The following measures were assessed at the baseline condition as well as 12 weeks after initiating the treatment: primary outcome included WOMAC, CRP, and MDA. Secondary outcome was LDL-c, TC, high density lipoprotein-cholesterol (HDL-c), triglycerides (TG), BMI, fat mass, free fat mass, as well as waist circumference (WC) and hip circumference (HC).

To conduct the laboratory tests, 5 mL of venous blood samples was obtained after the patients had fasted for 8 h overnight. Serum samples were produced from the collected blood samples immediately after the centrifugation (3000 g, 10 min). They were then frozen at − 20 °C, stored at − 70 °C, and measured at the same time. The total TC, HDL-c, and TG were later measured using Pars Ammon kit (Iran). LDL-c was then calculated using Friedewald’s equation [24]. Serum CRP and MDA concentrations were measured through enzyme-linked immunosorbent assay kits and thiobarbituric acid reactive substances Zellbio kit (Germany), respectively.

To assess the clinical symptoms, WOMAC questionnaire was employed. Patients filled out the Persian version of WOMAC index [25] which consists of 24 questions (related to pain, stiffness, and physical function). Items were answered on a Likert scale: none (0), mild (1), moderate (2), severe (3), or extreme (4).

The weight and body composition were also measured for all patients using a portable digital scale (Omeron BF511, Japan) with an accuracy of 100 g. Participants were in light clothes and stood on the scale without help. Furthermore, the height was measured in standing position without shoes using an audiometer fixed on a straight wall to the nearest 0.1 cm. Measuring WC was performed to the nearest 1 cm using non-stretch plastic tape placed midway between iliac crest and lowest rib while participants were in standing position. Moreover, HC was measured over the largest part of buttocks with the accuracy of 1 cm. BMI was also calculated as weight (kg) divided by height squared (m2). Fat mass, and free fat mass were also measured for all patients using a portable digital scale (Omeron BF511, Japan).

For physical activity, the Persian version of IPAQ was applied [26]. The continuous score shows the weekly energy expenditure expressed in MET-min/week (metabolic equivalent-minutes). Individuals were classified into three categories of ‘inactive’, ‘moderately active’, and ‘highly active’ using the categorical classification.

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