the health promotion lifestyle of metabolic syndrome individuals with a diet and exercise programme

R E S E A R C H P A P E R

The health promotion lifestyle of metabolicsyndrome individuals with a diet

and exercise programme

Yu-Hua Lin RN PhDAssociate Professor, Department of Nursing, I-Shou University, Kaohsiung, Taiwan

Li-Ling Chu RN MSNRegistered Nurse, Community Health Center, Tainan, Taiwan

Accepted for publication November 2012

Lin Y-H, Chu L-L. International Journal of Nursing Practice 2014; 20: 142–148The health promotion lifestyle of metabolic syndrome individuals with a diet and

exercise programme

The purpose of this study was to explore a health promotion lifestyle (HPL) with a diet and exercise programme (DEP)in metabolic syndrome adults. The study consisted of 207 individuals who followed a DEP and 185 who did not. Thesubjects were rural community adults. Their HPL was evaluated using the Chinese version of the Health PromotionLifestyle Profile Short Form (HPLP-S). The average HPLP-S score was significantly higher in the DEP group (3.28 ± 0.36)than in the group without the DEP (2.05 ± 0.65). Stepwise regression analysis revealed that group, gender, smoking,alcohol use, marital status, religion and chronic disease were predictors of an HPL and accounted for 67.0% of the variancein the HPLP-S score. This study demonstrates that a DEP has positive effects on a health promotion lifestyle. Thecommunity-based DEP targeting health promotion behaviours should be presented as a strategy for metabolic syndromein adults.

Key words: community, diet and exercise programme, health promotion lifestyle, metabolic syndrome.

INTRODUCTIONMetabolic syndrome is increasingly recognized as a riskfactor for cardiovascular diseases (CVDs), stroke, diabe-tes and associated complications, placing a substantialburden on health-care resources.1–4 In Taiwan, the preva-lence of metabolic syndrome among adults 20 years andolder ranges from 14.4% to 42.6%.5–8 Increasing patientunderstanding of health information was included as a

target area in Healthy People 2010 and will be carriedover into Healthy People 2020.9 Metabolic syndrome,however, is a complex problem and requires a wide rangeof strategies.10 Some of the literature has considered thepotential of particular aspects of diet and physical activityin prevention.10–12 The American Nursing Associationstandards of care require nurses to provide educationalinformation related to illness management, health promo-tion and disease prevention.13 The literature shows thatpatient education in health promotion, disease preventionand disease management is needed for optimal health.14

Resnick recognized that health promotion activitiesshould include both disease prevention and early

Correspondence: Yu-Hua Lin, Nursing Department, I-Shou University,No.8, Yida Road, Yanchao District, Kaohsiung 82445, Taiwan.Email: [email protected]

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International Journal of Nursing Practice 2014; 20: 142–148

doi:10.1111/ijn.12149© 2013 Wiley Publishing Asia Pty Ltd

detection of disease.15 Through health promotion, healthprofessionals, especially nurses, can improve the ability ofindividuals to take responsibility for their health. Li et al.conducted a study to understand health promotion behav-iours among elderly subjects in Taiwan and found thatamong health promotion behaviours, regular exerciseappears to be the most prevalent.16 However, physicalactivity or diet alone cannot effect satisfactory improve-ment of metabolic syndrome. Lee et al.’s study suggeststhat community-based intervention exercise and diet pro-grammes targeting health promotion behaviours shouldimmediately be developed by health-care professionals.17

Therefore, we combined diet and exercise as an interven-tion programme in this study. The purpose of the studywas to explore the health promotion lifestyle (HPL) witha diet and exercise programme (DEP) in metabolicsyndrome adults.

Research questionsThe four research questions were: (i) What are the HPLPheld by metabolic syndrome adults before the DEP pro-gramme?; (ii) What are the HPLP held by metabolic syn-drome adults after the DEP programme?; (iii) Are theredifferences in metabolic syndrome adults’ HPLP betweenwith or without DEP programme?; and (iv) How manypredictors related HPLP among metabolic syndromeadults?

METHODSSetting and samples

Following institutional review board approval from thefirst author’s university, a sample of local adults wasrecruited from the Meinong District community healthcentre in rural southern Taiwan. There are 19 villagesin the Meinong District. We selected the four mostpopulous villages as the DEP group; the other villagesconstituted the group without a DEP (both totallingapproximately 10 000). Of 1480 individuals identified ashaving abnormal metabolic syndrome symptoms duringthe screening in 2010, 210 individuals signed the contractto participate in the DEP group, and 1400 remained in thegroup without a DEP (age matched). We applied system-atic randomized sampling, using 7 (1400/210 = 7) as theinterval, to select 210 individuals from the other villagesin the group without a DEP. The inclusion criteria for theparticipants included the following: (i) age over 40 years;(ii) abnormal anthropometrics and metabolic syndrome

biomarkers; and (iii) the ability to communicate withresearchers. People were excluded from the DEP if theywere not able to engage in regular physical activity, had asignificant intellectual disability or cognitive impairment,or were unable to participate in the full 3-month pro-gramme. The DEP group contained 207 individuals, but 3were lost (1 refused participation due to a stay in thehospital for a disease, and 2 moved to urban areas to livewith a child). The group without a DEP contained 185individuals, but 15 were lost (5 refused participation dueto a stay in the hospital for a disease, and 10 moved tourban areas to live with a child). A total of 392 partici-pants (207 in the DEP group and 185 in the group withouta DEP) completed the 3-month study (retention rate:93.3%). The data were collected from May 2010 toFebruary 2011.

DEPThis study applied a comparison study design. All partici-pants attended a 1-hour class about metabolic syndromeand the relationship between diet and exercise. In theDEP group, the participants signed the contract to par-ticipate in the DEP as part of their daily activities. TheDEP consisted of five servings of fruits and vegetables perday and regular exercise for at least 30 to 45 min, 3 to 5days per week, as suggested by the literature.11,12,18 Theparticipants were to choose the type of exercise theypreferred. To track their compliance with the pro-gramme, the second author conducted a telephone con-sultation each week to encourage continued participationand visited the community centre monthly to check thedietary logs and discuss any problems that had arisen. Toincrease the participants’ adherence to the intervention,we also taught the participants’ families (spouses and chil-dren) about the programme, suggested ways to preparefoods, and encouraged family members to exercise withthe participants and to remind the participants to eatproperly and exercise. When the participants and theirfamilies came to the community centre, we asked thefamilies about the frequency of the participants’ exerciseto help evaluate the participants’ adherence to theprogramme.

In contrast, the group without the DEP ate and exer-cised as usual, and there were no telephone consultations.They visited the community centre as usual (wheneverthey wanted). We examined the outcome variables after3 months.

Diet and exercise and health promotion 143

© 2013 Wiley Publishing Asia Pty Ltd

InstrumentsThe major concepts of interest in this study regardedhealth promotion. We used the Chinese version of theHealth Promotion Lifestyle Profile Short Form (HPLP-S)in this study. The original version of the HPLP was devel-oped to measure the components of a healthy lifestyle19,20

using a a 52-item self-reporting scale to examine patients’perceptions of their conditions. The Chinese version ofthe HPLP-S was simplified by Wei and Lu to a 24-itemquestionnaire.21 The HPLP-S consists of six subscales withfour items per subscale. The six subscales were named forthe items of that subscale, that is, health responsibility(HR), physical activity (PA), nutrition (NUTR), self-actualization (SA), interpersonal support (IPS) and stressmanagement (SM). A higher score indicates greater healthpromotion, using a 4-point Likert scale with choicesranging from never (1) to always (5). The overallCronbach’s alpha was 0.90, with 0.63 to 0.79 for thesubscales.21 When Chen used HPLP-S to explore themetabolic syndrome individuals’ health promotion life-style, the overall Cronbach’s alpha was 0.88.22 In thepresent study, the overall reliability coefficient was 0.94,and the alphas for the subscales were 0.83 (HR), 0.78(PA), 0.85 (NUTR), 0.89 (SA), 0.79 (IPS) and 0.74(SM).

A background data sheet was used to collect demo-graphic and health-related information, including age,gender, marital status, education level, employmentstatus, religion, living with a caregiver or family, havingchildren, and chronic disease. Lifestyle-related variableswere also included: smoking habits, alcohol use and betelnut abuse.

Statistical analysisStatistical analysis was performed using the StatisticalPackage for the Social Sciences version 17.0 (SPSS, Inc.,Chicago, IL, USA). Descriptive analyses, including meas-ures of central tendency (mean, standard deviations, andrange) and frequencies (for categorical variables), wereconducted for all demographic and outcome variables. Achi-squared analysis determined the demographic differ-ence between the two groups. Each HPLP-S was treatedas ordinal level data, on which we used non-parametricstatistics, including descriptive analysis and the Mann–Whitney U-test. Finally, we used the mean of the HPLP-Sscores as the main outcome variables, with or without theDEP as the independent variable. Stepwise regressionanalysis was then employed to explore possible predictors

of health promotion lifestyle. A two-sided P-value of lessthan 0.05 was considered to be statistically significant.

RESULTSA summary of the demographic characteristics of thestudy participants is presented in Table 1. The meanage of the DEP group (119 females) was 69.20 years(SD = 9.21), with a range of 40 to 87 years. The meanage of the group without the DEP (123 females) was69.72 years (SD = 9.02), with a range of 40 to 87 years.The majority of the participants in each group weremarried (75.4% vs. 68.6%), had an educational level ofless than 6 years (65.2% vs. 71.4%) and were retired(66.7% vs. 74.1%). Most of the participants had children(97.6% vs. 97.3%), were living with family (89.4% vs.88.1%) and had at least one chronic disease (77.8% vs.76.8%). Approximately 1/5 of the participants hadsmoking habits (13.0% vs. 11.9%) and used alcohol(10.1% vs. 10.8%); few participants abused betel nuts(4.3% vs. 3.2%).

All demographic variables for participants in the twogroups were similar (test by Pearson χ2, all P > 0.05)(Table 1). The average HPLP-S score was significantlyhigher in the DEP group (3.28 ± 0.36) than in the groupwithout the DEP (2.05 ± 0.65). Comparing the twogroups, the Mann–Whitney U-test revealed that therewere significant differences in overall health promotionand in all subscale scores between these two groups (allP < 0.001) (Table 2). The results indicated that partici-pants in the DEP group had positive health promotionbehaviour when compared with the group withoutthe DEP.

Stepwise regression analysis revealed that the groupthat entered in step one accounted for 61.9%, andgender, smoking, alcohol use, marital status, religionand chronic disease occurred in descending order andincreased the explained variance to 67.0% of the variancein the HPLP-S score (Table 3). Other variables were notentered into the equation.

DISCUSSIONThis study demonstrates that adults who have participatedin a DEP see positive effects from a health promotionlifestyle. These results support the suggestion of Leeet al.’s study that nurses should facilitate health promotionbehaviours through nursing interventions to improve the

144 Y-H Lin and L-L Chu


overall health of the community.17 There is literature tosuggest that adults benefit greatly from health promotionbehaviours.23–25

Even though the overall scale and all subscales hadsignificantly higher mean scores in the intervention group,

the order of the subscales’ mean scores on a health pro-motion lifestyle are totally different in the two groups. Inthe DEP group, the mean scores in decreasing orderwere nutrition, self-actualization, interpersonal support,stress management, health responsibility and exercise.

Table 1 Demographic characteristics of participants (N = 392)

Variables (n, %) DEP group

(n = 207)

Without DEP

group (n = 185)

χ2 P-value

n (%) n (%)

Age range: 40–87 Mean = 69.44 (SD = 9.11) 0.47 0.492< 65 (93, 23.7) 52 (25.1) 41 (22.2)≥ 65 years (299, 76.3) 155 (74.9) 144 (77.8)

Gender 3.35 0.067Male (150, 38.3) 88 (42.5) 62 (33.5)Female (242, 61.7) 119 (57.5) 123 (66.5)

Marital status 2.19 0.139Single (109, 27.8) 51 (24.6) 58 (31.4)Married (283, 72.2) 156 (75.4) 127 (68.6)

Education 1.69 0.193≤6 years (267, 68.1) 135 (65.2) 132 (71.4)> 6 years (125, 31.9) 72 (34.8) 53 (28.6)

Religion 0.01 0.931Yes (315, 80.4) 166 (80.2) 149 (80.5)No (77, 19.6) 41 (19.8) 36 (19.5)

Job 2.55 0.111Yes (n = 117, 29.8) 69 (33.3) 48 (25.9)No (275, 70.2) 138 (66.7) 137 (74.1)

Children 0.03 0.857Yes (382, 97.4) 202 (97.6) 180 (97.3)No (10, 2.6) 5 (2.4) 5 (2.7)

Living 0.16 0.692Alone (44, 11.2) 22 (10.6) 22 (11.9)With family (348, 88.8) 185 (89.4) 163 (88.1)

Chronic disease 0.06 0.810Yes (303, 77.3) 161 (77.8) 142 (76.8)No (89, 22.7) 46 (22.2) 43 (23.2)

Smoking habits 0.12 0.731Yes (49, 12.5) 27 (13.0) 22 (11.9)No (343, 87.5) 180 (87.0) 163 (88.1)

Alcohol used 0.05 0.830Yes (41, 10.5) 21 (10.1) 20 (10.8)No (351, 89.5) 186 (89.9) 165 (89.2)

Betel nut abuse 0.32 0.569Yes (15, 3.8) 9 (4.3) 6 (3.2)No (377, 96.2) 198 (95.7) 179 (96.8)

Note: Cell count less than 5 used Fisher’s exact test. DEP, diet and exercise programme.



However, the mean scores in the control group indecreasing order were self-actualization, interpersonalsupport, health responsibility, exercise, stress manage-ment and nutrition. These scores imply that participantsin the DEP group understand that nutrition (diet) is moreimportant than exercise in managing their metabolic syn-drome. These findings may support some literatureresults that suggest that exercise does not always affectmetabolic syndrome and improve physical health.26,27

Using a stepwise regression model, we found that theDEP was the major predictor, and gender, smoking,alcohol use, marital status, religion and chronic diseasealso contributed to participants’ HPL. These results areconsistent with those of Lee et al.’s study, which foundthat gender accounted for statistically significant differ-ences in the mean score of health promotion behaviours,as did smoking and alcohol use.17

We used the two groups’ total HPLP-S mean scores toconduct a power analysis to test whether the study’s

sample size was appropriate. The results showed that bothgroups had a high effect size (value of 2.55) and a highpower (value of 0.95), with an associated alpha of 0.05(calculated by G*Power 3.0.1),28 indicating that the 392participants were sufficient for this study (an effect sizegreater than 0.80 is considered large).29

LimitationsOur study had several limitations. First of all, as across-sectional survey study, we did not measure theHPLP-S scores before implementing the DEP. It is there-fore difficult to establish the causality of the significantassociations. A further investigation may conduct a lon-gitudinal study to examine the effects of a DEP. Second,this study might be limited by a selection bias because theDEP groups were recruited from among communityresidents who were known to the second author andtherefore more willing to participate. Third, we did notexpand our investigation to include other parameters

Table 2 Health promotion lifestyle comparison (n = 392)

Variables DEP group

(n = 207)

Mean (± SD)

Without DEP

group (n = 185)

Mean (± SD)

Z P

Health promotion lifestyle 3.29 (± 0.36) 2.05 (± 0.65) −15.59 0.000Nutrition 3.73 (± 0.32) 1.81 (± 0.69) −17.05 0.000Self-actualization 3.60 (± 0.52) 2.43 (± 0.98) −11.65 0.000Interpersonal support 3.28 (± 0.63) 2.21 (± 0.88) −11.13 0.000Stress management 3.25 (± 0.58) 1.85 (± 0.71) −14.59 0.000Health responsibility 2.98 (± 0.79) 2.04 (± 0.95) −9.23 0.000Exercise 2.90 (± 0.67) 1.96 (± 0.79) −10.54 0.000

Note: P values for subscale scores were assessed using between-group analysis of variance; the items were tested by Mann–Whitney U-test;

higher scores reflect better health promotion lifestyle. DEP, diet and exercise programme.

Table 3 Stepwise multiple regression predicting health promotion lifestyle (N = 392)

Variable Beta SE t P R2 95% CI

Group 28.82 1.12 24.42 0.000 0.619 26.62∼31.01Gender −8.18 1.37 −5.99 0.000 0.008 −10.87∼−5.50Smoker −6.29 1.88 −3.34 0.001 0.013 −9.99∼−2.59Alcohol drinker −6.47 1.95 −3.33 0.001 0.009 −10.30∼−2.65Marital status 3.84 1.24 3.10 0.002 0.008 1.40∼6.27Religion 4.23 1.47 2.88 0.004 0.007 1.34∼7.12Chronic disease −3.58 1.33 −2.68 0.008 0.006 −6.20∼−0.96



potentially relevant to health promotion, such as thehabits of exercise and eating before intervention,the person who cooked the food, details of exercisetypes, and the perceived barriers to a health promotionlifestyle.

CONCLUSIONThis study demonstrates that the DEP is an effectivestrategy for metabolic syndrome adults’ HPLP. The keyfactor contributing to the HPLP also were gender,smoking, alcohol use, marital status, religion and chronicdisease. Community health-care providers play an impor-tant role in educating and supporting individuals withmore detailed information related to the health promo-tion lifestyle of metabolic syndrome. Furthermore, manycommunity residents commented that they appreciatedthe information and resources they received and felt asthough a health professional was concerned about theirwelfare.

ACKNOWLEDGEMENTSWe thank the health professional team of the communityhealth centre in Meinong District, Kaohsiung. Specialthanks also go to all community adults for participating inthis study.

REFERENCES1 Alexander CM, Landsman PB, Teutsch SM, Haffner SM.

NCEP-defined metabolic syndrome, diabetes, and preva-lence of coronary heart disease among NHANES IIIparticipants age 50 years and older. Diabetes 2003; 52:1210–1214.

2 Isomaa B, Almgren P, Tuomi T et al. Cardiovascularmorbidity and mortality associated with the metabolicsyndrome. Diabetes Care 2001; 24: 683–689.

3 Stern M, Williams K, Gonzalez-Villalpando C, HuntKJ, Haffner SM. Does the metabolic syndrome improveidentification of individuals at risk of type 2 diabetes and/or cardiovascular disease? Diabetes Care 2004; 27: 2676–2681.

4 Ford ES, Gles WH, Dietz WH. Prevalence of the metabolicsyndrome among US adults: Findings from the ThirdNational Health and Nutrition Examination survey. JAMA:The Journal of the American Medical Association 2002; 287:356–359.

5 Bureau of Health Promotion, Department of Health,R.O.C. (Taiwan). The criteria of metabolic syndromeamong Adults, 2007. Available from URL: http://www.hpa.gov.tw/BHPNet/Portal/File/ThemeDocFile/20110

2140310199776/2007%e4%b8%89%e9%ab%98%e5%b0%88%e8%bc%af_%e7%b0%a1%e5%96%ae%e7%89%88_20121218%e4%bf%ae.pdf. Accessed 1 August 2013.

6 Chaung SY, Chen CH, Tsai ST, Chou P. Clinical identifi-cation of the metabolic syndrome in Kinmen. ActaCardiologica Sinica 2002; 18: 16–23.

7 Cheng CL, Chiu SL, Ming ML et al. Metabolic syndrome ina Taiwanese metropolitan adult population. BMC PublicHealth 2007; 7: 239–245.

8 Lee LT, Chang YC, Huang KC, Pan WH, Chen CY.The prevalence survey of metabolic syndrome of theelderly in Taiwan. Taiwan Geriatrics and Gerontology 2005; 1:9–18.

9 U.S. Department of Health and Human Services(USDHHS). Health communication and health informationtechnology, 2009. Available from URL: http://www.healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=25&;TopicArea=Health+Communication+and+Health+IT. Accessed 10 July 2010.

10 World Health Organization. Global health risk: mortalityand burden of disease attributable to selected major risk. Avail-able from URL: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf.Accessed 1 August 2013.

11 International Council of Nurses. Delivering quality,serving communities: Nurses leading chronic care, 2010.Available from URL: http://www.parlatore.com.br/whocc/images/online/arquivo_indkit2010.pdf. Accessed20 December 2011.

12 Kutschman RF, Hadley S. Diagnosing and treatingmetabolic syndrome. Geriatric Nursing 2004; 25: 218–223.

13 American Nurses Association. Nursing: Scope and Standards ofPractice. Washington, DC: American Nurses AssociationPublishing, 2004.

14 Heinrich C, Karner K. Ways to optimize understandinghealth related information: The patients’ perspective.Geriatric Nursing 2011; 32: 29–38.

15 Resnick B. Care of the elderly adults. In: Nettina S (ed.).The Lippincott Manual of Nursing Practice. New York:Lippincott, 1999; 118–140.

16 Li IC, Chen YC, Kuo HT. The health status and healthpromotion behavior of low-income elderly in the Taipeiarea. Journal of Nursing Research 2005; 13: 305–312.

17 Lee TW, Ko IS, Lee KJ. Health promotion behaviors andquality of life among community-dwelling elderly in Korea:A cross-sectional survey. International Journal of NursingStudies 2006; 43: 293–300.

18 Hsieh CH. The effects of regular exercise training onbody composition, cardiorespiratory fitness, and bloodbiochemical index in subjects with metabolic syn-drome. Unpublished thesis. Taipei Medical University,2005.



19 Walker SN, Sechrist KR, Pender NJ. The Health-Promoting Lifestyle Profile: Development and psycho-metric characteristics. Nursing Research 1987; 36: 76–81.

20 Pender N, Murdaugh C, Parsons MA. Health Promotion inNursing Practice, 5th edn. Upper Saddle River, NJ, USA:Pearson Education, 2005.

21 Wei MH, Lu CM. Development of the short-form Chinesehealth promotion lifestyle profile. Journal of Health Education2005; 24: 25–46.

22 Chen YR. Health-Promoting Lifestyles and related factorsin adult health check-up group with different risk factors ofmetabolic syndrome—A medical center in Taipei. Unpub-lished Thesis. Taipei, Taiwan: National Taiwan NormalUniversity, 2008. Available from URL: http://ir.lib.ntnu.edu.tw/ir/handle/309250000Q/72236. Accessed 08March 2012.

23 Bloom H. Preventive medicine: When to screen for diseasein older patients. Geriatrics 2001; 56: 41–45.

24 Dwyer J. Chronic disease and dietary management in theelderly: Alive and kicking. Journal of Nutritional Health andAging 2001; 5: 103–107.

25 Stark MA, Chase C, DeYoung A. Barriers to health promo-tion in community dwelling elders. Journal of CommunityHealth Nursing 2010; 27: 175–186.

26 Boule NG, Haddad E, Kenny GP, Wells GA, Sigal RJ.Effects of exercise on glycemic control and body mass intype 2 diabetes mellitus: A meta-analysis of controlled clini-cal trials. JAMA: The Journal of the American Medical Association2001; 286: 1218–1227.

27 Wang XW, Hsu FC, Isom S et al. Effects of a 12-monthphysical activity intervention on prevalence of metabolicsyndrome in elderly men and women. The Journals of Ger-ontology. Series A, Biological Sciences and Medical Sciences 2012;67A: 417–424.

28 Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: Aflexible statistical power analysis program for the social,behavioral, and biomedical sciences. Behavior ResearchMethods 2007; 39: 175–191.

29 Cohen J. A power primer. Psychological Bulletin 1992; 112:155–159.



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