital vein as much as 3 mL and used a 3 mL syringe after
disinfection was completed at the collection site. Each venous blood sample taken was collected in
a tube and then centrifuged at a rate of 2-3 x 103 rpm for 15 minutes to obtain serum. The serum
was pipetted using a micropipette and put in an Eppendorf tube and labeled according to the
randomization number and then stored in the refrigerator at -40-80oC until the examination was
proceeded (fasting blood glucose level and fasting insulin level examination). Blood samples were
taken by laboratory staff.
Blood glucose level was measured using the glucose oxidase-para amino phenazone (GOD-PAP)
method in mg/dL unit using the Diasys kit (Diasys Diagnostic System GmbH Alte Strasse 9 65558
Holzheim, Germany). Fasting insulin level was measured using the Microparticle Immunoassay
Enzyme (MEIA) method in μIU / mL unit. Fasting insulin level was analyzed using ELISA Insulin
kit (The Calbiotech Inc., A Life Science company, USA). Measurement of fasting blood glucose and
fasting insulin was performed before and after the interventions (pre-post).
To find the presence of insulin resistance was determined by using the Homeostasis Model
Assessment-Insulin Resistance (HOMA-IR) Index to express the measure of insulin activities.
HOMA-IR was calculated using the HOMA calculation software (HOMA calculator 2.2.3 version,
Diabetes Trial Unit of the University of Oxford).
Ethical Considerations
Researchers had submitted to Universitas Gajah Mada Faculty of Medicine, Public Health
and Nursing Research Ethics Commission to obtain Ethical Clearance with Ref: KE FK/00995/
EC/2018. Data collection was conducted after obtaining approval from the Ethics Commission

and participants or guardians of participants by signing informed consent by both researchers and
participants/ guardians of participants. One doctor was provided to anticipate any unexpected
possibilities related to the subjects’ health. All research information and data are only used for
scientific purposes and confidentiality is maintained.
Statistical analysis
Data on subject characteristics (sex, age, supplement consumption, herbal/tea consumption,
family medical history, drug consumption, smoking status, infection and abscess presence,
occupation, duration of DM), blood pressure data, fasting blood glucose level data, insulin level
data, and HOMA-IR data were processed with the assistance of SPSS 21 version. Anthropometric
data (weight and height) were processed through ANTRO 2008. Nutrition intake data were
processed with nutrysurvey program by comparing their needs.
Categorical data are described by frequency distribution and percentage, while numerical data
are described by means and standard deviations. Data normality test used Student T-Test.
Analysis of the effect of Rosella capsule consumption on systolic blood pressure, diastolic blood
pressure, fasting blood glucose level, fasting insulin level & HOMA-IR in group 1 T2DM patients
used Wilcoxon Signed Rank-Test as the data were not normally distributed. To find differences
between groups was conducted using Mann Whitney test because the data were not normally
distributed with a significance level of 95% (p<0.05).
RESULTS
In the intervention, 60 samples fulfilled the inclusion and exclusion criteria included
in the clinical trial, 30 samples for control group and 30 samples for Rosella group. Before the
intervention was given, 3 samples withdrew after taking blood for the baseline, 2 samples from the
control group and 1 sample from intervention group so there was total of 57 samples received the
intervention. The withdrawal reasons were due to family members’ permission issues, abundant
medicine consumption and out of town for a long time. At the time of data analysis, only there
were 52 participants could be analyzed because percentage of compliance with the intervention
capsules below 80% (n = 3) and changing in the type and dose of hypoglycemic drugs consumed
before the study was completed (n = 1) (Figure 1). The lowest percentage of compliance with
capsule consumption for control group was 80% and the highest was 99% with an average of
90.86%, while for Rosella group the lowest was 81% and the highest was 100% with an average of
91.08%. Noncompliance during capsules consumption intervention was due to several factors such
as leaving the city for a long time, illness and hospitalized and forgetting.
Variables that affected insulin resistance before intervention are presented in Table 1 and Table
2. Table 1 shows the quantitative variables before the intervention with no difference between the
control group and Rosella group, thus, the condition was homogeneous for the characteristics of
age, duration of diabetes, weight, height, nutritional status, carbohydrate intake, fat intake, protein
intake, physical activity, systolic blood pressure, diastolic pressure and also blood biochemical
parameters (fasting blood glucose level, fasting insulin level) and insulin resistance status (HOMA-
IR).

Assessed for eligibility (n=90)
Excluded (n=30)
Not meeting inclusion criteria (n=20)
Declined to participate (n=8)
Other reasons (n=2)
Randomized (n=60)
Allocation
Allocated to control group/placebo Allocated to intervention group/Rosella
capsule (n=30) capsule (n=30)
Received allocated intervention (n=28) Received allocated intervention (n=29)
Did not receive allocated intervention Did not receive allocated intervention
(give reason)(n=2) (give reason)(n=1)
Follow-Up
Lost to follow-up (give reason)(n=0) Lost to follow-up (give reason)(n=0)

Discontinued intervention (give Discontinued intervention (give
reasons)(n=2) reasons)(n=0)
Analysis
Analysed (n=28) Analysed (n=24)
Excluded from analysis (give Excluded from analysis (give
reason(n=0) reason(n=5)
Figure 1. Consort Flow Diagram Intervention Steps
Table 1. Comparison of the Quantitative Variables between the Two Groups before Intervention
Control group/placebo Intervention group/
Variables P-value*
(n=28) Rosella (n=24)
Age (year) 56.14±5.11** 54.08±5.89** 0.183
Duration of with diabetes (year) 7.62±5.82 7.25±6.01 0.819
Weight (kg) 62.26±8.88 66.98±11.42 0.100
Height (cm) 152.64±6.82 155.09±7.75 0.231
Body mass index (kg/m2) 26.69±3.19 27.82±4.20 0.273
Dietary intake
Energy (Kcal/day) 828.91±394.89 710.77±327.92 0.251
Carbohydrate (g/day) 129.67±61.75 113.42±38.92 0.271
Protein (g/day) 98.00±34.31 27.82±16.67 0.183

Fat (g/day) 75.20±25.07 74.50±19.66 0.253

Systolic blood pressure (mm/Hg) 146.80±20.00 188.00±143.54 0.575
Diastolic blood pressure (mm/Hg) 81.47±9.71 79.14±8.24 0.360
Physical Activity (MVPA/day) 350.95±388.90 819.95±2028.77 0.236
Fasting glucose level (mg/dL) 157.25±54.29 143.95±48.51 0.36
Fasting insulin level (μIU/mL) 11.11±8.34 13.45±12.44 0.423
HOMA-IR 1.71±1.60 3.17±4.76 0.375
*Student t-test, **mean±SD
Table 1 provides an overview of sample characteristics, clinical and biochemical parameters

before intervention were homogeneous (p≥0.05). Most of the samples were elderly (50 years and
older) with an average of T2DM duration 7 years and more, the average BMI was above 25 kg/m2
(over body weight), food intake was less than necessary. Systolic blood pressure shows high above
130 mm/Hg, while diastolic blood pressure is good (<80 mm / Hg). Fasting insulin level and
HOMA-IR before normal intervention, while fasting blood glucose level is high (above 108 mg/
dL).
Table 2 shows that most of the samples were female (82.1% in control group and 70.8% in
Rosella Group) and were patients with long duration of T2DM. In control group, the number of
patients taking hypoglycemic drugs (60.7%) was bigger than Rosella group, but the Rosella group
consumed more blood pressure medications (50%) and lipids (4.2%).
Table 2. Comparison of the Qualitative Variables between the Two Groups before Intervention
Variables Control group/placebo (n=28) Rosella group (n=24)
Gender
Male 5(17.9) 7(29.2)
Female 23(82.1) 17(70.8)
Taking oral hypoglycemic agents 17(60.7) 11(45.8)
Taking anti-hypertensive drug 11(39.3) 12(50.0)
Taking anti-hyperlipidemia drug 0 1(4.2)
Duration of DM
Newly 3(10.7) 4(16.7)
Long 25(89.3) 20(83.3)
Table 3 shows that after the intervention there were a decrease in systolic blood pressure, fasting
blood glucose, fasting insulin, and HOMA-IR levels but an increase in diastolic blood pressure in
both control group and Rosella group. The decreasing of systolic blood pressure and fasting glucose
level after the intervention in the control group was higher but in fasting insulin and HOMA-IR
values were higher in Rosella group. The administration of Rosella can reduce fasting insulin level
by 0.04 mg/dL greater than control group. Meanwhile, the decreasing on HOMA-IR values also
was greater by 0.55 μIU/mL than control group.
Statistical tests show no significant difference between control group and Rosella group on
systolic blood pressure, diastolic blood pressure, fasting blood glucose level, fasting insulin level
& HOMA-IR value (p≤0.05), so there was no effect of consuming Rosella as complementary
medicine on insulin resistance in T2DM patients.

Table 3. Comparing Means of Diferrence (Δ) Clinical and Biochemical Parameters Between
Control and Rosella Groups During Intervention
Variables Control group Rosella Group P-value*
(mean±SD) (mean±SD)
Systolic blood pressure (mm/Hg) -5,69±17.28 -4.04±17.69 0.854
Diastolic blood pressure (mm/Hg) 0.13±8,40 4,73±12.77 0.378
Fasting blood sugar (mg/dL) -24.64±26.01 -24.25±29.69 0.949
Fasting blood insulin (μIU/mL) -0.73±10.13 -0.77±9.73 0.783
HOMA-IR -0.25±1.75 -0.80±4.12 0.497
* Mann Whitney Test, significance rate 95 %
Comparison of average systolic blood pressure, diastolic blood pressure, fasting blood glucose
level, fasting insulin level and HOMA-IR before and after intervention in 1 group is shown in Table
4. There was a decrease in all clinical and biochemical blood parameters but only fasting blood
glucose level showing a very significant difference between before and after the intervention in both
control group and Rosella group (p = 0.001).
Table 4. Comparing Means of Clinical and Biochemical Parameters Between Baseline and End In
Two Groups
Variables Baseline (mean±SD) End (mean±SD) P-value*
Control Group
Fasting blood sugar (mg/dL) 157.25±54.29 132.61±40.01 0.001
Fasting blood insulin (μIU/mL) 11.11±8.34 10.37±7.22 0.690
HOMA-IR 1.71±1.60 1.45±0.93 0.322
Rosella Group
Fasting blood sugar (mg/dL) 143.95±48.51 119.71±36.54 0.001
Fasting blood insulin (μIU/mL) 13.45±12.44 12.68±8.01 0.932
HOMA-IR 3.17±4.76 1.73±1.05 0.368
* Wilcoxon Signed Rank Test, significance rate 95 %
DISCUSSION
This study shows that consumption of Rosella capsules twice a day for 8 weeks has no effect on
insulin resistance in T2DM patients. This is not in accordance with the research by Mozaffari et.al.
(2014) which has proven that administration of Hibiscus sabdariffa Linn tea can improve insulin
resistance in T2DM patients. This study used pure Rosella extract of 50 mg to anticipate that all
bioactive compounds in Rosella can be well-absorbed in the body with a longer duration than the
research by Mozaffari et.al. (2014). The absence of significant effects might due to less large extract
dose. In addition, the duration of T2DM also affected the IR parameters in which the longer the

T2DM patients suffered, the more likely the patients would experience IR. In research Mozaffari
et.al. (2014), the average duration of DM was 24 years and more, while the duration of T2DM this
study was under 1 year.
This study does not support the research of Chuenta et al. (2011), Bunbupha et al. (2012),
Huaysrichan et al. (2016), Singh & Pannangpetch (2017), Belwal et al. (2017) proving that Rosella
extract consumption boosts insulin resistance in T2DM because the participants in those studies
are experimental animals which are easy to control its food intake and physical activity. Researches
of Rosella’s effect on insulin resistance in experimental animals were also conducted by Lin et al.
(2016), Ojewumi & Kadiri (2013), Andraini & Yolanda (2014), Atiqoh et al. (2011), Rosemary
et al. (2014) and Mardiah et al. (2015). Although the results of this study are not statistically
significant, there is a decrease in systolic blood pressure, fasting blood glucose level, fasting insulin
level and HOMA-IR value between control group and Rosella group. Statistically significant fasting
glucose level is highly significant between before and after the intervention in each group. The
results of this study are in line with the research of Mozaffari-Khosravi et al. (2014) explaining there
is a decrease in blood glucose levels of 1.6 ± 26 mg/dL in T2DM & 22.5 mg/dL in prediabetes
women in Yogyakarta (Rohmah et al., 2018).
Rosella’s ability to reduce fasting blood glucose level is generated by the enzymes α-glucosidase
and α-amylase (enzymes inhibiting key enzymes in digestion of carbohydrates to form glucose)
and polyphenol compounds (flavonoids, phenolic acids, and tannins) (Ademiluyi & Oboh, 2013).
Phenolic compounds are able to regulate postprandial glucose levels and inhibit glucose intolerance
due to insulin response and decrease glucose secretion induced by insulinotropic polypeptide (GIP)
and glucagon like polypeptide (GLP-1). Antidiabetic Rosella is due to protocatechuic acid which
has the ability to reduce plasma glucose levels and increase insulin levels in diabetic rats (Lin et al.,
2016). Quercetin, hibiscetin, gossypetin, protocatechuic acid in Rosella according to Nerdy (2015) are
more potent as PEPCK enzyme inhibitors than metformin. The ability of Rosella phenolic acid
in glucose uptake is similar to the absorption of metformin & thiazolidinedione. High vitamin C
content potentially reduces blood glucose and HbA1c levels (Wu et al., 2014).
This study has several limitations, including there was no the third group as a positive control
group that consisting of healthy individuals or non-diabetic patients. In healthy individuals,
the effect of providing food or natural ingredients or functional food will bring more effective
results because healthy individuals contain no drug factors involved so it can precisely illustrate
its effectiveness in reducing fasting blood glucose level and fasting insulin level. In this study, all
patients took hypoglycemic drugs with different doses, so the effect of Rosella consumption was
ineffective. Furthermore, drugs greatly influenced the biochemical parameters of blood in a short
time because of large doses. The next drawback is the possibility of a less large capsule dose. The
extract dose added in capsules was only 10% of the weight of 500 mg meaning it contained only 50
mg purely extract per capsule. So that this capsules have low antioxidant activity. The effectivity of
antioxidant activity of Rosella for recovering insulin resistance in T2DM patient must be compared
with other herbal medicine as the fourth group, so the fourth group must be required as the group
that is given the intervention of other herbal medicine.
There was no difference between control group and Rosella group in age, duration of diabetes,
weight, height, nutritional status, carbohydrate intake, fat intake, protein intake, physical activity,
systolic blood pressure, diastolic pressure, fasting blood glucose level, fasting insulin level and
insulin resistance (by HOMA-IR) status at the beginning of this study. Those were strengths of
this research. Another strength of this research are the samples condition in the initial study were
homogeneous so that it could be compared with after treatment (comparable). In terms of the

number of samples chosen (60 samples), 86.7% could follow the research protocol until the end of
the study. In addition, the average percentage of compliance in consuming capsules intervention
reached 90.86% for control group and 91.08% for Rosella group. This proves that participants
were very committed to following the instructions of this study.
Based on the potential of Rosella as an antidiabetic, it is necessary to study the mechanism of
Rosella in inhibiting insulin resistance in T2DM. Consideration to choose capsule form is those
with stability in storage & transportation, the shape is more practical & attractive, can be combined
with several kinds of oral diabetes medications, mask unpleasant odors & bad flavors and can avoid
direct contact with air and sunlight (Syamsuni, 2006).
Statistically, there was no significant effect on insulin resistance in this research but herbal
medicines were proven to reduce insulin resistance parameters in T2DM patients, especially
fasting blood glucose levels. For this reason, it is recommended for further studies to use a higher
dose of Rosella extract (75-100 mg) and can be applied to T2DM patients with complications
(hyperlipidemia, hypertension), Type 1 Diabetes Mellitus (insulin-dependent DM) and gestational
diabetes patients.
CONCLUSION
This study shows that consumption of Rosella capsules 500 mg 2 times a day can significantly
reduce fasting blood glucose levels, also can reduce fasting insulin level dan HOMA-IR value but
not significantly in T2DM outpatient at Public Health Center Yogyakarta. Based on the potential
of Rosella as an antidiabetic for improving insulin resistance, it is necessary to study the mechanism
of Rosella in inhibiting insulin resistance in T2DM.
ACKNOWLEDGMENT
We greatly appreciate the support for all patients and sincerely thank all the participants of this
study for their cooperation. The authors also thank for education fund management agency of the
Republic of Indonesia’s Finance Minister, Gadjah Mada University, and Universitas Muhammadiyah
Surakarta for supporting.
CONFLICTS OF INTEREST STATEMENT

The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.
REFERENCES
Ademiluyi, A. O., & Oboh, G. (2013). Aqueous Extracts of Roselle ( Hibiscus sabdariffa Linn.)
Varieties Inhibit a -Amylase and a -Glucosidase Activities In Vitro, 16(1), 88–93. https://doi.
org/10.1089/jmf.2012.0004
American Diabetes Association. (2018). Standards of medical care in diabetes. The Journal of Clinical
and Applied Research and Educationon, 41(January). https://doi.org/https://doi.org/10.2337/
dc18-Sint01
Andraini, T., & Yolanda, S. (2014). Prevention of insulin resistance with Hibiscus sabdariffa Linn.
extract in high-fructose fed rat. Medical Journal of Indonesia, 23(4), 192–196. https://doi.
org/10.13181/mji.v23i4.848

Ardalani, H. (2016). The Ethnopharmacological Review Of Medicinal Plants In Ueses Hypertension

Treatment In Iranian Complementary Medicine. Journal of Herbal Drug, 7(1), 9–13.
Atiqoh, H., Wardani, R. S., & Wulandari, M. (2011). Uji Antidiabetik Infusa Kelopak Bunga
Rosella (Hibiscus Sabdariffa Linn.) Pada Tikus Putih Jantan Galur Wistar Yang Diinduksi
Glukosa. Jurnal.unimus.ac.id 4, 7(1), 43–50.
Badan Penelitian dan Pengembangan Kesehatan. (2013). Riset Kesehatan Dasar (RISKESDAS)
2013. Laporan Nasional 2013, 1–384. https://doi.org/1 Desember 2013
Belwal, T., Nabavi, S. F., Nabavi, S. M., & Habtemariam, S. (2017). Dietary Anthocyanins
And Insulin Resistance: When Food Becomes A Medicine. Nutrients, 9(10). https://doi.
org/10.3390/nu9101111
Bunbupha, S., Pakdeechote, P., Kukongviriyapan, U., & Pannangpetch, P. (2012).
Antihyperinsulinemia Effect of Hibiscus Sabdariffa Extract in High Fructose Diet Induced
Insulin Resistance Rats Methods Objective Proceeding. Srinagarind Med J, 27, 4–7.
Chuenta, S., Pannangpetch, P., Kongyingyoes, B., & Yutanawiboonchai, W. (2011). The Effect
of Roselle Extract on Insulin Resistance , Adiponectin Secretion and Fat Tissue Weight in
High Fructose-High Fat Diet Induced Insulin Resistant Rats Methods Proceeding Results
Proceeding, 26, 25–28.
Farombi EO, Ige OO. (2007). Hypolipidemic And Antioxidant Effects Of Ethanolic Extract From
Dried Calyx Of Hibiscus sabdariffa in Alloxan-Induced Diabetic Rats. Fundam Clin Pharma-
col, 21:601-9
Gulam, A. H., Otieno, F. C., & Oyoo, G. O. (2017). Prevalence Of Psychological Insulin Resistance
Among Patients With Type 2 Diabetes At Kenyatta National Hospital, Kenya. Health Science
Journal, 11(3), 1–8. https://doi.org/10.21767/1791-809X.1000508
H. Syamsuni. (2006). Farmasetika Dasar & Hitungan Farmasi. (W. R. Syarief, Ed.) (1st ed.).
Jakarta: Penerbit Buku Kedokteran EGC Jakarta. Retrieved from https://books.google.co.id/
books?id=rLWvvfL8-BcC
Hopkins, A.L., Lamm, M.G., Funk, J., Ritenbaugh, C. (2013). Hibiscus sabdariffa L. In The
Treatment Of Hypertension And Hyperlipidemia: A Comprehensive Review Of Animal And
Human Studies. Fitoterapia 85, 84–94. Doi:10.1016/J.Fitote.2013.01.003.
Huaysrichan, W., Prachaney, P., Kongyingyoes, B., & Kukongviriyapan, U. (n.d.). Asia-Pacific
Journal of Science and Technology Hibiscus sabdariffa Linn . calyx extraction and Gallic acid
improving cardiac diastolic dysfunction in high fat diet-STZ-induced type 2 diabetic rats,
1–10.
Kim, J. D., & Lee, W. Y. (2016). Insulin Secretory Capacity and Insulin Resistance in Korean
Type 2 Diabetes Mellitus Patients. Endocrinology and Metabolism (Seoul, Korea), 354–360.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27546870
Kumar, A., Tewari, P., & Sahoo, S. S. (2005). Type-2 Diabetes Mellitus Patients : a Prospective
Study in North. Indian Journal of Clinical Biochemistry, 20(2), 10–17.
Lin, D., Xiao, M., Zhao, J., Li, Z., Xing, B., Li, X., … Chen, S. (2016). An Overview of Plant
Phenolic Compounds and Their Importance in Human Nutrition and Management of Type 2
Diabetes. Molecules (Basel, Switzerland), 21(10). https://doi.org/10.3390/molecules21101374
Mardiah, Zakaria FR, Prangdimurti. (2015). The Effect of Roselle Extract (Hibiscus sabdariffa
Linn) On Blood Glucose Level And Total Antioxidant Level On Diabetic Rat Induced By
Streptozotocin. IOSR Journal Of Pharmacy (e)-ISSN:2250-3013.(p)-ISSN:2319-4219

Mizokami-stout, K., Cree-green, M., & Nadeau, K. J. (2015). NIH Public Access, 19(4), 255–262.
https://doi.org/10.1097/MED.0b013e3283557cd5.Insulin
Mozaffari, K.H., Jalali, K.B., dan Afkhami, A.M. (2009). The Effects Of Sour Tea (Hibiscus
Sabdariffa) On Hypertension In Patients With Type II Diabetes. J Human Hypertension.
23:48–54, 200956
Mozaffari-Khosravi, H., Ahadi, Z., & Fallah Tafti, M. (2014). The Effect of Green Tea versus
Sour Tea on Insulin Resistance, Lipids Profiles and Oxidative Stress in Patients with Type 2
Diabetes Mellitus: A Randomized Clinical Trial. Iran J Med Sci, 39(5), 424–432. https://doi.
org/10.3109/19390211.2013.790333
Rohmah, M., Hartati, M. S., & Wahyuningsih. (2018). Antidiabetic Effect of Rosella-Stevia Tea
on Prediabetic Women in Yogyakarta, Indonesia, 5724. https://doi.org/10.1080/07315724.2
017.1400927
Rosemary & , Rosidah & Haro, G. (2014). Antidiabetic Effect Of Roselle Calyces Extract (Hibiscus
Sabdariffa L.) In Streptozotocin Induced Mice. International Journal of PharmTech Research.
6. 1703-1711.
Shah, N., Amanullah, & Ataullah, S. (2008). Prevalence of insulin resistance in type-2 diabetic
patients. JPMI - Journal of Postgraduate Medical Institute, 22(1), 52–56.
Singh, R., & Pannangpetch, P. (2017). Asia-Pacific Journal of Science and Technology Roselle (
Hibiscus sabdariffa ) calyce ethanolic extract decreases insulin resistance in high carbohydrate
diet fed cats, 1–7.
Srihardyastutie, A., Soeatmadji, D. W., Fatchiyah, F., & Aulanniam, A. (2014). The Relationship
between HbA1c , Insulin Resistance and Changes of Insulin Secretion in Indonesian Type 2
Diabetic Subjects. Adv. in Nat. Appl. Sci., 8(8), 25–30.
Tangvarasittichai, Surapon. (2015). DM (Oxidative stress, insulin resistance, dyslipidemia and type
2 diabetes mellitus). World J Diabetes, Apr 15, 20, 456–480. https://doi.org/http://dx.doi.
org/10.4239/wjd.v6.i3.456
Syamsuni. (2006). Farmasetika Dasar & Hitungan Farmasi. (W. R. Syarief, Ed.) (1st ed.). Jakarta:
Penerbit Buku Kedokteran EGC Jakarta. Retrieved from https://books.google.co.id/
books?id=rLWvvfL8-BcC
Vimaleswaran, K. S., Radha, V., Ghosh, S., Majumder, P. P., Rao, M. R. S., & Mohan, V. (2011).
Uncoupling Protein 2 and 3 Gene Polymorphisms and Their Association with Type 2 Diabetes
in Asian Indians DownloadedNo Title, 13(1). https://doi.org/10.1089/dia.2010.0091
Wang et al. 2013. Treating Type 2 Diabetes Mellitus with Traditional Chinese and Indian Medicine
Herb. Hindawi Publishing Coorperation: Evidence Based Complementary And Alternative
Medicine,
Wang, C. J., Wang, J. M., Lin, W. L., Chu, C. Y., Chou, F. P., Tseng, T. H. (2000). Protective Effect
Of Hibiscus Anthocyanins Against Tert-Butyl Hydroperoxide-Induced Hepatic Toxicity In
Rats. Food Chem. Toxicol., 38(5): 411-416.
Wang, S.C., Lee, S.F., Wang, C.J., Lee, C.H., Lee, W.C., and Lee, H.J. (2011). Aqueous Extract
from Hibiscus sabdariffa Linnaeus Ameliorate Diabetic Nephropathy via Reglukosating
Oxidative Status and Akt/Bad/14-3-3γ in an Experimental Animal Model. Hindawi Publishing
Corporation: Evidence Based Complementary and Alternative Medicine. Volume 2011. Artikel
ID 938126. Page 9pooooooo

Whiting, D. R., Guariguata, L., Weil, C., & Shaw, J. (2011). IDF Diabetes Atlas: Global Estimates
Of The Prevalence Of Diabetes For 2011 And 2030. Diabetes Research and Clinical Practice,
94(3), 311–321. https://doi.org/10.1016/j.diabres.2011.10.029
World Health Organization. (2016). Global Report on Diabetes. Isbn, 978, 88. https://doi.org/
ISBN 978 92 4 156525 7
Wu et al., (2014). Risk Factor Contributing Two Type Diabetes And Recent Advanced In The
Treatment And Prevention. International Journal Of Medidical Sciences Vol 11 (11):1185-1200
Zarrabal, O.C., Jones, P.M.H., Flores, Z.O., Hipolito, C.N., Dermitz, D.M.B., Uscange, M.G.A.,
Hernandez, M.F.P. (2009). Effect of Hibiscus sabdariffa L. Dried Calyx Ethanol Extract on
Fat Absorption-Excretion, and Body Weight Implication in Rats. Journal of Biomedicine and
Biotechnology: 394592. / doi: 10.1155/2009/394592.

Penyakit Mikro Dan Makrovaskular

Uploaded by

Copyright:

Available Formats

Penyakit Mikro Dan Makrovaskular

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Penyakit Mikro Dan Makrovaskular

Uploaded by

Copyright:

Available Formats

International Summit on Science Technology and Humanity (ISETH2019) p-ISSN: 2477-3328

Advancing Scientific Thought for Future Sustainable Development e-ISSN: 2615-1588

The Effect of Rosella (Hibiscus sabdariffa Linn) on Insulin

ISETH 572 International Summit on Science Technology and Humanity

International Summit on Science Technology and Humanity 573 ISETH

PATIENTS AND METHODS

ISETH 574 International Summit on Science Technology and Humanity

International Summit on Science Technology and Humanity 575 ISETH

ISETH 576 International Summit on Science Technology and Humanity

International Summit on Science Technology and Humanity 577 ISETH

Assessed for eligibility (n=90)

Lost to follow-up (give reason)(n=0) Lost to follow-up (give reason)(n=0)

Figure 1. Consort Flow Diagram Intervention Steps

ISETH 578 International Summit on Science Technology and Humanity

Fat (g/day) 75.20±25.07 74.50±19.66 0.253

Table 1 provides an overview of sample characteristics, clinical and biochemical parameters

International Summit on Science Technology and Humanity 579 ISETH

ISETH 580 International Summit on Science Technology and Humanity

International Summit on Science Technology and Humanity 581 ISETH

CONFLICTS OF INTEREST STATEMENT

ISETH 582 International Summit on Science Technology and Humanity

Ardalani, H. (2016). The Ethnopharmacological Review Of Medicinal Plants In Ueses Hypertension

International Summit on Science Technology and Humanity 583 ISETH

ISETH 584 International Summit on Science Technology and Humanity

International Summit on Science Technology and Humanity 585 ISETH

You might also like