An estimated 50 million adults in the United States now have metabolic syndrome.1 The incidence of this disorder in women, especially in the black and Mexican Hispanic populations, is increasing.2 This article focuses on Hispanic woman because this syndrome is often underdiagnosed in this population.3,4 The reasons for the high prevalence in Hispanic women are thought to include decreased access to medical care, poor diet and physical inactivity leading to obesity and insulin resistance.1,4,5
Studies suggest that many Hispanic people do not perceive being overweight or obese as a health issue, but rather a characteristic of good health.6 In addition, researchers have found that Hispanic women put family needs above their own. Taking time to concentrate on themselves is not a usual practice.6,7
Because these beliefs are instilled in childhood and part of family dynamics, strategies that incorporate lifestyle changes must address cultural barriers and influences.6,7
Physical inactivity and obesity are key risk factors in metabolic syndrome and are directly linked to the components of this syndrome.1,5-8 Metabolic syndrome is not considered an independent risk factor, but people with this condition face a fivefold increase in type 2 diabetes risk and a doubling of risk for cardiovascular disease within 5 years.8
The most universally accepted criteria for the diagnosis of metabolic syndrome are from the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III; http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf). This document characterizes metabolic syndrome as the occurrence of any three of the five following components: abdominal obesity, high blood pressure, low high-density lipoprotein levels, high triglyceride levels and high fasting plasma glucose levels.
Risk factors for metabolic syndrome include physical inactivity, obesity, insulin resistance and genetic predisposition.1,5-9 Central or abdominal obesity is believed to be at the core of this syndrome and it is the foremost problem in cultures whose members are sedentary and have diets high in carbohydrates and fats.1,5,7,8 Physical inactivity and abdominal obesity are the key risk factors in metabolic syndrome because they are directly linked to elevated blood pressure, insulin resistance, low HDL-C, high triglyceride levels, and elevated fasting glucose.3,8,10,11
The 10 studies reviewed for this article demonstrated improved cardiometabolic outcomes with varying intervention strategies.7,10,12-19 Weight loss was the key intervention. Therefore, it is recommended that lifetime adherence to lifestyle changes is vital for long-term management of metabolic syndrome and its components.10
The question that guided this review was "What are the current research findings about the effects of successful lifestyle changes on the components of metabolic syndrome in Hispanic women?" I used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to formulate a systematic literature review to answer this question.11
To reflect the most current evidence, the search was limited to studies published between 2007 and 2011. Six hundred ninety-five articles were identified through database searches of Ovid, CINAHL and PubMed, and five additional articles were identified through hand search of reference lists. Only quantitative research that addressed lifestyle change strategies utilized to manage metabolic syndrome was considered and evaluated. After ruling out articles that did not meet criteria for study, I evaluated 10 articles.
The primary overall finding was that diet and exercise are important in reducing the components of metabolic syndrome. The exact interventions varied, but all were successful in the management of metabolic syndrome.
Mediterranean diet. Two studies and one meta-analysis investigated the effects of the Mediterranean diet on the components of metabolic syndrome.12-14 The Mediterranean diet emphasizes high consumption of fruits, vegetables and whole grains, encourages poultry and fish, and limits red meat. The diet recommends the use of olive or canola oil and herbs and spices for flavoring.12-14
All three articles stated that adherence to this diet reduced the components of and decreased the risk for metabolic syndrome. The meta-analysis14 found that studies conducted for more than 3 months demonstrated a beneficial effect on four components: reduced fasting glucose, lowered blood pressure, elevated HDL-C and lowered triglycerides. Interventions that lasted less than 3 months showed significant results only in the reduction of glucose levels and diastolic blood pressure.12-14 The meta-analysis also showed that both exercise and adherence to the Mediterranean diet significantly improved all components of metabolic syndrome except waist circumference.14
Babio et al12 found that metabolic syndrome was more common in women. The authors applying the NCEP/ATPIII criteria reported a decreased prevalence for metabolic syndrome with adherence to the Mediterranean diet.
The study by Rubenfire et al13 utilized cardiac rehabilitation and showed significant reduction in both waist circumference and fat composition.13
Overall the data from these two studies and one meta-analysis suggested that lower metabolic syndrome prevalence and progression were associated with long-term adherence to the Mediterranean diet.12-14
Low-calorie lifestyle change intervention. One study examined a low-calorie lifestyle intervention.10 The authors conducted a 15-week fee-for-service program that blended exercise, dietary and behavioral management with a low-calorie meal replacement diet.10 The average weight loss for patients with metabolic syndrome who completed the 15-week program was 10.5 kg + 5.7 kg. At the completion of the study 61% of the participants no longer met criteria for metabolic syndrome.10
Physical activity. One meta-analysis addressed physical activity.7 The 12 studies in the analysis examined the effects of regular exercise. Researchers found that by encouraging social support, peer interaction with feedback and incorporating patients' families in the study, women showed improvement in problem-solving skills and motivation to increase physical activity. However, the researchers also found that aerobic activity was an impractical form of physical activity for this population.7 Lack of follow-up was due to completion of the study with no built in follow-up protocol, such as activities or continuation of resources after implementation of the intervention. The authors did not conduct post-evaluations, so the long-range impact isn't known.7
Nutritional education. Five articles examined nutritional education. The concept of motivation was predominate in the study by Busnello et al.15 Women were assigned to a control group or an intervention group.15 The authors found that participants who were highly motivated at the start of the study had a greater reduction in body mass index (BMI) and waist circumference at completion of the 4 months. Overall findings suggested that dietary counseling in conjunction with motivation and a willingness to change are vital to treatment success.15
Bo et al16 found that the intervention group that received professional education on lifestyle interventions showed significant improvement in both lifestyle changes and the components of metabolic syndrome. The control group received general lifestyle information from their provider and showed worsening of the components.16
A 12-month prospective control trial by Christian et al17 used a computer program for the intervention group and written materials for the control group. The researchers found that at 1 year, the intervention group had a weight loss greater than or equal to 5% (26.3%) compared to the control group (8.5%). Because of the moderately low burden for the provider and the simplicity of the intervention, the researchers believe that this intervention can be easily implemented in the primary care setting as a first step toward ongoing health promotion.17
Appel et al studied the effectiveness of two behavioral weight loss interventions in obese Hispanic women.18 This 2-year trial used three interventions and found that the mean reduction in weight from baseline was 0.8 kg in the control group, 4.6 kg in the group receiving remote support only and 5.1 kg in the group receiving in-person support.18 At completion of this study, participants who had lost 5% or more of their original weight numbered 18.8% in the control group, 38.2% in the group receiving remote support alone, and 41.4% in the group treated in person.18
The final study used the Lifestyle Exercise Attitudes Relationships Nutrition (LEARN) weight management program.19 The 10-week study provided weekly education, promoted peer support through interactive discussions and facilitated healthy lifestyle changes through use of the Cooperative Health Care Clinics (CHCC) model. This shared group model provided ample opportunity for patient education and instruction in self-management.19 At the end of the 10-week intervention, the researchers found significant statistical differences in waist circumference but no significant statistical differences in mean weight or BMI. At the end of the study, the overall knowledge base improved and patient satisfaction with the program was high.19
Implications for Practice
This literature review found that lifestyle change strategies must be multifaceted and comprehensive to successfully prevent and modify metabolic syndrome. Lower prevalence for metabolic syndrome was associated with adherence to a healthy diet. The addition of physical activity, peer support and nutritional education also contributed to reduction in the risk factors associated with this syndrome.
Metabolic syndrome is a growing health problem encountered daily in the primary care setting. Hispanic women are about 1.5 times as likely as non-Hispanic white women to meet criteria for a diagnosis of this syndrome.2,5,8 Lifestyle changes for metabolic syndrome must take cultural beliefs and influences into consideration. The 10 studies reviewed demonstrated improved cardiometabolic outcomes through varied intervention strategies and time. The studies that used the Mediterranean diet in conjunction with physical activity13,14 had the best overall results. Interventions lasting more than 3 months showed a beneficial effect,13,14 but Perez et al7 found that studies lasting longer than 12 weeks had high attrition rates and no further improvement in physical activity. Appel et al18 did not mandate physical attendance and found that remote support within the primary care setting allowed for flexibility and significant weight loss throughout the 24 months.
Lifestyle changes were examined in several studies. Greer et al19 found that using group and individual visits encouraged self-management and enhanced lifestyle changes. They also showed statistically significant reductions in waist circumference through education and hands-on learning via the LEARN weight management program. Bo et al16 found that lifestyle interventions taught by trained professionals were more effective in reducing components of metabolic syndrome than the standard education that occurred in the provider's office. Lastly, Christian et al17 documented significant weight loss and improvement in cardiovascular risk factors over a 12-month trial utilizing a computerized tool and provider counseling.
Intervention Needed Now
As the Hispanic population continues to grow in the United States, so does the risk for metabolic syndrome. Without treatment, Hispanic women with this syndrome are at risk for further complications including cardiovascular disease and type 2 diabetes.3 Metabolic syndrome is a lifestyle-dependent disorder. Prevention and management should be individualized across the lifespan and be tailored to racial and ethnic characteristics.1,2,5,8
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