Lupine Publishers | Development and Application of HPLC/Post-Column Method for Analysis of Low Molecular Weight Organic Acids in Beers, Wines and Fruit Juices

 Lupine Publishers | Scholarly Journal of Food and Nutrition

Abstract

A post-column reaction method, which involves use of the pH indicator BTB, was developed and applied to the analysis of low molecular weight organic acids in commercial beers, wines, and fruit juices. Organic acids identified in these beverages were formic, acetic, citric, pyruvic, tartaric, malic, succinic, lactic, and pyroglutamic. Amounts of total acids in samples ranged from 980.4 mg/L to 513.5 mg/L in beers, from 7,502.3 mg/L to 5,573.3 mg/L in wines, and from 11,162.8 mg/L (orange) to 2,995.8 mg/L (mango) in fruit juices. Citric acid was found in the greatest amount-ranging from 286.7 ± 4.5 mg mg/L to 139.0 ± 5.3 mg mg/L in beers. The greatest level of malic acid was in a wine with 4,248.4 mg/L. The method developed is applicable to determine amounts of organic acids, formic and acetic acids, in beverages quickly and accurately.

Keywords: Organic acids analysis; HPLC/post-column; Beers; Fruit juices; Wines

Introduction

Low molecular weight organic acids (LMWOAs), including formic, acetic, malic, citric, tartaric, lactic, succinic, and oxalic acid, are found in various beverages, such as beers, wines and fruit juices (citrus, apple, grape, and melon), as well as in some foods [1,2]. These acids contribute characteristic tastes to beverages. For example, formic acid possesses pungent odor and sour taste in proper dilution. It is particularly adaptable to the pineapple flavor. Acetic acid also has a pungent and stinging sour odor, but it gives a clean-sour and acid taste at dilute concentrations (lower than 1%) in water and been used in flavor compositions, such as butter, chocolate, grape strawberry and wine. Malic acid is present in plum, peach, apricot and related fruits and used for imitation fruit flavors, such as maple [3]. Citric acid is the major acid component of citrus species and possesses a clean acid taste in an aqueous solution [3,4]. In addition to the role of organic acids in taste and flavor of beverages, they also play an important role in quality of beverages, including beers [5], wines [6] and fruit juices [7]. A capillary electrophoresis (CE) with spectrophotometric method achieved successfully analysis of a limited number of LMWOAs [8].

This method has been widely used for LMWOAs analysis in foods and beverages [9]. However, the resolution and detection of LMWOAs formic and acetic, achieved better by chromatographic methods than by the spectrophotometric method [10]. In the case of the most commonly used gas chromatography (GC), a tedious derivatization of organic acids is required to prepare samples for analysis because they are highly soluble in water [11]. On the other hand, HPLC, which can take aqueous samples directly, has been widely used to analyze LMWOAs in water samples; such as wine, beer [12], vinegar and fruit juices [13], coffee [14] and alcoholic beverage meads [15]. A HPLC interfaced to enzyme reactor analyzed oxalic acid in fruit and vegetable juices [16]. After the electronspray ionization system was advanced to interface between HPLC and mass spectrometers (LC/MS), LC/MS application for the analysis of water-soluble chemicals, including LMWOAs, developed significantly [17]. However, separation of LMWOAs by HPLC, formic acid and acetic acid, remains relatively difficult.

In the present study, a previously reported simple and accurate post-column reaction method for LMWOAs [18] was improved and successfully applied to analyze LMWOAs, including formic and acetic acids, in beers, wines, and fruit juices.

Materials and Methods

Beverage Samples

All commercial beverages-10 kinds of beers, 6 types of wines (5 red and 1 white), and 25 kinds of fruit juices-were bought from a local market in Seoul, Korea.

Chemicals and Reagents

Bromothymol blue (BTB, 95%), sodium phosphate dibasic anhydrous (98.5%), sodium hydroxide (98%), perchloric acid (67– 72%), oxalic acid (99.5–100.2%), phosphoric acid (85%), citric acid (99.5%), tartaric acid (99.5%), malic acid (95–100%), quinin acid (100%), succinic acid (99%), fumaric acid (99%), lactic acid (85%), formic acid (95%), acetic acid (99.7%), pyroglutamic acid (99%) were purchased from Sigma–Aldrich Chemical Co. (St. Louis, MO, USA) or TCI Chemical Co. Ltd. (Tokyo, Japan). The purified water was prepared with a Zener Power II (Human Co., Korea). A stock solution of standard organic acids (10g/L) was prepared in purified water for preparation of standard solutions and spike analysis.

Preparation of Beer and Wine Samples

Beer and wine samples (2 mL each) were filtered with an Arcadis Syringe Filter with 0.45 mm PVDF membrane (Waters Co, Milford, MA).

Preparation of Fruit Juice Samples

Well-mixed juice samples were centrifuged at 10,000 rpm for 5min at 4 ºC to collect the supernatant. The supernatant was filtered with an Arcadis Syringe Filter with 0.45mm PVDF membrane (Waters Co, Milford, MA) and were analyzed with HPLC.

Analysis of Organic Acids in Beverages

Figure 1 shows the systematic diagram of the post-column method used in the present study. A prepared beverage sample was injected (10mL) into an Agilent 1100 model HPLC equipped with a 5cm x 8.0 mm i.d. Shorex RS pack KC-LG guard column, which was connected to two 30 cm x 8.0 mm i.d. KC-811 separation columns in series. The mobile phase was a 3mmol perchloric acid solution with a 0.7 mL/min flow rate. Temperature of the separation columns was 80ºC. The eluate from HPLC was mixed with a reaction solution containing 0.2mmol bromothymol blue (BTB), 15 mmol Na₂HPO₄, and 2 mmol NaOH. The reaction solution was purged at a 0.7mL/ min flow rate in a T-way connector as shown in Figure 1. Adducts formed from the acids and BTB in a 50 cm x 0.25 mm i.d. stainless reaction coil was monitored with a UV detector at l = 440 nm.

 

Results and Discussion

As mentioned above, analysis of LMWOAs is a difficult process. There have been advances in HPLC/MS methods recently but some problems, such as insufficient resolution of formic acid and acetic acid, remain. In order to resolve these problems, we developed a post-column reaction method, which involved use of pH indicator BTB. This method and related theory were originally advanced nearly three decades ago [18]. Figure 2 shows an HPLC postcolumn chromatogram of standard acids. This chromatogram shows satisfactory resolution of low molecular weight acids for quantitation. Phosphoric acid peak in this chromatogram may come from a phosphate in a reaction solution. However, phosphoric acid is not organic acid, which is out of scope of this study. The limits of detection (LOD) of acids were 25.0mg/L for citric, malic and quinin, lactic; 12.5mg/L for formic and acetic; and 50mg/L for pyroglutamic. The limits of quantitation (LOQ) of each acid were 75.0mg/L for citric, malic, quinin, and lactic; 30.0 mg/L for formic; 50.0 mg/L for acetic; and 150 mg/L for pyroglutamic.

Organic Acids Found in Beer Samples

Table 1 shows the results of LMWOAs analysis in beer samples. There are three monoprotic acids (lactic, acetic and pyroglutamic), two diprotic acids (malic and succinic), and one triprotic acid (citric acid). Amounts of total acids in beer samples varied considerably, ranging from 1,801.3 mg/L (brand E) to 776.0 mg/L (brand D). Among the acids identified in the beer samples, citric acid was generally found in the greatest amount-ranging from 286.7 ± 4.5 mg/L (brand E) to 139.0 ± 5.3 mg/L (brand G), followed by lacticranging from 274.3 ± 5.6 mg/L (brand E) to 19.3 ± 2.2 mg/L (brand G), and pyroglutamic acid-ranging from 264.9 ± 1.4 mg/L (brand E) to 105.5 ± 2.4 mg/L (brand D. ) Previously, the electrophoresis method was successfully used to analyze LMWOAs in beers. Klampft [19] found citric acid with level of 193 ± 2.4 mg/L in Chinese rice beer, 171 ± 1.5 mg/L in white beer and 178 ± 1.1 mg/L in Lager beer. Cordeiro-Ramirez et al. [20] reported citric acid (ND – 59 ± 2 mg/L), fumaric acid (ND – 5.9 ± 0.7 mg/L), malic acid (106 ± 12 mg/L), pyroglutamic acid (92 ± 6 mg/L) in 6 different beers. Citric acid exhibited synergistic effects with lactic acid-producing bacteria toward inhibition of pathogenic bacteria grow [21]. The amounts found in these acids in the present study were like these reports. For example, the present study found citric acid with amounts ranging from 146.2 ± 3.8 mg/L brand D to 286.7 ± 4.5 mg/L in brand E. In addition, the present study found pyroglutamic acid with levels ranging from 105.5 ± 2.4 mg/L in brand D to 264.9 ± 1.7 mg/L in brand E. The level of acetic acid ranged from 98.2 ± 3.0 mg/L (brand C) to not detected (brand H) in the present study, whereas acetic acid was not reported from the studies conducted with the electrophoresis method.

Organic Acids Found in Wine Samples

Table 2 shows the results of LMWOAs analysis in wine samples. The total amounts of acids were similar in all wine samples, ranging from 7,052.3mg/L (brand B) to 5,573.3mg/L (brand C). Tartaric acid was generally found in the highest concentration, ranging from 2,599.9 ± 7.5mg/L (brand F) to 1,495.1 ± 5.6mg/L (brand B). Amounts of citric acid, malic acid and lactic acid varied significantly among brands. Lactic acid was found at high levels in brands A (2,497.1 ± 2.8mg/L), C (2,271.1 ± 5.7 mg/L), and E (2,954.6 ± 4.2mg/L), but at relatively low levels in brands B (169.8 ± 1.9mg/L), D (170.4 ± 6.3 mg/L), and F (101.5 ± 4.9mg/L). On the other hand, high levels of malic acid were found in brands B (4,248.4 ± 13.8 mg/L), D (2,403.2 ± 8.0mg/L), and F (2,248.8 ± 5.3mg/L), whereas its concentrations in A was only 35.6 ± 3.8 mg/L in, C was 17.3 ± 1.4 mg/L and in E was 58.7 ± 4.2mg/L. A similar trend was observed in the case of citric acid. A previous study found lactic and tartaric acids in Ribeiro Sacra wines as the predominant organic acid components [9]. Lactic acid and tartaric acid levels ranged from 3,784mg/L to 452mg/L and 1978mg/L 866mg/L. These results are consistent to the ones from the present study. As mentioned above, the quality of wines depends on, in part, acidity associated with the composition of acids [22]. The results in the present study demonstrate that the composition of acids in different brands of wines varies. Therefore, the analytical method developed can be useful in evaluating wine quality as well as a guide to improvement in the winemaking process.

Organic Acids Found in Fruit Juice Samples

Table 3 shows the results of LMWOAs analysis in fruit juice samples. Formic acid and acetic acid, which are the lowest and 2^nd lowest molecular weight acids among LMWOAs and difficult to determine by a CE method [10], were satisfactorily analyzed in the present study. The levels of formic and acetic acids found ranged from 19.8 ± 1.0mg/L (mulberry) to 4.0 ± 0.2mg/L (mandarin) and from 27.7 ± 2.7mg/L (tomato) to 17.7 ± 2.6mg/L (grape), respectively. Orange juice samples had the greatest total concentration of acids, ranging from 11,162.8 mg/L (brand D) to 8,469.5 mg/L (brand C), followed by mandarin juice samples, ranging from 10,683.1mg/L (brand C) to 5,560.6 mg/L (brand B) and grape juice samples, ranging from 5,208.2 mg/L (brand E) to 4,016.2 mg/L (brand C). Citric acid and malic acid were generally detected in higher levels than other acids, ranging from 10,270.1 ± 2.9mg/L (mandarin) to 36.9 ± 12.0mg/L (mulberry) and from 3,990.3 ± 11.6mg/L (Grape) to 66.9 ± mg/L (mango), respectively. The pear juice sample contained the lowest level of total acid with 596.2 mg/L. The total amounts of acids in mixed juices ranged from 7,237.2mg/L (brand F) to 4,105.8 mg/L (brand A), which are comparable to those of grape juices.

One previous report demonstrated satisfactory analysis of organic acids in fruit juices (apple, peach, pear and apricot) using HPLC with an ion- exclusion column [23]. Another previous study reported the amounts of citric, malic, quinin and tartaric acids in apple, orange, cranberry, white/red grapes, and pomegrante juices analyzed using LC/MS/MS [24]. Effect of malic acid for the inactivation of common food pathogens on fresh-cut lettuce was reported, suggesting that malic acid possesses some biological activity [25]. The presence of formic and acetic acids was, however, not reported in these studies. On the other hand, the present study found 9.5 ± 3.6 mg/L formic acid in pear juice, 4.0 ± 0.2 – 10.0 ± 0.8 mg/L in mandarin juice, 12.5 ± 0.5mg/L – 15.2 ± 2.4mg/L in orange juice, 13.4 ± 0.3 mg/L in grape fruit, 5.8 ± 0.5 – 10.7 ± 0.3 mg/L in grape juice, 6.6 ± 1.5mg/L in mango juice, 10.1 ± 0.7 mg/L in tomato juice, and 19.8 ± 1.0 mg/L in mulberry juice. In addition, acetic acid was determined in pear juice (8.4 ± 1.3 mg/L), grape juice (17.7 ± 2.6 mg/L – 21.1 ± 1.0 mg/L), mango (23.2 ± 0.5 mg/L), and tomato (27.7 ± 2.7 mg/L). However, it is difficult to compare the results from the present study to those from the previous study because the compositions of the juices vary in the different brands.

Conclusion

The present study demonstrates that the method developed was useful to determine LMWOAs, formic acid and acetic acid, present in samples with complex matrices of beverages. Acids composition are important to evaluate quality of beverages. Therefore, the method developed in the present study would useful to analyze LMWOAs levels for evaluating quality of beverages. The CE method is also well-established method for LMWOAs analysis. Therefore, it is recommended to use both methods, the present method for formic acid and acetic acid

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Lupine Publishers | Nutritional and Therapeutic Properties of Pomegranate

Lupine Publishers | Scholarly Journal of Food and Nutrition

Abstract

Pomegranate, grown in tropical climatic conditions has various therapeutic benefits due to bioactive compounds in it. This fruit is rich in antioxidants has been used from centuries for the treatment of inflammation, cancers, diabetes, hypertension, infertility and so many diseases. It is now being utilized in medicinal as well as nutrition industries due to its strong potential. Polyphenols present in pomegranate shows anti-proliferative properties as strong bases. Various in vitro and in vivo studies show that pomegranate is rich in organic acids, anthocyanins, sterols and catechin. India is among the top most countries producing and exporting this fruit. Some of its varieties are being used for commercial and ornamental means. However, some stress factors need to be evaluated in future to enhance its production and cultivation on national levels. In addition to this area that are producing pomegranate should be supplied by better climatic and fertility means to increase its demand.

Keywords: Pomegranate; Cultivation; Medicinal properties; Nutritional properties

Introduction

Pomegranate, the fruit of Punicacae family is a shrub or tree that grows approximately 16 to 26 feet tall. Punica granatum is its scientific name. It is also named as Seeded apple or Chinese apple. In northern areas this fruit grows during September to February while in southern parts it is available during March to May. Pomegranate has multiple long-lived branches its leaves are 2cm wide and 3-7cm long Newman [1]. Flowers have 3-7 petals and are red in color and seeds may vary from about 200 to 1400 in number. Seeds can be utilized in salads, appetizers, soups and desserts Still .

This fruit can grow as ornamental tree in parks and gardens. They are drought tolerant and can survive in dry areas. They are perfect winter foods, rich in fiber and rated among healthier fruits. Pomegranate is known for its quality of improving heart health, protecting against prostate cancer, help in preventing diabetes and are rich in antioxidants that help fight against cancers and free radical formation Seeram [2]. Juice and seeds of pomegranate contain vitamins, potassium and antioxidants three times more than green tea. Seeds are mostly used as spice in Pakistani food as Anar dana. These seeds are dried and used in curry formation. Supplements are available as dried form but by drinking concentrated juice which contains polyphenolic antioxidants one can survive from blood pressure and high cholesterol level in the body Heftmann.

Edible part of fruit consist 20% seed and 80% juice. In juice fructose and glucose are present in equal quantity. Polyphenol part consist of catechins, tannins, ellagic acid and anthocyanins. Its seeds are rich of pectin, sugars and fiber that benefits against heart diseases. Pomegranate reduces LDL cholesterol from the body and prevents against atherosclerosis Julie [3-6].

Cultivation

Pakistan produces pomegranate as major fruit. Balochistan is being the largest producer while KPK and Punjab are contributing to its production on isolated areas. 40thousand tons are producing on 9thousand hectares. This fruit grows on tropical and subtropical regions and its propagation can be done sexually as well as asexually. Pakistan has tremendous climatic conditions for the production of pomegranate but due to lack of knowledge of farmers, poor orchards management and lack of basic modern techniques limited its successful production AR Awan.

Varieties

Various varieties are present and are famous for their taste. Some famous are:

Bedana: Its seeds are soft and are of whitish or brown color. Pulp is of pink color and is sweet it is of medium to large sized fruit.

Kandhar: It contains hard seeds with blood red color pulp. This fruit is of large size and is sour in taste.

Alandi: Its seeds are very hard. It is medium size fruit with subacid pulp and it has fleshy pink color.

Dholki: This fruit is of commercial importance. It has hard seeds and whitish sweet pulp. It has dark patches of purple color at base. It is regarded as evergreen plant.

Kabul: This variety of pomegranate is large sized with dark yellow rind, and bitter taste pulp.

Muscat Red: Contain juicy pulp with hard seeds. This fruit is usually small in size and has thick covering.

Paper shell: It contains very sweet juicy pulp with fleshy covering and seeds are often soft. It is mostly of round shape.

Poona: This is often spotted and has grey to green color rind. This fruit has orange to red color combination and is large in size.

Spanish Ruby: It has combination of rosy aromatic pulp with seeds often soft and bright in color. It varies in size from medium to large size fruit.

Vellodu: It is of medium quality with sweet pulp and large size seeds Holland.

Global production

According to the current situation in the world USA, Iran, India, Pakistan and China are major producers of this fruit. Annual global production is said to be about 1.5 million tones. India has being ranked first in the production of 1.140 million tones on 0.125 million hectares. Iran exports the most amount 60,000 tones. Saudi Arab, UAE and Bangladesh import millions of tone of pomegranate from India. West Pakistan used to import this fruit to India in earlier centuries. Some countries like Mexico, France, Italy, Egypt and Greece are using this fruit as ornamental tree. Each part of pomegranate its leaves, roots, seeds and peel are of economical importance to the world [7-10].

Pollination

Pomegranate is pollinated by insects by cross and self means. Very little amount of pollen is dispersed by wind. 45 percent of fruit is settled down by self- pollination of flowers and cross means increase its production to about 68 percent. According to the season and variety of fruit size of pollen and fertility may vary [11-16].

How to eat it

a) To enjoy this fruit one need a knife, spoon and bowl

b) To lose its seeds roll around the pomegranate

c) Put the knife in center of the fruit and cut it into two parts

d) Take half part while facing towards bowl and tap its back with the spoon for seeds to come out

e) Repeat if for the other half and enjoy fruit with sweet juice and seeds (Table 1).

Serving sizes may differ

a) 1 pomegranate: 105 calories.

b) 1oz pomegranate: 19 calories.

c) 100gram contains: 68 calories (Table 2).

Therapeutic Importance of Pomegranate

a) Seeds of pomegranate contains low quantity of fats while high carbohydrate and protein content. According to an estimate ½ cup consist of 1 gram of fat, 16 grams carbohydrates and 1.5 grams proteins. 72 percent calories are provided by these components. It contains appreciable amount of vitamin C which is beneficial for blood clotting and immune system. Potassium the necessary mineral of the body is present in this fruit which is required for normal regulation of the blood pressure, muscle synthesis and nerve conduction system (Figure 1).

b) Antioxidants minimize the effect of cellular damage from oxidation process. These compounds are present in different vegetables fruits and cereals in great quantities. Department of Agriculture in USA regarded pomegranate as fifth largest fruit rich in antioxidant content. It has potential for the absorbance of radicals which are dangerous for human body.

Cholesterol level

Pomegranate is rich in major antioxidants like anthocyanins and tannins that may help to block the buildup of cholesterol in arteries which in return protect heart damage. Juice of this fruit may help to reduce the concentration of low density lipoproteins from the body which may protect the body from stroke attack (Behrenbeck, 2001). Leaf extract of pomegranate has potential to reduce serum cholesterol in mouse fed with high fat diet according to the weight of rats 400 to 800mg of extract was administrated for 5 weeks period. High fat diet with obesity symptoms rat were chosen. After this induction results were significant in reducing total cholesterol and triglycerides level of the body. Weight was reduced and intestinal absorption of fat was decreased. Energy and body HDL levels decreased showing beneficial effects of leaf extract of pomegranate (Lan et al., 2009)

Blood Pressure

Systolic blood pressure can be reduced by juice of pomegranate to a significant level. Potassium in it can prevent arteries from stiffness and atherosclerosis. It improves blood flow to the heart and reduces the incidents of heart attack. Clinical examination of improving blood pressure and endothelial functions of the body by consuming pomegranate juice have been performed. In order to measure the beneficial effects of juicy part of pomegranate 21 hypertensive patients were selected. Their age vary between 30 to 67 years. One group of 11 patients was given 150ml of juice to be taken either in lunch or dinner for 2 weeks. Similarly other group of 10 people was treated with the same amount of water. After the completion of the study results were positive in reducing systolic (p=0.002) and diastolic blood concentrations (0.038). It was also seen that serum level of vascular endothelial adhesion molecule was decreased up to (p=0.008) which has curative effects for patients regarding endothelial functions and blood pressure profile [17-22].

Memory and mood Enhancer

Flavonoids are believed to improve memory from declining and delay the onset of Alzheimer disease. These antioxidants have potential role for fighting against depression that can cause memory loss. Vinegar of pomegranate juice contains flavonoids of deep red color that helps prevent against radical formation. Pomegranate juice have natural compound Estrone that improves mood in menopausal women. It is generally believed that this compound can act as a replacement therapy for women suffering from mood disturbances.

Cancer Cells

Pomegranate juice can hinder the proliferation of cancerous cells in human body. It can block the flow of blood towards the tumors resulting in reducing its size and ultimately its destruction. Breast and prostate cancer cells have significant evidence of declining. Inhibition of cancerous cells causing prostate cancer in adults has been well recognized. USA has higher prevalence of prostate cancer. Pomegranate extract has shown positive correlation with the reduction of PC-3 carcinoma prostate cells it induces regular apoptosis of cancer cells. In addition to these benefits it also stops the proliferation of these dangerous cells to other parts of the body. In order to evaluate the effects of extract on cancer cells scientist performed different experiments. 22 participants were taken and 8 ounces of pomegranate extract was given for 13 months. After this time period results were drawn. Serum level of apoptosis of cancer cells reduced to a significant level in vitro study. It was seen that 40 percent oxidative stress in serum was reduced. Similarly there was a 90 percent blockage of invasion of cells across matrix [23-26].

Arthritis and Joint Pain

Inflammation of joints can result in pain and swelling in later age. Presence of Flavones in pomegranate extract has antiinflammatory effects that may reduce collagen induced arthritis and painful swelling of joints. Cyclooxygenases and lipoxygenase enzymes inhibits by extracts present in pomegranate seed oil. These key mediators of inflammation decreases by 75 percent by seed oil while pomegranate juice causes 23.8 percent reduction in these enzymes. In osteoarthritis these extracts diminishes matrix metallo-proteinases which is involved in degradation of extracellular joint matrix.It prevents collagen degradation and stops joint destruction.

Bacterial Infections

Pomegranate has millions of bioactive compounds fighting against infections like diarrhea and ulcers. Parasitic and bacterial infection reduces to the limit that may protect against respiratory disorders and cancers. Ellagic and gallic acids as natural antimicrobial agents has been used against Staphylococcus aureus and Escherichia coli for their ability to precipitate membrane proteins and inhibit enzymes that leads to lysis of cells. 80 percent of the inhibitory effects have been shown by this method [27].

Carotid Artery Disease

Study conducted in 2004 shows that daily consumption of 50ml of juice for 3years reduces the cholesterol damage of artery walls by almost half and lessens the incidence of stroke buildup. In a study 19 subjects with artery stenosis were given 50ml of pomegranate juice for two years. Participants were treated with similar hypocholesterolemic and antihypertensive medications. There was a 35% reduction in intima thickness of right and left arteries during these 2 years similarly 90% lipid peroxidases were reduced.

Breast Cancer

Extracts of pomegranate have anti estrogenic properties. It can delay the onset of breast cancer by blocking aromatase enzymes and cancer cell differentiation. Hormone levels in serum are well controlled by pomegranate extracts. Few studies have shown plausible effect of endocrinal breast cancer therapy in postmenopausal women where a non- significant response to estrogen receptor positive MCF-7 breast tumors were seen. Anticancer properties were tested at rate of 300ug/ml along with tamoxifen. Cancer cell proliferation inhibits to a great amount.

Anti-artherogenic effect

Seeds of pomegranate are rich in oil. This oil consists of Punicic acid approximately 95% which exerts its functions as an active component both in vivo and vitro studies. Process of apoptosis is induces by this oil and prevents from metastasis. Anti-atherogenic effect of Punicic acid present in seed oil of pomegranate was tested in laboratory for investigation. In the trial 51 subjects were treated with 800mg of seed oil two times a day for 4 weeks. Results have shown significant decrease in HDL level approximately 2.75mmol/L whereas glucose metabolism remains constant. Triglycerides concentration reduces to 5.7mmol/L and serum cholesterol has no effect. Punicic acid therefore has the ability to prevent arteries from dangerous accumulation of bad cholesterol and ultimately stroke.

Hypercholesterolaemia

A recent study shows that peel of pomegranate has prebiotic potential for lowering down the fat content of the body. It reduces the cholesterol of high fat diet over a period of 4 weeks and gut microbiota supports its action. Polyphenols present in pomegranate has the ability to prevent atherosclerosis and macrophage formation. This can be done by either direct combination of polyphenols with lipoproteins of the body or by indirect means through accumulation in arterial microphages. This in return blocks the synthesis of oxygen species and lipid peroxidation and lipid rich microphages. It also results in hydrolysis of lipids in atherosclerotic lesions. These polyphenols result in prevention of oxidation and heart attack in vitro as well as in vivo models.

Antiviral

Pomegranate has same effect in fighting viruses as do vitamin C and E has. Infections can be minimized by drinking juice regularly so that efficiency of immune system can be enhanced. Antiviral properties are attributed to RNA replication of influenza virus by pomegranate polyphenol extract. Punicalagin compounds at 40ug/ ml present in it has inhibitory effect on RNA replication of virus. Similarly phenolics of peel deactivate intracellular viral replication.

Skin Health

Pomegranates have vitamin C in it which is excellent antioxidant for skin health. It delays the process of aging and wrinkles. It has been said that if we mix powder of pomegranate peel with lemon juice and small amount of honey and apply it on face for sometimes it can remove dark circles around eyes and can treat pigmentation. Studies have shown ellagitannins at 500-10,000mg concentration inhibits free radical generation and protects it from DNA fragmentation, skin burns and depigmentation.

Tooth loss

Dental plaque and tooth loss can be prevented by seeds of this fruit. It possesses anti-microbial functions which can be helpful against oral bacteria. Health of gums can be improved by its seeds. It has been demonstrated by performing a study regarding the ability of peel or pulp of pomegranate richness in antioxidants. Ferric reducing antioxidant power assay ranked pomegranate as the richest fruit containing antioxidant potential among 28 fruits. Antioxidants were separated by the combined mixture of water, acetone and methanol. Different compounds like phenolic substances and anthocyanins were also evaluated by this study. Results shows that in preventing the formation of hydroxyl, superoxide anions and CuSO4 low density lipoproteins induction peel extract has greatest potential as compare to pulp extract. Flavonoids and phenolic compounds were also high in peel extract that were beneficial against oxidation and atherosclerosis and can be used as a natural supplement.

Weight Loss

Pomegranates are rich in fiber content that can bind extra fat and cholesterol from the body and facilitates its excretion and thus can prevent obesity in return. Leaves of this fruit induce fat and weight loss up to a significant level. In this study water, ethyl acetate and methanol were used to separate antioxidant fractions from seeds and peel of pomegranate. Diphenyl Hydrazyl and B-carotene linoleate models were utilized for this extraction. At 100ppm by using these two model’s methanol extract for seeds show 22.6 percent and 23.2 percent antioxidant potential. Similarly, for peel these models at 50ppm show 83 and 81 percent results for methanol solution. As peel extracts show highest antioxidant potential so it was used for testing its effects on low density lipoproteins level, peroxidation of lipids as well as on hydroxyl radicals in humans. For testing this method of thiobarbituric acid was used at 100ppm. This shows inhibition of these dangerous mechanisms up to 56, 58 and 93.7 percent respectively. So, this shows strong evidence of antioxidants potential in peel and seeds of pomegranate.

Immune System

Various health conditions related to throat and respiration can be resolved by pomegranates. As this fruit is rich in iron content it ensures normal platelet count of the body by which a person feels less fatigue symptoms. These fruits are often recommended for liver prevention. Pomegranate juice helps in the reduction of platelet aggregation and oxidative stress in mice and humans. In laboratory two human studies were carried out. In the first part 13 people having age between 20 to 35 years taking no medications and who were non-smokers were given daily 50ml of juice for 2 weeks while in the second part increased doses were given up to 80ml for 10 weeks to 3 subjects. Body mass index of all subjects remains same during the study. Blood samples of twelve hour fast were taken before study and after juice supplementation after 2 weeks. Results on lipoproteins and lipid levels were: Pomegranate juice inhibits aggregation and oxidation of atherosclerotic lesion and attenuate platelet activation (Table 3).

Myocardial perfusion

This study involves both the placebo and treatment groups at same time. Treatment group of 23 patients were given 240ml of juice while placebo group of 16 subjects was served with same caloric dose of sports drink. Patients in both groups were suffering from stress induced ischemia. After 3 months it was shown that angina attack and stress induced ischemia in treatment groups were reduced to 50 percent and (4.5±3.1 to 3.7±3.7) ratio while in placebo group it was increased up to 38 percent and (5.9±4.3 to 7.1±5.5). Therefore, myocardial perfusion in these patients was improved by consuming pomegranate juice.

Anti-diabetic Effect

By various studies it has been confirmed that by giving 200mg of peel extract according to weight per kg of the body polyphenols present in it affects glycemic index of the body by either inhibiting the uptake of glucose to peripheral tissues or by blocking its absorption by the gut. Similarly seed extract of this fruit when given to diabetes induced rats at an amount of 300 to 600mg for 12 hours reduces blood glucose level up to 47 and 52 percent.

Pregnancy Outcomes

As we have studied many times that pomegranate are rich in antioxidants so they protect placenta from oxygen reactive species. They also contain little amount of folate that helps fight against birth defects. It can help in the purification of blood and can enhance milk production. Acidity of urine reduces by the intake of pomegranate juice and improves health of urinary bladder by preventing harmful bacteria from entering into the urinary tract. This prevents inflammation and enhances immunity of the body.

Conclusion

Pomegranate is been studied from centuries and shows various outstanding therapeutic benefits both in vitro and in vivo trials. It has been regarded best as compare to green tea due to its antioxidant potential. All parts of this fruit have been utilized in food industry for prevention and treatment of various diseases. It shows no toxic effects to liver and other organs even if taken1420mg of tablet of pomegranate extract and can be used as natural supplement. However, it is the need of the time to promote its cultivation by traditional and non- traditional means in order to gain benefits of this fruit as well as to compete in global market for its export. In addition to this more studies and experiments are needed to evaluate effects of pomegranate in treating diarrheal diseases and in preventing fungal proliferation. Potential of this fruit in overcoming infections can bring tremendous progress in nutritional and therapeutic industries

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Lupine Publishers | Food Allergy 1.5 Soy Allergy

 Lupine Publishers | Scholarly Journal of Food and Nutrition

Abstract

Soybean allergy is the familiar hypersensitivity particularly in infants and children. Soy allergy, like other sensitivities can cause mellow side effects and can be dealt with by eliminating out soy and its items from the eating regimen. Common responses incorporate loose bowels, diarrhea and vomiting. To prevent a response, it is imperative that you maintain a strategic distance from soy and soy-based items by continuously reading food labels. Also, totally maintaining a strategic distance from soy-based items is the main treatment. You additionally need to stay away from some unforeseen sources like baked products, canned juices and soups, canned fish and meat, cereals, cookies, crackers, infant formulas, processed meats, sauces, soaps and creams. Allergens are not always a part of these nourishments and items, yet soy can show up in amazing spots so again dependably read labels carefully.

Keywords: Soybean Allergy, Legume, Soy lecithin, IgE antibodies

Abbrevations: AAFA: Asthma and Allergy Foundation of America, ACAAI: American College of Allergy Asthma and Immunology, FPIES: Food Protein-Induced Enterocolitis Disorder, FPIAP: Food Protein-Induced Allergic Proctocolitis, FPE: Food Protein-Induced Enteropathy

Introduction

The soybean, or soya bean, is a member from legume family broadly grown for its palatable bean which has various uses [1]. Fat-free soybean dinner is a critical and shabby source of protein for creature feed and many bundled suppers [2]. The Asthma and Allergy Foundation of America (AAFA) gauges that soy is among the eight most regular allergens for pediatric and grownup sustenance hypersensitivity patients [3,4]. Beans, peas, lentils and peanuts are likewise legumes. In any case, being susceptible to soy does not mean you have a more noteworthy possibility of being hypersensitive to another legumes.

Statistics of soy allergy around the world

According to the estimations of American College of Allergy, Asthma and Immunology (ACAAI), soy is an allergen causing the allergy symptoms for around 0.4 percent of kids in the United States [5].

Types of soy allergy in children

There are no under 15 proteins in soybeans that have been found to realize allergic responses. There are five regular kinds of soy sensitivities found among children.

Soy milk allergy: Some children build up an allergy towards soymilk. In reality, about half of the children influenced by dairy animals’ milk sensitivity are likewise susceptible to soy as well. The best part about soy milk sensitivity is that it will resolve once the youngster pivots 3 years of age.

Soy lecithin allergy: Soy Lecithin, a byproduct from soy, is a standout amongst the most broadly utilized food additives available today and is non-dangerous in nature. It is utilized as a part of the food production that need a characteristic emulsifier. Ordinarily, it is utilized to expand the time span of usability of a few items. Notwithstanding, kids who have soy sensitivity should stay away from any sustenance items that contain soy lecithin in them.

Soy protein allergy:When contrasted with different products, soy oil is viewed as less unfavorably susceptible, as it contains low amount of allergen proteins. It is extremely uncommon that youngsters who devour completely refined soybean oil to demonstrate a seriousv unfavorably susceptible response. On the off chance that the kid has a place with that uncommon group, he or she will demonstrate the indications not long after in the wake of consuming the food containing soy oil. So, if your child is adversely affected by soy, it is prudent not to utilize soy oil for cooking foods.

Soy sauce sensitivity: Soy sauce produced using soy can trigger a hypersensitive response like inflammation of mouth and dermatitis. Soy sauce likewise contains histamines, which can cause histamine harming among kids. In this way, keep away from it if your child is adversely affected by soy [6].

Diagnosis of Soy Allergy

Your allergy specialist will get some information about your indications and may play out a physical exam. He or she may suggest either of the accompanying tests.

Skin test

Specialists may prick your skin and open your skin to little measures of the proteins found in soy. In case you’re unfavorably susceptible, you build up a raised knock (hive) at the test site on your skin. Hypersensitivity specialists more often than not are best prepared to perform and decipher sensitivity skin tests.

Blood test

A blood test can gauge your immune system’s reaction to soy by estimating the measure of specific antibodies in your circulatory system, known as immunoglobulin E (IgE) antibodies [7].

Signs and Symptoms

Food allergies can have quick beginning (from seconds to 60 minutes) or moderate beginning (from hours to a few days) contingent upon the mechanism. Indications may include: rash, hives, tingling of mouth, lips, tongue, throat, eyes, skin, or different territories, swelling of lips, tongue, eyelids, or the entire face, trouble gulping, runny or congested nose, dry voice, wheezing, shortness of breath, looseness of the bowels, stomach torment, unsteadiness, blacking out, queasiness and retching. Side effects of allergies change from individual to individual and may differ from incident to incident. Serious danger with respect to allergies can start when the respiratory tract or blood flow is influenced. The previous can be demonstrated by wheezing, a blocked aviation route and cyanosis, the last by powerless heartbeat, fair skin, and swooning. At the point when these side effects happen the hypersensitive response is called anaphylaxis [4]. Anaphylaxis happens when IgE antibodies are included, and territories of the body that are not in coordination with the sustenance end up influenced and indicate serious symptoms. [4,5] Untreated, this can continue to vasodilation, a low circulatory strain circumstance called anaphylactic shock, and death (exceptionally rare) [5,6]. Non-IgE intervened responses are slower to show up, and tend to show as gastrointestinal side effects, without cutaneous or respiratory symptoms [7]. Within non-IgE responses, clinicians recognize among Food Protein-Induced Enterocolitis Disorder (FPIES), Food Protein-Induced Allergic Proctocolitis (FPIAP) and Food Protein-Induced Enteropathy (FPE). Regular trigger foods for all are soy infant formula, and furthermore dairy animals’ milk formula. FPIAP is thought to be at the milder end of the range and is portrayed by discontinuous bloody stools. FPE is distinguished by unending loose bowels which will resolve when the culpable food is expelled from the newborn child’s eating routine. FPIES can be serious, portrayed by constant vomiting 1-4 hours after an allergen-containing sustenance, to the point of lethargy. Watery and sometimes bloody diarrhea can create 5-10 hours after the triggering supper, to the point of lack of hydration and low pulse. Babies responding to soy formula may likewise respond to cow’s milk formula.

Nutrients lost when taking Soy-Free Diet

Soybeans give one of the most noteworthy quality proteins in a kid’s eating regimen. They additionally contain thiamin, riboflavin, iron, protein, phosphorus, magnesium, calcium, zinc and vitamin B6. Except if your kid consumes extensive segments of soy, the little measures of soy in prepared nourishments don’t supply a lot of these nutrients. A soy-restricted eating regimen won’t represent any dietary hazard if your child is eating an assortment of organic products, vegetables, enriched and fortified grains, and tolerated sources of protein. You may need to increase other protein nourishments, for example, meat, fish, poultry, vegetables, eggs, dairy (if ok for your child); fruits, vegetables, leafy greens and enriched grains [4].

Treatment of Soy Allergy

The best way to prevent an unfavorably susceptible response is to dodge soy and soy proteins. Medicines, for example, antihistamines, may decrease signs and indications of minor soy allergies. Taking an antihistamine after introduction to soy may control your response and help calm distress. Over-the-counter antihistamines include: diphenhydramine (Benadryl, Banophen Complete Allergy Medication), chlorpheniramine (Chlor-Trimeton, Aller-Chlor), cetirizine (Zyrtec, Equate Allergy Relief) and loratadine (Alavert, Claritin). Regardless of your earnest attempts, you can eat soy unconsciously. On the off chance that you have a genuine unfavorably susceptible response, you may require an emergency infusion of epinephrine and to go to the emergency room.

Precautions while dealing with Soy Allergy in children

Here are a few safety measures that you can take if your child is determined to have soy sensitivity:

a) Avoid bolstering your child with food with unknown ingredients or something that you have not cooked.

b) When eating out, ensure you specify to the restaurant staff or your relatives who are preparing the food that your kid has soy sensitivity.

c) Try and make your child’s snacks and bites at home just keeping in mind the end goal to have control over what you are feeding him.

d) Avoid going to restaurants in the event if the staff is hesitant about your demand for a protected meal for your child.

Is there a cure to Soy Allergy?

There is no remedy for food allergy except by keeping away from the issue food(s) and figuring out how to perceive and treat responses side effects. Food allergy treatments are under examination in clinical preliminaries, however none has been demonstrated yet for general utilize.

Conclusion

Various medications are in clinical trials. Promising medications incorporate Oral (gulped) Immunotherapy (OIT) and Sublingual (under the tongue) Immunotherapy (SLIT) to build resistance to nourishments that are the reason to allergic responses. Yet, more research is required.

https://lupinepublishers.com/food-and-nutri-journal/pdf/SJFN.MS.ID.000117.pdf

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Lupine Publishers | Financial Anxiety in Hospitalized Cardiovascular Patients

 Lupine Publishers | Scholarly Journal of Food and Nutrition

Abstract

Introduction: Due to the nature of hospitals, the importance of mental relaxation along with the physical health of patients, this study was conducted to investigate the anxiety of hospitalized patients(discharge), looking at the impact of health costs on the rate Anxiety.

Materials and methods: This cross-sectional descriptive-analytic study was carried out using a researcher-made questionnaire. The statistical population of the study included 80 patients with myocardial infarction referring to the Hospital of Farmanieh, Tehran from 23 October to 21November 2017, 12 of whom were discontinued for some reason and 68 completed the questionnaire. The collected data were analyzed using SPSS software and sequential regression statistical test.

Findings: There was a significant relationship between pay out of pocket, employment status and insurance and the amount of anxiety; variables such as age, gender and marital status did not have a significant relationship with patient anxiety. Among the factors indicating anxiety, they received too much concern about the cost of treatment and sleep disturbances in relation to treatment costs, respectively with the highest and lowest levels of financial anxiety.

Conclusion: According to the results, increasing pay out of pocket has a positive effect on patient’s anxiety.

Keywords: Anxiety, Out of Pocket Payment, Myocardial Infarction

Introduction

Anxiety and anxiety disorder is a great health problem, which involves many dimensions including health, finance, family, and work. Over time, symptoms of anxiety may get worse or better, but usually it gets exacerbated when stress occurs [1]. According to development of health-related issues, and the increase in the cost of health-care interventions, a distinct part of household income is allocated to these costs. On the other hand, the fall in the value of household income, due to rising inflation rates, and economic constraints, leads to double pressure on households. Recent investigations shows that the decline of the socioeconomic level can negatively impact on the health status of individuals, while societies and mortality factors evolve, the decline in socio-economic status of individuals can remove them from access to resources that protect or enhance their health against harm caused by dangers. As a result, socioeconomic benefits can increase the health, and reduce the health risk factors. Education and occupation are two key factors in determining household income, which are important determinants, in the individual and household’s socio-economic status [2].

Family, as the most important unit of society, plays an important role in the individual’s health and ability to adapt to different situations. But some factors can affect the health of the family abruptly and change its structure. Several stressors, such as acute and severe illness, or hospitalization of one of the members, can lead the family to anxiety and crisis. Various studies show that, from every 4 to 5 people, one person suffers from psychiatric disorders each year due to stress. Therefore, it is essential that some protections and strategies used to prevent and reduce the anxiety risk factors [3]. One of these risk factors that always causes increased stress and anxiety at the onset time of illness, is the psychological stress caused by the inability to pay treatment costs.

According to a recent WHO report, death in the 10 past years have been the highest rates of heart disease (15 million deaths in 2015, 17 million deaths in 2008) [4]. Anxiety is always one of the causes of heart disease, which at the same time is one of the side effects of the disease. Anxiety is one of the most commonly diagnosed psychiatric patients’ responses to cardiovascular events which may lead to physical or psychological consequences if they continue or intensify [5,6]. Expecting cardiac surgery, hospitalization, fear of death, hearing about the deaths of people with the same disease, and generally fear of unknowing and unknown causes anxiety in the patient and his fellows [7].

According to a study by Jeff C Huffman [8], the anxiety among heart patients is common, and 20 to 50% of these patients have expressed anxiety. Panthee [9] in their study concluded that patients with myocardial infarction had a high degree of anxiety, which reduced their quality of life [9]. According to these studies, the purpose of this study was to investigate the financial anxiety of patients referred to cardiac problems (with a priority of myocardial infarction), at the time of discharge from the hospital, so that if the cost of treatment is effective on anxiety of patients, in addition to other stressors, we will achieve some strategies to prevent and ultimately reduce the psychological effects of hospital costs, because the main goal of each health center is to reduce suffering and relieve the clients, not to add to their inconveniences and concerns.

Materials and Methods

The present study is descriptive-analytic, cross-sectional, and questionnaire based evaluation (validated by experts). The study population included patients with myocardial infarction referring to the Hospital of Farmanieh, Tehran, from October 23 to November 21, 2017. The reason for randomly choosing of these patients was the high cost of their treatment in all over the world, as well as the high frequency of this disease patient, compared to the rate of disease and its costs in other patient groups. The sample size is 65 and we recruited 15 more patients for sample loss probability. After the census, 68 were willing to participate in the research with oral satisfaction (7 people died and 5 did not agree to do research).

In order to determine the level of financial anxiety of patients, we used 6 questionnaires, five options Likert, with the options, very high (5), high (4), medium (3), little (2), and very little (1). Grades were classified as follows: 1-2.5 for low anxiety levels, 2.5-3.5 for moderate anxiety, and more than 3.5 for high anxiety levels. Also, to investigate the total cost of patients, and the direct payment share, we inquired about the discharge unit, and we filed the sums. Paid patients out of pocket were also 38% nationwide, based on reported rates (referrals), and patients were divided into two groups, pay out pocket up 38%, and pay out of pocket more than 38% . The variables of the research are described in the table below Table 1. The data were analyzed by SPSS software version 22 and sequential regression tests at individual level (crude chance ratio) and overall level, and the findings were reported in terms of odds ratio, confidence interval, and amount meaningful.

Findings

The demographic data of 68 patients were presented in Table 2. Most patients were female (69.1%), employees (44.1%), married (83.8%), and in the age group of 31-60 (45.6%). According to the research findings, the excessive feeling of concern regarding treatment costs and sleep disturbances in relation to treatment costs resulted in the highest and lowest levels of financial stress, with a mean of 1.41 ± 3.08 and standard deviation, and 1.63 ± 2.38 (Table 3). The study of the effective factors on financial anxiety showed that there was no significant difference in the level of anxiety of patients based on variables such as gender, marital status and age (p>0.05). In case of having health insurance, non-insured patients were 2.03 times more likely than those with insurance. The likelihood of exposure to financial anxiety in the treatment costs was p=0.012 (CI: 0.1-3.98 OR=2.03). In terms of job variables, unemployed patients had 1.23 times more chance of financial anxiety and a significant difference was found between the patients in terms of job (p = 0.043; CI: 0.13-3.05; OR=1.23). Pay out pocket, in patients who paid more than 38% of the total cost of the disease, had caused 2.03 times more exposure to financial anxiety, indicating that patients’ financial anxiety increased more with increasing Pay out the pocket, (p=0.012; CI: 0.1-3.98; OR=2.03) (Table 4).

 

Discussion and Conclusion

The results of the study indicate that the relationship between pay out of pocket patients and their anxiety levels is positive, and if the increase in direct payments exceeds 38% of total costs, patients’ levels of anxiety increase. Patel, Kleinman’s [10] study confirmed the correlation between low incomes in developing countries and the risk of mental illness. Mirsamadi [11] concluded that living costs are one of the main causes of stress in health center managers, they are fully aware that heavier medical costs will reduce the likelihood of their therapeutic interventions on the patient and will lead to a decline in the quality of their health center actions [11]. Pourreza et al. [12] Stated that the adoption of new policies on the payment of heavy costs for cancer patients, in particular by insurance agencies, financial support from financial institutions such as banks, or charities, the distribution of specialized cancer centers, or Providing housing for patients who have come from distant cities, in addition to realizing health equity indicators, can reduce the financial problems facing cancer patients, and helps them to better overcome their own illness with no significant anxiety risk factors changes.

Ross et al. [13], in a study conducted in 2003 and 2004, reported about financial stress in patients with Acute Myocardial Infarction (AMI), half of the patients reported having some levels of financial stress while admitting to the hospital, and close One third of patients reported having a financial stress, that these stressful conditions led to their deterioration, increased hospitalization time, decreased patient response to treatment interventions and increased surgical risk. Along with this study, the increase in treatment costs has led to a worsening of the outcomes of the disease in these patients.

One of the reasons for inducing anxiety among people in cope with health costs is the current limitation of the current and available financial resources of individuals, who are investigating the impact of the status of their clients’ employment, as well as their insurance coverage, on this. The economic conditions in developing countries are such that most people have limited monthly income, and no amount is considered for this treatment. Also, in these countries, the risk of developing cardiovascular disease is higher than other countries, in other words, developing countries have a greater role in the incidence of cardiovascular disease worldwide, more risk factors, and less government support. In current study, it was concluded that the job status has a significant relationship with patient anxiety and non-insurance patients with a higher chance of anxiety. In this regard, Herman [14] announced in his report that health insurance should be available to all individuals globally, as a result of protecting the patient in unexpected circumstances and preventing the debtor from being financially mistreated, is one of the requirements for reforming the health system in any country.

Puccard, et al. (2005) Also noted that individual, interpersonal, social, economic, psychological, and environmental factors, contributed to the anxiety of the family members of the patient hospitalized are effective factors . Particularly, various studies have pointed to the impact of pocket payments on household income cuts [15]. Crawford [16] concluded that there is no significant relationship between age and marital status, and stress . In the present study, the relationship between these two variables and the level of patient anxiety was not significant. Arab [17] state, with increasing health spending, which is more than wage increases, more people need more welfare insurance coverage. Health insurance protects customers, especially those with limited financial resources, or excessive need for health services. Bakar [18] also state that the amount of pay out of pocket costs is one of the factors influencing the decision to buy insurance from stateless people. In this regard, the present study confirms that patients without insurance coverage have anxiety more than those who have insurance coverage.

Therefore, the high cost of treatment in cardiovascular diseases leads to anxiety in patients, anxiety during the hospitalization period, an increase in the length of the hospitalization period, a decrease in the effectiveness of the results of interventions in patients and an increase in mortality rates in these patients. On the other hand, with the improvement in treatment costs, the reduction in community anxiety reduces the incidence of various diseases, including cardiovascular disease [19]. Therefore, government support for treatment costs is a form of economic investment in the health system of the country, and governments are advised to support healthcare costs. Based on the results, it is suggested that research be conducted in the field of patient surveys, in order to receive comments and suggestions on how to deal with the personnel of the clearance unit, and to declare costs by him, the appointment of a psychologist if symptoms are manifested Anxiety in patients, and promotion of solutions to the ill-health of patients who do not have adequate insurance coverage, in addition to ensuring the health of patients, also their mental health during discharge.

Acknowledgements

We would like to thank the participants for their participation and invaluable contribution to this study. Compliance with Ethical Standards

Ethical Approval

All procedures followed were in accordance with ethical standards of the responsible committees on human experimentation and with the Helsinki Declaration of 1975 and its later amendments or comparable ethical standards. This study was a survey and verbal consent was obtained from all participants for completing the questionnaires

 https://lupinepublishers.com/food-and-nutri-journal/pdf/SJFN.MS.ID.000116.pdf

https://lupinepublishers.com/food-and-nutri-journal/fulltext/financial-anxiety-in-hospitalized-cardiovascular-patients.ID.000116.php

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