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Efficacy of Malunggay ( Moringa oleifera ) leaves in improving the iron and

vitamins A and B status of Filipino schoolchildren

Article in Acta Horticulturae · April 2017

DOI: 10.17660/ActaHortic.2017.1158.33

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Efficacy of Malunggay (Moringa oleifera)
leaves in improving the iron and vitamins A
and B status of Filipino schoolchildren
M.E. Seraficoa, L.A. Perlas, C.R. Magsadia, J.A. Desnacido, R.V. Viajar, E.O. Rongavilla,
G.P. Azana and T.P. Trinidad
Food and Nutrition Research Institute, Department of Science and Technology, Bicutan, Taguig City, Philippines.

Abstract
The prevalence of iron deficiency anemia (IDA) and vitamin A deficiency (VAD) remain at a significant p

Keywords: moringa, hemoglobin, vitamin A deficiency, folic acid, riboflavin

INTRODUCTION
Iron and vitamin A deficiencies continue to be problems in developing countries
(Yang et al., 2006b). In the Philippines, the prevalence of iron and vitamin A deficiencies
continuously remain at levels that pose a public health concern. The 7 th National
Nutrition Survey conducted by the Food and Nutrition Research Institute-Department of
Science and Technology (FNRI-DOST) in 2008 showed that among 6-12 years old
children, 19.8 and 11.1% were anemic and vitamin A deficient, respectively (Food and
Nutrition Research Institute-Department of Science and Technology (FNRI-DOST),
2010a, b).
On the other hand, the status of B-vitamins of Filipino schoolchildren has not been
assessed for the past ten years. Vitamin B deficiencies may become a public health concern
because foods rich in these vitamins such as dairy products and dark green leafy vegetables
like romaine lettuce, kale, spinach, watercress and broccoli are relatively expensive.
Government investments have poured to various intervention programs designed to
address the malnutrition problem. Approaches have included fortification,
supplementation, nutrition education and supplementary feeding programs utilizing
nutritious and low cost
a
E-mail: mes@fnri.dost.gov.ph

Acta Hortic. 1158. ISHS 2017. DOI 10.17660/ActaHortic.2017.1158.33

293
Proc. I International Symposium on Moringa
Eds.: A.W. Ebert and M.C. Palada
foods.
Recent developments in the search for finding solutions to malnutrition, have
identified food-based approaches as a sustainable complement to supplementation
programs. Findings of Yang’s group (2006) showed that Moringa oleifera is one of the
promising crops which could contribute to increased intake of micronutrients and
antioxidants. The World Health organization has likewise promoted moringa as an
alternative to imported food supplies to treat malnutrition (Sreelatha and Padma, 2009;
Johnson, 2005).
Food based approaches to eliminate micronutrient deficiencies have been
conducted and found to be effective, both in animal and human studies. In several animal
studies, feeding Moringa oleifera leaves to rats (Nambiar and Seshadri, 2001), cows
(Sarwatt et al., 2004) and hens (Kakengi et al., 2007) resulted in both weight gain and
improved nutritional status.
Most of the studies on the efficacy of Moringa oleifera on improvement of the
nutritional and hematological status of malnourished humans were conducted in very
young children. Weight gain was recorded when infants were fed complementary foods
mixed with moringa seeds in Burkina Faso (Compaoré et al., 2011) and moringa leaf
powder in Uganda (Jilcott et al., 2010). An intervention study using traditional
complementary food (CF) with moringa among infants in Nigeria resulted in improved
hemoglobin, serum ferritin and serum retinol level (Nnam, 2009). On the other hand,
increase in hemoglobin level was not significant in the CF with moringa among infants
in Burkina Faso (Compaoré et al., 2011).
In-vitro studies on bioavailability of micronutrients from moringa leaves were also
reported. In a recent study conducted by Trinidad et al. (2013), the bioavailability of iron
and zinc from moringa leaves was 17.1 and 70.6%, respectively. Beta-carotene and lutein
from fresh and dried moringa leaves are also highly bioavailable (Pullakhandam and Failla,
2007).
In the Philippines, Moringa oleifera, is commonly called Malunggay. Its leaves are
among the top 30 commonly consumed food items of Filipinos (Food and Nutrition Research
Institute-Department of Science and Technology (FNRI-DOST), 2010a, b). Among 6-12 year
old children, consumption of Malunggay is 15 g day-1.
Efficacy of Malunggay for undernourished children has not been fully established due
to limited science-based studies in humans. It is hoped that this study can support clinical
evidence to the various claims on the effectiveness of Malunggay, particularly on the
alleviation of micronutrient deficiency.
The study was carried out to determine the efficacy of Malunggay leaf powder added
to snack products in improving the iron and vitamins A and B status of 8-10 years old
schoolchildren. Specifically, the study sought to compare the changes in weight and height,
hemoglobin, serum ferritin, serum retinol, serum folic acid concentrations and riboflavin
status among the study participants.

MATERIALS AND METHODS

Study setting and design

The study was conducted in Muntinlupa City in the southernmost part of the
National Capital Region. Two public elementary schools with similar socio-economic
and environmental characteristics were purposely selected as study sites. Children with
below normal body mass index (BMI) were considered as participants of the study. A
total sample size of 121 children was conveniently allocated into experimental (60
students from School
1) and control (61 students from School 2) groups.
The experimental group was fed snack products with 3 g of MLP, while the control
group was fed with snack products without MLP. Nutrient composition of the snack
foods were computed from the Philippine Food Composition Tables (FNRI-DOST,
1997). Feeding lasted for 120 days. Baseline and end-line data collection was conducted
for both groups.

29
 The study protocol was reviewed and approved by the Food and Nutrition Research
Institute Institutional Ethics and Review Committee (FIERC). Informed, written consent
was

29
obtained from the children’s parents after the purpose and procedures of the study were
explained.

Moringa leaves
Moringa leaf powder was purchased from Japan-Philippines Malunggay Eco Farm, Inc.
(JPM) located in the Province of Laguna. Nutrient content of MLP was determined by the
Food Analytical Service Laboratory of FNRI.

Data and blood collection and analytical methods

Parents of study children were interviewed face-to-face using a pre-tested
structured questionnaire. At baseline, general profile of the children as well as health and
nutrition data was collected. Selected demographic and socio-economic data were also
obtained. Intake of vitamins and mineral supplements one month prior to data collection
and two weeks prior to blood extraction was recorded. All children participants were
dewormed before the start of the feeding trial.
Weight of children was measured at baseline and end-line using a calibrated 160-kg
capacity beam balance weighing scale. Height was measured using a microtoise posted
flat against a wall.
A two-day non-consecutive 24-h food recall was collected at baseline and end-line.
Study children or their parent/caregivers were interviewed on their food intake for the
past 24 h.
Blood samples were collected from all study children at baseline and after 120 days
of the intervention study. About 5 mL blood by venipuncture was extracted from each
child with approximately 2 mL transferred in a tube with an anticoagulant. Remaining
blood was allowed to set and serum was separated within 2 h after collection. Serum and
anticoagulated blood were then kept in a -80°C freezer until analyzed.
Hemoglobin was determined on site using the cyanmethemoglobin method (Zwart et
al., 1996), ferritin using an immunoradiometric assay procedure (DPC) and vitamin A via
HPLC method (Furr et al., 1992). For riboflavin status, erythrocyte glutathione reductase
activity in blood was determined, while serum folic acid was determined using a
radioimmunoassay method (DPC).

Statistical analysis
All data were transformed to numerical codes guided by a coding manual prepared
for the study. The Statistical Package for Social Sciences version 9.0 was used for
encoding and statistical analysis. Parametric tests such as t-test and paired t-test were
used to compare means among normally distributed variables. Chi-square test was used
to compare proportions between groups.

RESULTS

Energy and nutrient content of snack products

The energy and nutrient content of the five different snack foods utilized in the feeding
intervention is presented in Table 1. The 3 g MLP contains about 11.5 kcal, 0.8 g protein,
37.7 mg calcium, 0.4 mg iron, 225.9 µg vitamin A, and 2.1 mg vitamin C. Among the snack
foods, polvoron gave the highest nutrients per serving. On the other hand, arroz caldo had
the least amount of nutrients per serving. Meat was not added to the developed snack foods to
avoid confounding with the nutrients from the meat. Flavor enhancers were added instead.

Characteristics of study children

There were slightly more females (53.3 and 54.1% for the experimental and control
groups, respectively) than males in both study groups. Children in the experimental
group were significantly older (9.8±0.5 years) compared with the control group (9.1±0.8
years).
Less than half (40.0% for the experimental and 44.3% for the control group) of the
children in both study groups got sick in the past two weeks at baseline, whereas at end-

29
line

29
a lower percentage for both groups were noted (data not shown).

Table 1. Nutrient content of snacks foods and Malunggay leaf powder per serving.
Energy and nutrient content
Snack products Energy CHO Pro Fe Vit. A B2 Vit.C
(kcal) (g) (g) (mg) (µg) (mg) (mg)
Arrozcaldo (210 g) 219.6 40.4 5.1 1.5 0.8 0.1 0.0
Ginataang mais (210 g) 421.5 71.4 6.4 1.8 6.8 0.1 0.0
Pancit canton (210 g) 342.6 43.6 8.8 2.5 154.8 0.1 4.6
Macaroni soup (240 g) 262.4 45.1 9.6 2.4 35.8 0.2 0.0
Polvoron (60 g) 625.4 77.3 13.7 3.0 192.3 0.5 2.8
Malunggay leaves powder (3 11.5 1.51 0.8 0.4 225.91 No data 2.1
g)
1Converted from ß-carotene.

Anthropometric status
Baseline mean weight of children was similar for both groups (20.45±1.73 and
20.17±2.37 kg for the experimental and control group, respectively) as presented in Table
2. Mean weights for both groups increased significantly (p<0.001), with the control
group having slightly higher increase. The mean change in weight across periods
between study groups was not significant.

Table 2. Mean weight and height (±SD) of children by study group and period.
Study Group
Variables Experimental Control p-value1
n=60 n=61
Weight (kg)
Baseline 20.45±1.73 20.17±2.37 0.468
End-line 21.89±2.18 22.00±2.94 0.813
Difference +1.44 +1.82
p-value2 0.001 0.001
Height (cm)
Baseline 124.68±4.78 123.64±6.69 0.325
End-line 126.51±5.01 126.14±6.95 0.742
Difference +1.82 +2.51
p-value 0.001 0.001
1Using independent sample t-test.
2Using paired-sample t-test.
The baseline mean height of study children in the experimental group (124.68±4.78
cm) was not different with that of children in the control group (123.64±6.69 cm). Similarly,
at end-line their mean heights were not significantly different from each other (126.51±5.01
vs. 126.14±6.95 cm). The mean change in height between study groups was not significantly
different, while the mean change in height from baseline to end-line within study groups was
significantly different (p<.001).
The mean BMI-for-age z-score of children in the experimental and control groups
were both significantly different across periods but differences were not significant
between groups.

Biochemical indices
Table 3 shows mean hemoglobin, ferritin, serum retinol, folic acid and EGR-AC of
the study children. At the start of the feeding trial, hemoglobin levels of the experimental
and control groups were statistically the same (p=0.854). At the end of the feeding
period, mean

29
hemoglobin levels of the experimental group increased by 0.3 g dL-1 (p=0.015) and that
of the control group increased by 0.2 g dL -1 (p=0.025). Both had significant increases in
hemoglobin levels with the experimental group having a slightly higher increase.

Table 3. Mean concentration (±SD) of hemoglobin, ferritin, serum retinol, folic acid and
EGR-AC by study group and period.
Study group
Biochemical parameter Experimental Control p-value1
n=60 n=61
Hemoglobin (g dL-1)
Baseline 12.5±0.10 12.5±0.13 0.854
End-line 12.8±0.11 12.7±0.11 0.540
p-value2 0.015 0.025
Ferritin (ng mL-1)
Baseline 53.9±6.11 47.8±3.5 0.386
Endline 39.4±3.7 39.4±3.7 0.998
p-value 0.010 0.033
Serum rerinol (µg dL-1)
Baseline 34.0±0.89 32.9 ± 0.88 0.375
End-line 34.8±0.90 34.6 ± 0.85 0.897
p-value 0.438 0.036
Riboflavin
Baseline 1.03±0.015 1.03 ± 0.021 0.932
End-line 1.01±0.016 1.03 ± 0.018 0.487
p-value 0.384 0.931
Serum folic acid (ng mL-
1)

Baseine 8.6±0.32 9.1±0.30 0.241

End-line 9.2±0.29 9.4±0.35 0.593
p-value 0.047 0.328
1Using Chi-square test.
2Using Independent sample t-test.
Serum ferritin levels for both groups were similar at the start of the trial and at the
end of the study. Surprisingly, serum ferritin levels decreased significantly for both
groups (p=0.01 for the experimental group and p=0.033 for the control group).
Table 3 also shows results for retinol, riboflavin and folate status of the children before
and after feeding. At the start and end of the feeding trial, both the experimental and control
groups had adequate vitamin A levels. There was an increase in vitamin A concentration in
both groups. Unexpectedly, however, the increase in vitamin A concentration of the control
group was significantly higher (p=0.036). Although the study was limited to the analysis of a
few nutrients, other studies suggest that dried moringa leaves contain a relatively high
vitamin E content (Moyo et al., 2006; Sánchez-Machado et al., 2006; Yang et al., 2006a)
which could have had negative interaction with the beta-carotene present.
There was no change in the riboflavin status of both groups of participants. On the
other hand, serum folic acid had increased significantly (p=0.042) at the end of the
feeding trial for the experimental group. Although serum folic acid also increased for the
control group, the change was not significant.

Energy and nutrient intake of study children

Mean one-day energy and nutrient intakes of the children were determined before
and after the intervention. Table 4 presents the intake of the children during the
intervention period. The control group had higher mean one-day energy intake
(1235.13±297.54 kcal) compared to the experimental group (1131.83±360.58 kcal),
meeting 64.3 and 74.3% of the
29
energy requirement, respectively. There was no change in energy intake from baseline to
end-line for both groups, but end-line energy intake was significantly higher among the
participants in the control group (p=0.016). A similar trend was observed for the other
nutrients, with the control group having higher intakes compared to the experimental
group. However, the differences between the two groups were not significant.

Table 4. Mean one-day energy and nutrient intake (±SD) of children by study group and
period.
Study Group
Energy and nutrients Experimental Control p-value1
n=60 n=61
Energy (kcal day-1)
Baseline 1131.83±360.58 (64.3) 1235.13±297.54 (74.3) 0.088
End-line 1510.57±392.46 (85.9) 1684.34±438.87 (101.8) 0.023
p-value2 0.000 0.000
Protein (g day-1)
Baseline 32.22±12.32 (69.6) 35.34±9.00 (79.8) 0.115
End-line 42.36±11.94 (91.7) 46.58±13.74 (105.6) 0.074
p-value 0.000 0.000
Iron (mg day-1)
Baseline 6.52±2.80 (50.8) 6.99±2.70 (58.5) 0.348
End-line 8.85±2.21 (70.1) 9.11±2.83 (77.4) 0.582
p-value 0.000 0.000
Vitamin A (µg day-1)
Baseline 236.11±150.96 (59.0) 279.82±198.58 (70.0) 0.716
End-line 515.04±105.00 (128.8) 284.66±124.00 (71.2) 0.000
p-value 0.000 0.869
Vitamin C (mg day-1)
Baseline 12.38±15.31 (30.8) 13.16±14.23 (35.5) 0.772
End-line 14.06±11.41 (36.0) 17.55±34.98 (48.0) 0.462
p-value 0.000 0.000
1Using independent sample t-test.
2Using paired-sample t-test.

DISCUSSION
Moringa olefeira is said to be one of the world’s most useful plants. Almost all of
its parts – leaves, fruits and roots have been used for a variety of food and medicinal
purposes (bar.gov.ph). It is an excellent source of nutrition and a natural energy booster. It
is loaded with nutrients and vitamins and amino acids. Locally known as Malunggay, its
leaves are rich in protein and other nutrients, which can be used by doctors, nutritionists
and community health workers to treat undernutrition and a variety of illnesses (Thurber
and Fahey, 2009).
Malunggay is known to be very rich in several macronutrients, micronutrients and
antioxidants (Thurber and Fahey, 2009; Oduro et al., 2008) and thus is one of the
promising crops that could help alleviate micronutrient deficiencies. To date, there are
very few documented studies on this. Thus, the present study aimed to determine the
efficacy of MLP in improving the iron, and vitamins A and B status of Filipino children.
Popular snack foods such as arrozcaldo, ginataang mais, pancit canton, macaroni
soup and polvoron were chosen for the feeding trial. Acceptability tests were conducted
before the actual feeding trial, however, the amount of MLP added was limited because of the
very dark color it imparted to the snack foods. As well, taste of food with more than 3 g MLP
was bitter and unacceptable even for adults. This is lower than the 5-7 g of dried M. oleifera
leaf powder added to daily salty snacks of 1-5 year old children in India (Nambiar et. al.,
2003).

30
 Nutrient intake of the children in the control group at end-line was higher when
only household food and snack foods were considered, but the difference was reduced
when MLP was added. Highest reductions were recorded for protein, energy, calcium,
vitamin A and vitamin C intakes. It is widely reported that Malunggay is a very rich
source of nutrients. Nutrients from the MLP consumed by the study children may not
have provided the required amount for it to result in a significant increase in nutrient
intake among the children given 3 g MLP daily but resulted in increase in height and
weight of the children.
In Burkina Faso, a complementary food (CF) made with Moringa oleifera seeds,
was tested and compared to the existing CF in the area (Compaoré et al., 2011). The
study was conducted among severely malnourished, 6-36 months old infants. Feeding
lasted till children were eligible for the home-based therapy study when complications
were resolved and their appetite returned. Duration of recovery was about 45 days for the
group given CF with moringa compared to about 100 days for the group given the
existing CF. Weight gain was higher in those given CF with moringa. However, increase
in hemoglobin level was not significant in the CF with moringa.
The additional nutrients provided by 3 g MLP resulted in minimal changes in the
biochemical parameters studied. A significant increase in hemoglobin was recorded for both
groups. Three grams of MLP provided 0.4 mg Fe d-1 (Table 1), which unfortunately was not
enough to meet the requirement for iron. Moreover, the bioavailability of iron could have
been inhibited by the presence of phytate and fiber in MLP. It has been shown that as little as
2 mg phytate can reduce iron absorption by 18% (Hallberg et al., 1989). The bioavailability
of iron in MLP was reported to be 17.1% (Trinidad et al., 2013).
We have not found any study on efficacy of MLP among 8-10 year old children. A
four- week intervention study using the maize traditional CF with moringa, among
infants 6-12 months, conducted in Nigeria, resulted in an increase in hemoglobin, serum
ferritin and serum retinol level (Nnam, 2009). Likewise, mean hemoglobin levels
increased significantly in a 3-month efficacy trial among moderately anemic lactating
women in Senegal (Idohou- Dossou et al., 2011). These women received 100 g of MLP
each week which is much more than what we gave to the children in this study. We gave
3 g day-1 or 21 g week-1. Serum ferritin levels remained unchanged at the end of the
intervention, which is similar to findings of our study. Mean ferritin levels of the children
in our study were normal.
Malunggay is very rich in β-carotene which eventually converts to vitamin A.
Beta- carotene and lutein from fresh and dried Malunggay leaves are also highly
bioavailable (Pullakhandam and Failla, 2007). Increase in vitamin A intake in the
experimental group was highly significant as a result of the 3 g MLP. The end-line mean
vitamin A intake of the experimental group has increased to a level higher than that of
the requirement for vitamin A for this age group. However, this amount did not result in
an increase in serum retinol levels of the children. Mean serum retinol levels of the
children were normal at the start of the intervention. Studies have shown that intervention
and supplementation trials are more effective in those with low micronutrient levels.
A significant increase in serum folic acid was recorded among the children given 3 g
MLP day-1. This is an indicator of recent intake of the nutrient. Among green, leafy
vegetables, Malunggay leaves contain the highest dietary folate equivalents amounting to
370 µg 100 g-1 (Food and Nutrition Research Institute-Department of Science and
Technology (FNRI-DOST), 2010a, b). These could have been the driver to increase the
concentration of serum folate among the children in the experimental group.

CONCLUSIONS
The following conclusions can be drawn from the study:
- Increase in mean hemoglobin level was greater for children given snack foods with
three grams of Malunggay leaf powder compared to those given only snack foods.
However, both groups had a significant increase in hemoglobin level.
- Children given snack foods with three grams MLP achieved more than 100% of their
daily vitamin A requirement.

30
 - Improved serum folic acid concentration could be attributed to the high folate

30
 content of MLP. Significant increase in serum folic acid level was observed among
children given snack foods with MLP but not in the control group.

ACKNOWLEDGEMENTS
The authors would like to express their deepest gratitude to the following: the
Philippine Council for Health Research and Development for funding the study, DepEd NCR,
parents and student participants. In addition, thank you is extended to the staff of
Nutritional Biochemistry Section, Ms. Marites Alibayan, Ms. Joselita Rosario Ulanday, Ms.
Asuncion Torres, Ms. Adorie Sabenecio, Ms. Eva Rebato, Ms. Ma. Estrella Valle, Ms. Dovie
Domiquel, and Mr. Herbert Patalen who helped prepare the snack foods and assisted in field
data collection; Mr. Carl Vincent Cabanilla for retinol analysis; Mr. Jeffrey de Leon, Mr.
Eldridge Ferrer and Ms. Aileen Joy Ramos for the statistical analyses.

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