# Exercise as it relates to Disease/Enhancing physical activity using an internet intervention for adults with metabolic syndrome

This is a critical analysis of the journal article ‘Effects of an Internet Physical Activity Intervention in Adults With Metabolic Syndrome’ by Kelly A. Bosak, Bernice Yates and Bunny Pozehl. Written in 2009, the study is considered relatively recent.

## What is the background to this research?

Metabolic syndrome diagnosis occurs when a person is found with a combination of risk factors for type 2 diabetes and coronary heart disease, including insulin resistance, dyslipidaemia, obesity and hypertension. The risk factors have a tendency to cluster and are due to sedentarism and the over-consumption of nutrients.
Management of metabolic syndrome is undertaken by multiple ways and aims to reduce these risk factors. Physical inactivity is the focus of this study, though addressing nutrition and in some cases, pharmacotherapy are necessary. Cross-sectional studies have found that there is an inverse relationship between metabolic syndrome and cardiorespiratory fitness in men and women.

### Prevalence

The prevalence of metabolic syndrome in adults over 25 in Australia is one in three, and is 21.7% worldwide.

## Where is the research from?

Researchers are from the University of Kansas Medical Centre and the University of Nebraska Medical Centre. Although published in America, metabolic syndrome is a pandemic in Australia and is diagnosed through similar processes, therefore the findings are transferable. The authors are professors in nursing with research which focuses on interventions and self-care management for exercise adherence among people with chronic disease and other health-related topics.

## What kind of research was this?

The study was a randomized controlled trial and its purpose was to determine the effectiveness of a 6-week evidence-based internet intervention.

## What did the research involve?

The research involved an experimental design, in which 22 participants diagnosed with metabolic syndrome, 16 males and six females, within an age range of 32 to 66 years, were chosen from a university-based cardiology lipid clinic. They were randomly divided into two groups, a way of reducing selection bias, with the control group receiving the usual care, and the treatment group receiving the intervention. The Adult Treatment Panel III (ATP III) guidelines were used as diagnostic criteria in determining metabolic syndrome. Using these guidelines ensured that the background for the study and the diagnosis of metabolic syndrome was evidence-based.

### Data

The following pre- and post-intervention data were collected for both groups:

#### 7-Day Physical Activity Recall

Self-reported physical activity and duration. This measurement may not be completely accurate as with self-reported information, it is likely participants over- or under-estimate.

#### RT3 Accelerometer

Assessment of energy expenditure which gathered objective rather than subjective information.

#### Lipid Biomarkers

LDL, HDL, non-HDL cholesterol and triglycerides were measured.

#### Self-Efficacy for physical activity and barriers to physical activity questionnaires.

Two self-efficacy tools were used and were a valid way of gaining information due to the ability to analyze quantitative data and ask specific questions, without the risk of self-reporting errors.
Surprisingly, blood glucose was not measured in this study despite insulin resistance being a major risk factor.

### Usual Care Group

A dietitian and a physician provided guidance on nutrition and prescribed an exercise program. The participants in this group reported back to the clinic for normal treatment.

### Intervention Group

Participants in this group received an exercise routine provided over the internet and were exposed to an educative approach to reduce the barriers to physical activity. Their target throughout the intervention was 150 min/week of moderate or vigorous intensity PA and an energy expenditure goal of 1000 kcal/week. New information and access to resources were made available each week and individual feedback was given through email. A platform was accessible to enable communication between the participants.
Having the treatment provided over the internet could be a limitation due to the participants lacking direct supervision during their exercise routine. Being in a disease state, having an allied health professional monitor blood pressure, blood glucose, the rate of perceived exertion and correct technique ensures a safer exercise routine.

## What were the basic results?

The results showed that neither group reached the goal of 150 mins/week of physical activity or the expended kilocalories. Consequently, non-significant results came from the study. The intervention group saw an improvement in physical activity, exercising on average 72.9 min/week and expending 461.6 kcal/week. The usual care group stayed the same, exercising 74.7 min/week and expending 387.8 kcal/week. VO$_2$ max in the intervention group increased by 8.6% and decreased 1.9% in the control group. Analysis of the lipid biomarkers showed a statistically significant improvement for HDL cholesterol in the intervention group, a decrease in the usual care group, and insignificant changes in the other biomarkers.
Arguably, six weeks is not long enough to illicit enough change in cardiorespiratory fitness or lipid biomarkers. Performing an internet intervention is an inventive way of delivering treatment due to the accessibility of technology, however, more research needs to be done in improving the reception, adherence, and delivery. Also, because of the small sample size, there wasn’t much diversity in ethnicity, so the findings may not be transferable across the broader population.

## What conclusions can we take from this research?

With an inverse relationship between metabolic syndrome and cardiorespiratory fitness, the intention of the internet intervention showed some potential for more research. Future studies will need to be longer in duration and have a greater sample size, including representative ethnicities to elicit more significant change and repeatability. Using the internet as a mode to prescribe exercise will be beneficial if participants are self-efficient in following prescribed exercise, saving them reporting to the clinic for each session.

## Practical advice

Addressing the underlying causes of metabolic syndrome with physical activity is imperative. Achieving 150 mins/week of moderate or vigorous intensity exercise, and reducing time spent sedentary, is required in managing obesity and insulin resistance risk factors. Following nutrition guided by a dietitian and medications, when needed, can help to treat the other risk factors.

## Further reading

* For more information on metabolic syndrome: https://www.racgp.org.au/afp/2013/august/the-metabolic-syndrome/
* Australia’s Physical Activity & Sedentary Behaviour Guidelines for Adults (18-64 years):
http://www.health.gov.au/internet/main/publishing.nsf/Content/F01F92328EDADA5BCA257BF0001E720D/$File/brochure%20PA%20Guidelines_A5_18-64yrs.pdf
* Australian Guide to Healthy Eating: https://www.eatforhealth.gov.au/guidelines/australian-guide-healthy-eating

## References

* ↑ Bosak K, Yates B, Pozehl B. Effects of an Internet Physical Activity Intervention in Adults With Metabolic Syndrome. Western Journal of Nursing Research. 2009;32(1):5-22.
* 1 2 3 Grundy S. A constellation of complications: The metabolic syndrome. Clinical Cornerstone. 2005;7(2-3):36-45.
* 1 2 Cornier M, Dabelea D, Hernandez T, Lindstrom R, Steig A, Stob N et al. The Metabolic Syndrome. Endocrine Reviews. 2008;29(7):777-822.
* ↑ Finley C, LaMonte M, Waslien C, Barlow C, Blair S, Nichaman M. Cardiorespiratory Fitness, Macronutrient Intake, and the Metabolic Syndrome: The Aerobics Center Longitudinal Study. Journal of the American Dietetic Association. 2006;106(5):673-679.
* ↑ LaMonte M, Barlow C, Jurca R, Kampert J, Church T, Blair S. Cardiorespiratory Fitness Is Inversely Associated With the Incidence of Metabolic Syndrome. A Prospective Study of Men and Women. ACC Current Journal Review. 2005;14(11):18-19.
* ↑ Cameron A, Magliano D, Zimmet P, Welborn T, Shaw J. The Metabolic Syndrome in Australia: Prevalence using four definitions. 2007.
* ↑ National Cholesterol Education Program. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Final Report. [Internet]. 2002. Available from: https://www.nhlbi.nih.gov/files/docs/resources/heart/atp-3-cholesterol-full-report.pdf