recent epidemiological studies have revealed that overweight , particularly when characterized by central adiposity , has associated with elevated levels of proinflammatory factors , as well as the subsequent development of metabolic syndrome ( ms ) , a clustering of metabolic disturbances that increased diseases ( 1 , 2 ) .
recently studies have suggested that breast neoplasms has associated with metabolic syndrome ( 3 ) and inflammation ( 1 , 4 ) , both associated to sedentary life and energy - dense diet ( 5 ) .
a healthy lifestyle index score ( hlis ) has generated to investigate the joint effect of modifiable lifestyle factors among the postmenopausal breast cancer risk ( 5 ) .
in addition to the direct benefits of physical activity for breast neoplasms , physical activity could also reduce adiposity ( 6 , 7 ) , which has associated with increased risk of lifetime breast neoplasms in postmenopausal women ( 8 , 9 ) . also , exercise interventions have implemented concurrent with breast neoplasms treatment could cause increase in cardiovascular fitness , muscular strength , and body composition and decrease in cancer - related fatigue ( 10 , 11 ) .
various researchers have reported that water - based exercise is an ideal form of exercise for obese patients and might provide an attractive alternative to land - based exercise , to achieve improved health and fitness among these populations ( 12 , 13 ) .
the currently available therapeutic options such as dietary modification or a combination of synthetic antidiabetic , hypolipidaemic drugs have shown their own limitations and undesirable side - effects ( 2 ) . hence , there was an increased demand to search and evaluate traditional approaches for treatment of metabolic disorders , particularly the use of herbal medicines .
zingiber officinale , commonly known as ginger , has used in ayurvedic and chinese medicine for the treatment of metabolic syndrome , asthma , diabetes , nausea , pain and inflammation ( 2 , 14 , 15 ) . the role of oral ginger consumption as an anti - obesity , anti - metabolic syndrome , anti - cancer and anti - inflammatory factor in humans has not sufficiently studied .
thus , regarding to situation of these patients , whose need an exhilarating milieu , and the effect of physical activity in attractive environments like buoyant milieu , the purpose of this study was to determine the individual and concomitant effect of six - weeks water - based intermittent exercise in the pool , and oral ginger supplement on markers related to ms and pro - inflammatory markers in obese women suffering from breast neoplasms .
forty obese women have diagnosed with breast neoplasms , volunteered to participate in the study .
prior to participation , all subjects have read and signed an informed consent document consistent with the guideline established by the ethics committee of the university of mazandaran .
participants received comprehensive screening followed by an initial medical examination before they have included in the study .
inclusion and exclusion criteria have included a primary diagnosis of breast neoplasms during stage i - ii , no distant metastases , women have excluded if they had evidence of recurrent disease , have previously engaged in any formal exercise programs for at least six months prior to participation in this study . also , according to medical examinations , the subject hasnt shown any cardiovascular and diabetic diseases .
in addition , they have not smoked at least six months before beginning the study .  
subjects have randomly divided into four groups consisted to ; 1 ) placebo , 2 ) exercise training , 3 ) ginger supplement and 4 ) exercise training+ ginger supplement groups ( 10 cases in each group ) . the subjects anthropometric variables have included height ; age , and body mass , percent of body fat , lean body mass , and body mass index ( bmi ) have assessed .
subjects in the placebo and ginger supplement groups have not participated in any exercise program . however , each subject in the exercise training group and exercise training+ ginger supplement group have participated in four familiarization sessions .
each exercise session has generally included a 10 minutes warm up , 20 - 60 minutes of aerobic exercise in water and concluded with a 10-minute cool down .
deep - water exercise protocol has defined as those in which participants had no foot contact with the bottom of the pool ( 12 ) .
exercise intensity has based on the treadmill assessment results , and ranged from 50% to 75% of heart rate reserve ( hrr ) .
percentage of hrr has used to determine exercise heart rate intensity by using the formula ( exercise target heart rate = [ max hr - rest hr ]  % exercise intensity + rest hr ( 11 ) .
generally , the participants have exercised two sets daily during the first week , but for the next weeks , they have exercised three sets daily .
subjects in the ginger supplement group and the exercise training ginger supplement group have orally received 4 capsules ( each capsule contained 750 mg ) of ginger rhizome powder , 7 days a week and for 6 weeks , consistent with previous studies ( 16 ) the subjects have consumed the powder in approximately 250 ml of water .
the supplement has ingested 4 times a day , with breakfast , lunch , dinner and afternoon .
the placebo group has received capsules contained 1 gr starch , in the same manner and for the same duration of time as the experimental groups .
blood samples have collected from each subject at pretest and at the end of 6 weeks of water - based exercise with and without ginger supplement in an overnight 10 to12-h fasting state .
the blood samples have allowed to clot at room temperature for 10 min and then centrifuged .
the hs - crp concentration has determined by latex particle - enhanced , as described by roshan et al .
also , il-10 has assessed by commercially available enzyme immunesorbent assay ( elisa ) kit .
furthermore , fasting serum triglycerides ( tg ) , total cholesterol ( tc ) , high - density lipoprotein cholesterol ( hdl - c ) and low - density lipoprotein cholesterol ( ldl - c ) concentrations have measured by an enzymatic colorimetric method .
furthermore , plasma insulin levels have measured using an immunoradiometric assay . also , the homeostasis model assessment for insulin resistance ( homa - ir ) as determined by the following equation ( 3 ) :   statistical analysis has performed spss version 16.0
mean values of the subjects characteristics ( age , height , body mass , bmi and fat mass ) for the four groups have shown in table 1 . at first
changes in the inflammatory markers ( hs - crp and il-10 ) and biomarkers of the ms ( insulin , glucose , insulin resistance , blood lipids such as ; ldl - c , hdl - c , tc , tg ) in women with breast neoplasms in each group have shown in table 2 .
six weeks of the ginger supplementation have resulted in a reduction of hs - crp ( p = 0.002 ) , il-10 ( p = 0.001 ) , insulin ( p = 0.516 ) , glucose ( p = 0.003 ) , insulin resistance(p = 0.005 ) , ldl - c ( p = 0.432 ) , tg ( p = 0.851 ) and an increase in tc ( p = 0.514 ) , and another increase in hdl - c ( p = 0.716 ) and hdl - c / ldl - c ( p = 0.264 ) , in comparison with the period of time before 6-wk ginger supplementation ( table 2 ) .
data have presented as the mean  sd for 10 subjects . significantly different from placebo group . significantly different from ginger + exercise group .
in contrast , 6-wk of the water - base exercise has caused a reduction of hs - crp ( p = 0.059 ) , il-10 ( p = 0.054 ) , insulin ( p = 0.035 ) , glucose ( p = 0.051 ) , insulin resistance ( p = 0.003 ) , ldl - c ( p = 0.094 ) , tc ( p = 0.300 ) , tg ( p = 0.031 ) and an increase in hdl - c ( p = 0.033 ) , and hdl - c / ldl - c ( p = 0.012 ) , in comparison with the period of time before 6-wk water - base exercise .
however , the water - base exercise + ginger treatment was more effective than the water - base exercise and the ginger supplement , alone treatment , such that , it has led to a reduction of hs - crp ( p = 0.001 ) , il-10 ( p < 0.001 ) , insulin ( p = 0.008 ) , glucose ( p = 0.036 ) , insulin resistance ( p = 0.002 ) , ldl - c(p = 0.003 ) , tc ( p = 0.654 ) , tg ( p = 0.003 ) and an increase in hdl - c ( p = 0.010 ) and hdl - c / ldl - c ( p < 0.001 ) , in comparison with 6-wk treatment ( tables 2 and 3 ) .
furthermore , the ginger supplement resulted in a significant decrease in hs - crp ( p < 0.001 ) and il-10 ( p < 0.001 ) levels , in comparison with the placebo group . also ,
significant decreases in hs - crp and il-10 levels were present , not only in the water - base exercise group ( p = 0.010 and p = 0.001 , respectively ) , but decreases have also observed in the water - base exercise + ginger supplement group ( p < 0.001 and p < 0.001 , respectively ) , in comparison with sedentary control group ( table 2 ) .
the water - base exercise has significantly decreased the insulin resistance ( p = 0.039 ) , insulin ( p = 0.030 ) , and significantly increased hdl - c / ldl - c ( p = 0.011 ) , in comparison with placebo group .
in addition , it has caused insignificant decrease in ldl - c ( p = 0.089 ) and insignificantly increased the hdl - c ( p = 0.061 ) , in comparison with placebo group .
the water - base exercise and ginger supplement group has shown significantly larger positive effect in all of the outcomes , in comparison with the water - base exercise or ginger supplement alone groups ( table 3 ) .
data are presented as the mean  sd for 10 subjects . significantly different from ginger
weight gain has been a risk factor for postmenopausal breast neoplasms . in addition , a significant percentage of women whose have treated the breast neoplasms , have reported undesirable weight gain during and after treatment ( 1 , 18 ) .
this study has designed to determine whether 6 weeks of individually , and combined water - based exercise with ginger supplement would influence the inflammatory markers and metabolic syndrome in obese women with breast neoplasms .
the primary novel findings in present study have shown that consumption of ginger was beneficial in alleviating the systemic inflammation , insulin resistance and glucose , while it has not shown significant effect on tc , tg , insulin , ldl - c , hdl - c , and the hdl - c to ldl - c ratio .
on the other hand , 6 weeks of water - based exercise have caused significant reduce in insulin resistance , insulin , tg , hdl - c and hdl - c / ldl - c levels , and insignificant decrease in hs - crp , il-10 , ldl - c , tc and glucose concentrations , in comparison with placebo group .
however , the main findings of our study was that water - based exercise with ginger supplementation has significantly attenuated systemic inflammation and metabolic syndrome in obese women with breast neoplasms , in comparison with the other groups .
( 19 ) that has reported reduction in blood lipid , glucose and insulin response , and improvement in cardiovascular health following water versus land based exercise in breast cancer survivors .
overall , non - weight bearing exercise has recommended as a possible alternative to improve health and well - being for individuals who found weight bearing exercise difficult ( 12 ) .
the regular physical activity might influence prognosis by similar mechanisms to those thought to prevent the incidence of breast neoplasms , including decreased lifetime estrogen exposure and improved immune function ( 20 ) .
furthermore , lower blood - estrogen levels , higher insulin growth factor - i concentration , and lower levels of fatty tissue have all been associated with participation in physical activity .
specific obesity - associated factors , including blood lipids , insulin and inflammatory mediators , have seemed to influence breast neoplasms growth and prognosis independently of estrogens ( 21 ) .
inflammatory cytokines have produced as acute phase proteins by the liver , and might provide much more accurate reflection of cytokine activity .
il-6 has been a known inflammatory cytokine that has secreted by activated macrophage and involved in several functions of the immune response that has also exerted various metabolic and endocrine activities .
( 21 ) has reported the cessation of ovarian function after menopause results in withdrawal of ovarian sex steroid hormones , estrogen , and progesterone .
accumulating evidence has suggested that the withdrawal of estrogen and progesterone has caused homeostasis imbalances , including decreases in insulin sensitivity and changes in glucose and lipid metabolism , resulting in a total reduction in energy expenditure .
together with a decrease in physical activity and consumption of high fat diet , these factors have significantly contributed to obesity in postmenopausal women .
obesity has caused localized inflammation , an increase in local estrogen production , and changes in cellular metabolism .
in addition , obese women have shown a higher risk of insulin insensitivity , and an increase in insulin , and other growth factor secretion ( 1 , 3 ) . the factors that have influenced inflammatory responses include age , gender , repeated bouts of eccentric exercise , antioxidant supplements , intracellular calcium homeostasis , and anti - inflammatory drugs ( 22 ) .
results from the few studies that have investigated the effects of water - based training on the markers related to metabolic syndrome have been inconsistent .
twelve weeks of shallow water circuit training has reported to significantly reduce tc and ldl - c levels with no significant changes in hdl - c or tg in older , overweight women .
the lack of markedly change in some of the ms ( ldl - c , tc and glucose ) after chronic water - based training was a disagreement with the effects of inflammatory markers .
the discrepant results might be due to the duration of the training programs enlisted , the intensity of the training program , or the baseline lipid status of the participants .
the present study has revealed that ginger supplementation has caused improvement in inflammation and metabolic syndrome , in comparison with the supplementation period , as well as the placebo group . in laboratory experiments , ethanolic extract of z. officinale
has shown to reduce plasma lipids in cholesterol - fed hyperlipidaemic rabbits and in streptozotoc in induced diabetic rats and has also found to inhibit ldl oxidation in atherosclerotic mice .
besides , the aqueous extract of z. officinale has also shown to reduce serum cholesterol and triglycerides in normal rats ( 14 ) .
moreover , ginger has suppressed inflammation by inhibiting the nuclear factor-b activation , which led to inhibition of gene expression of proinflammatory cytokines , chemokines and cyclooxygenase ( cox)-2 as well as osteoclastogenesis ( 23 ) . in addition
, ginger extract has found to inhibit beta - amyloid peptide - induced cytokine and chemokine expression in cell line of human monocytes ( 23 ) .
the question of whether ginger had large effects on pain in women with breast neoplasms will be best addressed by future studies , which used the same scale to assess pain perceptions . in summary ,
our data has indicated a protective effect of the nondrug strategies such as water - base exercise and ginger supplementation has played an important role in the pathogenesis of inflammatory and metabolic responses in obese women , who have diagnosed with breast neoplasms .
however , the combination of water - base exercise and ginger supplement has shown better effect on the systemic inflammatory and metabolic syndrome , rather than using each of them separately .
 background : breast neoplasms has known as the most common cancer among the women worldwide , and relationship between obesity , metabolic syndrome , inflammation and cancer has been recognized since many years ago.objectives:the aim of this study was to determine the individual and concomitant effect of 6-weeks water - based exercise and oral ginger supplement on markers that have related to metabolic syndrome and systemic inflammation in obese women with breast neoplasms.patients and methods : forty women whose have diagnosed with breast neoplasms have volunteered to participate in the study . 
 subjects have randomly assigned into four groups ; placebo , exercise training , ginger supplement and exercise training+ ginger supplement groups . 
 subjects in the ginger supplement group and the exercise training+ ginger supplement group have orally received 4 capsules , 7 days a week and for 6 weeks . the water - based exercise training program 
 have collected at a progressive intensity and time , have ranged from 50% to 75% of heart rate reserve , in a pool , 4 times a week for 6 weeks . 
 fasting blood sampling has collected at the pretest and post-test.results:the ginger supplementation and the water - base exercise have resulted in a reduction of hs - crp , il-10 , insulin , glucose , insulin resistance , ldl - c , tg ; but an increase in hdl - c and hdl - c / ldl - c . the water - base exercise and ginger supplement group 
 have significantly shown larger positive effect in all outcomes , in comparison with the water - base exercise or ginger supplement alone groups.conclusions:findings have suggested that obese breast neoplasms survivors have commonly shown metabolic syndrome and elevated inflammation , which placed them at an increased risk for cardiovascular diseases . 
 moreover , data has indicated a protective effect of the nondrug strategies , such as water - base exercise and ginger supplementation have played an important role in pathogenesis of inflammatory and metabolic responses , among diagnosed breast neoplasms . 
1. Background
2. Objectives
3. Patients and Methods
4. Results
5. Discussion