Journal of Traditional and Complementary Medicine 7 (2017) 165e171

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Journal of Traditional and Complementary Medicine

journal homepage: http://www.elsevier.com/locate/jtcme

Original article

Blood immune function parameters in response to combined aerobic

dance exercise and honey supplementation in adult women
Marhasiyah Rahim a, 1, Foong Kiew Ooi a, b, *, Wan Zuraida Wan Abdul Hamid c
a
Sports Science Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
b
Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
c
Immunology Department, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: To date, information on the effectiveness of combined aerobic dance exercise with honey supplemen-
Received 18 January 2016 tation on immune function in women is lacking. The present study investigated the effects of 8 weeks of
Received in revised form combined aerobic dance exercise and honey supplementation on blood immune function parameters in
31 May 2016
adult women. In this study, forty four healthy sedentary women (25e40 year-old) were assigned into
Accepted 2 June 2016
Available online 9 July 2016
four groups with n ¼ 11 per group: sedentary without supplementation control (Con), honey supple-
mentation (H), aerobic dance exercise (D) and combined aerobic dance exercise with honey supple-
mentation (HD) groups. Aerobic dance exercise was carried out for one hour per session, three sessions
Keywords:
Aerobic dance
per week for eight weeks. Honey drink was consumed by H and HD groups, in a dosage of 20 g of honey
Honey supplementation diluted in 300 ml of plain water, consumed 7 days a week for 8 weeks. In HD group, the participants were
Immune functions required to consume honey drink 30 min before performing exercise. Before and after 8 weeks of
Lymphocyte experimental period, blood samples were taken to determine the concentrations of immune parameters
T cytotoxic which include full blood counts and immunophenotyping measurements. It was found that after 8 weeks
of experimental period, there were statistically significant increases in T cytotoxic (CD8) (p < 0.05) in HD
group. Additionally, the percentages increase in total lymphocyte counts, T helper (CD4), and T cytotoxic
(CD8) counts after 8 weeks were the highest in HD group among all the groups. As conclusion, combined
aerobic dance and honey supplementation may have potential to enhance immune functions in women.
Copyright © 2016, Center for Food and Biomolecules, National Taiwan University. Production and hosting
by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction type of stress that affects immune response2 differently dependent

Physical activity is believed to have close relationship with im-
mune function. Exercise induces physiological changes in the im-
mune system. The benefits of exercise may result from the direct
effect on immune response modulations or from the mechanism of
psychological effects of exercise.1,2 Exercise may be considered a
* Corresponding author. Associate Prof. Dr. Foong Kiew Ooi, Sports Science Unit,
School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan, Malaysia. Tel.: þ60 09 767 6931; fax: þ60 09 764 1945.
E-mail addresses: marhasiyah@unisza.edu.my (M. Rahim), fkooi@usm.my
(F.K. Ooi), wzuraida@usm.my (W.Z. Wan Abdul Hamid).
Peer review under responsibility of The Center for Food and Biomolecules,
National Taiwan University.
1 granulocyte and monocyte phagocytosis and oxidative burst ac-
Physiotherapy Program, School of Rehabilitation Science, Faculty of Medicine
and Health Sciences, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu,
Malaysia.
on the duration, intensity and frequency of the stress.3 Generally,
many researchers found that low intensity4 and moderate intensity
exercise5 improves immunity, conversely strenuous exercise and
overtraining decrease immunity and raise infection risk.6e11
Besides regular weight-bearing exercise, nutrition also plays an
important role in influencing immune function status. Besides
green tea and ginseng, honey is one of the nutraceuticals which are
becoming more widely accepted as an adjunct to conventional
therapies for enhancing general well being.12,13 Honey contains
mainly of carbohydrates14 that may elicit beneficial effects on
reducing stress to the immune system.13 This speculation is based
on a study by Nieman6 which mentioned that ingestion of fluids
that contain carbohydrate can reduce perturbations in the immune
system with fewer disturbances in blood immune cell counts, lower
tivity, diminished pro- and anti-inflammatory cytokine responses.
Honey also has properties of antioxidant,15,16 antimicrobial,12,17e19

http://dx.doi.org/10.1016/j.jtcme.2016.06.001
2225-4110/Copyright © 2016, Center for Food and Biomolecules, National Taiwan University. Production and hosting by Elsevier Taiwan LLC. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
166 M. Rahim et al. / Journal of Traditional and Complementary Medicine 7 (2017) 165e171
anti-inflammatory20 and immunomodulatory12 which are believed
able to enhance immune functions.13
Understanding the relationship between exercise, honey sup-
plementation and immune response has potential implication for
public health. In addition to the important role of honey on the
immune response, scientists also accept honey as a new effective
medicine for many kinds of women related diseases.21 Therefore,
health programs for women could be developed in view of vast
advantages of honey on the immunes system. Previous study has
been carried out to confirm the hypothesis that carbohydrates may
influence exercise-induced immune changes.22,23 In addition,
several studies revealed that honey is an effective carbohydrate
source to be consumed at pre, during and post physical training and
exercise in athletes.24,25 Nevertheless, the combined effects of
aerobic dance exercise with honey supplementation which is a
source of carbohydrate on immune functions has not yet been
investigated in non-athletes, i.e. sedentary women with age
ranging from 25 to 40 year-old. Hence, the present study was
proposed for determining the effectiveness of this combination on
blood immune function parameters in adult women.
2. Methods
2.1. Participants
Forty four physically healthy sedentary adult female partici-
pants, age between 25 to 40 years old from Kelantan region,
Malaysia were recruited in the present study. The inclusion criteria
of the participants were: No health problems, non-smoker, not
habitual consumer of honey daily, do not engage in any training
program and do not exercise more than once per week. Physical
Activity Readiness Questionnaires (PAR-Q) forms were answered by
the participants to screen for any signs or symptoms of heart dis-
eases, pulmonary or contraindications during physical activity for
ensuring the participants were eligible to engage with the exercise
training programme without risking their health condition, and
limiting the medication drugs' effect on the outcome later. The
qualified participants were matched in age, body mass, height and
percent of body fat before they were randomly assigned into the
experimental groups.
All participants were fully informed by the researcher about the
nature of the experiments, purpose of the study, procedures, ben-
efits, risks of feeling discomforts experienced in this present study
before giving their written and signed formal consent. The present
study was approved by the human research ethics committee of
Universiti Sains Malaysia (Ethical approval number: USMKK/PPP/
JEPeM[226.3(08)]). The human research ethics committee of Uni-
versiti Sains Malaysia is in compliance with ICH GCP guidelines.
During the experimental period, the participants were provided
checklists which have also been used in a published previous
study,26 and they were required to record their participation, i.e.
frequency of performing aerobic dance in a week and daily honey
consumption rate in the checklists for ensuring their compliance
and commitment to the present study. Please refer to the Figure 1
for the flow chart of the experimental design for the study.
2.2. Experimental design
2.2.1. Participants grouping
The participants were randomly divided into four groups with
11 participants per group (n ¼ 11): 8 weeks of sedentary without
supplementation control (Con), 8 weeks of honey supplementation
(H), 8 weeks of aerobic dance exercise (D), and 8 weeks of com-
bined aerobic dance exercise and honey supplementation (HD)
groups. Participants in the control group (Con) did not perform
exercises nor take any honey supplementation. Meanwhile, par-
ticipants in the honey group (H) consumed honey drink for 7 days
per week for a total of 8 weeks. Participants of aerobic dance ex-
ercise group (D) performed one hour aerobic dance exercise per
session, 3 times per week for 8 weeks. Participants in combined
aerobic dance exercise with honey supplementation group (HD)
performed aerobic dance exercises one hour per session, 3 times
per week for 8 weeks and consumed honey drink 7 days/week for 8
week with dosage similar to honey group (H). The participants in
HD group were required to consume honey drink 30 min before
performing aerobic dance exercise on the exercise days.
Sample size used in this study was calculated by using G Power
Software. The power of the study was set at 80% with 95% confident
interval and 30% of effect size. 20% was estimated as dropout rate
which was equal to two participants per group. Thus, the actual
numbers of participants recruited were 11 Participants per group,
and the total numbers of participants recruited in this study were
44 Participants.
2.2.2. Aerobic dance exercise program
The participants of aerobic dance exercise group (D) and com-
bined aerobic dance exercise with honey supplementation group
(HD) were required to have aerobic dance sessions for 3 sessions
per week, one hour per session (from 5.30 pm to 6.30 pm) for 8
weeks. The aerobic dance exercise program of this study consisted
of 2 sessions of ‘high and low impact’ and one session of a ‘step
board’ aerobic dance exercises in a week. The 1-hour session star-
ted with 10e15 min of warm up period, 30e35 min of aerobic
dance activities, and ended with 5e7 min of cool down. The ac-
tivities prescribed in the present aerobic dance exercise program
involved continuous, controlled movement of legs and trunk, and
intermittent movement of arms. Movements involved were side
stepping, fast walking, forward and backward stepping, leg lifts,
placing foot to the front, side and behind, knee bends, forward and
side-lunging, heel raise and also high impact movement such as
jumping. In the high-impact and low-impact aerobic dance exercise
sessions, participants were required to do upper and lower limb
movements according to the beats of the music played, which
ranged from slow to fast. In the ‘step board’ exercise sessions,
participants were required to step up and down the step board
while dancing. The intensity of aerobic dance exercise was esti-
mated by using heart rate monitor (Polar, S710, USA) worn by
participants throughout the dancing sessions. Besides, the partici-
pants were given pre-recorded CD containing aerobic dance
workout, and they were required to follow the workout in the CD
given at home if they missed any of the aerobic dance sessions.
2.2.3. Honey supplementation
A honey drink was consumed by the participants in the honey
(H) group and combined aerobic dance exercise and honey sup-
plementation (HD) group in a dosage of 20 g27,28 of Malaysian local
Gelam honey diluted in 300 ml of plain water,29 for 7 days per week
for a total of 8 weeks. On the exercising days, the participants of the
combined aerobic dance exercise and honey supplementation (HD)
group were required to consume honey drink 30 min before per-
forming aerobic dance exercise.
2.2.4. Anthropometric measurements
Before the 8 weeks of experimental period, participants'
anthropometric measurements such as body height, weight and
percentage of body fat were carried out. The participant's body
heights were measured by using a stadiometer (Seca 220, Ger-
many), the body weight and percentage body fat were measured by
using a digital body composition measuring device (Tanita TBF-410,
Japan).
 M. Rahim et al. / Journal of Traditional and Complementary Medicine 7 (2017) 165e171 167

Adult females
Age: 25-40 year-
old
N=44

Pre test: Blood sample taking for immune function parameters measurement

8 weeks of sedentary 8 weeks with honey 8 weeks of aerobic 8 weeks of honey

without honey consumption group dance exercise without consumption with
consumption control (H) honey consumption aerobic dance
group n=11 group exercise group
(Con) (D) (HD)
n=11 n=11 n=11

Post test: Blood sample taking for immune function parameters measurement

Blood and statistical analysis

Fig. 1. Flow chart of the experimental design.

2.2.5. Blood sample collection and analysis
Before and after the 8-week of experimental periods, partici-
pants were seated and a 2 ml of venous blood sample was taken
from an antecubital vein after 8-hour overnight fast (drinking plain
water was allowed). The blood was withdrawn by the laboratory
technologists in the Sports Science Laboratory, Universiti Sains
Malaysia. Blood taking sessions for participants in D and HD in post
test were carried out were carried out at 8.30 the next morning
after performing aerobic dance exercise, i.e. 14 h post exercise.
Blood samples were used to determine the levels of full blood
counts such as white blood cells, neutrophils and total lymphocyte
counts by using an automated haematology analyser (Sysmex XS-
800i). Meanwhile, the concentration of blood immunophenotyp-
ing parameters, i.e. total T lymphocyte (CD3), T helper (CD4), T
cytotoxic/suppressor (CD8) and natural killer (NK) cell counts were
analysed by using a flow cytometer (BD FACS Cantor™ II, Becton
Dickinson, USA), and three-colour direct immunofluorescence re-
agent kit (BD Tritest™, USA).
2.3. Statistical analysis
Statistical analysis was done by using Statistical Package for
Social Science (SPSS) version 18.0. All values are presented as
mean ± standard deviations (SD). Two way repeated measure
analysis of variance (ANOVA) was performed to determine the
significance of the differences between and within groups. The
difference was considered statistically significant at p < 0.05.
Confounding variables such as participants' age, body mass, height
and body fat were considered before the commencement of the
study. The participants were matched in age, body mass, body
height and body fat before they were randomly assigned into the
experimental groups. One-way analysis of variance (ANOVA) was
performed to ensure that there were no significant differences in
the aforementioned confounding variables among the groups at the
beginning of the study.
3. Results
3.1. Participant physical characteristics
A total of forty healthy sedentary adult women (mean age
29.7 ± 5.3 years) completed the present study. Two participants
from honey supplementation group (H) and two participants from
combined aerobic dance exercise with honey supplementation
group (HD) were unable to continue the program due to pregnancy
and personal reason during the experimental period. Participants'
mean body height in Con, H, D and HD was 154.2 ± 5.6 cm,
153.8 ± 4.8 cm, 154.6 ± 6.1 cm, and 156.4 ± 6.0 cm respectively. The
mean body weight and percentage of body fat of the participants
were 56.0 ± 9.9 kg and 32.5 ± 9.8 % in Con group, 54.5 ± 7.8 kg and
33.0 ± 7.2 % in H group, 55.3 ± 5.0 kg and 32.7 ± 5.0 % in D group,
and 53.4 ± 7.7 kg and 30.0 ± 7.4% in HD group respectively. There
were no significant differences (p > 0.05) between groups in means
age, body height, body weight and percentage body fat at the
beginning of the experimental period.
3.2. White blood cells (WBC), neutrophil and total lymphocyte
counts
Mean concentration of white blood cells (WBC), neutrophils and
lymphocytes counts of all groups are presented in Table 1. At pre
test, WBC count concentrations were significantly higher (p < 0.05)
in HD, D and H groups compared to Con group respectively, and this
measured parameter was also significantly higher (p < 0.05) in D
group compared to H group. At post test, mean WBC count con-
centration was significantly higher (p < 0.05) in HD group
168 M. Rahim et al. / Journal of Traditional and Complementary Medicine 7 (2017) 165e171

Table 1
Mean white blood cell (WBC), neutrophils and total lymphocytes counts (Mean ± SD).

Groups White blood cell (103/uL) Percent difference Neutrophils (103/uL) Percent difference Total lymphocyte (103/uL) Percent difference
compared to compared to compared to
Pre test Post test Pre test Post test Pre test Post test
pre-test (%) pre-test (%) pre-test (%)

Control (Con) 6.30 ± 1.43 6.57 ± 1.64 þ4.29 3.52 ± 1.06 3.64 ± 1.36 þ3.69 2.00 ± 0.57 2.19 ± 0.62 þ9.50
Honey (H) 6.95 ± 1.62 7.03 ± 1.16 þ1.15 3.75 ± 1.42 3.81 ± 1.01 þ1.60 2.48 ± 0.42 2.45 ± 0.48 0.81
Aerobic dance(D) 8.63 ± 2.54 7.35 ± 1.79* 14.83 5.26 ± 2.36 3.90 ± 1.06* 25.86 2.47 ± 0.51 2.61 ± 0.74 þ0.06
Combined (HD) 7.88 ± 2.13 8.06 ± 2.84 þ2.28 4.46 ± 1.50 4.48 ± 1.93 þ0.45 2.44 ± 0.68 2.71 ± 0.98 þ11.07

*p < 0.05 significantly different from pre test.

Con ¼ sedentary without honey supplementation control group.
H ¼ honey supplementation group.
D ¼ aerobic dance exercise group.
HD ¼ combined aerobic dance exercise and honey supplementation group.

compared to Con group. There were no statistically significant main
effect of time (p > 0.05) on WBC count between pre- and post tests
in all the groups except for D group, in which WBC concentration
was significantly lower (p < 0.05) in D group after 8 weeks of
intervention in post test compared to pre test value.
Neutrophil counts were significantly higher (p < 0.05) in D
group compared to Con group at pre test. However, there were no
significant simple effect of intervention (p > 0.05) on neutrophil
counts between all the experimental groups at post test. There was
statistically significant main effect of time (p < 0.05) on neutrophils
counts between pre- and post tests in D group, in which D group
exhibited statistically significant lower (p < 0.05) neutrophil counts
after 8 weeks compared to pre test value.
In lymphocyte counts, there were significantly higher (p < 0.05)
values in HD, D and H groups compared to Con group respectively
at pre test. At post test, there were significant difference (p < 0.05)
between HD group compared to Con group. However, there was no
statistically significant main effect of time (p > 0.05) on lymphocyte
counts in all the groups. The percentage increase in lymphocyte
counts after 8 weeks of study was the highest (þ11.07%) in HD
group compared to the other three groups.
3.3. Total T cells (CD3), T helper/inducer (CD4) counts, T cytotoxic/
suppressor (CD8) and natural killer (NK) cells
Mean concentration of T lymphoctyes and natural killer (NK)
cells of all groups are presented in Table 2. Regarding total T cells
(CD3) counts, repeated measures ANOVA revealed that at pre test,
total T cells (CD3) count were significantly higher (p < 0.05) in H
group compared to Con group. However, there were no significant
simple effect of intervention (p > 0.05) on this cells count between
all experimental groups after 8 weeks of experimental period at
post test. Additionally, there was no significant main effect of time
(p > 0.05) on post test mean total T cells (CD3) counts compared to
pre-test mean for each experimental group.
At pre test, T helper/inducer (CD4) count were significantly
higher (p < 0.05) in H group compared to Con group (Table 2).
However, there were no significant simple effect of intervention on
this cells count (p > 0.05) between all experimental groups after 8
weeks of experimental period in post test. There was no significant
main effect of time (p > 0.05) on post test mean T helper/inducer
(CD4) counts compared to pre-test mean for each experimental
group. It was found that HD group showed highest percentage in-
creases among the groups in CD4 with þ16.20%.
Mean T cytotoxic/suppressor (CD8) count of all groups are pre-
sented in Figure 2. At pre test, T cytotoxic/suppressor (CD8) count
were significantly higher (p < 0.05) in HD and H groups compared
to Con group respectively, and this measured parameter was sig-
nificant lower (p < 0.05) in D group compared to H group. At post
test, T cytotoxic/suppressor (CD8) count were significantly higher
(p < 0.05) in HD group compared to D and Con groups respectively,
and this measured parameter was significant higher (p < 0.05) in H
group compared to Con group. A statistically significant main effect
of time (p < 0.05) on T cytotoxic/suppressor (CD8) count was found
between pre- and post tests in HD group, where the CD8 count in
HD group was significantly higher (p < 0.05) in post test than pre
test. It was also found that the percentage increase in T cytotoxic/
suppressor (CD8) counts after 8 weeks of study was the highest
(þ19.98%) compared to other experimental groups.
Mean natural killer (NK) cells counts of all groups are presented
in Table 2. The results showed that natural killer (NK) cells count
were significantly (p < 0.05) higher in D group compared to Con
group before and after 8 weeks of experimental period. There were
no statistically significant main effect of time on natural killer (NK)
cells counts (p > 0.05) between pre- and post tests in all the groups.
4. Discussion
Generally, physical activity is a type of stress and able to reduce
WBC and neutrophil counts.6,7 In the present study, it was found that

Table 2
Mean total T cells (CD3), T helper/inducer (CD4) and natural killer (NK) cell counts (Mean ± SD).

Groups CD3 e Total T cells absolute Percent CD4 e T helper/inducer absolute Percent CD16 e NK cells absolute Percent
counts (cells/mm3) difference counts (cells/mm3) difference counts (cells/mm3) difference
compared to compared to compared to
Pre test Post test Pre test Post test Pre test Post test
pre-test (%) pre-test (%) pre-test (%)

Control (Con) 1327.95 ± 336.26 1528.34 ± 365.68 þ15.09 706.35 ± 218.07 806.60 ± 223.24 þ14.19 330.15 ± 155.86 236.83 ± 89.25 28.27
Honey (H) 1755.67 ± 394.30 1714.33 ± 346.99 2.35 868.32 ± 240.91 893.53 ± 235.75 þ2.90 334.04 ± 159.25 329.47 ± 156.95 1.37
Aerobic dance (D) 1575.34 ± 519.58 1666.32 ± 592.13 þ5.78 788.53 ± 262.92 810.64 ± 303.11 þ2.80 476.56 ± 227.93 527.85 ± 297.48 þ10.76
Combined (HD) 1604.62 ± 437.23 1804.17 ± 645.30 þ12.44 737.21 ± 169.18 856.63 ± 298.18 þ16.20 448.92 ± 259.31 448.58 ± 262.87 0.08

Con ¼ sedentary without honey supplementation control group.

H ¼ honey supplementation group.
D ¼ aerobic dance exercise group.
HD ¼ combined aerobic dance exercise and honey supplementation group.
 M. Rahim et al. / Journal of Traditional and Complementary Medicine 7 (2017) 165e171
p<0.05 significantly different from pre test
Con = sedentary without honey supplementation control group
H= honey supplementation group
D = aerobic dance exercise group
HD = combined aerobic dance exercise and honey supplementation group
Fig. 2. Mean T cytotoxic/suppressor (CD8) cell counts.
there was no statistically significant change in WBC and neutrophil
counts30 in HD group. However, WBC counts decreased significantly
by 14.83% and neutrophil counts also decreased by 25.86% in
exercise alone (D) group in post-test compared to pre-test. The
reduction in WBC with exercise observed in the present study is
inconsistent with most of the published studies which reported in-
creases in total leukocytes and leukocytes subsets after exercise,31e33
and the present findings may reflect that both the duration and the
intensity of exercise in the present study need to be considered. The
questions raised were whether the participants in the exercise alone
group perceived the prescribed exercise in the current study as a type
of stress, even though the participants' average heart rates recorded
during exercise were ranging from 120 to 140 beats min1, which was
equivalent to 60%e70% of the participants' maximum heart rate,
reflecting that the intensity of the prescribed exercise in the present
study was considered moderate. The reductions in WBC and
neutrophil cell counts in exercise group may imply that the pre-
scribed exercise of this study may have acted as a stress to reduce the
WBC and neutrophil counts. This speculation is based on Moynihan
et al.,34 which mentioned that the circulating numbers and func-
tional capacities of white blood cells may be decreased by repeated
bouts of intense, prolonged exercise. The reason is probably related
to increased levels of stress hormones during exercise and entry into
the circulation of less mature white blood cells from the bone
marrow.35 Additionally, neutrophil is reported to be intensity
dependent generally in which exercise at low to moderate intensity
could enhance some aspects of neutrophils function, while
maximum exercise suppressed neutrophil functions,6,7 and can
cause functional alterations in neutrophil function.7
It was hypothesized that when exercise and honey supple-
mentation combined together in the present study, this combina-
tion may enhance immune function of the participants greater than
if exercise or honey supplementation is carried out alone. The
notable finding of the present study was that there were statisti-
cally significant increases in T cytotoxic (CD8) counts in HD group
after 8 weeks of experimental period, implying that honey sup-
plementation combined with aerobic dance exercise increased CD8
T cell counts greater than consumed honey and performed aerobic
dance exercise alone. These findings supported our hypothesis.
Similarly Kwon et al.,36 reported that four weeks soybean
169
supplementation combined with moderate intensity endurance
swimming exercise could prevent impairment of T cell through
changes of CD4/CD8 ratio in rats. Therefore, it is suggested that
honey and its constituent also have the beneficial effects on CD8 T
cell counts. The precise mechanism for inducing the beneficial ef-
fects on this immune function parameter in the present study is
unclear. However, it is speculated that during exercise, more blood
is needed by participants' body, therefore more vital nutrients in
honey have been absorbed into participants' body during exer-
cise.13 These vital nutrients enhanced immune functions of the
participants by increasing the lymphocyte cell counts.
Another notable finding of the present study was that the per-
centage increases in total lymphocyte, T helper (CD4), and T cyto-
toxic (CD8) cell counts after 8 weeks were the highest in HD group
among all the groups, even though statistically significant increases
were not observed. Collectively, these findings may indicate that
combined honey supplementation and aerobic dance exercise may
have potential to enhance immune functions compared to honey
supplementation alone or exercise alone. It is speculated that car-
bohydrate contained in honey may be able to modulate immune
function either by reducing the stress effect of exercise,22 Nehlsen-
Cannarella et al.37 also reported that carbohydrate ingestion is
associated with higher plasma glucose concentrations and it could
attenuate stress hormones. In our present study, the findings reflect
the effects of two months honey supplementation and aerobic
dance exercise on the measured parameters, but not the acute ef-
fects such as a single session of honey supplementation and aerobic
dance exercise on immune function parameters, and this may cause
discrepancies between the present study results and other previous
studies. For instance, Natale et al.,38 found that exercise induced a
significant increase in total T lymphocyte (CD3) cell counts
immediately after exercise. Nevertheless, 3 h after exercise, the CD3
cell counts for peak aerobic exercise are 35% below baseline. They
also found that circulating CD4 (T helper) cell counts showed a
significant increase with peak aerobic exercise and prolonged ex-
ercise but not for resistance exercise, and the counts were sub-
normal 3 h after the peak aerobic exercise. Additionally, significant
increased in CD8 T cell counts were observed immediately after
exercise, but were restored to baseline 3 h after exercise. Their
study have shown the changes of immune parameters during and a
few hours after exercise, where the present study found that the
changes in immune parameters occurred 14 h after the last exercise
session of 8 weeks' intervention. Additionally, it was suggested that
the difference in sampling time is one of the possible reason for
variation in blood analysis results. In the present study, blood
samples were collected for immune function test 14 h after exercise
ended. It is believed that the sampling time used in the present
study may have caused absence of some significant changes in
certain measured immune parameters.
Mobilisation of NK cells is one of the most robust changes to the
immune system in response to physical exercise.39,40 The striking
exercise-induced increase of NK cells count in peripheral pool is
thought to translate into enhanced immune function, while post-
exercise reduction in blood NK cells is proposed to increase one's
susceptibility to infection.41 One of the most notable findings in the
present study was that there was no significant changes in NK cells
count in HD group, however great increase (þ0.76%) in NK cell
counts could be observed in D group with greatest percent differ-
ence between pre and post test among the groups. Based on this
finding, aerobic dance exercise alone may have potential to increase
NK cell counts.
Increase in NK cells count resulted from exercise has been re-
ported by Shephard and Shek,42 and Timmons.43 Elevated NK cells in
response to acute exercise were found in adults42 and children.43 In
another study, peak aerobic exercise induced significant increase in
170 M. Rahim et al. / Journal of Traditional and Complementary Medicine 7 (2017) 165e171
circulating NK cell counts immediately after exercise, however NK
cells counts returned to baseline by 3 h post exercise.6 These changes
are probably due to an enhanced state of readiness against potentially
harmful pathogen in human.41 On the other hand, it was reported
that high intensity exercise could induce suppression of NK cell
function.41 The absence of reduction in NK cells induced by the aer-
obic dance exercise prescribed in the exercise group of the present
study may reflect that the exercise intensity perceived by participants
in the exercise group was not high enough for reducing the NK cells.
In the present study, it was found that NK cells decreased over
time in HD group. A previous study which reported that combined
carbohydrate intake with 60 min and high-intensity cycling was
not associated with an alteration in innate immunity. Nevertheless,
previous study mentioned that the effect of exercise on NK cell
activity cannot be denied.44 Furthermore, Timmons and Bar-Or39
showed that NK cell function is neither enhanced nor reduced
following exercise in young girls, however carbohydrate intake
attenuates the NK cell subsets responses to exercise in children. In
the present study, NK cells count reduced when exercise combined
with honey (HD). Additionally, reduced in NK cells count was
observed in honey supplementation alone (H) group. These ob-
servations were in agreement with statement mentioned by Nie-
man6 that by maintaining higher plasma glucose levels and thus
attenuating the cortisol and growth responses during exercise,
carbohydrate beverage ingestion may reduce stress to the immune
system in individuals.
In general, the discrepancy of the measured parameters be-
tween the present study and previous studies may be due to dif-
ferences in type of exercise, duration of exercise, age range, types of
nutritional supplementations given and particularly time of blood
withdrawal after exercise. One of the limitations of the study is that
despite statistical analysis of One-way ANOVA was performed to
minimize the differences in the measured parameters among the
groups at the beginning of the study, differences in certain
measured blood parameters between the groups during pre test
could not be avoided. Thus, the present study focused on the
comparison of the variables between pre- and post-tests in each
group. Another limitation of this study is that the sample size used
is rather small. It is suggested that future studies with multicentric
experimental conditions such as different types of exercise and
nutritional supplementation, prolonged intervention period and
repeated blood withdrawing after exercise, as well as larger sample
size are needed for details and comprehensive findings.
5. Conclusion
The present study found that combination of aerobic dance
exercise and honey supplementation elicited more beneficial ef-
fects on immune functions generally compared to aerobic dance
exercise or honey supplementation alone in sedentary women.
Therefore, supplementation of honey drink with 20 g of honey
diluted in 300 ml of plain water combined with 3 days per week of
aerobic dance exercise has potential to be proposed for formulating
guidelines in planning exercise and nutrition promotion program
for increasing immune functions in sedentary women.
Competing interests
The authors declare no conflict of interest.
Acknowledgements
This work was financially supported by Fundamental Research
Grant Scheme (FRGS) (Grant number: 203/PPSP/6171143). We
would like to thank all the Participants for their cooperation in this
study. The Gelam honey used in the present study was sponsored
by Federal Agricultural Marketing Authority (FAMA) of Malaysia,
and the arrangement for this sponsorship by Prof. Dr. Siti Amrah
Sulaiman is very much appreciated. Special thank to Madam
Jamaayah Meor Osman, Mr. Jamaruddin Mat Asan, Madam Par-
imalah Velo and Madam Nor Aini Sudin for their technical assis-
tance throughout the study.
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