Evaluating the effect of grape syrup on iron deficiency anemia in women: A randomized clinical trial

Abstract Globally, iron deficiency reigns as the most prevalent nutritional disorder, with anemia disproportionately impacting women of childbearing age. Despite the effectiveness of existing treatments, like iron supplements, their side effects remain a concern. This study explores the potential of grape syrup (GS), a functional iron‐rich food, to modulate markers of iron‐deficient anemia in women. A randomized, double‐blind study explored the impact of GS on iron deficiency anemia markers in 130 women. Participants were allocated to intervention or placebo groups. For 4 weeks, the intervention group received a daily 50 mg ferrous sulfate tablet alongside 10 cc of GS thrice daily. The placebo group received a 50 mg ferrous sulfate tablet with a 10 cc placebo syrup thrice daily. Before and after the intervention, key markers like red blood cell count (RBC), mean corpuscular volume (MCV), hemoglobin (Hb), hematocrit (Hct), ferritin, total iron binding capacity (TIBC), and serum iron were assessed. Notably, both Hb and Hct levels were significantly higher in the GS group (p < .05). Additionally, RBC and MCV values showed significant improvement compared to the placebo group (p < .05). However, no significant difference was observed for other iron deficiency markers like serum iron, ferritin, and TIBC (p > .05). This study's findings suggest that combining grape syrup with iron tablets might offer potential advantages over iron tablets alone in managing iron deficiency anemia.

, and an increase in the number of pathological bacteria in the colon that can lead to inflammatory diseases and colon cancer (Tolkien et al., 2015).This underscores the urgent need for safe and effective alternative treatments to address this widespread health concern.
The role of nutrition in managing IDA has gained significant attention in recent years (Newhall et al., 2020;Zulfiqar et al., 2021).Traditional Persian Medicine (TPM) emphasizes the importance of dietary interventions for both the prevention and treatment of various ailments (Avicenna, 2005;Bahaeddin et al., 2023;Nimrouzi & Zare, 2014).Notably, TPM recommends various foods like meat, eggs, figs, grapes, and grape syrup for addressing anemia (Avicenna, 2005;Fatali et al., 2020).Grape syrup, a delicious and nutritious food typically enjoyed at breakfast with milk or sesame, is a popular processed product derived from grapes.
It features a dark color, a sweet taste, and a dense consistency.
Traditionally produced for centuries by boiling and condensing grape juice (Helvacioglu et al., 2018), it has recently gained traction in the food industry as a natural sweetener alternative to refined sugar (Levent et al., 2022;Mousavi Kalajahi, 2021).
Grape syrup boasts a rich nutritional profile, comprising high levels of glucose, fructose, organic acids, and essential minerals like iron, copper, zinc, calcium, and magnesium (Helvacioglu et al., 2018;Tavakolipour et al., 2020).This mineral content, coupled with its easy digestibility, allows grape syrup to meet up to 37% of daily iron needs (Aşcı & Baydar, 2021).Additionally, it possesses antioxidant, anti-mutagenic, anticancer, and anti-inflammatory properties (Pérez-Ortiz et al., 2019;Wang et al., 2011).Given its potential, this study investigated the effect of grape syrup on hematological markers of IDA (hemoglobin, hematocrit, red blood cell count, mean corpuscular volume, ferritin, and serum iron) in women with the condition.We hypothesized that grape syrup supplementation in women with IDA would significantly improve key hematological markers of the condition, including hemoglobin, hematocrit, red blood cell count (RBC), mean corpuscular volume (MCV), ferritin, and serum iron.

| Preparation of grape syrup and placebo
Locally sourced grape syrup (GS), prepared with white grapes, was obtained in 250-mL dark glass bottles.Patients received a 4-week supply (four bottles) at the prescribed dosage.
Both GS and placebo were stored in identical 250-mL dark glass bottles.Iron tablets containing 50 mg of ferrous sulfate were sourced from Darupakhsh Chemical Co., Iran.

| Randomization, blinding, and intervention
Eligible women were randomly assigned (1:1) to intervention or placebo groups using a computer-generated table.Allocation was concealed via serially numbered opaque envelopes.A separate computer program assigned unique codes to each drug/placebo, included on labels with consumption instructions.Both researchers and participants remained blinded to the codes.
For 4 weeks, the intervention group received 50 mg of ferrous sulfate tablets orally and 10 cc of grape syrup in lukewarm water thrice daily (1 h before meals).The control group received the same dose of ferrous sulfate but with 10 cc placebo syrup instead of grape syrup, also administered thrice daily, 1 h before meals.

| Outcomes
Both groups underwent pre-and post-intervention assessments of vital signs (pulse, respiration, blood pressure).Both groups underwent pre-and post-intervention assessments of key hematological markers for anemia (Hb, Hct, MCV, RBC, serum iron, ferritin, and TIBC).The primary outcome was the change in Hb concentration over the 4-week intervention.
Secondary outcomes included changes in other laboratory markers (HCT, MCV, RBC, serum iron, ferritin, TIBC, AST, and ALT), vital signs, adverse effects, participant dropout rates, and quality of life.
Both groups participated in quality-of-life assessments using the validated Persian translation of the General Health Questionnaire-28 (GHQ-28) at baseline and after 4 weeks.Researchers have previously established the validity and reliability of this questionnaire in the Iranian context (Nazifi et al., 2014).A dedicated questionnaire specifically designed to record potential side effects was used to monitor for any adverse reactions throughout the study.

| Sample size
The sample size was determined using a superiority analysis assuming normally distributed data, a 5% type I error, a two-sided test, and 80% power.We considered a minimum of 40 participants per group based on previous studies (Powers et al., 2017;Shokri & Ali, 2022).

| Data analysis
Data analysis was conducted using SPSS (version 26).Quantitative data were presented as mean ± standard deviation (SD), while qualitative data were reported as frequencies and percentages.
Between-group comparisons were performed using independent t-tests for normally distributed data and Mann-Whitney U-tests for non-normally distributed data.All reported p-values were interpreted at a significance level of p < .05.

| RE SULTS
Initially, 159 women with IDA expressed interest in the study.After screening for eligibility and availability, 130 were enrolled and randomly assigned to either the grape syrup (n = 63) or placebo (n = 67) group.However, 50 participants dropped out throughout the study (23 in the GS group and 27 in the placebo group), as shown in Figure 1.Ultimately, 80 participants completed the study and were analyzed (40 in each group) with similar baseline characteristics across both groups (Table 1).
Both groups showed significant improvements in key hematological markers after 4 weeks of intervention (Table 2).Notably, the red blood cell count (RBC) increase was significantly greater in the GS group (0.29 ± 0.30) compared to the placebo group (0.11 ± 0.03) (p = .003).Similarly, the MCV increase was significantly higher in the GS group (4.13 ± 0.67) compared to the placebo group (1.47 ± 0.48) (p = .002).These findings suggest that the GS intervention led to greater improvements in RBC and MCV compared to placebo.
Hemoglobin and hematocrit levels showed significantly higher increases in the GS group compared to the placebo (p = .0001),suggesting a more substantial improvement in these key anemia TA B L E 1 Baseline characteristics of women with iron deficiency anemia.markers (Table 2).However, no significant differences were observed for iron, ferritin, or TIBC between the groups after the intervention.

Characteristics
Quality of life, as measured by the GHQ-28, did not differ significantly between the GS and placebo groups after the intervention.However, the GS group showed a statistically significant improvement in GHQ-28 scores compared to the baseline (p = .001),suggesting an overall positive impact on quality of life.No significant changes were observed in vital signs or liver function tests in the intervention group compared to the placebo (p > .1)(Table 3).The analysis of heavy metals in the grape syrup confirmed levels within the acceptable ranges set by the Iranian Standard Organization (Table 4).
Both groups reported mild gastrointestinal side effects, including nausea, abdominal pain, and stomach discomfort.However, the incidence was slightly higher in the placebo group (15) compared to the grape syrup group (10).No severe side effects were observed in either group.

| DISCUSS ION
The study found significant improvements in key blood parameters for anemia after the intervention in the GS group compared to the placebo (p < .003).This included higher increases in hemoglobin, hematocrit, red blood cell count, and MCV in the GS group.Additionally, quality of life, as measured by the GHQ-28 score, significantly improved in the GS group (p = .001).Intriguingly, serum iron, ferritin, and total iron-binding capacity (TIBC) did not differ significantly between groups, suggesting these markers may require longer observation periods (3-6 months) to reflect changes after oral iron supplementation, as noted in previous studies (Camaschella, 2015;Ning & Zeller, 2019).
Grape syrup, a popular food product globally, is particularly common at breakfast in many Middle Eastern countries, often paired with sesame paste.It also finds application in desserts and cookies as a sugar substitute to enhance taste (Özmen et al., 2023;Rahbari et al., 2023).Its high carbohydrate content makes it a good source of energy, while its mineral compounds, phenolic content, and organic acids contribute to its functional food status (Karaman et al., 2017).Notably, iron (Fe) in grape syrup demonstrates high digestibility and absorption by the digestive system (Aşcı & Baydar, 2021).A study involving 56 children aged 6-36 months compared iron absorption from grape syrup and ferrous sulfate, concluding that grape syrup could be an effective iron source for preventing iron deficiency anemia in children (Aslan et al., 1997).
Grapes are a significant fruit source of valuable nutrients, including antioxidants, antimicrobials, and anticancer compounds (Soleymanfallah et al., 2022).Incorporating various grape products into daily diets undoubtedly plays a crucial role in promoting healthy food habits and overall well-being (Aşcı & Baydar, 2021).Grape juice, in particular, boasts high levels of glucose, fructose, sucrose, vitamins A, C, B1, B2, minerals, organic acids, and antioxidant agents (Rezaei et al., 2020).This makes it a valuable dietary component for individuals of all ages, especially children, women, and athletes (Hatamikia et al., 2013).This study aimed to determine the macroand microelement content of a specific grape product known as grape shinny (molasses).
This study revealed a high concentration of essential minerals in grape syrup, including iron, zinc, calcium, potassium, and copper.Levels of toxic elements were minimal, confirming their safety for human consumption and potential benefits for child development (Rasulov et al., 2020).However, concerns exist regarding the heavy metal content in food products like grape syrup (Krarapina & Kilicel, 2020) Comparison of hematological indices in women with iron deficiency anemia at baseline visit and at 4 weeks after treatment within and between groups.
TA B L E 2 Comparison of vital signs and liver tests between two groups after intervention.Concentration of heavy metals in grape syrup.
Heavy metals fall into two categories: essential and nonessential.Non-essential and hazardous metals like Hg, Pb, Cr, Cd, and As are well known for inducing human poisoning.Essential heavy metals like Cu, Fe, Mn, Co, and Zn, on the other hand, are crucial for various biochemical and physiological functions (El TA B L E 3 TA B L E 4 a The permissible limits were determined based on Iranian National Standards Organization (INSO) index.