Assessment of Physical Activity Levels in Patients with Metabolic Syndrome

Introduction

According to International Diabetes Federation (IDF), Metabolic Syndrome (MetS) also known as Syndrome X, is a group of the cardiovascular risk factors including abdominal obesity, elevated blood glucose level, elevated blood pressure and dyslipidemia.¹ The two important reasons leading to the increased prevalence of metabolic syndrome are increased consumption of high calorie – low fiber fast food, decreased physical activity and sedentary life style. The global prevalence of MetS was found to be one quarter of the world’s population.²

The management of metabolic syndrome includes pharmacotherapy of individual components like hypertension, insulin resistance and dyslipidemia and modification of the underlying risk factors (obesity, physical inactivity, and atherogenic diet) through lifestyle changes. The key target of any healthy lifestyle program includes proper balanced diet, physical activity, emotion control, sleep, peer support, avoidance of tobacco and alcohol and drugs/ medications that reduce body weight.³

Physical activity (PA) is defined as any body movements by skeletal muscles that requires energy expenditure. PA includes all the activities at any intensity, performed during any time of day or night.⁴ According to WHO, more than a quarter of the world’s adult population are physically inactive. Levels of inactivity are twice as high in high-income countries compared to low-income countries.⁵

Regular exercise and fitness have been shown to reduce the risk of diabetes, hypertension, coronary heart disease, stroke and dyslipidemia. Increasing physical activity also assists in weight reduction, hence must be considered to be an important contributor.⁶ Current physical activity guidelines recommend practical, regular and moderate regimens for exercise. The standard exercise recommendation is a daily minimum of 30 minutes of moderate-intensity physical activity such as brisk walking on most, and preferably all days of the week. Sixty minutes or more of continuous or intermittent aerobic activity, preferable done every day, will promote weight loss or weight loss maintenance. Preference is usually given to 60 minutes of moderate intensity brisk walking which is also supplemented by other multiple short activities (10 – 15 minutes) like using simple exercise equipment (eg. Treadmill), jogging, swimming, team sports. Avoiding common sedentary activities in leisure times like watching television and computer games is also advised.⁷ The low physical activity is partly because of the reduced activity in leisure time and sedentary lifestyle at both work and home.

Physical activity levels are assessed by various methods like self-report questionnaires, self-report activity diaries/logs and devices such as accelerometers, pedometers, heart-rate monitors and armbands are also used.⁸ In the present study, physical activity levels were assessed by administering the International Physical Activity Questionnaire (IPAQ).

International Physical Activity Questionnaire

An international measure for physical activity was developed and originated in Geneva in 1998. The IPAQ long form is available in different languages and is used in many settings for prevalence studies of participation in physical activity. Physical activities that MetS patients do as a part of their everyday lives were assessed. The questions were asked about the time they spent being physically active in the last seven days as part of work, transportation, house and yard work, recreation, sports and leisure time. Vigorous and moderate activities that they did in the last seven days were recorded as well. The total scores for the long form was calculated by the summation of the duration (in minutes) and frequency (days) for all the types of activities in all domains.⁹ Scoring was done by using guidelines given by IPAQ and were categorized into low, moderate and high physical activity levels.¹⁰

Since MetS is associated with poorer health related quality of life caused mainly due to sedentary lifestyle, it becomes necessary to assess physical activity level in these patients as physical activity is the mainstay of the overall health related quality of life.

Materials and Methods

A six month prospective study with a sample size of 156 patients, who participated on voluntary basis by giving their consent was conducted in a tertiary care teaching hospital (Heart centre), Bangalore, India, on approval from Institutional Ethics Committee. (Ref No: KIMS/ IEC/P07-2019).

Both in-patients and out-patients of either gender, in the age group of 18-70 years, presenting with diagnosed metabolic syndrome were included in the study. Exclusion criteria included patients with chronic renal disease, hepatic diseases, chronic obstructive pulmonary disease, psychiatric conditions, polycystic ovary syndrome and terminal illness.

The data required for the study were recorded in self designed data collection form by reviewing patient’scase sheet and personally interviewing the patients. Data like demographic details (age, gender, level of education, occupation), current complaints, past medical history drug history and social history were obtained.

Patient’s physical activity was assessed by administering International Physical Activity Questionnaire (IPAQ – long form), which contains a set of questions for each domain like work, transportation, domestic and gardening, leisure time related physical activity and time spent sitting; related to the time spent by an individual being physically active in the last 7 days. Responses for the same were recorded by personal interview. MET (Metabolic Equivalent Time) is one of the easiest method for recording the intensity of PA. METs are the multiplies of the resting metabolic rate and a MET minute is computed by multiplying the MET score of an activity by the minutes performed. Scoring of domains and sub domains (walking, moderate and vigorous activities) was done by using IPAQ guidelines and were categorised into low, moderate and high physical activity levels based on total physical activity scores.

• Total Walking Met-minutes/week = 3.3 x walking minutes/week (at Work + for Transport + in Leisure)
• Total Moderate Met-minutes/week = 6.0 x Cycling minutes/week for Transport + 4.0 x Moderate activity minutes/week (Work + Yard chores + Inside chores + Leisure) + 8.0 x Vigorous yard chores minutes
• Total Vigorous Met-minutes/week = 8.0 x vigorous minutes/week (at Work + in Leisure)

• Total Physical Activity Met-minutes/week = Walking MET-minutes/week + Moderate MET minutes/week + Total Vigorous MET-minutes/week

Also,

• Total Physical Activity Met-minutes/week = Total MET-minutes/week (at Work + for Transport + in Chores + in Leisure).

Analysis of data: Descriptive statistics in terms of number and percentage was used to assess the subject characteristics, whereas the quantitative parameters for the same was assessed and reported in terms of Mean ± SD. Median and IQR was used to assess and report domain, subdomain and total physical activity scores. Statistical analyses were performed using ANOVA and the results were presented at 5% level of significance.

Results

Out of 156 patients, 38.46% were females and 61.54% were males. Current diagnosis of the patients showed that 32.26% patients had Type 2 DM, 34.37% had hypertension, 7.58% had dyslipidemia and 20.08% had ischemic heart disease (IHD). 78% patients had both diabetes melitus (DM) and hypertension, whereas only 12.8% patients had Type 2 DM, hypertension and dyslipidemia. 47.98% had past medical history of DM and 48.99% had hypertension. Almost all the patients had past medication history and were taking anti-diabetic and anti-hypertensive drugs respectively.

Physical activity is an important determinant of MetS and thus occupation of the patient was taken into consideration. Occupational activity was categorized into No occupation (40.38%), Self-employed (15.38%), Agriculture (13.46%), Housewife (14.1%) and Professional (16.67%).

In our study, 73.72% patients were found to have no habits of addiction like smoking, drinking alcohol, chewing tobacco, drug abuse, etc., indicating higher awareness about the ill effects of such habits. The diagnosis of patients was based on IDF criteria. Subject characteristics such as age, gender, occupation, waist circumference and clinical parameters were classified according to physical activity levels and are summarized in Table No. 1.

The categorical scoring was performed for the total physical activity scores and the levels were categorized as low, moderate and high. Each domain and sub-domain physical activity scores are summarized in Table No. 2. Out of 60 females, 37 patients were having low physical activity, out of which 56.76% were in the age group of 61 to 70 years, 2.43% were in the age group of 51 to 60 years and 0.81% were between 41 to 50 years. Out of 96 males, 71 patients were having low physical activity, out of which 52.11% were in the age group of 61 to 70 years, 26.76% were in the age group of 51 to 60 years, 16.9% were in the age group of 41 to 50 years and 4.23% were between 31 to 40 years.

Discussion

Physical activity has been reported to be significantly lower in patients with MetS and having individual metabolic risk factors (abdominal obesity, elevated blood glucose level, elevated blood pressure, dyslipidemia) in the general population due to sedentary lifestyle.

In our study, it was found that the occurrence of the metabolic syndrome was greater in males (61.54%) than in female (38.46%) subjects. A similar study by Sawant A et al. showed that the prevalence of MetS in males was higher than in females.¹¹

We observed that, nearly half of the total sample population were between the age group 61 to 70 years and as the age increased, the number of patients with MetS also increased. Swastika K et al. found significant higher prevalence of MetS in the elderly age group (≥60 years) than the younger age group.¹²

It is quoted that professionals are usually office workers who are characterized typically by sedentary work, unhealthy lifestyle and physical inactivity.¹³ In our study, we estimated that more than half of the subjects had no occupation and had a sedentary lifestyle. As a result, they had cardiovascular complications.

It was observed that hypertension and diabetes were more associated components of metabolic syndrome in lower physical activity level (Figure 1). It was observed that males had higher total scores in almost all domains when compared to females. A similar result was observed in a study carried out by Maddison R et al., which aimed at measuring physical activity of populations from different countries and socio-cultural contexts using IPAQ and New Zealand physical activity questionnaire (NZPAQ).¹⁴ It was found that majority of the patients with low physical activity were in the age group 51-70 years in both the genders.

Effects of physical activity on the components of MetS

Obesity: A strong association between obesity and physical inactivity was demonstrated by epidemiological and cohort studies. An inverse association between physical activity, Body Mass Index (BMI), Hip Waist Ratio (HWR) and waist circumference was found to be reported.¹⁵

Insulin resistance: Short-duration physical activity is associated with low insulin sensibility and physical inactivity is known to increase the insulin resistance. A single physical exercise session increases the glucose disposition by means of the insulin in normal subjects, in individuals with insulin resistance, in obese individuals with insulin resistance as well as in individuals with type 2 diabetes mellitus; whereas, chronic physical exercise improves the insulin sensibility in healthy individuals, non-obese, non-diabetic individuals and in individuals with type 1 and 2 diabetes mellitus.¹⁶

Hypertension: Epidemiological and clinical studies have demonstrated beneficial effects of the practice of physical exercises in individuals of all ages with hypertension. Studies suggests that individuals engaging in daily physical activity were found to have lower levels of blood pressure associated with age and also showed prevention of blood pressure in individuals who were at higher risk of developing hypertension.17 Physical activity programs have demonstrated to decrease both the systolic and diastolic blood pressure in hypertensive and normotensive individuals.¹⁸

Dyslipidemia: Individuals who are physically active presented higher levels of HDL-cholesterol and lower levels of triglycerides, LDL and VLDL-cholesterol when compared to inactive individuals.¹⁹

Conclusion

In conclusion, it was evident from the present study that patients with lesser physical activity scores were found to be associated with the higher prevalence of metabolic syndrome. Along with pharmacotherapy, regular PA is the key for prevention and management of metabolic syndrome. It becomes necessary to identify the underlying risk components of MetS, so that better recommendations can be made to address the specific physical activity types, duration, frequencies, that could be beneficial for the patients to prevent and manage the condition of metabolic syndrome. Tools like IPAQ that assesses physical activity helps the researchers, clinicians and clinical pharmacists, in evaluating the patients to arrive at suitable measures that can reduce health and economic impact due to cardiovascular complications associated with metabolic syndrome.