Makara Journal of Science

Volume 27 Article 5
Issue 4 December

12-10-2023

Relation of Salivary Alpha-Amylase (sAA) Concentration to

Fatigue Biomarkers in Palm Oil Office Workers in Jambi Province:
Preliminary Study
David Kusmawan
Occupational Health and Safety, Department of Public Health, Faculty of Medicine and Health Science,
University of Jambi, Muaro Jambi 36361, Jambi, Indonesia, david.kusmawan@unja.ac.id

Willia Novita Eka Rini

Occupational Health and Safety, Department of Public Health, Faculty of Medicine and Health Science,
University of Jambi, Muaro Jambi 36361, Jambi, Indonesia

Wahyu Indah Dewi Aurora

Medical Study Program, Faculty of Medicine and Health Science, University of Jambi, Muaro Jambi
36361, Jambi, Indonesia

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Part of the Biochemical Phenomena, Metabolism, and Nutrition Commons, and the Occupational
Health and Industrial Hygiene Commons

Recommended Citation
Kusmawan, David; Eka Rini, Willia Novita; and Aurora, Wahyu Indah Dewi (2023) "Relation of Salivary
Alpha-Amylase (sAA) Concentration to Fatigue Biomarkers in Palm Oil Office Workers in Jambi Province:
Preliminary Study," Makara Journal of Science: Vol. 27: Iss. 4, Article 5.
DOI: 10.7454/mss.v27i4.1450
Available at: https://scholarhub.ui.ac.id/science/vol27/iss4/5

This Article is brought to you for free and open access by the Universitas Indonesia at UI Scholars Hub. It has been
accepted for inclusion in Makara Journal of Science by an authorized editor of UI Scholars Hub.
 Makara Journal of Science, 27/4 (2023), 289−297
doi: 10.7454/mss.v27i4.1450

Relation of Salivary Alpha-Amylase (sAA) Concentration to Fatigue

Biomarkers in Palm Oil Office Workers in Jambi Province:
Preliminary Study

David Kusmawan1,2*, Willia Novita Eka Rini1, and Wahyu Indah Dewi Aurora3

1. Occupational Health and Safety, Department of Public Health, Faculty of Medicine and Health Science,
University of Jambi, Muaro Jambi 36361, Jambi, Indonesia
2. Center of Excellent e-Medical Research, LPPM University of Jambi,
Muaro Jambi 36361, Jambi, Indonesia
3. Medical Study Program, Faculty of Medicine and Health Science,
University of Jambi, Muaro Jambi 36361, Jambi, Indonesia

*
E-mail: david.kusmawan@unja.ac.id

Received October 25, 2022 | Accepted September 24, 2023

Abstract
The salivary α-amylase (sAA) concentration has a potential role as a biological indicator of occupational fatigue. This
study aimed to determine the levels of sAA and its influencing factors. This research used a cross-sectional design with
a sample of 40 office staff respondents at PT. X (Persero). Mental workload (MWL), sleep quality, and occupational
fatigue were measured using the NASA-Total Load Index (TLX), Pittsburgh Sleep Quality Index, and Industrial Fatigue
Research Committee, respectively. Meanwhile, the basic sAA levels was measured through the sandwich enzyme-linked
immunosorbent assay method using the Bioenzy® Kit Assay. Descriptive analysis showed that the workers were mostly
men, 75% of which had a high education level and 72.5% were of marital status. MWL scoring in NASA-TLX revealed
an average score of 70.91, which indicates a high MWL. Pearson’s correlation analysis unveiled that occupational fatigue
and sleep quality were significantly correlated with sAA concentration. The final model showed that for each one-unit
increase in occupational fatigue, the sAA concentration increased by 15.90 U/mL. Furthermore, for every unit increase
in sleep quality, the sAA concentration decreased by 13.38 U/mL. sAA concentration can be used as a potential noninva-
sive biological marker related to sleep quality and occupational fatigue.

Keywords: biomarker, occupational fatigue, sAA, sandwich enzyme-linked immunosorbent assay, sleep quality

Introduction peripheral muscles and the perception of fatigue mediated

Occupational fatigue is one of the risk factors that
contribute greatly to the occurrence of occupational
accidents that can cause death. Furthermore, the nominal
claim by Badan Penyelenggara Jaminan Sosial
Ketenagakerjaan due to occupational accidents has
reached IDR 1.2 trillion every year, with a total of
173,105 cases. Fatigue conditions pose extreme danger
and increases the at-risk behavior of workers. Experience
of fatigue by workers contributes negatively to safety
performance (PE), results in a decrease in productivity
levels, low quality of work, and increased risk of
occupational accidents, and may possibly result in death.
Fatigue has multifactorial causes, such as poor sleep
quality, increased mental activity and load, and prolonged
of physical activity. The fatigue caused by sustained
physical activity is correlated with the loss of strength in
by signaling pathways in the central nervous system [1].
The alteration of (sAA), which is an enzyme present in
the oral cavity, can be measured as a stress marker. In
humans and animals, two main systems in the body are
involved in the stress response process, namely, the
autonomic nervous system (ANS) and the hypothalamus
pituitary adrenal (HPA) axis. The measurement of sAA
concentration is a useful technique for monitoring ANS
reactivity under stress conditions [2]. sAA is a digestive
enzyme involved in starch breakdown. This enzyme is
synthesized in acinar cells, stored in granules, and released
into the saliva in response to neuronal stimulation [2].
During stressful conditions, the sympathetic nervous
system is stimulated, which results in the increased
secretion of sAA by the salivary glands. sAA has been
widely used as a biological marker of stress conditions
[3, 4].

289 December 2023  Vol. 27  No. 4

290 Kusmawan, et al.
Biomarkers using saliva are increasingly becoming
popular in stress-related studies because saliva is easy to
produce, noninvasive in the collection process, not
limited by geographic distance, and does not require the
use of a number of equipment in the collection process.
Several salivary fluid biomarkers, such as cortisol,
amylase, and immunoglobulin, have been used as
markers in stress studies [5]. The use of salivary
biomarkers has had many positive effects on the
measurement of fatigue. The development of the fatigue
biomarker index has taken stress and fatigue study to a
new level with its capability to measure fatigue
objectively. Fatigue can alter small-molecular-weight
salivary proteome composition during a 10 h session of a
moderate physical activity [4, 5].
The sAA shows a high level of sensitivity to changes in
stress levels (including psychological stress), such as
during medical procedures, and physical stress, such as
during exercise. During exercise, the sympathetic activity
increases, which triggers the adrenergic activity in
salivary glands and results in an increased concentration
of sAA in the saliva after the exercise [2]. Although
saliva samples are easy to collect, researchers often
overlook its important properties, such as the diurnal
nature of saliva secretion, individual variations (age,
gender, possibly ethnicity, and oral or systemic health),
microorganisms in the saliva and oral cavity, oral
hygiene (including hygiene habits and other oral
conditions), diet and medications, and physical activity
or exercise [6–8]. Therefore, the protocol in saliva
collection must be standardized and should include the
careful selection of subjects, abstinence from oral
hygiene protocols, the timing of collection, ideal
collection method for unstimulated whole saliva, and
rapid processing via centrifugation at 4 °C to remove
debris. More importantly, as saliva is affected by
individual variations, a baseline sample is needed to
compare the changes in biomarkers.
The relationship between mental workload (MWL), sleep
quality, and fatigue level with sAA concentrations is still
unclear. Workload, sleep quality, and fatigue may
contribute to stress. Fatigue associated changes,
including biochemical alterations in cellular signaling
processes, can be observed in the molecular composition
of saliva. Moreover, the sAA concentration in oil-palm
plantation workers in Jambi Province has not been
studied clearly. This study aimed to find a baseline for
sAA concentration in oil-palm plantation workers and the
related influencing factors and determine its potential as
a noninvasive biological marker of occupational fatigue.
Materials and Methods
Study design, instrument, and population. This study
obtained ethical review approval from the Research Ethics
Committee, Faculty of Medicine and Health Sciences,
Makara J. Sci.
Universitas Jambi with Number: 736/Lolos Etik 2021.
Informed consent was given to the respondents during
filling out of questionnaires and collection of saliva
samples. This work used a cross-sectional study design
and selected 40 office staff respondents of PT X (Persero)
via simple random sampling, in accordance with the
inclusion criteria. The study was conducted from
September 2020 to March 2021.
The dependent variable was sAA concentration, and the
independent variables included sociodemographic data
(gender, level of education, marital status, age, and
working years), occupational fatigue, sleep quality, and
MWL. The level of education referred to the highest
formal education attained by the respondents and can be
less than or equal to senior high school (moderate) and
higher (high). The study instruments used were the
Industrial Fatigue Research Committee (IFRC)
questionnaire for occupational fatigue measurement,
National Aeronautics and Space Administration Task
Load Index (NASA-TLX) questionnaire for MWL, and
the Pittsburgh Sleep Quality Index (PSQI) for sleep
quality measurement. The NASA-TLX consists of six
item scales, and it was used to evaluate the different
aspects of workload: mental demand, physical demand,
temporal demand, effort (EF), performance (PE), and
frustration level. Workload measurement involved two
steps. First, the respondents were subjected to 15
pairwise comparisons of all six dimensions of the
instrument to determine the NASA-TLX dimensions that
are prominent in performing their daily task. The
weighted average of scores associated with various
dimensions were considered as the total score of the
workload. This instrument was valid and widely used for
the measurement of MWL and sleep quality [9–11].
Bioenzy® enzyme-linked immunosorbent assay (ELISA)
kit was used for measurement of sAA levels. The data
obtained were analyzed using univariate, bivariate, and
multiple linear regression analyses to determine the factors
that affected the sAA concentration. The inclusion
criteria used were oil-palm sector workers, workers who
did not smoke, and those who were not currently infected
with severe acute respiratory syndrome coronavirus
2based on the results of rapid swab antigen. The exclusion
criteria were smoking, unwillingness to participate, and
having a congenital disease (diabetes and heart disease).
Saliva sample collection. Saliva sampling was carried
out after working hours at 4 p.m. The collection was
carried out at the PT. X office using equipment, such as
saliva collection tubes, alcohol, and tissue. Before saliva
collection, the respondents were asked to fill in the
informed consent and questionnaires related to self-
reported occupational fatigue (IFRC), NASA-TLX, and
sleep quality of workers (PSQI) after working hours at
13.00 a.m. After the saliva samples were obtained, they
were temporarily stored in a cooler at a temperature of
December 2023  Vol. 27  No. 4
 Relation of Salivary Alpha-Amylase (sAA) Concentration 291

4 °C–10 °C and then sent to the Oral Biology Laboratory,
Faculty of Dentistry, University of Indonesia to check the
alpha-amylase concentration. The method used was
sandwich ELISA (ELISA kit, Bioenzy®) using alpha-
amylase.
The saliva samples were collected in a centrifuge tube
and then frozen at minus 70 °C for 1 h. After the samples
were thawed on ice, they were centrifuged at 1000x speed
for 20 min, and the supernatant was collected for use.
Alpha-amylase assay was carried out at a wavelength of
405 nm. The salivary total protein concentration was
measured using the Bradford assay (Table 1). The
examination was performed at the 1st and 3rd min.
ELISA Protocol (Bioenzy®). An ELISA kit was used to
measure the sAA concentration. The plates were pre-
coated with human alpha amylase (AMS) antibody. The
AMS present in the sample was added and bound to the
coated antibody on the well. Then, biotinylated human

Table 1. sAA Concentrations and ELISA Results

Conc. matrix
1 2 3 4 5 6 7 8 9 10 11 12
A 4,063.748 4,063.748 681.938 681.938 1,059.116 1,059.116 1,519.965 1,519.965 1,055.579 1,055.579 1,149.849 1,149.849
B 1,866.294 1,866.294 1,136.259 1,136.259 1,081.680 1,081.680 1,330.453 1,330.453 1,307.448 1,307.448 1,229.625 1,229.625
C 1,148.609 1,148.609 984.011 984.011 1,148.609 1,148.609 1,326.374 1,326.374 676.324 676.324 540.996 540.996
D 425.889 425.889 9.704 9.704 967.125 967.125 1,103.317 1,103.317 1,472.770 1,472.770 1,423.756 1,423.756
E 273.392 273.392 1,344.110 1,344.110 507.506 507.506 1,056.757 1,056.757 1,100.901 1,100.901 1,398.268 1,398.268
F 103.968 103.968 805.948 805.948 1,360.621 1,360.621 1,342.740 1,342.740 1,228.332 1,228.332 1,288.701 1,288.701
G 76.605 76.605 1,035.667 1,035.667 1,481.539 1,481.539 938.243 938.243 1,409.557 1,409.557 1,138.722 1,138.722
H 0.000 0.000 1,018.279 1,018.279 1,239.997 1,239.997 1,188.685 1,188.685 1,278.067 1,278.067 900.122 900.122
< Plate layout >
1 2 3 4 5 6 7 8 9 10 11 12
A STD07-1 STD07-2 SAM01-1 SAM01-2 SAM02-1 SAM02-2 SAM03-1 SAM03-2 SAM04-1 SAM04-2 SAM05-1 SAM05-2
B STD06-1 STD06-2 SAM06-1 SAM06-2 SAM07-1 SAM07-2 SAM08-1 SAM08-2 SAM09-1 SAM09-2 SAM10-1 SAM10-2
C STD05-1 STD05-2 SAM11-1 SAM11-2 SAM12-1 SAM12-2 SAM13-1 SAM13-2 SAM14-1 SAM14-2 SAM15-1 SAM15-2
D STD04-1 STD04-2 SAM16-1 SAM16-2 SAM17-1 SAM17-2 SAM18-1 SAM18-2 SAM19-1 SAM19-2 SAM20-1 SAM20-2
E STD03-1 STD03-2 SAM21-1 SAM21-2 SAM22-1 SAM22-2 SAM23-1 SAM23-2 SAM24-1 SAM24-2 SAM25-1 SAM25-2
F STD02-1 STD02-2 SAM26-1 SAM26-2 SAM27-1 SAM27-2 SAM28-1 SAM28-2 SAM29-1 SAM29-2 SAM30-1 SAM30-2
G STD01-1 STD01-2 SAM31-1 SAM31-2 SAM32-1 SAM32-2 SAM33-1 SAM33-2 SAM34-1 SAM34-2 SAM35-1 SAM35-2
H BLK01-1 BLK01-2 SAM36-1 SAM36-2 SAM37-1 SAM37-2 SAM38-1 SAM38-2 SAM39-1 SAM39-2 SAM40-1 SAM40-2
< Raw abs. matrix >
P1 1 2 3 4 5 6 7 8 9 10 11 12
A 2.906 3.018 1.415 0.923 1.444 1.611 1.740 2.009 1.495 1.553 1.626 1.579
B 2.178 2.001 1.434 1.749 1.502 1.591 1.775 1.708 1.777 1.671 1.567 1.763
C 1.660 1.542 1.522 1.403 1.690 1.513 1.706 1.771 1.234 1.093 1.062 0.960
D 0.880 0.859 0.204 0.160 1.348 1.546 1.425 1.704 1.882 1.803 1.826 1.790
E 0.681 0.635 2.036 1.466 1.051 0.891 1.728 1.322 1.587 1.538 1.789 1.792
F 0.390 0.369 1.430 1.162 1.833 1.694 1.762 1.739 1.777 1.551 1.883 1.537
G 0.335 0.319 1.546 1.468 1.848 1.848 1.507 1.336 1.793 1.804 1.498 1.688
H 0.074 0.068 1.468 1.516 1.661 1.686 1.651 1.615 1.679 1.726 1.484 1.288
< Blanked abs. matrix >
P1 1 2 3 4 5 6 7 8 9 10 11 12
A 2.835 2.947 1.344 0.852 1.373 1.540 1.669 1.938 1.424 1.482 1.555 1.508
B 2.107 1.930 1.363 1.678 1.431 1.520 1.704 1.637 1.706 1.600 1.496 1.692
C 1.589 1.471 1.451 1.332 1.619 1.442 1.635 1.700 1.163 1.022 0.991 0.889
D 0.809 0.788 0.133 0.089 1.277 1.475 1.354 1.633 1.811 1.732 1.755 1.719
E 0.610 0.564 1.965 1.395 0.980 0.820 1.657 1.251 1.516 1.467 1.718 1.721
F 0.319 0.298 1.359 1.091 1.762 1.623 1.691 1.668 1.706 1.480 1.812 1.466
G 0.264 0.248 1.475 1.397 1.777 1.777 1.436 1.265 1.722 1.733 1.427 1.617
H 0.000 0.000 1.397 1.445 1.590 1.615 1.580 1.544 1.608 1.655 1.413 1.217

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292 Kusmawan, et al.

AMS antibody were added and bound to the AMS in the
samples, followed by the addition of streptavidin–
horseradish peroxidase (HRP), which was then bound to
the biotinylated AMS antibody. After incubation, the
unbound streptavidin–HRP was washed during the
washing step. The substrate solution was then added, and
color developed in proportion to the amount of human
AMS. The reaction was terminated by the addition of an
acid-stopping solution, and the absorbance was measured
at a wavelength of 450 nm [Figure 1].
Reagent preparation. All reagents were stored at room
temperature before use. Standard reconstitute (120 µL
standard (8000U/L) with 120 µL standard diluent) was
used to produce a standard stock solution of 4.000 U/L.
The standard was placed at room temperature for 15 min
with gentle stirring before preparing the dilution.
Duplicate standard points were prepared by serial dilution
of the standard stock solution (4.000 U/L) at a 1:2 ratio
using the standard diluent to produce 2.000, 1.000, 500,
and 250 U/L solutions (Table 2). The standard diluent
served as the zero standard (0 ng/mL). Any remaining
solution was frozen at −20 °C and used within one month.
PSQI. The PSQI questionnaire measures sleep quality in
the last one-month interval and consists of 19 questions
that measure seven assessment components, namely,
subjective sleep quality, sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbance, sleeping
medication, and daytime dysfunction. The validity and
reliability analysis of this study were obtained using this
instrument, which determined all the corrected item–total
correlations that were larger than the degree of freedom
(0.325) and Cronbach’s alpha 0.786 (>0.6). From the
results, we concluded that the instrument was valid and
reliable.

Abs.

0
0 4,200
Formula: Conc.
Abs = (a0−a3)/(1+power(C/a2,a1))+a3
a0: 0.08298
a1: 0.8952
a2: 3,219.2
a3: 5.17
R2: 0.9943
Figure 1. Graph of ELISA Results

Table 2. Suggested Dilutions of Standard Solutions

Standard Concentration Standard Number Suggested Dilutions

4.000 U/L standard No. 5 120 µL standard + 120 µL standard diluent
2.000 U/L standard No. 4 120 µL standard No.5 + 120 µL standard diluent
1.000 U/L standard No. 3 120 µL standard No.4+ 120 µL standard diluent
500 U/L standard No. 3 120 µL standard No.3+ 120 µL standard diluent
250 U/L standard No. 1 120 µL standard No.2 + 120 µL standard diluent

Makara J. Sci. December 2023  Vol. 27  No. 4

 Relation of Salivary Alpha-Amylase (sAA) Concentration 293

IFRC. IFRC was used to measure the symptoms of
occupational fatigue. IFRC includes a subjective self-
rating test, and it was used to obtain the value of
occupational fatigue through subjective fatigue symptoms
felt by workers. Three sections, with each section having
30 questions, were used to inquire from the respondents.
The first, second, and third parts contain 10 questions
regarding indications of weakened activity, 10 questions
regarding indications of weakened motivation, and 10
questions regarding symptoms of physical fatigue,
respectively. The instrument used in this study provided
acceptable criteria for the validity and reliability analysis,
in which all the corrected item–total correlations were
larger than 0.325 (valid) and had a Cronbach’s alpha of
0.964 (reliable).
Statistics analysis. The data obtained in the form of
sociodemographic variables, sAA concentration data,
sleep quality, fatigue, working years, marital status, and
MWL were then analyzed univariately, bivariately with
Pearson’s correlation (fatigue, sleep quality, MWL, age,
and working years), through independent t-test (gender,
level of education, and marital status), and multivariately
with multiple linear regression using IBM SPSS statistical
software version. 21.
Result and Discussion
Based on the descriptive analysis results, the data show
that the 40 worker respondents were mostly males (75%),
with the distribution of higher education levels and
marital status at 72.5%. Based on the results on MWL
scoring obtained using the NASA-TLX instrument, the
respondents had an average score of 70.91, which
indicates a high MWL (Table 3). This high workload is
in line with the level of stress or fatigue qualities
experienced by workers.
The final model analysis revealed that the factors that
affect the sAA concentration in oil-palm–plantation
office workers in Jambi Province were occupational
fatigue (P value < 0.001) and sleep quality (P value <
0.001) [Table 4]. The IFRC instrument showed that for
every unit increase in occupational fatigue, the sAA
concentration increased by 15.90 U/mL. Meanwhile, for
every one-unit increase in sleep quality, the sAA
concentration decreased by 13.38 U/mL [Table 5].
The sAA concentration after waking up was not related to
waking time, sleep duration, and sleep quality. However,
in another study, respondents who woke up without using
an alarm clock in the morning showed decreased sAA
concentrations in the first hour after waking up [12].
The diurnal profile of sAA is relatively strong against
transient effects and may therefore be useful in assessing
sympathetic nervous system activity. In addition, time
must be controlled in studies using sAA as the dependent
variable [12]. To examine the independence of the effect
of body mass index (BMI), smoking status, and the use
of an alarm clock to wake up in the morning, we included
the important influencing factors of these variables in the
combined model. An independent effect on sAA was
observed. Similar to the results of separate models, the
combined model showed that sAA concentrations were
considerably higher in respondents who used alarms and
negatively associated with BMI; in addition, the sAA
concentrations after waking up decreased at a greater rate
and had a clearer curvature in smokers than in nonsmokers
[12].
The inclusion criteria used in this study included not
having a smoking history because smoking can affect the
consistency and stability of salivary analytes [13, 14].
The sAA secreted by salivary glands is a stress biomarker
in humans, and its concentration increases in stressful
situations and conditions [15]. Although this study did not
measure the stress level of the respondents, it determined
their level of fatigue and sleep quality. Many studies have
shown the correlation between sleep quality and fatigue

Table 3. Results of Descriptive Analysis of Respondents

No. Variable Frequency Percentage (%) Minimum Maximum Mean Standard Deviation
1. Gender
a. Male 30 75.00
b. Female 10 25.00
2. Level of Education
a. High 29 72.5
b. Moderate 11 27.5
3. Marital Status
a. Married 29 72.5
b. Unmarried 11 27.5
4. Respondent Age 21 53 35.76 8.632
5. Working Years 1 33 11.03 8.888
6. Fatigue 25.0 54.17 41.60 10.06
7. Sleep Quality 57.14 96.43 75.13 10.09
8. MWL 66.67 74.00 70.91 1.55

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294 Kusmawan, et al.

Table 4. Factors Associated with [sAA]

[sAA]
Variables Description
Pearson Correlation Sig. Independent t-test Sig.
Fatigue 0.740 0.000* - - Significantly Correlated
Sleep Quality −0.721 0.000* - - Significantly Correlated
Mental Workload −0.211 0.192 - - Not Significantly Correlated
Age −0.016 0.921 - - Not Significantly Correlated
Working years 0.089 0.587 - - Not Significantly Correlated
Gender - - −0.634 0.530 Not Significantly Correlated
Level of Education - - 0.191 0.850 Not Significantly Correlated
Marital Status - - −0.195 0.846 Not Significantly Correlated
Abbreviations:
IFRC = Industrial Fatigue Research Committee
PSQI = Pittsburg Sleep Quality Index
MWL = Mental workload

Table 5. Final Model Results of Multiple Linear Regression Analysis

Variable B Std Error Beta t Sig

Fatigue (IFRC) 15.901 3.973 0.525 4.003 0.000
Sleep Quality (PSQI) −13.38 4.006 −0.443 −3.34 0.002
Mental Workload 14.698 22.236 0.075 0.661 0.513
Age 0.082 12.282 0.002 0.007 0.995
Gender 142.754 75.612 0.205 1.888 0.068
Level of education −4.705 84.631 −0.007 −0.056 0.956
Marital status 31.994 81.342 0.047 0.393 0.697
Working years −0.837 13.041 −0.024 −0.064 0.949
Note: Dependent variable: α amylase Concentration (U/mL)

due to stress associated with sAA concentrations. sAA
has been proposed as a sensitive biomarker. Fatigue and
perceived stress had significant negative effects on
worker PE and sleep quality. Thus, stress may be a risk
factor facilitating fatigue [16–18].
Several factors, such as smoking habits, alcoholic
beverages, and drugs (hypertension drugs, antidepressants,
and drugs that interfere with salivary secretion), can reduce
the concentration of sAA secretion in saliva, and they are
regulated by the sympathetic and parasympathetic
nervous systems [19]. Studies [20, 21] that involved
samples from children showed that sAA activity can be
influenced by sleep-time variables. Sleep deprivation is
predicted as a marker of changes in neuroendocrine
function. The results of this study provide information on
pathways that can link poor sleep quality with health
problems. Sleep has been correlated with daily patterns
of stress-responsive physiological systems, in particular
the HPA and ANS axes [22].
These results support previous findings, which indicate
that in addition to the reported increase in fatigue, basal
activity concentrations of sAA were higher in the sleep-
restricted group than in the rested group. These findings
also support data showing that increased sleep duration
results in low resting sAA concentrations [23]. For the first
time, the sAA was shown to be important in assessing
sleepiness in a large population studied longitudinally.
The sAA was also used in the evaluation of sleep
deprivation among the adolescent population. These
findings suggest that the measurement of sAA activity
may be a suitable noninvasive biochemical parameter for
the objective assessment of sleep deprivation among
individuals and at the population level. More importantly,
studies on a larger population consisting of various sectors
of the society will be helpful for further validation of the
results [24].
The increase in sAA concentrations in this study was in
line with those of other research that showed that the
stress caused by fatigue in Indonesian civil pilots resulted
in higher sAA concentrations compared with those who
did not experience stress due to occupational fatigue. A
positive correlation was observed between sAA
concentrations and burnout scores, and women showed a
considerable increase in sAA alertness in the presence of
a stressor compared with men. In addition, women
exhibited a more pronounced increase in sAA throughout
the day than men [25–28].

Makara J. Sci. December 2023  Vol. 27  No. 4

 Relation of Salivary Alpha-Amylase (sAA) Concentration
sAA biomarkers can be measured exclusively in the
saliva. Over the last few years, an increasing number of
studies have used sAA as a biological marker and a
noninvasive substitute for sympathetic nervous activity.
sAA is considered a sensitive candidate biomarker for the
detection of stress-related changes in the body, which
reflect sympathetic nervous system activities, and more
studies are being conducted to support the validity and
reliability of this biomarker parameter [29]. sAA has
emerged as a valid and reliable marker of ANS activity
in stress studies and is therefore an important biomarker
to consider. Fatigue refers to the change in the
psychophysiological control mechanism that regulates
the task behavior resulting from preceding mental or
physical EFs. In general, fatigue is defined as a
physiological state where a person is inadequate to
perform a task or has decreased ability at the desired level
of PE beacuse of reduced mental or/and physical
strength, sleep loss, circadian phase, and workload [30].
Moreover, the higher the perceived stress, the poorer the
sleep quality.
More importantly, the salivary fluid holds promise in the
development of objective fatigue measurements applicable
to a remarkably wide population in an uncontrollable
environment [31, 4]. However, an appropriate study
design must be applied when attempting to decipher the
clinically and biologically appropriate changes in the
natural variation of diurnal cortisol and alpha-amylase
[32]. According to the results of a previous study [33]
that evaluated the effect of firefighting activity
simulation intervention on the parameters of sAA, free
cortisol, anxiety, and mood profiles, at 30 min
postintervention, the sAA increased by 174% and the sC
by 109%. In addition, the results of this previous work
indicate that sAA promotes concerning physical
activities, such as exercise, which reflect increases in
plasma catecholamines and thermal stress. Other studies
[34–39] revealed biochemical changes in respondents
after conducting mental and physical activities that cause
fatigue, with subjective fatigue scores increasing. After
mental exhaustion sessions, urine vanillylmandelic acid
levels were higher, and plasma valine levels were lower
than those observed after relaxation sessions. By
contrast, after a physical session that causes fatigue,
higher levels of serum citric acid, triacylglycerol, free
fatty acids, ketone bodies, total carnitine, acylcarnitine,
uric acid, creatine kinase, aspartate aminotransferase,
lactate dehydrogenase, cortisol, dehydroepiandrosterone,
dehydroepiandrosterone sulfate, transforming growth
factor beta1 and beta2, white blood cell and neutrophil
counts, cortisol and sAA, and urinary vanillylmandelic
acid were observed, and serum-free carnitine and plasma
total amino acids and alanine levels were lower than
those observed after the relaxation session. Salivary
cortisol and sAA are proxy measures of the two main
stress response systems. The sAA profile is insensitive to
daily variations in sleep but is an indicator of stress-
Makara J. Sci.
295
induced ANS dysregulation over a long period. Saliva is
a potential medium and a biomarker of fatigue because
of its easy collection. However, special procedures are
needed in the decision-making process, and many
confounding variables must be considered to ensure that
the quality of analysis results remains validat.
Conclusions
The study showed the baseline of sAA concentration in
oil-palm-plantation workers. Based on the final modeling
analysis, the factors that affect the concentration or levels
of sAA were occupational fatigue (P value < 0.001) and
sleep quality (P value < 0.005). In the measurement of
occupational fatigue using the IFRC questionnaire, the
data showed that for every one-unit increase in
occupational fatigue, the sAA concentration increased by
15.901 U/mL. Meanwhile, for every one-unit increase in
sleep quality, the sAA concentration decreased by 13.38
U/mL. Therefore, sAA can be used as a candidate
noninvasive biomarker for the measurement of sleep
quality and occupational fatigue.
Conflicts of Interest
All authors have no conflicts of interest to declare.
Acknowledgement
The authors would like to acknowledge Dominikus
Raditya A, S.Gz., M.P.H. (Universitas Airlangga), Ira
Gustina, S.Stat., M.K.M. (Department Biostatistics, Fac-
ulty of Public Health, Universitas Indonesia) and Asti from
the Faculty of Dentistry, Universitas Indonesia for their
technical help. This research was supported by LPPM
Universitas Jambi, Indonesia (grant number
370/UN21.11/PT.01.05/SPK/ 2021).
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