Effect Of Wet Cupping Therapy On Changes In Cholesterol And Hemoglobin Levels In Patients Given Cupping Therapy At Hamdalah Clinic Makassar.docx

Effect of Wet Cupping Therapy on Changes in Cholesterol and Hemoglobin Levels in patients given Cupping Therapy at Hamdalah Clinic Makassar Wahyuni Tahir, Rini Rachmawaty, Takdir Tahir Nursing Science Program, Faculty of Medicine, University of Hasanuddin Jl. Perintis Kemerdekaan Kampus Tamalanrea KM.10 Makassar Telp./Fax (0411) 581431 e-mail: [email protected], [email protected], [email protected]

ABSTRACT High level of blood cholesterol is a risk factor the occurrence of atherosclerosis. Atherosclerosis is a plaque that can clog arteries. Cupping therapy is a complementary therapy that is based on Islamic believed to help reducing the cholesterol levels. The secretion of number of blood due to wet cupping therapy process result the important blood components in the body as well go wasted such as hemoglobin. The purpose of this study was to determine the effect of cupping therapy on changes in levels of cholesterol and hemoglobin in patients given wet cupping therapy at Hamdalah Clinic Makassar. This study method used a pre-experiment design: one group pre-post test design. Data obtained by using consecutive sampling within 3 weeks. Data were collected by using a measurement of cholesterol and hemoglobin levels on the 30 respondents who had met the inclusion criteria. Cholesterol and hemoglobin measured 5 minutes before and 15 minutes after wet cupping therapy was given. In this study showed that there was change in decreased of cholesterol and hemoglobin levels before and after cupping therapy. The average decreased in cholesterol as many as 29.36 mg / dl and hemoglobin 1.41 g / dl, with the value of p<0.05. There was significant effect statistically and clinically on wet cupping therapy to reduce cholesterol and hemoglobin levels in patients given wet cupping therapy at Hamdalah Clinic Makassar. Keywords: cholesterol, hemoglobin, cupping therapy

INTRODUCTION Most people think that cholesterol is a disease. But the fact, cholesterol is a lipid component. Cholesterol is the main constituent of the plasma membrane and the plasma lipoprotein and is often found as cholesteryl ester with the hydroxyl group in the third position esterified with a long chain fatty acid (Murray, Granner, & Rodwell, 2003). Cholesterol is a needed substance in the body, especially in the formation of cell walls as well as the formation of steroid hormones. However, if the excess cholesterol levels in the blood, it will be buried in the walls of blood vessels and lead to atherosclerosis which is a narrowing or hardening of the arteries which is a major cause of cardiovascular disease (Anies, 2015). High levels of blood cholesterol or hypercholesterolemia is a risk factor for atherosclerosis which is a plaque that clogs arteries. Atherosclerosis most often occurs in the arteries that flow through heart, brain, kidneys and lower extremity causing myocardial infarction, stroke due to cerebral infarction and sudden cardiac death (Robbin, Cotran, & Kumar, 2007). According to the World Health Organization (WHO), 80% of all cardiovascular Diseases deaths (CVDs) are due to heart attack and stroke. In 2013 the prevalence of coronary heart disease in Indonesia is based on a doctor's diagnosis is approximately 2.650.340 inhabitants. South Sulawesi is in the eight position of the number of patients with the most cardiovascular disease in Indonesia (data and information center Ministry of Health Affairs, 2014), and heart disease is the second case of death of people in the city of Makassar in 2014 (Books pocket of health department of Makassar, 2014). The handling of high cholesterol levels can be handled by using pharmacological and non pharmacological therapy. Pharmacological therapy is commonly used to consume drugs known as statins, fibrates, resins and others (Bull & Morrel, 2007). While the nonpharmacological treatment can be done with medical nutrition therapy (high-fiber diet), increased physical activity such as

brisk walking, small running, cycling 3-5 times per week for 30-60 minutes as well as alternative therapies (cupping therapy) (Fikri, 2011 ). In many health services places, some clients ask about complementary therapies or the alternative to the health care workers such as doctors and nurses (Widyatuti, 2008). The reason that the client using complementary therapies is they wanted to be directly involved in decision making in the treatment and improved quality of life. Approximately 82% of patients reported adverse reactions are perceived from conventional medicine so as choose complementary therapies (Snyder & Lindquist, 2002). Cupping Therapy in Indonesia has been widely known by the public, it can be seen by the number of houses or clinics that provide cupping therapy services. Cupping is the best choice for people to seek treatment because it is cheap, safe, practical and follow the Sunnah of the Prophet Muhammad (Gustriansyah, Sunardi, & Suhandi, 2014). Cupping therapy is actually one of non-invasive complementary therapy which is a traditional therapy combined with the modern medical treatment (Widyatuti, 2008). As a complementary therapy, cupping has existed since long time, it is about 2000 years BCE and is widely known in the community with all its various versions such as cupping therapy, cupping, blood-letting therapy, al-hijamah, candhuk and so forth. Cupping therapy is done by suction with or without bleeding through a small incision in the skin surface which aims to detoxification or harmful toxic secretion for health (Umar, 2013). The mechanisms underlying the effect of cupping therapy on cholesteroldecreased according to Sayed, (2013) that allows the excretion through the skin artificially due to small and thin injury as well as vacuumitation. This process called analogous from renal excretion. The potential components to be excreted i.e. waste products of the body's metabolism, free radicals, chemical and biological substances are released into the interstitial fluid and blood, including hydrophilic or hydrophubic including lipoprotein or cholesterol.

Research conducted in Syria by using cupping method on 300 diseases was found that in patients with hypertension were decreased to normal levels, cardiac electrical wave signal into a proportional and an increase in cases of anemia, Hemoglobin levels to the normal range. It was also reported that about 75% of cases that had excess levels of creatinine in the blood was decreased. In addition 83% of cases on hypercholesteromia patients experienced cholesterol decreased in the blood, as well as 66% of cases there was an increase of iron levels in the normal range in patients with iron deficiency (Sharaf, 2012). Results of research conducted by Saad (2006) entitled aspects of molecules on the relationship of cupping therapy on immune function in patients with chronic HCV infection revealed that the results showed the effect of cupping can improve platelet counts in cupping that done repeatedly, the increase in the number of lymphocytes, as well as increased levels of hemoglobin in the blood. Research conducted by Fikri, (2011), entitled decrease in cholesterol levels with cupping therapy was found that there is a significant effect of cupping therapy on cholesterol-decreased. The highest cholesterol levels decreased as many as 82 mg / dl and the lowest was 10 mg / dl in patients aged 45 years and over with hypercholesterol. Other studies conducted by Widodo & Khoiriyah, (2014) that the average initial total blood cholesterol 283.5 mg / dl decreased to 246 mg / dl in the second stage and into 244.25 mg / dl at the final stage. These levels tend to decline based on the progress of the intervention, which means that there are significant differences in levels based on the progress of treatment or indicated the presence of wet cupping therapy to decrease total blood cholesterol levels in patients with hypercholesterolemia. Research conducted by Yunus, (2015) about the effectiveness of Cupping Therapy on Cholesterol Levels decreased in 36 people in Ash Shihhah Clinic Makassar concluded that the average cholesterol levels of respondents prior to the cupping therapy 230.39 mg / dl. After cupping therapy average cholesterol levels

of respondents as many as 205.97 mg / dl. Based on information obtained at Hamdallah Clinic Makassar by interviewing the head of the clinic found that 73% - 75% of patient with hypercholesteromia history after cupping therapy, decreased the cholesterol levels in the blood. Based on the background above, researchers are interested in conducting research about "The Effect of Cupping Therapy on Changes in cholesterol and Hemoglobin levels in Patients Given Cupping Therapy".

METHODS This study method used preexperiment design: one group pre-post test design. Data were collected by using a measurement of cholesterol and hemoglobin levels on 30 respondents who had met the inclusion criteria. Data were obtained by using consecutive sampling within 3 weeks was analyzed using a statistical test. The instrument used in this study was a questionnaire on demographic data, cholesterol and hemoglobin measurement tool (easy touch GCHB) Prior to the study, the researchers gave informed content to the cupping therapy patient. Researchers explain the procedures to patients begin from measurement procedures of cholesterol and hemoglobin to the benefits that can be obtained. Patients are willing to become respondent then given the informed content sheet to be signed on the consent to be respondents. Cholesterol and hemoglobin levels measurements in this study performed twice. The first measurements of cholesterol and hemoglobin by these researchers performed 5 minutes before cupping therapy. Furthermore, researchers measured levels of cholesterol and hemoglobin 15 minutes after respondents were given by experts cupping therapy at hamdalah Clinic Makassar.

RESULTS

Variable

Characteristics of Respondents All respondents in this study were female and had no smoking history as many as 30 people (100%). Judging from the age characteristics obtained the average mean of respondent is (37.17) with standard deviation (9.063). Mean average of respondent visitation in performing cupping therapy is (3.67) with standard deviation (6177). Seen through the respondent duration following cupping therapy the mean average is (1.97) with standard deviation (8.65). From the total respondents the mean average of cupping treatment amount is (14.93) with standard deviation (3542). Table 5.1 Distribution Kareteristik Respondents by Age, Visits to, and amount Lama Following Cupping Cupping Clinic Makassar hamdalah DecemberJanuary 2017 (n = 30) Max

N

Percentage (%)

Male

30

(100%)

History Not Smoking

30

(100%)

Mean

(SD)

37.17

(9063)

25

58

Characteristic

Min

Gender

age Visitation

3.67

(6177)

1

24

Long follow

9:33

(15 593)

2

48

Number of cupping

14.93

(3542)

10

22

By using SPSS Statistics 20 researchers find the content in the data that cholesterol level before cupping therapy were normally distributed, whereas in cholesterol levels after cupping therapy is given the data were not normally distributed. Because one of the data was not normally distributed, the researchers decide to use the Wilcoxon test. While the data of hemoglobin levels before and after cupping therapy were normally distributed so that researchers decide to use Paired t-test Table 5.2 Cholesterol and Hemoglobin Levels Before And After Cupping Therapy Given at hamdalah Clinic Makassar (n = 30)

*Cholesterol ** HB

Mean (SD) Pre

Mean (SD) Post

Changes

P

0:00

242.73 (± 37 622)

213.37 (± 24 604)

29.36

12.46 (1.19123)

11.05 (0.99989)

1.41

* Wilcoxon test ** Paired t-test

By using the Wilcoxon test found that of each group of data (pre and post) it appears that the mean average values before treatment was (242.73 mg / dl) with standard deviation (37.622) which is smaller than the value before treatment i.e. (213.37 mg / dl) with standard deviation (24 604). Where the magnitude of the decreased in cholesterol levels pre and post cupping therapy is given as many as 29.36 mg / dl with the value of p = 00:00 then (p <0.05). It is concluded that there are significant effect statistically and clinically on wet cupping therapy to decrease cholesterol levels. In table 5.2 can be seen in the mean average of hemoglobin levels are equal to (12:46 g / dl) with standard deviation (1.19123). While hemoglobin levels after cupping therapy, the mean average is smaller than before the therapy as many as (11:05 g / dl) with standard deviation (0.99989). Confidence Interval minimum value is (1.04404) for the maximum value is (1.76263). The value of p = 0.000 with a significance level of 95% then (p<0.05). It is concluded that there are effect significant statistically and clinically on wet cupping therapy to decrease the hemoglobin levels. Table. 5.3 Correlation of the long followed Cupping, Number of Cupping with Cholesterol and Hemoglobin Levels after Wet Cupping Therapy Given at Hamdalah Clinic Makassar, December 2016 - January 2017 (n = 30) Variable

Cholesterol level

Hemoglobin level

Long followed cupping

R -0147

p 0439

r -. 062

P 0745

Number of cupping

0153

0418

-0386

0035

The table above shows the value of p on long followed cupping as many as (0.0439) with significant p > 0.05. This study indicated that there was no effect between the long followed respondents in

therapy with cholesterol levels after given wet cupping therapy. The value of p on hemoglobin as many as (0.745) with significant p > 0.05. This study indicated that there was no effect between the long followed respondents in therapy with hemoglobin levels after given wet cupping therapy. In the table above also shows the value of p on cholesterol as many as (0.41b) with significant of p > 0.05. This study indicated that there was no effect of cupping frequency given to the respondent with cholesterol levels after given wet cupping therapy. And the value of p on hemoglobin as many as (0.035) with significant of p > 0.05. This study indicated that there was effect of the amount of cupping given to respondents with hemoglobin level during therapy after given wet cupping therapy.

DISCUSSION 1. a.

Characteristics of Respondents Gender In this study, all respondents were female as many as 30 respondents (100%) with average cholesterol levels before cupping therapy was 242.73 mg / dl. Based on gender, males approximately 50 years old had 2-3 times greater risk than women to suffer atherosclerosis. However, during menopause women tend to have equivalent cholesterol levels as male (Anies, 2015). Results of research conducted by Ujiani, (2014) about the relationship between age and gender with cholesterol levels of obese people explained that there was no significant correlation between gender factor with cholesterol levels. But women have a greater risk of increased cholesterol levels. Before menopause, women tend to have lower total cholesterol levels than men of the same age. Cholesterol levels in women and men, naturally increases with age and menopause are often associated with increased cholesterol in women. From the results of research conducted by researchers on hemoglobin level before given cupping therapy had mean average (12:46 g / dl). It is known that hemoglobin levels of women are lower than men hemoglobin levels. The difference is because women menstruate. In addition there are hormonal differences

in men and women that affect hemoglobin (Hidayat & Utomo, 2004) b. Age In this study, the average respondent age ± 37 years with the cholesterol levels result were 242.73 mg / dl. Hypercholesterolemia usually occurs when a person is 50 years old and above. However, research conducted in 2004 in Indonesia showed that about 9.3% of hypercholesterolemia occurs at a young age i.e. 25-34 years old (Anies, 2015). Results of research conducted by Ujiani, (2014) with the sample as many 57 and 63.3% are women using Spearmean correlation test was p = 0.252. These results explain that there was no significant correlation between age and cholesterol levels. Based on the results of research carried out in 30 respondents were on average aged 37.17 years had an average cholesterol levels before treatment amounted to 242.17. Results of research conducted by Rizkiawati, (2012) stated that there is a relationship between age and hemoglobin level. In the study explained that increasing age and decreased function of organs including the lungs makes it easy to lead into the respiratory system further into the lungs and affect the levels of hemoglobin in the blood. c. smoking history According Anies(2015) explained that there were several factors that influence blood cholesterol levels one of them is smoking. The smokers tend to suffer atherosclerosis and coronary heart disease. Smoking habits may also decrease levels of HDL cholesterol, resulting in easier blood clot. Smoking is an addictive substance made from ingredients produced from tobacco and can result in respiratory distress. Besides harmful to the body, smoking can also increase the production of blood hemoglobin (Makawekes, Kalangi, & paisak, 2016). Research conducted by Makawekes, Kalangi, & paisak (2016) by comparing the blood hemoglobin levels in male smokers and non-smokers. Showed that hemoglobin level is higher in male smokers compared with men who did not. In the study explained that the increased of hemoglobin in men smoking occurs because the reflexes of compensatory mechanisms of the body to

low levels of oxygen binds to hemoglobin as a result shifted by carbon monoxide has an affinity for stronger hemoglobin. So the body will improve and increase hemotopoesis then increase the production of hemoglobin, due to the low partial pressure of oxygen (PO2) in the body. d. Visitation and history of cupping therapy Results showed that the mean average of the respondent visitation in performing cupping therapy as many as 3.67 with mean average of respondent follow the cupping therapy as many as 1.97. In many health services places some clients ask about complementary therapies or alternative to health care workers such as doctors and nurses (Widyatuti, 2008). The reason the client using complementary therapies is the client wanted to be directly involved in decision making in the treatment and improved quality of life. (Snyder & Lindquist, 2002). There are several factors regarding the respondents chose cupping for treatment. Nurdiyana, et al (2010) stated that there are three patient motivations in following the cupping therapy. Patients simply want to cure the illness (motivation biogenetic), patient follow cupping therapy because of the influence of the environment (sosiogenetis motivation) and the factor to follow religious norms (motivation teogenesis). e. Number of cupping Results of research conducted by researchers at hamdalah Clinic Makassar, the average value of number of cupping given to the respondents were 14 cup. The number of each cup given to respondents is various according to the complaint and the patient's condition. 2. Changes in cholesterol levels pre and post cupping therapy Cholesterol is a chemical compound that is naturally produced by the body and the combination of lipid (fat) and steroid. Approximately 80% of the body's cholesterol is produced by liver, while the rest comes from the food we eat. The liver can regulate cholesterol levels in the blood stream and can secrete cholesterol if it is needed by the body. LDL cholesterol is called bad cholesterol because increased levels of LDL cholesterol are associated with an increased risk of coronary heart disease. Whereas HDL cholesterol is

called good cholesterol because HDL cholesterol particle prevent atherosclerosis by extracting cholesterol from the artery walls and remove them through the liver (Hall, & Edward, 2011). According to traditional medicine, presence a humid heat element in the liver is a cause hypercholesterolemia. If moist heat in the liver is excessive it will cause damage to the liver, stomach and spleen. Therefore, it is necessary to spend a hot humid element of the liver, stomach and spleen. In this case the cupping can remove the element of moist heat through a process of bloodletting. In addition Cupping can also repair organs or blood vessels damaged by stimulating the organ with the treatment. Cupping is also expected to restore full function of blood vessels cholesterol plaques through hemostatic theory (Umar, 2013). The results using Wilcoxon statistical tests obtained mean cholesterol levels after therapy is smaller than before the therapy. The value of P = the because of P <0.05, it can be concluded that there are differences in cholesterol levels before and after cupping therapy given at hamdalah clinic Makassar. According to Sayed, (2013) that the cupping therapy enabling small and thin injury to the skin surface. Excretion through the skin artificially due vacuumitation in the area of injury or incision is a spending waste products the body's metabolism, free radicals, chemistry substances, and biology are released into the interstitial liquid and blood including Hydropic and hydropubic substance including lipoprotein or cholesterol. Research is also conducted by Mustafa Dawood, and Al-Sabawy, (2012), entitled wet cupping effect on serum lipid profile in patients with hyperlipidemia. This study aimed to evaluate the effect of cupping therapy on serum lipids, the concentration profile and its relationship with some of the elements Cu, Zn, and Mn. The results of these studies have demonstrated significant decreased in total cholesterol, LDL-cholesterol and LDL / HDL ratio in the 1st and 2nd weeks. Meanwhile, there is no significant change in HDL cholesterol and triglycerides. In a study carried out by Mahdavi, Ghazanfari, Aghajni, Danyali, & Naseri which aimed to see a decreased in serum

lipoproteins, especially LDL cholesterol on atherosclerosis prevention by wet cupping due to blood secretion process. The study used two comparison groups. The first group was given treatment procedure and another group as a control group treatment. The concentration of serum lipids were collected from the brachial vein taken during wet cupping for 3 weeks. It was found that the decreased in LDL cholesterol was found in the treatment group compared with the control group. There are no significant changes in serum triglyceride between groups. Although no statistically significant changes in total cholesterol and HDL cholesterol, total cholesterol decrease of 7% and 3% increase in HDL may be important clinically. Niasari, et al., (2007) suggested that the concentration of HDL, LDL, TG and cholesterol in wet cupping is significantly higher than the venous blood. This means that the cupping may play an important role in decreasing risk factors for atherosclerosis with advanced extrusion lipid. Although cupping therapy has been used for thousands years as a traditional therapy for various diseases, the mechanisms that underlie the workings of cupping therapy remain unknown. Many questions arise from time to time about the proper role of cupping in treating disease to explain the benefits of cupping therapy. 3. Changes in hemoglobin levels pre and post cupping therapy Erythrocytes or RBCs have a biconcave disk-like structure without a core diameter of approximately 0.007 mm and contains 300 million molecules of hemoglobin (Parker, 2007). The hemoglobin protein is a major component of red blood cells. Hemoglobin composed of molecules containing iron (heme) and was bound by globulin protein (Kowalak, Weish, and Brenna, 2011). Anemia or hemoglobin below 13g% in men and 12g% in women are the signs and symptoms of certain diseases. Anemia can be caused due to reduced production, increased destruction or loss of red blood cells (Oehadian, 2012). If there is quickly bleeding, the body will replace the fluid plasma within 1 to 3 days, but the concentration of red blood cells become low. The concentration of red blood cells will be back within 3 to 6

weeks if no bleeding occurs next. In chronic intestinal blood loss cannot absorb enough iron to form hemoglobin as soon as blood loss. Red blood cells are formed also have a smaller structure and the hemoglobin contained in them very little (Guyton & Hall, 2011). Cupping is a treatment by sucking the blood and removing it from the skin surface which is then accommodated into the glass that causes concentration and secretion of blood, then made an incision surface of the skin with a scalpel to bleeding (Aldjoefri, 2015). The secretion of number of blood due to wet cupping therapy process result the important blood components in the body as well go wasted such as hemoglobin. So that the person given cupping therapy, the hemoglobin level in these patients is lessened.

Conclusion From the research, it can be concluded that: 1. There is difference in the decrease of cholesterol levels before and after given wet cupping therapy which is decreased in average as many as 29.36 mg / dl. 2. There is difference in the decrease of hemoglobin levels before and after wet cupping therapy which is decreased in average as many as 1.41 g / dl 3. There was a significant effect statistically and clinically wet cupping therapy to decrease cholesterol and hemoglobin levels in patients given wet cupping therapy at hamdalah Clinic Makassar.

ADVICE 1. In patients given wet cupping therapy should not be in a state of menstruation. Because of blood loss during wet cupping process can increase the amount of blood loss due to wet cupping process so that patients can suffer anemia. 2. Wet cupping therapy should not be performed in patients with hemoglobin levels below normal. 3. Before the patient is given the wet cupping therapy should do hemoglobin test. 4. Further research must be done by calculating the amount of secretion blood when the patient is given wet

cupping therapy. 5. Further studies should be done to examine the male respondents and used for control group as comparison group. 6. Recommendations for further research to take samples with a larger number and use better of measuring instruments. 7. For future studies should also examine the input and output of nutrients in patients given cupping therapy to see changes in hemoglobin and cholesterol levels. 8. Scientific mechanisms underlying the workings of cupping therapy is still unknown with certainty, it should be done further research on the mechanism of how the cupping therapy works

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