INTRODUCTION

Hypertension or "high blood pressure" is a condition when a person experiences a rise in blood pressure either slowly or suddenly1). The diagnosis of hypertension is established if a person’s systolic blood pressure persists at 140 mmHg or more2). Hypertension remains a domi-nant risk factor for cardiovascular diseases and others around the world. The number of people with systolic blood pressure (SBP) of 140 mm Hg or higher was estimated to have increased from 442 million in 1990 to 874 million in 2015 when this SBP level was responsible for 14% of total deaths and 143 million disability-associated life-years. The rate of hypertension increased from 17.307/100.000 in 1990 to 20.525/100.000 in 20153). Also, approximately 10-30% of the population of almost all countries experience hypertension. In 2013, it stated that the prevalence of hypertension in Indonesia reached 25.8%, with a higher incidence of cardiovascular complications in women 52% and men 48%4).

Handling hypertension can be divided into non-pharmacological and pharmacological treatments. One method of non-pharmacological treatment that can be done is to improve the lifestyle by regular physical activity, reduce sodium intake, maintain potassium and magnesium intake, reduce cholesterol intake5). Fruits and vegetables contain high

potassium and low sodium to maintain blood pressure within normal limits. One example of a fruit that is rich in benefits is coconut, water-melon, and papaya in 30 ml of coconut water containing 61 mg of potassium (potassium). The highest content of young K mineral water can restore stamina. Consuming K minerals can also reduce hyperten-sion6).

Other fruits that can lower blood pressure are watermelon because of the content contained in anti-hypertension. In watermelon rich in water content, potassium, amino acids, L-arginine can maintain healthy blood pressure. Increasing potassium intake by 30-45 mmol is associat-ed with the reduced systolic blood pressure of 2-3 mmHg7). Another fruit that can reduce blood pressure is papaya. In terms of mineral con-tent, ripe papaya fruit has a potassium content of 257 mg/100 g8). Potassium serves to maintain intracellular fluid balance. Increasing potassium intake by 30-45 mmol is associated with the reduced systolic blood pressure of 2-3 mmHg. The ideal ratio of potassium to sodium is five to one9).

This research was conducted based on the results of previous stud-ies with the same title but on respondents with normal blood pressure. The results showed that coconut water, watermelon juice, and papaya juice were effective in reducing systolic and diastolic blood pressure (p-value < 0.05). This study applies the results of previous studies to

International Medical Journal Vol. 28, No. 2, pp. 202 - 207 , April 2021

HYPERTENSION

Benefits of Young Coconut Water, Watermelon, and Papaya for Blood Pressure among Hypertension

Siti Fadlilah1), Adi Sucipto1), Mohamad Judha1), Nazwar Hamdani Rahil1), Lala Budi Fitriana1), Sukismanto2), Sumarni3), Diyah Candra Anita4)

ABSTRACTObjective: Herbal therapies can be used to maintain blood pressure. This study aimed to determine the effect of young coco-

nut water, watermelon juice, and papaya juice on blood pressure. Methods: This research was a quasi-experimental with nonequivalent control group pre-posttest. This study consisted of four

groups, 18 respondents per group. Samples are patients with hypertension stage 1 in the community were taken by simple ran-dom sampling. Samples were given young coconut water, watermelon juice, and papaya juice every day for seven days. Blood pressure assessed by digital sphygmomanometer Omron-8712 measured serially everyday pre-posttest. Statistical analyses included Paired T-test and Independent T-test.

Result: This study found that young coconut, watermelon juice, and papaya juice useful to reduce systolic (p0.030, 0.032, and 0.011) and diastolic (p0.024, 0.037, and 0.015). The comparison of systolic and diastolic blood pressure of young coconut water, watermelon juice, and papaya juice with the control group obtained p0.014, 0.013, 0.003, and 0.017, 0.042, 0.012. The highest decrease in mean pre-posttest systolic and diastolic pressures was in the papaya juice group -5.2 and -2.7 mmHg.

Conclusion: Consumption of young coconut water, watermelon juice, and papaya juice effective in reducing systolic and dia-stolic blood pressure in patients with hypertension.

KEY WORDSblood pressure, cardiovascular, citrullus, cocos, papaya, phytotherapy

Received on March 4, 2020 and accepted on June 11, 20201) Nursing Programme Study Respati Yogyakarta Tajem Street Km 1.5 Maguwoharjo Sleman Yogyakarta, 55282, Indonesia2) Public Health Programme Study Respati Yogyakarta Kadilobo, Purwobinangun, Pakem, Sleman, Yogyakarta 55582, Indonesia3) Nursing Programme Study Poltekkes Kemenkes Semarang Bakalan RT 01 RW 01 Kecamatan Kandeman Kabupaten Batang Jawa Tengah, Indonesia4) Nursing Programme Study Universitas Aisyiyah Yogyakarta Jl. Ringroad Barat No 63, Mlangi Nogotirto Gamping Sleman Yogyakarta, IndonesiaCorrespondence to: Siti Fadlilah(e-mail: sitifadlilah@respati.ac.id)

202

C 2021 Japan University of Health Sciences & Japan International Cultural Exchange Foundation

Fadlilah S. et al. 203

respondents with hypertension.

METHODOLOGY

Study Design and Participants in the StudyThe type of research used is a quasi-experiment, with pretest and

posttest nonequivalent control group. Respondents were divided into four groups, three treatment groups and one was the control group as a comparison. Treatment groups were the young coconut group, water-melon juice group, and papaya juice group (Figure 1). This research consist of two variables is the dependent variable and the independent variable. The dependent variable was blood pressure, while independent variables were young coconut water, watermelon juice, and papaya juice. The population is prehypertension in Maguwoharjo, Depok, Sleman, Yogyakarta, Indonesia, in May 2018. Samples with inclusion criteria were early adult age (18-49 years old), normal of body mass index (18.5-22.9), Javanese, activity level mild to medium, and were willing to become respondents. Exclusion criteria were taken medica-tion for blood pressure disorders, have heart and kidney disease. One group consists of 18 respondents. Samples were taken by simple ran-dom sampling and calculated using the Slovin formula with a margin error of 5%.

Instruments and Data CollectionIn the control group, samples did not receive treatment and blood

pressure was measured daily pre-posttest. In the experimental group (1), samples were given 170 ml of young coconut water daily in the after-noon (01.00 to 02.00 pm) in 7 days. In the experimental group (2), sam-ples received watermelon juice from 300 gram watermelon daily in the afternoon (01.00 to 02.00 pm) in 7 days. In the experimental group (3), samples received papaya juice from 250 gram papaya daily in the after-noon (01.00 to 02.00 pm) in 7 days. Blood pressure was measured daily pre-posttest. Blood pressure pretest was measured before treatment and blood pressure posttest was measured after treatment. Blood pressure assessed by digital sphygmomanometer Omron-8712.

Data Analysis and Ethical ConsiderationIBM SPSS Statistics 23.0 was used for all statistical analyses in this

study. Descriptive statistics were computed for all variables, including the minimum, the maximum, the means, and Standard Deviations (SD) for continuous variables, and frequencies and percentages for categori-cal variables. The normality test used Shapiro Wilk with the results of pretest and posttest systolic blood pressure 0.124; 0.50; and 0.37. The results of the normality test were pretest and posttest diastolic blood pressure 0.147; 0.58; and 0.27. The results of the normality test were obtained > 0.05, which means that the data is normally distributed. Statistical test pretest-posttest each group used Paired T-test. Statistical analysis for comparison effect between control group and treatment group used Independent T-test. Data collection held after receiving approval from Head of Wedomartani village and Ethical clearance No: 124.2/UNRIYO/PL/V/2018 from Ethic Commission of Respati Yogyakarta University. An informed consent was signed to all respon-dents prior to data collection

RESULT

Sample CharacteristicAs shown in Table 1, the most age of all groups were middle adults.

Most of the sex of the control group is male (55.6%). While other groups, most of the sex of the are female. The most categories of BMI in all groups were normal. Most respondents in all groups categories of the non-smoking category.

Pretest and Posttest Systolic Blood PressureAs shown in Table 2, the lowest mean systolic blood pressure in

pretest-posttest among control group was obtained on the 3rd and 1st day = 148.1 mmHg and 146.1 mmHg, the young coconut water group, was on the 4th day = 139.8 mmHg and 137.9 mmHg, the watermelon juice group was on the 3rd day = 138.0 mmHg and 136.7 mmHg, and the papaya juice was on 5th day =143.8 mmHg and 138.7 mmHg. The high-est mean systolic blood pressure in pretest-posttest among control was obtained on the zero and 8th day = 153.3 mmHg and 154.6 mmHg, in young coconut water group were on the zero and 1st day = 145.7 mmHg and 142.1 mmHg, in watermelon juice group was on the 2nd and 1st day = 144.7 mmHg and 141.2 mmHg, and papaya juice group was on 3rd day = 151.3 mmHg and 146.0 mmHg.

Table 1: Frequency Distribution Of Respondent Characteristics On The Benefits Of Young Coconut Water, Watermelon Juice, And Papaya Juice For Blood Pressure Among Hypertension.

Characteristic Control Group Coconut Water Watermelon Papaya

Group Juice Group Juice Group

f % f % f % f %

Age Early adult 7 38.9 8 44.4 7 38.8 8 44.4Middle adult 10 55.5 9 50.0 9 50.0 9 50.0Late adult 1 5.6 1 5.6 2 11.2 1 5.6

Total 18 100.0 18 100.0 18 100.0 18 100.0

Gender Female 8 44.4 12 66.7 12 66.7 10 55.6Male 10 55.6 6 33.3 6 33.3 9 44.4

Total 18 100.0 18 100.0 18 100,0 18 100.0

IMT Underweight 0 0.0 0 0.0 3 16.7 2 11.1Normal 18 100.0 18 100.0 10 55.5 13 72.2Overweight 0 0.0 0 0.0 5 27.8 3 17.7

Total 18 100.0 18 100.0 18 100.0 18 100.0

Smoking Yes 5 27.8 2 11.2 2 11.2 2 11.2No 13 72.2 16 88.8 16 88.8 16 88.8

Total 18 100,0 18 100.0 18 100.0 18 100.0

Herbal Therapy to Hypertension204

Pretest and Posttest Diastolic Blood PressureAs shown in Table 5, the lowest mean diastolic blood pressure in

pretest-posttest among control group was obtained on the 3rd day = 88.2 mmHg and 85.7 mmHg, the young coconut water group, was on zero and 8th day = 83.6 mmHg and 81.9 mmHg, the watermelon juice group was on the zero and 8th day = 82.2 mmHg and 80.1 mmHg, and the papaya juice was on 1st day = 87.8 mmHg and 85.6 mmHg. The highest mean diastolic blood pressure in pretest-posttest among control was obtained on the 2nd and 8th day= 91.8 mmHg and 94.8 mmHg, in young coconut water group were on the 2nd and 3rd day = 89.5 mmHg and 85.2 mmHg, in watermelon juice group was on the 1st and 6th day= 87.2 mmHg and 85.7 mmHg, and papaya juice group was on 2nd and 5th day = 91.8 mmHg and 90.0 mmHg.

Effects of Young Coconut Water and Watermelon Juice to Blood Pressure

Based on Table 3, the mean difference systolic/diastolic blood pres-sure between pretest-posttest in control group, young coconut group, watermelon juice group, and papaya juice was -1.3/3.4 mmHg, -4.7/-2.4 mmHg, -2.9/-2.1 mmHg, and -5.2/-2.7 mmHg. Also, in Table 3, bivari-ate analytical pre-posttest systolic in the control group, young coconut water group, watermelon juice group, and papaya juice p-value 0.100;

0.030; 0.032; and 0.011. Based on this finding, there was no effect on the systolic blood pressure of the control group, but young coconut, watermelon juice, and papaya juice affected systolic blood pressure. The analytical pre-posttest was diastolic in the control group, young coconut water group, watermelon juice group, and papaya juice p-value 0.450, 0.024, 0.037, and 0.15. There was no effect on the diastolic blood pres-sure of the control group, while young coconut, watermelon juice, and papaya juice effected to diastolic blood pressure. As shown in Table 3, the comparison of systolic/diastolic blood pressure between the control group with the young coconut water and group watermelon juice group, and papaya group was obtained p values 0.014/0.017; 0.013/0.042; 0.012/0.003. Based on that, it can be concluded that young coconut water, watermelon juice, and papaya juice effectively reduce the systolic and diastolic blood pressure of respondents compared to the control group.

DISCUSSION

Blood pressure is the pressure given by the blood to the arterial wall. Systolic blood pressure is the pressure produced by the heart mus-cle when it pushes blood from the left ventricle to the aorta (pressure when the heart's ventricular muscles contract). Diastolic blood pressure

Table 2: Pretest-Posttest on Systolic and Diastolic Blood Pressure Data in The Benefits Of Young Coconut Water, Watermelon Juice, And Papaya Juice For Blood Pressure Among Hypertension

Group Systolic/Diastolic Blood Pressure Pretest-Posttest (mmHg)

Days Min Max Mean SD

0 130/82 168/104 153.3/91.4 7.9/6.1 1 130-126/75-72 167-165/100-99 148.8-146.1/87.8-85.7 10.3-11.2/8.6-9.2 2 140-132/83-77 164-160/103-99 150.0-146.8/91.8-89.5 8.8-8.9/7.1-8.1 3 130-129/79-76 166-167/101-99 148.1-146.4/88.2-86.9 11.3-11.8/6.0-6.7 Control 4 130-128/80-77 162-160/109-98 149.6-146.6/88.4-85.7 10.1-10.0/5.1-6.1 5 138-130/77-75 163-162/102-99 151.2-148.4/91.6-90.0 8.6-9.1/7.3-7.9 6 140-139/76-75 163-163/109-98 151.3-148.5/90.3-89.0 7.7-8.1/5.7-5.8 7 131-130/80-79 166-165/100-99 149.7-147.2/90.8-89.8 9.4-9.8/6.1-6.1 8 130/84 162/99 154.6/94.8 8.8/4.1

0 140/70 159/98 145.7/83.6 6.5/5.3 1 130-128/75-71 165-165/100-100 145.6-142.1/86.6-84.5 8.1-9.7/7.7-7.9 2 125-124/75-70 156-154/120-99 143.5-140.7/89.5-83.8 8.6-8.5/12.5-7.9 Young 3 126-126/73-70 156-155/98-96 143.8-141.1/87.8-85.2 8.6-7.8/6.2-6.6 Coconut 4 129-126/75-74 155-155/95-93 139.8-137.9/84.9-82.8 7.1-7.0/5.6-5.9 Water 5 130-124/73-71 164-165/98-98 144.7-141.4/87.4-85.2 9.7-11.5/6.1-6.3 6 130-127/75-72 160-158/95-94 142.6-139.4/84.1-81.7 9.5-9.8/5.7-6.6 7 133-129/77-73 156-152/100-99 144.3-140.0/87.3-84.9 7.4-7.8/6.6-7.3 8 129/75 159/109 141.0/81.2 8.7/8.6

0 130/76 168/99 142.1/82.2 14.1/8.3 1 128-120/70-71 167-163/104-104 143.3-141.2/87.2-85.1 10.1-9.9/9.1-8.9 2 130-123/70-64 163-157/98-96 144.7-140.9/83.8-81.7 11.4-11.4/8.2-8.1 Water 3 127-121/73-66 154-155/96-95 138.0-136.7/83.5-81.4 9.3-10.1/7.8-7.4 melon 4 125-121/75-70 161-155/103-104 144.2-138.2/84.8-83.1 10.1-9.9/6.8-8.1 Juice 5 125-119/75-70 167-166/98-97 142.6-137.6/85.5-84.1 11.7-12.2/7.3-7.9 6 127-127/76-74 162-160/102-100 140.3-138.8/87.1-85.7 10.8-10.7/8.3-8.7 7 129-128/77-75 165-163/96-93 139.7-138.8/84.9-83.2 10.4-10.1/5.5-5.9 8 120/74 157/95 139.8/80.1 10.8/6.4

0 131/82 169/104 147.8/91.4 13.7/6.1 1 125-123/75-72 162-162/100-99 146.3-143.3/87.8-85.6 12.2-12.5/8.6-9.2 2 130-123/83-77 170-165/103-100 144.3-140.6/91.8-89.5 13.8-13.4/7.1-8.1 Papaya

3 130-126/79-76 201-196/101-100 151.3-146.0/88.2-86.9 17.4-17.2/6.1-6.7

Juice 4 130-124/80-77 165-166/99-98 145.3-142.9/88.4-85.7 10.9-11.5/5.1-6.1

5 128--120/77-75 162-157/102-102 143.8-138.7/91.6-90.0 11.3-11.1/7.3-7.9 6 132-126/76-75 165-162/99-98 149.4-145.1/90.3-89.0 11.2-11.1/5.7-5.8 7 132-100/80-79 160-157/100-99 146.5-142.9/90.8-89.8 9.1-8.9/6.1-6.3 8 129/84 159/84 142.6/88.7 9.8/4.1

Fadlilah S. et al. 205

is the pressure on the walls of the arteries and blood vessels due to the loosening of the heart's ventricular muscles (pressure when the atrial muscles of the heart contract and blood to the ventricles)7,10). The normal range of systolic blood pressure is < 119-86 mmHg, while Diastolic < 79-56 mmHg8). Blood pressure in the study was pretest and posttest. Pretest blood pressure is the result of blood pressure measurement on the left arm, and before the 15 minutes rest measurement, in a sitting position, blood pressure measurement is done before being given coco-nut water, watermelon juice, or papaya juice. Blood pressure at the posttest was the result of the blood pressure measurement on the left arm, and before the measure was 15 minutes resting, in a sitting posi-tion, blood pressure measurements were made after giving coconut water, watermelon juice, or papaya juice.

It is known that most of the sex of the control group is male, and other groups were female. The factors that influence blood pressure, one

of which is gender, where after puberty, females tend to have lower blood pressure than the male of the same age. Gender factors affect hypertension, where males suffer more from hypertension compared to females, with a ratio of about 2.29 for an increase in systolic blood pres-sure and 3.76 for an increase in diastolic blood pressure. The risk of hypertension also associated with elevated blood pressures (BP) may be affected by age9).

Smoking, either active or passive, can cause cardiovascular disease via a series of interdependent processes, such as enhanced oxidative stress, hemodynamic and autonomic alterations, endothelial dysfunc-tion, thrombosis, inflammation, hyperlipidemia, or other effects11). Cigarette smoke contains more than 4000 chemical substances, includ-ing nicotine and carbon monoxide (CO), that have harmful effects on cardiovascular function12). Nicotine causes catecholamine release both locally and systemically, leading to an increase in heart rate, blood pres-sure, and cardiac contractility. It reduces blood flow in cutaneous and coronary vessels; and increases blood flow in the skeletal muscles. Due to reduced myocardial oxygen delivery, there is reduced cardiac work13). Nicotine alters the structural and functional characteristics of vascular smooth tissue and endothelial cells. It enhances the release of the essen-tial fibroblast growth factor and inhibits the production of transforming growth factor-β1. These effects lead to increased DNA synthesis, mito-genic activity, endothelial proliferation, and increases atherosclerotic plaque formation14).

The results of the study support the Finding, individuals who con-tinue to use tobacco tend to increase the risk of hypertension due to the cumulative consumption of tobacco use15). These results are in line with the research indicating that more and more cigarettes are smoked every day; it will affect the increase in systolic and diastolic blood pressure16). Other research found the unhealthy relationship between blood pressure and smoking, and that smokers appeared more likely to develop high blood pressure in comparison with non-smokers17).

The results showed that all groups experienced a decrease in the average difference systolic and diastolic blood pressure with the highest reduction in papaya juice group (-5.2 mmHg and -2.7 mmHg). Based on table 3, the mean difference systolic and diastolic blood pressure between the pretest-posttest in the watermelon juice group was -2.9 and -2.1 mmHg. Watermelon has many varieties the examples; seedless watermelons are genetically modified varieties of seeded watermelons. For generations, the watermelon is used as a blood pressure reduction. This fruit has minerals, both macro minerals, and micro minerals. The macro minerals they contain are potassium, magnesium, and sodium, while the micronutrients include zinc and manganese7. The level of potassium is 82 mg/100 g, the sodium content is 1 mg/100 g, and the

Table 3: Effect of Coconut Water, Watermelon Juice, and Papaya Juice Consumption on Systolic and Diastolic Blood Pressure Reduction

Group Mean Systole/Diastole(mmHg) The Mean Difference Systole/Diastole P-value

ControlPretest 153.3/91.4 1.3/3.4 0.100/0.450*Posttest 158.6/98.8 Coconut WaterPretest 145.7/83.6 -4.7/-2,4 0.030/0.024*Posttest 141.0/81.2 Watermelon JuicePretest 142.1/82.2 -2,9/-2.1 0,032/0.037*Posttest 139.8/80.1 Papaya JuicePretest 147.8/91.4 -5.2/-2.7 0.011/0.015Posttest 142.6/88.7 Systole Blood Pressure PrePosttest Control-Young Coconut Water 0.014**PrePosttest Control-Watermelon Juice 0.013**PrePosttest Control-Papaya Juice 0.003**Diastolic Blood Pressure PrePosttest Control-Young Coconut Water 0.017**PrePosttest Control-Watermelon Juice 0.042**PrePosttest Control-Papaya Juice 0.012**

*tested using Paired T-test

** tested using Independent T-test

Note: Pretest-Posttest Blood pressure examined every day

Figure 1: Study framework

Herbal Therapy to Hypertension206

magnesium content is ten mg/100 g18).The watermelon juice affected systolic and diastolic blood pressure

(p-values 0.032 and 0.032). The watermelon juice effectively reduces the systolic and diastolic blood pressure of the respondent compared to the control group (p values 0.013 and 0.042). Watermelon is a rich natu-ral source of lycopene, a carotenoid of great interest because of its anti-oxidant capacity and potential health benefits19). Watermelon also has the highest citrulline content from other citrulline sources. Phenolic compounds such as carotenoids (lycopene and beta carotene), which function as antioxidants and anti-inflammatory, are also found in water-melons. Phenolic compounds work to neutralize free radicals, especially from the results of metabolism of Nitric oxide (NO)20,21). L-citrulline is a non-essential amino acid that is thought to affect VO2 max. L-citrulline will be converted to L-arginine, which is a precursor of nitrite oxide (NO) by the enzyme NO synthase. nitric oxide (NO) is a vasodilator of blood vessels. L-arginine and L-citrulline can improve peripheral arteri-al endothelial function. An increase in NO will reduce peripheral vascu-lar tone, resulting in wider blood vessels and increase blood flow. Increased blood flow causes an increase in the supply of oxygen and more nutrients to the muscles, so VO2 max increases. Other foods that contain citrulline are beef, dark chocolate, legumes, nuts, and fish22,23).

As shown in Table 3, the young coconut water reduced the mean difference systolic and diastolic blood pressure between the pre-test-posttest (-4.7 and -2.4 mmHg). The young coconut water contains 95.5% water, 0.1% protein, less than 0.1% fat, 4.0% carbohydrate, and 0.4% ash. Young coconut water also contains vitamin C 2.2-3.4 mg/100 ml and vitamin B complex. Besides, coconut water not only contains water but also contains nutrients. In 30 ml of coconut water contains 61 mg of potassium (potassium), 5.45 mg of sodium, and 1.3 mg of sugar6). The young coconut affected systolic and diastolic blood pressure (p-val-ues 0.030 and 0.024).

The young coconut water effectively reduces the systolic and dia-stolic blood pressure of the respondent compared to the control group (p values 0.014 and 0.017). Coconut water contains a high amount of potassium, which causes vasodilatation and also improves endothelial function24). The administration of potassium has been proven in several previous studies to reduce blood pressure. This is estimated through the mechanism of natriuresis, endothelium-dependent vasodilatation decreases Rennin Angiotensin Aldosteron (RAA) activity and sympa-thetic nerves. High levels of potassium in young coconut water are reported to reduce blood pressure or as an antihypertensive25).

So far, no results have been obtained that report side effects due to the consumption of young coconut water. The impact of excess potassi-um from food intake is almost non-existent; even there is no upper intake (UI) value for potassium because the consumption of food sourc-es of potassium to achieve adequacy is rarely achieved. The mineral content of K (potassium) in coconut water is the most abundant. Eating mineral K can reduce hypertension26). In a previous study found, on the t reatment with coconut water, the cardiac enzymes Lactate Dehydrogenase (LDH), Aspartate Aminotransferase (AST), and Alanine Aminotransferase (ALT)) were decreased while antioxidant vitamins (C and E) improved. This implies that coconut water possesses beneficial antioxidant and cardioprotective potentials27).

Potassium content in this fruit is believed to have contributed to its diuretic effect. Potassium is an intracellular ion and is associated with an exchange mechanism with sodium. Increased potassium intake in the diet has been linked to decreasing blood pressure because potassium

triggers natriuresis (loss of sodium through urine) Sodium is the prima-ry cation in blood and extracellular fluid which covers 95% of all cat-ions. Therefore, this mineral plays a significant role in regulating body fluids, including blood pressure and acid-base balance. Healthy magne-sium levels can maintain smooth muscle tone and have implications for blood pressure control. Magnesium can also protect the heart muscle from damage during ischemia25).

As shown in Table 3, the papaya juice reduced the mean difference systolic and diastolic blood pressure between the pretest-posttest (-5.2 and -2.7 mmHg). The papaya juice affected systolic and diastolic blood pressure (p-values 0.011 and 0.015). The papaya juice effectively reduced the systolic and diastolic blood pressure of the respondent com-pared to the control group (p values 0.003 and 0.012). In terms of min-eral content, ripe papaya fruit has a potassium content of 257 mg/100 g and very little sodium of 3 mg/100 g. Potassium serves to maintain intracellular fluid balance. Papaya is proven to reduce the workload of the heart and can reduce blood pressure, and this is due to the diuretic content in papaya, which has an antihypertensive effect by increasing the release of water and sodium salt. Potassium also maintains the sta-bility of the body’s electrolytes through a potassium sodium pump, which reduces the amount of water and salt in the body8).

The fruit juice of C. papaya contains antihypertensive agent(s), which exhibits mainly alpha-adrenoceptor activity28). Systemic blood pressure is controlled by the Renin-Angiotensin System (RAS) and baroreflex which control the heart rate response. Uncontrolled activa-tion of RAS in people with hypertension has an important role in the development of cardiac hypertrophy. Angiotensin Converting Enzyme (ACE) inhibitors are an important treatment option, because ACE is the main component of RAS that will activate the formation of angiotensin II. Angiotensin II is the main vasoconstrictor of RAS and can reduce baroreflex sensibility so that it can increase blood pressure, through the regulation of sympathetic nerves29).

ConstraintThis study had several constraints. Researchers cannot observe the

diet and activities of the respondents during the data collection process. Researchers only control by advising patients about diets and physical activities that must be carried out during the research process.

CONCLUSION

Based on the results of the study, it was found that young coconut water, watermelon juice, and papaya juice effectively lowered blood pressure. Statistically the most effective sequence for reducing systolic blood pressure is papaya juice, watermelon juice, and young coconut water. Herbal sequences that are more effective at reducing diastolic blood pressure are papaya juice, young coconut water, watermelon juice. It is expected that the research results can be used as a basis for utilizing young coconut water, watermelon juice, or papaya juice to maintain blood pressure in the normal range.

Figure 3: Average Diastolic Blood Pressure of Pretest-PosttestFigure 2: Average Systolic Blood Pressure of Pretest-Posttest

Fadlilah S. et al. 207

ACKNOWLEDGEMENT

This work was supported by the Indonesian Ministry of Research and Technology Fund in 2018.

REFERENCES

1. Santoso, D. (2010). Reducing Hypertension. Surabaya: Jaring Pena. www.academia.edu/31395808/Konsep_Tekanan_Darah_2.1.1_Pengertian_Tekanan_Darah.

2. Rodriguez, C.J, Katrina, SSunil K. A., et al. (2014). Systolic Blood Pressure Levels Among Adults With Hypertension and Incident Cardiovascular Events. JAMA Intern Med, 174 (8): 1252-1261. DOI: 10.1001/jamainternmed.2014.2482

3. Huffman MD and Lloyd-Jones DM. (2017). Global burden of raised blood pressure: Coming into focus. JAMA, 10 (317): 142. http://dx.doi.org/10.1001/jama.2016.19685

4. Safitri, A.R & Iwmawati R. (2018). Effectiveness of Mengkudu fruit (Morinda citrifolia L) Fruit Tea in Reducing Elderly Blood Pressure With hypertension (Study at UPTD. Griya Werdha City of Surabaya in 2018). Journal UNAIR, 2018; 163-171. http://dx.doi.org/10.20473/amnt.v2i2.2018.163-171

5. Setiawan, G. W. (2013). The Effect of Elderly Gymnastics on the Quality Life of Hypertensive Patients. e-Biomedik Journal (eBM, 1(2): 760-764. https://media.neliti.com/media/publications/68668-ID-none.pdf

6. Vita, D. (2016). Young Coconut Release Thirsty and Millions benefit. Stomata: Surabaya. 2016 https://www.bukupedia.com/id/book/id-47-108098/kesehatan-ga-ya-hidup/kelapa-muda-pelepas-dahaga-sejuta-khasiat.html

7. Black & Hawk. (2014). Medical-Surgical Nursing Clinical Management for Positive Outcome (Ed.7). St Louis: Missouri Elsevier Saunders, 155-156. https://books.google.co.id/books?id=GqvHDgAAQBAJ&pg=PA384&lpg=PA384&dq=18.%09Black+%26 +Hawk.+(2014).+Medical+Surgical+Nursing+Clinical+Management+for+Positive+ Outcome+(Ed.7).+St+Louis:+Missouri+Elsevier+Saunders.&source=bl&ots= IRURoTPavM&sig=ACfU3U0apB0OR6AtkRVZ7WgIynT4Flk0WA&hl=id&sa= X & v e d =2a h U K E w j Y n _ Z j t n g A h U J Yo8K H d99C U Q Q6A E w B H o E C AY Q A Q # v=snippet&q=diastolic%20blood%20pressure&f=false

8. Suryani, I. (2009). Papaya fruit, astounding nutritional content in http:/?health.indexar-ticles.com.html.

9. Kowalski, R. E. (2010). The Blood Pressure Cure: 8 Weeks to Lower Blood Pressure without Prescription Drugs. Bandung: Qanita

10. Smeltzer, S. C., & Bare, B. G. (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott. 375-380 http://zu.edu.jo/UploadFile/Library/E_Books/Files/LibraryFile_9134_13.pdf

11. Hall, J. E. Guyton, and Hall. (2015). Medical Physiology E-Book. Saunder, an Imprint of Elsevier Inc, 249-250. https://books.google.co.id/books?id=krLSCQAAQBAJ& printsec=frontcover&dq=1.%09Guyton,+Arthur+C.+and+Hall,+John+E&hl= id&sa=X&ved=0ahUKEwimraOQkNngAhUNVH0KHTzKAiUQ6AEIOTAC#v=o-nepage&q=1.%09Guyton%2C%20Arthur%20C.%20and%20Hall%2C%20John% 20E&f=false

12. Deedwania, PC. (2002). The changing face of hypertension: is systolic blood pressure the final answer?. Arch Intern Med, 162: 506-508. http://dx.doi.org/10.1001/archinte.162.5.506

13. Ambrose JA, Barua RS. (2004). The pathophysiology of cigarette smoking and cardio-vascular disease: An update. J Am Coll Cardiol, 43: 1731-1737. https://doi.org/10.1016/j.jacc.2003.12.047

14. Bullen CH. (2008). Impact of tobacco smoking and smoking cessation on cardiovascu-lar risk and disease. Expert Rev Cardiovasc Ther, 6(6): 883-895. https://doi.org/10.1586/14779072.6.6.883

15. Mishra, A., Pankaj C., Sourav, D. Anita, S., Poonam, J., Apurva G., (2015). Harmful effects of nicotine. Indian Journal of Paediatric Oncology. Jan-Mar; 36(1): 24-31. https://dx.doi.org/10.4103%2F0971-5851.151771

16. Benowitz NL, Jacob P 3rd, Herrera B. (2006). Nicotine intake and dose-response when smoking reduced nicotine content cigarettes. Clin Pharmacol Ther, 80: 703-14. https://doi.org/10.1016/j.clpt.2006.09.007.

17. Gao, K., Xin, S., Wenbin, W. (2017). The life-course impact of smoking on hyperten-sion, myocardial infarction, and respiratory diseases. Scientific Report. 7: 4330. https://doi.org/10.1038/s41598-017-04552-5

18. Li, G., Hailing, W., Ke, W., Wenrui, W., et al. (2017). The association between smoking and blood pressure in men: a cross-sectional study. Biomed Central Public Health. 17: 797 https://doi.org/10.1186/s12889-017-4802-x

19. Ain, Q., & Krishna, R. (2015). The effects of smoking in developing hypertension in Pakistan: a systematic review. 1(11). https://doi.org/10.3329/seajph.v5i1.24845

20. Edwards, A. J., Vinyard, B. T., Wiley, E. R., Brown, E. D., Collins, J. K., Perkins-Veazie, & Clevidence, B. A. (2003). Consumption of watermelon juice increases plas-ma concentrations of lycopene and β-carotene in humans. The Journal of nutrition, 133(4): 1043-50. https://doi.org/10.1093/jn/133.4.1043

21. Murray, J. (2007). Watermelon. Minnesota: ABDO Publishing Company. 6-8. https://www.researchgate.net/publication/322627374_Watermelon_and_melon_fruit_quality_The_genotypic_and_agro-environmental_factors_implicated

22. Rouge, C., Des Robert, C., Robins, A., Le Bacquer, O., Volteau, C., De La Cochetiere, M.-F., & Darmaun, D. (2007). Manipulation of citrulline availability in humans. American Journal of Physiology. Gastrointestinal and Liver Physiology, 293(5): 1061-67. https://doi.org/10.1152/ajpgi.00289.2007

23. Arturo Figueroa, Julian A. Trivino, Marcos A. Sanchez-Gonzalez, Florence Vicil. (2010). Oral L-Citrulline Supplementation Attenuates Blood Pressure Response to Cold Pressor Test in Young Men. American Journal of Hypertension, 23(1): 12-16. https://doi.org/10.1038/ajh.2009.195.

24. Bescos, R., Antoni, S., Josep., A.T., Antony, P. (2012). The Effect of Nitric-Oxide-Related Supplements on Human Performance. Sports Medicine, 42(2): 99-117. http://dx.doi.org/10.2165/11596860-000000000-00000

25. Gullapali, H.S., Avanish, P.T., Namrata. H.G. (2013). Effect of supplementation of ten-der coconut water on blood pressure of primary hypertension subjects. International Journal of Medical Research & Health Sciences, 2(2): 172-176. https://www.ijmrhs.com/medica l - research /e ffec t -o f - supplementa t ion-of - tender-coconut -wa -ter-on-blood-pressure-of-primary-hypertensive-subjects.pdf

26. John Kennedy, N. Dike-Ndudim, J., Elendu, H.N. et al. (2013). Antioxidant and Card iopro tec t ive Effec t o f Coconut Water aga ins t Doxorubic in Induced Cardiomyopathy. JKIMSU, 2 (2): 37-41. http://www.jkimsu.com/jkimsu-vol2no2/jkimsu%20vol%202%20no%202%20july%20-%20dec%202013%2037-41.pdf

27. Farapti, F. & Sayogo, S. (2014). Young Coconut Water-Its Effect on Blood Pressure. Continuing Professional Development. CDK-223, 41(12) https://www.researchgate.net/publication/315096822_Air_Kelapa_Muda_-Pengaruhnya_terhadap_Tekanan_Darah

28. Eno, AE., Owo OI., Itam EH., Konya, RS. (2000). Blood pressure depression by the fruit juice of Carica papaya (L.) in renal and DOCA-induced hypertension in the rat. Phytotherapy Research: PTR, 14(4): 235-9

29. Lidiani F. Santana, Aline C. Inada, Bruna L.S.E.S et al. (2019). Nutraceutical Potential of Carica papaya in Metabolic Syndrome. Nutriens, 11(7): 1608. https://doi.org/10.3390/nu11071608