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Design and preliminary results of a metropolitan lifestyle intervention program for people with metabolic syndrome in South Korea
diabetes research and clinical practice 101 (2013) 293–302
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Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Design and preliminary results of a metropolitan lifestyle intervention program for people with metabolic syndrome in South Korea Yo-Han Lee a, Seok-Jun Yoon b,*, Hyeong-Su Kim c, Sang-Woo Oh d, Ho-Sihn Ryu e, Jin-A Choo e, So-Nam Kim f, Young-Ae Kim a, Mi-Suk Park g, Yun-Suk Park g, Sun-Young Kim g, A-Rom Kwon g a
Graduate School of Korea University, Department of Public Health, Seoul, Republic of Korea Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea c Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Republic of Korea d Center for Obesity, Nutrition, and Metabolism, Department of Family Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Gyeonggi, Republic of Korea e Korea University College of Nursing, Seoul, Republic of Korea f Department of Nursing, Seojeong College, Gyeonggi, Republic of Korea g Metabolic Syndrome Management Center of Seoul Metropolitan Government, Seoul, Republic of Korea b
article info
abstract
Article history:
Introduction: The Seoul Metabolic Syndrome Management (SMESY) project, a metropolitan
Received 30 January 2013
lifestyle intervention program aimed at decreasing the risk of metabolic syndrome to the
Received in revised form
residents of the city, has recently been implemented in 2011.
15 May 2013
Methods: Our target population consisted of residents of Seoul who were 30–64 years old.
Accepted 6 June 2013
Subjects visiting a Public Health Center were screened for five risk factors for metabolic
Available online 11 July 2013
syndrome and then divided into three groups according to the number of the risk factors:
Keywords:
one or two; and information support for having none. Members of the active counseling
active counseling, for having more than three risk factors; motivational guide, for having Counseling
group, the main target of the project, were provided with monthly in-person counseling on
Lifestyle
health-related lifestyle choices, as well as a follow-up examination every 3 months during
Metabolic syndrome
the 12-month program.
Non-communicable disease
Results: In the active counseling group, subjects showed statistically significant improve-
Prevention
ments in all five risk factors and the average number of retained risk factors decreased from 3.5 to 2.7. However, the percentage of active counseling group members who attended at least 3 out of the 4 sessions provided was only 11.3%. As for the motivational guide group and the information support group, clinically significant improvements were not observed and the percentage of members who attended all sessions were 10.4% and 11.8%, respectively.
* Corresponding author at: Department of Preventive Medicine, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbukgu, Seoul 136-705, Republic of Korea. Tel.: +82 2 920 6412; fax: +82 2 927 7220. E-mail addresses: [email protected] (Y.-H. Lee), [email protected], [email protected] (S.-J. Yoon), [email protected] (H.-S. Kim), [email protected] (S.-W. Oh), [email protected] (H.-S. Ryu), [email protected] (J.-A. Choo), [email protected] (S.-N. Kim), [email protected] (Y.-A. Kim), [email protected] (M.-S. Park), [email protected] (Y.-S. Park), [email protected] (S.-Y. Kim), [email protected] (A.-R. Kwon). 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.06.006
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Conclusions: Increased public participation for the ongoing project is expected to lead to great positive changes in the health of people with metabolic syndrome. # 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Non-communicable disease (NCD) is becoming a major public health problem in both developed and developing countries due to the decrease in communicable diseases and increase in life expectancy [1,2]. Globally, NCD is responsible for half of all mortality and disease burden, with cardiovascular disease (CVD) and diabetes mellitus (DM) accounting for half of all NCD mortalities [3]. Although high blood pressure, high blood glucose, and lipid abnormalities are the immediate causes of NCD, the underlying causes stem from unhealthy lifestyles; 80% of deaths caused by NCD are preventable [4]. Therefore, the best strategy for addressing NCD is prevention through lifestyle modification. There are effective national or regional prevention strategies for NCD in some developed countries, such as the North Karelia project in Finland (established to reduce coronary heart disease), and diabetes prevention programs exist in multiple countries around the world [5–8]. As a countermeasure to the rapid increases in the disease burden and medical costs of chronic disease, Japan launched a nationwide project in 2008 that implements focused health guidance and targets metabolic syndrome patients [9]. Japan’s project, unlike other existing NCD prevention programs, strategically targets metabolic syndrome, which is a pre-morbid state of NCD. In Korea, CVD and DM create the greatest burden of disease, and the socioeconomic costs from these conditions are steadily rising [10–12]. Considering the substantial adverse effects of these conditions, a national NCD prevention program is urgently needed in Korea. However, the country’s healthcare system is largely privatized and centered on treatment, and such a wide-scale prevention strategy has never been implemented. Public Health Centers acting as local public health agencies have been in charge of such preventive services, but there are no standardized programs. Amidst the urgent need for an effective and practical NCD prevention program in Korea, the Seoul Metabolic Syndrome Management (SMESY) project, a lifestyle intervention program aimed at decreasing the risk of metabolic syndrome, was officially implemented across Seoul in March 2011, a year after launching the demonstrative project. This paper discusses the design and preliminary results of this project.
1.1.
Theoretical framework for the project
The basic theoretical background of the SMESY project is based on metabolic syndrome as a high-risk condition for CVD and DM. Metabolic syndrome comprises a collection of cardiometabolic risk factors: abdominal obesity, high blood pressure,
hyperglycemia, and lipid abnormalities [13]. According to the Framingham Heart Study, people with metabolic syndrome are two times more likely to have CHD and five times more likely to have type 2 diabetes than people without metabolic syndrome [14]. Numerous studies have shown that metabolic syndrome is an important predictor of CVD and DM mortality [15]. The World Health Organization (WHO) states that metabolic syndrome should not be used as a tool for clinical diagnosis of a disease but should be considered a pre-morbid state of CVD and diabetes. The WHO recommends a populationbased program that utilizes the concept of metabolic syndrome as a cost-effective CVD reduction strategy [16]. In other words, metabolic syndrome is being recognized as an effective tool for identifying subjects who are at a high-risk of developing CVD and DM. The first management approach for metabolic syndrome is not drug treatment, but lifestyle modification, that is to say, making healthier choices in diet, exercise, and smoking [17]. Several randomized-controlled trials have shown that direct lifestyle interventions have a significant effect on improving health. Diet and exercise programs significantly decrease biochemical indicators of metabolic syndrome, weight, and waist circumference [18,19]. Similar results have been reported in lifestyle interventions for people with metabolic syndrome [20,21]. Unsurprisingly, the more closely a patient follows an intervention program, the greater the reduction in symptoms of metabolic syndrome [22]. Japan’s project provides evidence of the effectiveness of a population-based program for people with metabolic syndrome. About 400,000 metabolic syndrome patients participated in a 6-month consultation intervention program aimed at improving lifestyles and significant improvements in all risk factors of metabolic syndrome were observed. Based on the theoretical framework regarding the usefulness of the metabolic syndrome concept and the effectiveness of lifestyle intervention mentioned above, the SMESY project planned a counseling intervention program to improve the lifestyles of people with metabolic syndrome.
2.
Materials and methods
2.1.
Subject eligibility and recruitment
The target population consisted of residents of Seoul aged 30– 64 years. The prevalence of metabolic syndrome under the age of 30 is low, and the effectiveness of consultation intervention for people over 65 is reportedly lower. The project was promoted through various media outlets and directed interested citizens to the nearest Public Health Center which is public health agency uniformly distributed across Seoul city.
diabetes research and clinical practice 101 (2013) 293–302
Visit to a Public Health Center after 10 hours of fasting
Enrollment for the SMESY project
Screening for five risk factors of metabolic syndrome And group classification
Active counseling group
Motivational guide group
With more than three risk factors
Lifestyle counseling over the course of 12 months
With one or two risk factors
Information support group Without any risk factors
Fig. 1 – Basic process of the program.
2.2.
choices such as diet, smoking, alcohol consumption, and physical activity (Fig. 1). After being screened for the five risk factors of metabolic syndrome, they were divided into one of three groups based on the number of metabolic syndrome risk factors. The three groups received interventions that differed in both the contents and the frequencies of the service provided. In-person counseling was provided only to one group having metabolic syndrome while a follow-up program for 12 months was a part common to the interventions for all three groups. The goal of the interventions was to improve all aspects of participants’ lifestyle.
2.3.
Basic process of the program
When a respondent visited a Public Health Center to enroll in the program, they were first asked to provide demographic information such as sex, age, education level, and economic status, and to answer questions on health-related lifestyle
Screening examination
All subjects fasted for 10 h before being tested for the five risk factors of metabolic syndrome: waist circumference, blood pressure, plasma glucose, triglycerides, and high-density lipoprotein (HDL) cholesterol. Waist circumference was measured in triplicate at the midpoint between the lower rib and the iliac crest. Systolic blood pressure and diastolic blood pressure were measured with an automatic blood pressure cuff after the subject had been seated for 10 min. Serum triglycerides and HDL cholesterol levels were determined by enzymatic methods with a chemistry analyzer. Plasma glucose was measured with the glucose oxidase method.
2.4. Health tip t ext message service and f ollow-up examinations over the course of 12 months
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Definition of metabolic syndrome
Metabolic syndrome was defined with the widely used National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III) guidelines [23]. If any three of the five risk factors are beyond the criteria, NCEP-ATP III defines the case as metabolic syndrome [13]. Criteria provided by the International Diabetes Federation and others that factor in abdominal obesity are not appropriate for the SMESY project, as it is relatively common for Koreans to have metabolic syndrome without abdominal obesity [24]. Because Asians have a greater risk of fitting the metabolic profile at lower waist circumferences than Caucasians [23], the waist circumference standard was lowered for the SMESY project based on data from the Korean Society for the Study of Obesity (Table 1) [25].
Table 1 – Criteria for risk factors of metabolic syndrome and group classification. Risk factors/groups
Description a
Risk factors of metabolic syndrome Elevated waist circumference Elevated triglycerides Low high-density lipoprotein (HDL) cholesterol Elevated blood pressure Elevated fasting glucose Group classification Active counseling Motivational guide Information support
90 cm in men, 85 cm in women 150 mg/dL <40 mg/dL in men, <50 mg/dL in women 130/85 mmHg systolic/diastolic blood pressure 100 mg Presence of at least three of the above five risk factors Presence of one or two of the above five risk factors No risk factors
a Based on the criteria of the National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III), except for elevated waist circumference, which is based on the Korean Society for the Study of Obesity.
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Table 2 – Content and timeframe of counseling and follow-up programs by group. Group
Counseling
Active counseling
Motivational guide
Information support
2.5.
Follow-up
Content
Frequency
Content
Frequency
In-depth counseling on diet, smoking, alcohol use, and exercise Diet: Take dietary history, prescribe nutrition regimen, and monitoring Smoking and alcohol use: Step-by-step counseling based on changes in subject’s behavior Exercise: Prescribe exercise regimen and monitor based on subject’s physical activity level Not provided
Once a month
Re-examination for metabolic risk factors Text message with health tip
Every 3 months
Subjects were divided into the active counseling group, the motivational guide group, or the information support group, based on the number of risk factors present in each subject (Table 1). Subjects with more than three risk factors were considered to have metabolic syndrome and were provided active counseling, subjects with one or two risk factors were provided with motivational guide, and subjects without any risk factors were given informational support. Following WHO recommendations stating that subjects already in the disease stage should not be diagnosed with metabolic syndrome [16], people with hypertension, DM, or dyslipidemia who were taking medication were classified as a separate group regardless of the number of the risk factors and provided with the same program as the motivational guide group.
2.6.
Text message notifying subject of next re-examination
Re-examination for metabolic risk factors Text message with health-tip Text message notifying subject of next re-examination Re-examination for metabolic risk factors Text message with health tip Text message notifying subject of next re-examination
Not provided
Group classification
Lifestyle counseling program
Face-to-face lifestyle counseling on diet, physical activity, smoking, and alcohol consumption was provided monthly to the subjects in the active counseling group, the main target of the intervention program, for the following 12 months (Table 2). When a subject visited a Public Health Center for an appointment, the times for which were available only during the daytime on weekdays, one-to-one counseling with an expert was provided for each lifestyle choice. Four one-to-one counseling sessions for each lifestyle choice (diet, physical activity, smoking, and alcohol consumption) therefore were performed sequentially, each lasting 10–15 min, in one visit. The expert team consisted of a dietitian for diet control, an exercise specialist for physical activity regimen, and a medical doctor or a nurse for restriction of alcohol consumption and smoking cessation. Basically, lifestyle regimen and education tailored to each subject were provided according to one’s
Once a week Once a month
Every 6 months Every 2 months Every 3 months Once a year Once a month Once a year
lifestyle history and the number of metabolic risk factors he or she had. In ensuring reproducibility, the counseling provided was performed based on a standardized counseling manual, drafted specifically for the need of and use for this project on the basis of updated and practical researches on the Korean population. Inter-counselor variability, therefore, was expected to have been minimized. During a counseling session, multiple situations and cases were assumed and no specific goal for each metabolic risk factor was established, as the purpose of the lifestyle counseling was to motivate the subjects so that they would change their unhealthy lifestyle on their own. The lifestyle counseling was also offered to the subjects in the other two groups at their request, and a session was conducted via phone or e-mail when face-to-face counseling was not available.
2.6.1.
Diet
Dietary counseling was provided by dietitians and consisted of an inquiry into dietary history, a nutrition regimen, and regular monitoring. Dietary history was collected through a 24-hour recall method and a weekly meal diary. Diet regimen was developed according to each subject’s major health and dietary problems. The service consisted of calculating proper calorie needs and providing quantitative dietary recommendations. The diet plan for obese subjects with the focus on calorie restriction, for example, included visual aids, such as diagrams depicting desirable food combinations and their total calories for each meal. Subjects with increased blood pressure received a regimen focused on reducing salt intake and promoting balanced intake of key nutrients, based on Dietary Approaches to Stop Hypertension (DASH) diet pattern, which was developed by the United States Department of Health and Human Services [26]. During the following consultation, the subject’s adherence to the diet regimen was evaluated and future counseling plans were discussed accordingly.
diabetes research and clinical practice 101 (2013) 293–302
2.6.2.
Physical activity
Exercise specialists conducted physical activity counseling sessions. A subject’s physical activity was determined every session using a standardized physical activity questionnaire, which takes into account and sums up all physical activities from the three areas of exercise, domestic chores, and vocational activity, on a weekly basis by intensity and duration. If a subject’s totaled duration of moderate-intensity physical activity per week was less than 150 min, he or she was determined to have insufficient physical activity [27]. As with nutrition counseling, a tailored physical activity regimen was prescribed based on a subject’s determined physical activity level and his or her number of metabolic syndrome risk factors. Both measurements, physical activity level and the number of metabolic syndrome risk factors, were evaluated during each consultation. Targeting 150 min of moderate-intensity physical activity per week, the regimen provided more concrete goals for increasing physical activity through exercise and lifestyle change. For subjects with less than 100 min of moderate-intensity physical activity per week, for example, daily walking for more than 10 min was prescribed.
2.6.3.
Follow-up program
To monitor the five risk factors of metabolic syndrome and changes in lifestyle, the active counseling group was reassessed every 3 months, the motivational guide group every 6 months, and the information support group once at the end of the follow-up period. Since all South Korean adults are literate and possess their own mobile phones, mobile phone text messages which differ in contents according to the groups were sent to the subjects. For the active counseling group, one health tip text message was sent out once per week, a message encouraging further efforts was sent out once a month, and a message notifying the subject of upcoming visits was also sent out once a month. The motivational guide group and the information support group received text messages less frequently than the active counseling group (Table 2).
2.8.
of people who enrolled for the program and received the baseline testing during the period of 2 years from January 2010 to December 2011 was 134,092. The baseline lifestyle factors of smoking, drinking, and physical activity, and the averages of the five metabolic risk factors for this population are expressed as N (%) and mean standard deviation, respectively, by group. In assessing the degree of participation, a subgroup of the aforementioned enrolled 134,092 was selected. Participants who enrolled from January 2010 to April 2011 were pooled, and there were 65,197 subjects. Data on these participants were extracted and attendance in each group was evaluated. To evaluate the effects of the project, the group of subjects who did receive re-examination after 12 months out of the total 65,197 participants was selected. 12,596 participants who satisfied this criterion were therefore analyzed. The changes in metabolic risk factor values and the average number of retained risk factors between baseline and the 12-month re-examination were evaluated. Paired t-tests were used to test for significance. Data collection and analyses were performed using stata 11.0 (StataCorp, College Station, TX).
Smoking and alcohol use
Counseling for smoking and alcohol use was provided by a medical doctor and nurse and evaluation and counseling were conducted with widely used tools. The Korean version of the Alcohol Use Disorders Identification Test developed by WHO (AUDIT-K) was used to measure alcohol intake [28,29], and subjects were classified into moderate drinking, at-risk drinking, alcohol abuse, or alcohol dependence groups. Visual material based on medical evidence was used to advise moderation in drinking for all subjects, and subjects were counseled on a step-by-step strategy to help change their behavior. Counseling for smoking was based on Prochaska’s model for smoking cessation [30], and also included ‘the 5R’s and 5A’s method’ used by various smoking cessation programs [31].
2.7.
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Statistical analyses of preliminary results
For interim findings of this ongoing program, three different populations of subjects were analyzed. First, the total number
3.
Results
3.1.
Participant characteristics at baseline
Of all participants who enrolled for two years, 25,766 were classified into the active counseling group, and 84,467 and 23,859 were classified into the motivational guide group and information support group, respectively (Table 3). The proportion of males was highest in the active counseling group with 48.7% and was less in the motivational guide group (37.4%) and information support group (23.5%). As expected, the proportion of smokers was highest in the active counseling group, but drinking habits and physical activity levels did not differ among the groups. The metabolic risk factor values were most unfavorable in the active counseling group. The average number of risk factors in the active counseling group was 3.5; in the motivational guide group and information support group it was 2.0 and 0.0, respectively.
3.2.
Effects of the project
We observed different effects among the groups. In the active counseling group, all five risk factors showed statistically significant improvement, and the average number of retained risk factors decreased from 3.5 to 2.7 (Table 4). 41.4% of the active counseling group subjects, all of whom initially had metabolic syndrome before entering the project, were found to have fewer than three risk factors, a change signifying that they no longer had metabolic syndrome (data now shown). On the other hand, clinically significant improvements in the risk factor values and the number of risk factors were not observed in the motivational guide group and the information support group despite of the statistical significance, which resulted probably from the large sample size.
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Table 3 – Lifestyle choices and metabolic risk factors of participants at baseline.
Age (mean SD) Smoking (N (%)) Nonsmoker Ex-smoker Current smoker Alcohol consumption (N (%)) Yes No Regular physical activity (N (%)) Yes No Metabolic syndrome component (mean SD) WC (cm) SBP (mmHg) DBP (mmHg) FBG (mg/dL) HDL-C (mg/dL) TG (mg/dL) Average no. of retained metabolic risk factors
Motivational guide
Information support
Male (n = 12,545)
Female (n = 13,221)
Total (n = 25,766)
Male (n = 31,614)
Female (n = 52,853)
Total (n = 84,467)
Male (n = 5610)
Female (n = 18,249)
Total (n = 23,859)
47.6 9.4
52.1 8.5
49.9 9.2
49.9 9.7
51.6 9.1
51.0 9.4
44.7 10.1
44.9 9.8
44.9 9.9
4024(33.6) 3706(31.0) 4238(35.4)
12,027(95.2) 269(2.1) 336(2.7)
16,051(65.2) 3975(16.2) 4574(18.6)
11,217(37.1) 10,128(33.5) 8906(29.4)
48,853(95.9) 1026(2.0) 1044(2.1)
60,070(74.0) 11,154(13.7) 9950(12.3)
2317(43.3) 1502(28.0) 1538(28.7)
16,756(95.5) 448(2.6) 350(2.0)
19,073(83.2) 1950(8.5) 1888(8.2)
3235(29.1) 7865(70.9)
8181(65.6) 4284(34.4)
11,416(48.4) 12,149(51.6)
8866(30.8) 19,912(69.2)
32,048(63.7) 18,258(36.3)
40,914(51.7) 38,170(48.3)
1677(32.5) 3485(67.5)
9815(56.6) 7511(43.4)
11,492(51.1) 10,996(48.9)
6763(57.2) 5051(42.8)
6111(48.8) 6417(51.2)
12,874(52.9) 11,468(47.1)
18,567(62.1) 11,315(37.9)
28,154(55.7) 22,365(44.3)
46,721(58.1) 33,680(41.9)
3324(62.7) 1976(37.3)
9773(56.0) 7675(44.0)
13,097(57.6) 9651(42.4)
90.8 7.1 135.8 15.1 87.0 10.9 110.3 30.9 40.0 12.4 234.6 110.0
86.0 8.0 130.6 16.6 82.3 11.0 107.4 24.9 43.4 11.8 206.0 96.3
88.3 8.0 133.1 16.1 84.6 11.2 108.8 28.0 41.8 12.2 219.9 104.1
86.0 7.2 128.7 15.2 81.7 10.7 104.4 29.6 47.9 13.5 157.2 91.9
80.7 8.2 122.4 15.9 76.8 10.6 99.3 22.7 53.0 14.3 138.6 80.4
82.7 8.3 124.7 15.9 78.6 10.9 101.2 25.7 51.1 14.2 145.5 85.4
80.1 5.7 115.4 8.7 72.7 7.1 89.1 7.4 55.4 11.0 92.0 28.7
74.2 6.0 111.0 9.9 69.9 7.6 88.1 7.2 64.5 10.4 84.0 27.1
75.6 6.5 112.0 9.8 70.6 7.6 88.3 7.3 62.4 11.3 85.9 27.7
3.5 0.6
3.4 0.6
3.5 0.6
2.1 1.1
2.0 1.1
2.0 1.1
0.0 0.1
0.0 0.1
0.0 0.1
WC: waist circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure; FBG: fasting blood glucose; HDL-C: high density lipoprotein cholesterol; TG: triglyceride.
diabetes research and clinical practice 101 (2013) 293–302
Active counseling
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Table 4 – Changes in metabolic risk factors during the program by group. Risk factors
WC (cm) SBP (mmHg) DBP (mmHg) FBG (mg/dL) HDL-C (mg/dL) TG (mg/dL)
Active counseling (N = 1962)
Motivational guide (N = 8774)
Information support (N = 1860)
0 month
12 month
P value
0 month
12 month
P value
0 month
12 month
P value
88.3 7.7 132.8 16.1 83.8 11.0 106.3 24.1 41.7 11.5 213.8 101.7
87.1 7.6 126.5 14.4 80.6 10.2 102.3 19.1 43.7 12.4 175.6 90.2
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
83.5 8.2 125.7 15.9 78.5 10.6 101.0 22.8 50.8 14.2 148.7 86.3
83.2 8.0 124.1 15.4 77.7 10.1 100.3 20.5 50.2 14.1 139.7 76.1
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
75.7 6.5 111.8 10.0 70.9 7.7 88.0 7.6 62.3 11.4 86.9 28.1
76.2 6.8 112.9 12.1 71.6 8.6 90.5 9.2 59.8 13.6 100.7 52.0
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
3.5 0.6
2.7 1.2
<0.001
2.2 1.2
2.2 1.4
0.0 0.1
0.6 0.8
<0.001
Average no. of retained metabolic risk factors
0.001
P value: Analysis by paired t-test between 0 and 12 months. WC: waist circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure; FBG: fasting blood glucose; HDL-C: high density lipoprotein cholesterol; TG: triglyceride.
Table 5 – Program attendance by group. Active counseling (4 sessions)
Attended 1 session Attended 2 sessions Attended 3 sessions Attended 4 sessions Never attended
3.3.
N = 12,155
%
2141 1517 816 555 7126
17.6 12.5 6.7 4.6 58.6
Adherence to the program
Program participation rates by group are shown in Table 5. The percentage of active counseling group members who attended at least 3 out of 4 sessions provided was only 11.3% and more than half of the participants (58.6%) never attended a session. As for the motivational guide group and the information support group, the percentages of members who attended all sessions were 10.4% and 11.8%, respectively.
4.
Discussion
4.1.
Significance of the project
NCD prevention and management is one of the most important public health issues world-wide, and the WHO is emphasizing the need for practical and effective strategies [32]. The SMESY project is a community-based NCD prevention program that provides intensive care by strategically targeting metabolic syndrome, which is an early phase of NCD. The prevalence of metabolic syndrome in Koreans increased from 24.9% in 1998 to 31.3% in 2007 [33]. Although obesity is not as common in Korea as in Western countries, Koreans are more likely to be diagnosed with metabolic syndrome [34,35]. People who are ‘metabolically obese – normal weight’ are equally at risk for DM, hyperlipidemia, and CHD as obese people [36,37]. This implies that Koreans are more metabolically vulnerable than Westerners, and thus the need to improve Korean lifestyles is critical and more aggressive lifestyle intervention is needed. Therefore, it is important to
Motivational guide (2 sessions) N = 40,968
%
Information support (N = 1 session) N = 12,074
%
9875 4258
24.1 10.4
1428
11.8
26,835
65.5
10,646
88.2
fully implement a lifestyle counseling program such as the SMESY project.
4.2.
Features of the project
First, the project utilized both a ‘high-risk group approach,’ which is the traditional disease prevention strategy that focuses on high-risk individuals, as well as a ‘populationbased approach’ [38]. A systematic lifestyle intervention program for metabolic syndrome patients was implemented in conjunction with promotional strategies aimed at increasing public awareness of metabolic syndrome and the importance of lifestyle choices. The project was promoted via the press, advertising in Public Health Centers, the Internet, and promotional materials placed on public transportation. Promotional content consisted of information about metabolic syndrome and the benefits of managing symptoms, an explanation of the SMESY Project, and encouragement of public participation. This dual approach is underscored by the WHO as a guiding principle for NCD prevention and control [39]. Second, the SMESY project attempted intervention through face-to-face counseling in Public Health Centers, which are accessible to all citizens. Because Seoul is the most urbanized city in Korea, it is important to effectively use the city’s advantageous environment when creating a health improvement strategy for its residents [40]. Seoul city consists of 25 districts and every Public Health Center in every district can function as a provider for the program. Third, the management period of subjects with metabolic syndrome was lengthened to 12 months, which is twice as
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long as those subjects were managed in Japan’s study. In terms of support, the frequency of face-to-face counseling and reexamination was significantly longer in the SMESY project. The SMESY project focused on lifestyle modifications, which should be made gradually over a long period of time [41], and therefore a 12-month program seemed appropriate. Through this, the SMESY project aimed to encourage greater motivation and efforts for lifestyle improvements and enable more effective follow-up management.
4.3.
Comment on the effects of the project
Since this project is in progress and is in its initial stages, a crude evaluation of the available participants and data was made. There was a statistically significant improvement to the risk factors for metabolic syndrome in the active counseling group, which is the main target group of the project. In particular, the average number of retained risk factors in the active counseling group decreased to 2.7, a number that does not meet the diagnostic criteria for metabolic syndrome. This improvement is very meaningful considering the result of a study to Korean subjects reporting that as the number of risk factors for metabolic syndrome decreases, the mortality rate for cardiovascular disease patients significantly decreases [42]. When considering the low participation rates, however, one can raise questions about the true effect of the project for the following reasons: the result was obtained from the subjects who took the 12-month re-examination and these might be ‘active’ participants who were more interested in their health and thus practiced healthier lifestyles. In other words, the aforementioned result could be considered biased, leading to the possibility that the observed effects were only from the participants’ own abilities, without any contribution of the program. In assessing the effect of the program, it is however important to note that the ultimate goal of the project is to motivate people to change their lifestyles and manage their health on their own. In this design, it is not a surprise that highly motivated people are more likely to achieve positive results through the project since the subjects’ commitment and efforts are most crucial to lifestyle improvements and the program functioned as a platform for the desired change. Ultimately, improving self-management skills through selfempowerment has the biggest effect on personal health and lifestyle [43,44], and this philosophy is the foundation for various health promotion projects and chronic disease programs worldwide. A good example of this is the fact that strengthening individual autonomy and capacity was found to positively impact the ability to quit smoking [45]. On the other hand, no improvement was shown in the other two groups. It is assumed that because these two groups received relatively less services, there was relatively less room for improvement over the course of the project. The optimistic view of this result is that healthy and relatively healthy subjects maintained their health without further degeneration.
4.4.
Comment on the participation of the project
The most challenging part of the present project appears to be the low participation rate. Two explanations for this phenom-
enon would be possible. First, the Korean society, in general, is not familiar with the concepts of preventive care and health management through self-empowerment. As the society has placed a greater emphasis on the treatment-centered medical services, people have not had the chance to develop interest in and acknowledgement of the importance of taking preventive measures. In this aspect, the project fell short in motivating the participants for self-management. Organized efforts of individual education and public promotion would be necessary to motivate people and increase public participation. In addition, the public demand for the counseling service should be met, and the effectiveness of the counselors in motivating subjects should be raised. Unavailability of the project services, in terms of time and place, can be another critical factor in lowering the participation rate. It could have been that many people who were interested in the project might have had difficulties in attending sessions since the sessions were held only on weekdays during the daytime and in one place per district. This additional demotivating factor should be eliminated through opening sessions in the evening and on holidays and at the branch facilities of a Public Health Center as they could be utilized as service-providing places. In Japan’s project, counseling was offered during evening hours and on holidays in some areas and, there was a significantly large effect on health improvement [46].
4.5.
Scheme for future evaluation
The effectiveness of the project will be evaluated by analyzing changes in the prevalence of metabolic syndrome and the changes in risk factors of metabolic syndrome, based on the results of a re-examination of all subjects who completed the 12-month program. The change in the prevalence of metabolic syndrome will be measured against the baseline prevalence using the Generalized Estimating Equations (GEE) model. The rate of numerical change for each risk factor will also be analyzed based on the results of the re-examination using analysis of covariance (ANCOVA). In addition, the same methods mentioned above will be used to evaluate the subjects’ extent of lifestyle modification, which is the ultimate goal of this program. Because it is not possible to create a control group to compare the effects of the program, the project will measure changes in prevalence, levels of metabolic syndrome, and the rate of lifestyle modifications in participants who were unable to fully participate in the program. Demographic information such as age, sex, education, economic level, and place of residence for subjects who did and did not fully participate in the program will be analyzed using a chi-square test or t-test to understand why some subjects fully participated and others did not.
5.
Conclusions
The SMESY project is the first metropolitan-wide lifestyle intervention program for people with metabolic syndrome conducted in South Korea. The project has resulted in significant improvements to the risk factors of metabolic syndrome. Increased public participation for the project is
diabetes research and clinical practice 101 (2013) 293–302
expected to lead to great positive changes in the health of Seoul citizens.
Conflict of interest The authors declare that they have no competing interests.
Ethics Approval of the project was obtained from the Institutional Review Board of the Korean University Medical Center and all participants provided written informed consent.
Acknowledgements This project was supported by a grant from the Seoul Metropolitan Government.
references
[1] McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270(18):2207–12. [2] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367(9524):1747–57. [3] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global burden of disease and risk factors. Washington, DC: Oxford University Press; 2006. [4] World Health Organization. Preventing chronic disease: a vital investment. Available online at http://www.who.int/ chp/chronic_disease_report/order_form.pdf. [5] Puska P. Fat and heart disease: yes we can make a change – the case of North Karelia (Finland). Ann Nutr Metab 2009;54(Suppl. 1):33–8. [6] Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, et al. 10-Year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374(9702):1677–86. [7] Lindstrom J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, et al. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003;26(12):3230–6. [8] Nikki M, Sara A, Aliceon B, Mike S. The Norfolk diabetes prevention study (Norfolk DPS). Psychol Health 2011;26:270–1. [9] Kohro T, Furui Y, Mitsutake N, Fujii R, Morita H, Oku S, et al. The Japanese national health screening and intervention program aimed at preventing worsening of the metabolic syndrome. Int Heart J 2008;49(2):193–203. [10] Kang HY, Lim SJ, Suh HS, Liew D. Estimating the lifetime economic burden of stroke according to the age of onset in South Korea: a cost of illness study. BMC Public Health 2011;11:646. [11] Hong KS, Kim J, Cho YJ, Seo SY, Hwang SI, Kim SC, et al. Burden of ischemic stroke in Korea: analysis of disability-adjusted life years lost. J Clin Neurol 2011;7(2):77–84.
301
[12] Yoon SJ, Bae SC, Lee SI, Chang H, Jo HS, Sung JH, et al. Measuring the burden of disease in Korea. J Korean Med Sci 2007;22(3):518–23. [13] Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/ National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112(17):2735–52. [14] Grundy SM, Brewer Jr HB, Cleeman JI, Smith Jr SC, Lenfant C. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004;109(3):433–8. [15] Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005;28(7):1769–78. [16] Simmons RK, Alberti KG, Gale EA, Colagiuri S, Tuomilehto J, Qiao Q, et al. The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation. Diabetologia 2010;53(4):600–5. [17] Grundy SM, Hansen B, Smith Jr SC, Cleeman JI, Kahn RA. Clinical management of metabolic syndrome: report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation 2004;109(4):551–6. [18] Singh RB, Singh NK, Rastogi SS, Mani UV, Niaz MA. Effects of diet and lifestyle changes on atherosclerotic risk factors after 24 weeks on the Indian Diet Heart Study. Am J Cardiol 1993;71(15):1283–8. [19] Anderssen SA, Hjermann I, Urdal P, Torjesen PA, Holme I. Improved carbohydrate metabolism after physical training and dietary intervention in individuals with the ‘‘atherothrombogenic syndrome’’, Oslo Diet and Exercise Study (ODES). A randomized trial. J Intern Med 1996;240(4):203–9. [20] Watkins LL, Sherwood A, Feinglos M, Hinderliter A, Babyak M, Gullette E, et al. Effects of exercise and weight loss on cardiac risk factors associated with syndrome X. Arch Intern Med 2003;163(16):1889–95. [21] Poppitt SD, Keogh GF, Prentice AM, Williams DE, Sonnemans HM, Valk EE, et al. Long-term effects of ad libitum low-fat, high-carbohydrate diets on body weight and serum lipids in overweight subjects with metabolic syndrome. Am J Clin Nutr 2002;75(1):11–20. [22] Fappa E, Yannakoulia M, Pitsavos C, Skoumas I, Valourdou S, Stefanadis C. Lifestyle intervention in the management of metabolic syndrome: could we improve adherence issues? Nutrition 2008;24(3):286–91. [23] Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285(19):2486–97. [24] Yoon YS, Lee ES, Park C, Lee S, Oh SW. The new definition of metabolic syndrome by the international diabetes federation is less likely to identify metabolically abnormal but non-obese individuals than the definition by the revised national cholesterol education program: the Korea NHANES study. Int J Obes (Lond) 2007;31(3):528–34. [25] Lee SPH, Kim SM, Kwon HS, Kim DY, Kim DJ, Cho GJ, et al. Cut-off points of waist circumference for defining abdominal obesity in the Korean population. Korean J Obes 2006;15(1):1–9. [26] National Health Institution. Your guide to lowering your blood pressure with DASH; 2006 available online athttp:// www.nhlbi.nih.gov/health/public/heart/hbp/dash/ new_dash.pdf.
302
diabetes research and clinical practice 101 (2013) 293–302
[27] US Department of Health and Human Services. 2008 physical activity guidelines for Americans; 2008 Available online athttp://www.health.gov/PAGuidelines. [28] Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption – II. Addiction 1993;88(6):791–804. [29] Kim SS, Gulick EE, Nam KA, Kim SH. Psychometric properties of the alcohol use disorders identification test: a Korean version. Arch Psychiatr Nurs 2008;22(4):190–9. [30] Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 1993;12(5):399–405. [31] Chandler MA, Rennard SI. Smoking cessation. Chest 2010;137(2):428–35. [32] Beaglehole R, Yach D. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Lancet 2003;362(9387):903–8. [33] Lim S, Shin H, Song JH, Kwak SH, Kang SM, Yoon JW, et al. Increasing prevalence of metabolic syndrome in Korea: the Korean National Health and Nutrition Examination Survey for 1998–2007. Diabetes Care 2011;34(6):1323–8. [34] Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988–1994. Arch Intern Med 2003;163(4):427–36. [35] Choi J, Se-Young O, Lee D, Tak S, Hong M, Park SM, et al. Characteristics of diet patterns in metabolically obese, normal weight adults (Korean National Health and Nutrition Examination Survey III, 2005). Nutr Metab Cardiovasc Dis 2012;22(7):567–74.
[36] Ruderman NB, Schneider SH, Berchtold P. The metabolically-obese, normal-weight individual. Am J Clin Nutr 1981;34(8):1617–21. [37] Ruderman N, Chisholm D, Pi-Sunyer X, Schneider S. The metabolically obese, normal-weight individual revisited. Diabetes 1998;47(5):699–713. [38] Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 1981;282(6279):1847–51. [39] World Health Organization. 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available online at http:// www.who.int/publications/2009/9789241597418_eng.pdf. [40] Leviton LC, Snell E, McGinnis M. Urban issues in health promotion strategies. Am J Public Health 2000;90(6):863–6. [41] Sniehotta FF, Schwarzer R, Scholz U, Schuz B. Action planning and coping planning for long-term lifestyle change: theory and assessment. Eur J Soc Psychol 2005;35(4):565–76. [42] Park HS, Cho SI, Song YM, Sung J. Multiple metabolic risk factors and total and cardiovascular mortality in men with low prevalence of obesity. Atherosclerosis 2006;187(1):123–30. [43] Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns 1995;26(1–3):139–44. [44] Glasgow RE, Anderson RM. In diabetes care, moving from compliance to adherence is not enough. Something entirely different is needed. Diabetes Care 1999;22(12):2090–2. [45] Williams GC, McGregor HA, Sharp D, Levesque C, Kouides RW, Ryan RM, et al. Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial. Health Psychol 2006;25(1):91–101. [46] Imai H. Methods for maximizing of the effectiveness of the Special Health Guidance. National Institute of Public Health in Japan; 2010 [in Japanese].
Contents available at Sciverse ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Design and preliminary results of a metropolitan lifestyle intervention program for people with metabolic syndrome in South Korea Yo-Han Lee a, Seok-Jun Yoon b,*, Hyeong-Su Kim c, Sang-Woo Oh d, Ho-Sihn Ryu e, Jin-A Choo e, So-Nam Kim f, Young-Ae Kim a, Mi-Suk Park g, Yun-Suk Park g, Sun-Young Kim g, A-Rom Kwon g a
Graduate School of Korea University, Department of Public Health, Seoul, Republic of Korea Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea c Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Republic of Korea d Center for Obesity, Nutrition, and Metabolism, Department of Family Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Gyeonggi, Republic of Korea e Korea University College of Nursing, Seoul, Republic of Korea f Department of Nursing, Seojeong College, Gyeonggi, Republic of Korea g Metabolic Syndrome Management Center of Seoul Metropolitan Government, Seoul, Republic of Korea b
article info
abstract
Article history:
Introduction: The Seoul Metabolic Syndrome Management (SMESY) project, a metropolitan
Received 30 January 2013
lifestyle intervention program aimed at decreasing the risk of metabolic syndrome to the
Received in revised form
residents of the city, has recently been implemented in 2011.
15 May 2013
Methods: Our target population consisted of residents of Seoul who were 30–64 years old.
Accepted 6 June 2013
Subjects visiting a Public Health Center were screened for five risk factors for metabolic
Available online 11 July 2013
syndrome and then divided into three groups according to the number of the risk factors:
Keywords:
one or two; and information support for having none. Members of the active counseling
active counseling, for having more than three risk factors; motivational guide, for having Counseling
group, the main target of the project, were provided with monthly in-person counseling on
Lifestyle
health-related lifestyle choices, as well as a follow-up examination every 3 months during
Metabolic syndrome
the 12-month program.
Non-communicable disease
Results: In the active counseling group, subjects showed statistically significant improve-
Prevention
ments in all five risk factors and the average number of retained risk factors decreased from 3.5 to 2.7. However, the percentage of active counseling group members who attended at least 3 out of the 4 sessions provided was only 11.3%. As for the motivational guide group and the information support group, clinically significant improvements were not observed and the percentage of members who attended all sessions were 10.4% and 11.8%, respectively.
* Corresponding author at: Department of Preventive Medicine, Korea University College of Medicine, 126-1, Anam-dong 5-ga, Seongbukgu, Seoul 136-705, Republic of Korea. Tel.: +82 2 920 6412; fax: +82 2 927 7220. E-mail addresses: [email protected] (Y.-H. Lee), [email protected], [email protected] (S.-J. Yoon), [email protected] (H.-S. Kim), [email protected] (S.-W. Oh), [email protected] (H.-S. Ryu), [email protected] (J.-A. Choo), [email protected] (S.-N. Kim), [email protected] (Y.-A. Kim), [email protected] (M.-S. Park), [email protected] (Y.-S. Park), [email protected] (S.-Y. Kim), [email protected] (A.-R. Kwon). 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.06.006
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Conclusions: Increased public participation for the ongoing project is expected to lead to great positive changes in the health of people with metabolic syndrome. # 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Non-communicable disease (NCD) is becoming a major public health problem in both developed and developing countries due to the decrease in communicable diseases and increase in life expectancy [1,2]. Globally, NCD is responsible for half of all mortality and disease burden, with cardiovascular disease (CVD) and diabetes mellitus (DM) accounting for half of all NCD mortalities [3]. Although high blood pressure, high blood glucose, and lipid abnormalities are the immediate causes of NCD, the underlying causes stem from unhealthy lifestyles; 80% of deaths caused by NCD are preventable [4]. Therefore, the best strategy for addressing NCD is prevention through lifestyle modification. There are effective national or regional prevention strategies for NCD in some developed countries, such as the North Karelia project in Finland (established to reduce coronary heart disease), and diabetes prevention programs exist in multiple countries around the world [5–8]. As a countermeasure to the rapid increases in the disease burden and medical costs of chronic disease, Japan launched a nationwide project in 2008 that implements focused health guidance and targets metabolic syndrome patients [9]. Japan’s project, unlike other existing NCD prevention programs, strategically targets metabolic syndrome, which is a pre-morbid state of NCD. In Korea, CVD and DM create the greatest burden of disease, and the socioeconomic costs from these conditions are steadily rising [10–12]. Considering the substantial adverse effects of these conditions, a national NCD prevention program is urgently needed in Korea. However, the country’s healthcare system is largely privatized and centered on treatment, and such a wide-scale prevention strategy has never been implemented. Public Health Centers acting as local public health agencies have been in charge of such preventive services, but there are no standardized programs. Amidst the urgent need for an effective and practical NCD prevention program in Korea, the Seoul Metabolic Syndrome Management (SMESY) project, a lifestyle intervention program aimed at decreasing the risk of metabolic syndrome, was officially implemented across Seoul in March 2011, a year after launching the demonstrative project. This paper discusses the design and preliminary results of this project.
1.1.
Theoretical framework for the project
The basic theoretical background of the SMESY project is based on metabolic syndrome as a high-risk condition for CVD and DM. Metabolic syndrome comprises a collection of cardiometabolic risk factors: abdominal obesity, high blood pressure,
hyperglycemia, and lipid abnormalities [13]. According to the Framingham Heart Study, people with metabolic syndrome are two times more likely to have CHD and five times more likely to have type 2 diabetes than people without metabolic syndrome [14]. Numerous studies have shown that metabolic syndrome is an important predictor of CVD and DM mortality [15]. The World Health Organization (WHO) states that metabolic syndrome should not be used as a tool for clinical diagnosis of a disease but should be considered a pre-morbid state of CVD and diabetes. The WHO recommends a populationbased program that utilizes the concept of metabolic syndrome as a cost-effective CVD reduction strategy [16]. In other words, metabolic syndrome is being recognized as an effective tool for identifying subjects who are at a high-risk of developing CVD and DM. The first management approach for metabolic syndrome is not drug treatment, but lifestyle modification, that is to say, making healthier choices in diet, exercise, and smoking [17]. Several randomized-controlled trials have shown that direct lifestyle interventions have a significant effect on improving health. Diet and exercise programs significantly decrease biochemical indicators of metabolic syndrome, weight, and waist circumference [18,19]. Similar results have been reported in lifestyle interventions for people with metabolic syndrome [20,21]. Unsurprisingly, the more closely a patient follows an intervention program, the greater the reduction in symptoms of metabolic syndrome [22]. Japan’s project provides evidence of the effectiveness of a population-based program for people with metabolic syndrome. About 400,000 metabolic syndrome patients participated in a 6-month consultation intervention program aimed at improving lifestyles and significant improvements in all risk factors of metabolic syndrome were observed. Based on the theoretical framework regarding the usefulness of the metabolic syndrome concept and the effectiveness of lifestyle intervention mentioned above, the SMESY project planned a counseling intervention program to improve the lifestyles of people with metabolic syndrome.
2.
Materials and methods
2.1.
Subject eligibility and recruitment
The target population consisted of residents of Seoul aged 30– 64 years. The prevalence of metabolic syndrome under the age of 30 is low, and the effectiveness of consultation intervention for people over 65 is reportedly lower. The project was promoted through various media outlets and directed interested citizens to the nearest Public Health Center which is public health agency uniformly distributed across Seoul city.
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Visit to a Public Health Center after 10 hours of fasting
Enrollment for the SMESY project
Screening for five risk factors of metabolic syndrome And group classification
Active counseling group
Motivational guide group
With more than three risk factors
Lifestyle counseling over the course of 12 months
With one or two risk factors
Information support group Without any risk factors
Fig. 1 – Basic process of the program.
2.2.
choices such as diet, smoking, alcohol consumption, and physical activity (Fig. 1). After being screened for the five risk factors of metabolic syndrome, they were divided into one of three groups based on the number of metabolic syndrome risk factors. The three groups received interventions that differed in both the contents and the frequencies of the service provided. In-person counseling was provided only to one group having metabolic syndrome while a follow-up program for 12 months was a part common to the interventions for all three groups. The goal of the interventions was to improve all aspects of participants’ lifestyle.
2.3.
Basic process of the program
When a respondent visited a Public Health Center to enroll in the program, they were first asked to provide demographic information such as sex, age, education level, and economic status, and to answer questions on health-related lifestyle
Screening examination
All subjects fasted for 10 h before being tested for the five risk factors of metabolic syndrome: waist circumference, blood pressure, plasma glucose, triglycerides, and high-density lipoprotein (HDL) cholesterol. Waist circumference was measured in triplicate at the midpoint between the lower rib and the iliac crest. Systolic blood pressure and diastolic blood pressure were measured with an automatic blood pressure cuff after the subject had been seated for 10 min. Serum triglycerides and HDL cholesterol levels were determined by enzymatic methods with a chemistry analyzer. Plasma glucose was measured with the glucose oxidase method.
2.4. Health tip t ext message service and f ollow-up examinations over the course of 12 months
295
Definition of metabolic syndrome
Metabolic syndrome was defined with the widely used National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III) guidelines [23]. If any three of the five risk factors are beyond the criteria, NCEP-ATP III defines the case as metabolic syndrome [13]. Criteria provided by the International Diabetes Federation and others that factor in abdominal obesity are not appropriate for the SMESY project, as it is relatively common for Koreans to have metabolic syndrome without abdominal obesity [24]. Because Asians have a greater risk of fitting the metabolic profile at lower waist circumferences than Caucasians [23], the waist circumference standard was lowered for the SMESY project based on data from the Korean Society for the Study of Obesity (Table 1) [25].
Table 1 – Criteria for risk factors of metabolic syndrome and group classification. Risk factors/groups
Description a
Risk factors of metabolic syndrome Elevated waist circumference Elevated triglycerides Low high-density lipoprotein (HDL) cholesterol Elevated blood pressure Elevated fasting glucose Group classification Active counseling Motivational guide Information support
90 cm in men, 85 cm in women 150 mg/dL <40 mg/dL in men, <50 mg/dL in women 130/85 mmHg systolic/diastolic blood pressure 100 mg Presence of at least three of the above five risk factors Presence of one or two of the above five risk factors No risk factors
a Based on the criteria of the National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III), except for elevated waist circumference, which is based on the Korean Society for the Study of Obesity.
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Table 2 – Content and timeframe of counseling and follow-up programs by group. Group
Counseling
Active counseling
Motivational guide
Information support
2.5.
Follow-up
Content
Frequency
Content
Frequency
In-depth counseling on diet, smoking, alcohol use, and exercise Diet: Take dietary history, prescribe nutrition regimen, and monitoring Smoking and alcohol use: Step-by-step counseling based on changes in subject’s behavior Exercise: Prescribe exercise regimen and monitor based on subject’s physical activity level Not provided
Once a month
Re-examination for metabolic risk factors Text message with health tip
Every 3 months
Subjects were divided into the active counseling group, the motivational guide group, or the information support group, based on the number of risk factors present in each subject (Table 1). Subjects with more than three risk factors were considered to have metabolic syndrome and were provided active counseling, subjects with one or two risk factors were provided with motivational guide, and subjects without any risk factors were given informational support. Following WHO recommendations stating that subjects already in the disease stage should not be diagnosed with metabolic syndrome [16], people with hypertension, DM, or dyslipidemia who were taking medication were classified as a separate group regardless of the number of the risk factors and provided with the same program as the motivational guide group.
2.6.
Text message notifying subject of next re-examination
Re-examination for metabolic risk factors Text message with health-tip Text message notifying subject of next re-examination Re-examination for metabolic risk factors Text message with health tip Text message notifying subject of next re-examination
Not provided
Group classification
Lifestyle counseling program
Face-to-face lifestyle counseling on diet, physical activity, smoking, and alcohol consumption was provided monthly to the subjects in the active counseling group, the main target of the intervention program, for the following 12 months (Table 2). When a subject visited a Public Health Center for an appointment, the times for which were available only during the daytime on weekdays, one-to-one counseling with an expert was provided for each lifestyle choice. Four one-to-one counseling sessions for each lifestyle choice (diet, physical activity, smoking, and alcohol consumption) therefore were performed sequentially, each lasting 10–15 min, in one visit. The expert team consisted of a dietitian for diet control, an exercise specialist for physical activity regimen, and a medical doctor or a nurse for restriction of alcohol consumption and smoking cessation. Basically, lifestyle regimen and education tailored to each subject were provided according to one’s
Once a week Once a month
Every 6 months Every 2 months Every 3 months Once a year Once a month Once a year
lifestyle history and the number of metabolic risk factors he or she had. In ensuring reproducibility, the counseling provided was performed based on a standardized counseling manual, drafted specifically for the need of and use for this project on the basis of updated and practical researches on the Korean population. Inter-counselor variability, therefore, was expected to have been minimized. During a counseling session, multiple situations and cases were assumed and no specific goal for each metabolic risk factor was established, as the purpose of the lifestyle counseling was to motivate the subjects so that they would change their unhealthy lifestyle on their own. The lifestyle counseling was also offered to the subjects in the other two groups at their request, and a session was conducted via phone or e-mail when face-to-face counseling was not available.
2.6.1.
Diet
Dietary counseling was provided by dietitians and consisted of an inquiry into dietary history, a nutrition regimen, and regular monitoring. Dietary history was collected through a 24-hour recall method and a weekly meal diary. Diet regimen was developed according to each subject’s major health and dietary problems. The service consisted of calculating proper calorie needs and providing quantitative dietary recommendations. The diet plan for obese subjects with the focus on calorie restriction, for example, included visual aids, such as diagrams depicting desirable food combinations and their total calories for each meal. Subjects with increased blood pressure received a regimen focused on reducing salt intake and promoting balanced intake of key nutrients, based on Dietary Approaches to Stop Hypertension (DASH) diet pattern, which was developed by the United States Department of Health and Human Services [26]. During the following consultation, the subject’s adherence to the diet regimen was evaluated and future counseling plans were discussed accordingly.
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2.6.2.
Physical activity
Exercise specialists conducted physical activity counseling sessions. A subject’s physical activity was determined every session using a standardized physical activity questionnaire, which takes into account and sums up all physical activities from the three areas of exercise, domestic chores, and vocational activity, on a weekly basis by intensity and duration. If a subject’s totaled duration of moderate-intensity physical activity per week was less than 150 min, he or she was determined to have insufficient physical activity [27]. As with nutrition counseling, a tailored physical activity regimen was prescribed based on a subject’s determined physical activity level and his or her number of metabolic syndrome risk factors. Both measurements, physical activity level and the number of metabolic syndrome risk factors, were evaluated during each consultation. Targeting 150 min of moderate-intensity physical activity per week, the regimen provided more concrete goals for increasing physical activity through exercise and lifestyle change. For subjects with less than 100 min of moderate-intensity physical activity per week, for example, daily walking for more than 10 min was prescribed.
2.6.3.
Follow-up program
To monitor the five risk factors of metabolic syndrome and changes in lifestyle, the active counseling group was reassessed every 3 months, the motivational guide group every 6 months, and the information support group once at the end of the follow-up period. Since all South Korean adults are literate and possess their own mobile phones, mobile phone text messages which differ in contents according to the groups were sent to the subjects. For the active counseling group, one health tip text message was sent out once per week, a message encouraging further efforts was sent out once a month, and a message notifying the subject of upcoming visits was also sent out once a month. The motivational guide group and the information support group received text messages less frequently than the active counseling group (Table 2).
2.8.
of people who enrolled for the program and received the baseline testing during the period of 2 years from January 2010 to December 2011 was 134,092. The baseline lifestyle factors of smoking, drinking, and physical activity, and the averages of the five metabolic risk factors for this population are expressed as N (%) and mean standard deviation, respectively, by group. In assessing the degree of participation, a subgroup of the aforementioned enrolled 134,092 was selected. Participants who enrolled from January 2010 to April 2011 were pooled, and there were 65,197 subjects. Data on these participants were extracted and attendance in each group was evaluated. To evaluate the effects of the project, the group of subjects who did receive re-examination after 12 months out of the total 65,197 participants was selected. 12,596 participants who satisfied this criterion were therefore analyzed. The changes in metabolic risk factor values and the average number of retained risk factors between baseline and the 12-month re-examination were evaluated. Paired t-tests were used to test for significance. Data collection and analyses were performed using stata 11.0 (StataCorp, College Station, TX).
Smoking and alcohol use
Counseling for smoking and alcohol use was provided by a medical doctor and nurse and evaluation and counseling were conducted with widely used tools. The Korean version of the Alcohol Use Disorders Identification Test developed by WHO (AUDIT-K) was used to measure alcohol intake [28,29], and subjects were classified into moderate drinking, at-risk drinking, alcohol abuse, or alcohol dependence groups. Visual material based on medical evidence was used to advise moderation in drinking for all subjects, and subjects were counseled on a step-by-step strategy to help change their behavior. Counseling for smoking was based on Prochaska’s model for smoking cessation [30], and also included ‘the 5R’s and 5A’s method’ used by various smoking cessation programs [31].
2.7.
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Statistical analyses of preliminary results
For interim findings of this ongoing program, three different populations of subjects were analyzed. First, the total number
3.
Results
3.1.
Participant characteristics at baseline
Of all participants who enrolled for two years, 25,766 were classified into the active counseling group, and 84,467 and 23,859 were classified into the motivational guide group and information support group, respectively (Table 3). The proportion of males was highest in the active counseling group with 48.7% and was less in the motivational guide group (37.4%) and information support group (23.5%). As expected, the proportion of smokers was highest in the active counseling group, but drinking habits and physical activity levels did not differ among the groups. The metabolic risk factor values were most unfavorable in the active counseling group. The average number of risk factors in the active counseling group was 3.5; in the motivational guide group and information support group it was 2.0 and 0.0, respectively.
3.2.
Effects of the project
We observed different effects among the groups. In the active counseling group, all five risk factors showed statistically significant improvement, and the average number of retained risk factors decreased from 3.5 to 2.7 (Table 4). 41.4% of the active counseling group subjects, all of whom initially had metabolic syndrome before entering the project, were found to have fewer than three risk factors, a change signifying that they no longer had metabolic syndrome (data now shown). On the other hand, clinically significant improvements in the risk factor values and the number of risk factors were not observed in the motivational guide group and the information support group despite of the statistical significance, which resulted probably from the large sample size.
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Table 3 – Lifestyle choices and metabolic risk factors of participants at baseline.
Age (mean SD) Smoking (N (%)) Nonsmoker Ex-smoker Current smoker Alcohol consumption (N (%)) Yes No Regular physical activity (N (%)) Yes No Metabolic syndrome component (mean SD) WC (cm) SBP (mmHg) DBP (mmHg) FBG (mg/dL) HDL-C (mg/dL) TG (mg/dL) Average no. of retained metabolic risk factors
Motivational guide
Information support
Male (n = 12,545)
Female (n = 13,221)
Total (n = 25,766)
Male (n = 31,614)
Female (n = 52,853)
Total (n = 84,467)
Male (n = 5610)
Female (n = 18,249)
Total (n = 23,859)
47.6 9.4
52.1 8.5
49.9 9.2
49.9 9.7
51.6 9.1
51.0 9.4
44.7 10.1
44.9 9.8
44.9 9.9
4024(33.6) 3706(31.0) 4238(35.4)
12,027(95.2) 269(2.1) 336(2.7)
16,051(65.2) 3975(16.2) 4574(18.6)
11,217(37.1) 10,128(33.5) 8906(29.4)
48,853(95.9) 1026(2.0) 1044(2.1)
60,070(74.0) 11,154(13.7) 9950(12.3)
2317(43.3) 1502(28.0) 1538(28.7)
16,756(95.5) 448(2.6) 350(2.0)
19,073(83.2) 1950(8.5) 1888(8.2)
3235(29.1) 7865(70.9)
8181(65.6) 4284(34.4)
11,416(48.4) 12,149(51.6)
8866(30.8) 19,912(69.2)
32,048(63.7) 18,258(36.3)
40,914(51.7) 38,170(48.3)
1677(32.5) 3485(67.5)
9815(56.6) 7511(43.4)
11,492(51.1) 10,996(48.9)
6763(57.2) 5051(42.8)
6111(48.8) 6417(51.2)
12,874(52.9) 11,468(47.1)
18,567(62.1) 11,315(37.9)
28,154(55.7) 22,365(44.3)
46,721(58.1) 33,680(41.9)
3324(62.7) 1976(37.3)
9773(56.0) 7675(44.0)
13,097(57.6) 9651(42.4)
90.8 7.1 135.8 15.1 87.0 10.9 110.3 30.9 40.0 12.4 234.6 110.0
86.0 8.0 130.6 16.6 82.3 11.0 107.4 24.9 43.4 11.8 206.0 96.3
88.3 8.0 133.1 16.1 84.6 11.2 108.8 28.0 41.8 12.2 219.9 104.1
86.0 7.2 128.7 15.2 81.7 10.7 104.4 29.6 47.9 13.5 157.2 91.9
80.7 8.2 122.4 15.9 76.8 10.6 99.3 22.7 53.0 14.3 138.6 80.4
82.7 8.3 124.7 15.9 78.6 10.9 101.2 25.7 51.1 14.2 145.5 85.4
80.1 5.7 115.4 8.7 72.7 7.1 89.1 7.4 55.4 11.0 92.0 28.7
74.2 6.0 111.0 9.9 69.9 7.6 88.1 7.2 64.5 10.4 84.0 27.1
75.6 6.5 112.0 9.8 70.6 7.6 88.3 7.3 62.4 11.3 85.9 27.7
3.5 0.6
3.4 0.6
3.5 0.6
2.1 1.1
2.0 1.1
2.0 1.1
0.0 0.1
0.0 0.1
0.0 0.1
WC: waist circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure; FBG: fasting blood glucose; HDL-C: high density lipoprotein cholesterol; TG: triglyceride.
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Active counseling
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Table 4 – Changes in metabolic risk factors during the program by group. Risk factors
WC (cm) SBP (mmHg) DBP (mmHg) FBG (mg/dL) HDL-C (mg/dL) TG (mg/dL)
Active counseling (N = 1962)
Motivational guide (N = 8774)
Information support (N = 1860)
0 month
12 month
P value
0 month
12 month
P value
0 month
12 month
P value
88.3 7.7 132.8 16.1 83.8 11.0 106.3 24.1 41.7 11.5 213.8 101.7
87.1 7.6 126.5 14.4 80.6 10.2 102.3 19.1 43.7 12.4 175.6 90.2
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
83.5 8.2 125.7 15.9 78.5 10.6 101.0 22.8 50.8 14.2 148.7 86.3
83.2 8.0 124.1 15.4 77.7 10.1 100.3 20.5 50.2 14.1 139.7 76.1
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
75.7 6.5 111.8 10.0 70.9 7.7 88.0 7.6 62.3 11.4 86.9 28.1
76.2 6.8 112.9 12.1 71.6 8.6 90.5 9.2 59.8 13.6 100.7 52.0
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
3.5 0.6
2.7 1.2
<0.001
2.2 1.2
2.2 1.4
0.0 0.1
0.6 0.8
<0.001
Average no. of retained metabolic risk factors
0.001
P value: Analysis by paired t-test between 0 and 12 months. WC: waist circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure; FBG: fasting blood glucose; HDL-C: high density lipoprotein cholesterol; TG: triglyceride.
Table 5 – Program attendance by group. Active counseling (4 sessions)
Attended 1 session Attended 2 sessions Attended 3 sessions Attended 4 sessions Never attended
3.3.
N = 12,155
%
2141 1517 816 555 7126
17.6 12.5 6.7 4.6 58.6
Adherence to the program
Program participation rates by group are shown in Table 5. The percentage of active counseling group members who attended at least 3 out of 4 sessions provided was only 11.3% and more than half of the participants (58.6%) never attended a session. As for the motivational guide group and the information support group, the percentages of members who attended all sessions were 10.4% and 11.8%, respectively.
4.
Discussion
4.1.
Significance of the project
NCD prevention and management is one of the most important public health issues world-wide, and the WHO is emphasizing the need for practical and effective strategies [32]. The SMESY project is a community-based NCD prevention program that provides intensive care by strategically targeting metabolic syndrome, which is an early phase of NCD. The prevalence of metabolic syndrome in Koreans increased from 24.9% in 1998 to 31.3% in 2007 [33]. Although obesity is not as common in Korea as in Western countries, Koreans are more likely to be diagnosed with metabolic syndrome [34,35]. People who are ‘metabolically obese – normal weight’ are equally at risk for DM, hyperlipidemia, and CHD as obese people [36,37]. This implies that Koreans are more metabolically vulnerable than Westerners, and thus the need to improve Korean lifestyles is critical and more aggressive lifestyle intervention is needed. Therefore, it is important to
Motivational guide (2 sessions) N = 40,968
%
Information support (N = 1 session) N = 12,074
%
9875 4258
24.1 10.4
1428
11.8
26,835
65.5
10,646
88.2
fully implement a lifestyle counseling program such as the SMESY project.
4.2.
Features of the project
First, the project utilized both a ‘high-risk group approach,’ which is the traditional disease prevention strategy that focuses on high-risk individuals, as well as a ‘populationbased approach’ [38]. A systematic lifestyle intervention program for metabolic syndrome patients was implemented in conjunction with promotional strategies aimed at increasing public awareness of metabolic syndrome and the importance of lifestyle choices. The project was promoted via the press, advertising in Public Health Centers, the Internet, and promotional materials placed on public transportation. Promotional content consisted of information about metabolic syndrome and the benefits of managing symptoms, an explanation of the SMESY Project, and encouragement of public participation. This dual approach is underscored by the WHO as a guiding principle for NCD prevention and control [39]. Second, the SMESY project attempted intervention through face-to-face counseling in Public Health Centers, which are accessible to all citizens. Because Seoul is the most urbanized city in Korea, it is important to effectively use the city’s advantageous environment when creating a health improvement strategy for its residents [40]. Seoul city consists of 25 districts and every Public Health Center in every district can function as a provider for the program. Third, the management period of subjects with metabolic syndrome was lengthened to 12 months, which is twice as
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long as those subjects were managed in Japan’s study. In terms of support, the frequency of face-to-face counseling and reexamination was significantly longer in the SMESY project. The SMESY project focused on lifestyle modifications, which should be made gradually over a long period of time [41], and therefore a 12-month program seemed appropriate. Through this, the SMESY project aimed to encourage greater motivation and efforts for lifestyle improvements and enable more effective follow-up management.
4.3.
Comment on the effects of the project
Since this project is in progress and is in its initial stages, a crude evaluation of the available participants and data was made. There was a statistically significant improvement to the risk factors for metabolic syndrome in the active counseling group, which is the main target group of the project. In particular, the average number of retained risk factors in the active counseling group decreased to 2.7, a number that does not meet the diagnostic criteria for metabolic syndrome. This improvement is very meaningful considering the result of a study to Korean subjects reporting that as the number of risk factors for metabolic syndrome decreases, the mortality rate for cardiovascular disease patients significantly decreases [42]. When considering the low participation rates, however, one can raise questions about the true effect of the project for the following reasons: the result was obtained from the subjects who took the 12-month re-examination and these might be ‘active’ participants who were more interested in their health and thus practiced healthier lifestyles. In other words, the aforementioned result could be considered biased, leading to the possibility that the observed effects were only from the participants’ own abilities, without any contribution of the program. In assessing the effect of the program, it is however important to note that the ultimate goal of the project is to motivate people to change their lifestyles and manage their health on their own. In this design, it is not a surprise that highly motivated people are more likely to achieve positive results through the project since the subjects’ commitment and efforts are most crucial to lifestyle improvements and the program functioned as a platform for the desired change. Ultimately, improving self-management skills through selfempowerment has the biggest effect on personal health and lifestyle [43,44], and this philosophy is the foundation for various health promotion projects and chronic disease programs worldwide. A good example of this is the fact that strengthening individual autonomy and capacity was found to positively impact the ability to quit smoking [45]. On the other hand, no improvement was shown in the other two groups. It is assumed that because these two groups received relatively less services, there was relatively less room for improvement over the course of the project. The optimistic view of this result is that healthy and relatively healthy subjects maintained their health without further degeneration.
4.4.
Comment on the participation of the project
The most challenging part of the present project appears to be the low participation rate. Two explanations for this phenom-
enon would be possible. First, the Korean society, in general, is not familiar with the concepts of preventive care and health management through self-empowerment. As the society has placed a greater emphasis on the treatment-centered medical services, people have not had the chance to develop interest in and acknowledgement of the importance of taking preventive measures. In this aspect, the project fell short in motivating the participants for self-management. Organized efforts of individual education and public promotion would be necessary to motivate people and increase public participation. In addition, the public demand for the counseling service should be met, and the effectiveness of the counselors in motivating subjects should be raised. Unavailability of the project services, in terms of time and place, can be another critical factor in lowering the participation rate. It could have been that many people who were interested in the project might have had difficulties in attending sessions since the sessions were held only on weekdays during the daytime and in one place per district. This additional demotivating factor should be eliminated through opening sessions in the evening and on holidays and at the branch facilities of a Public Health Center as they could be utilized as service-providing places. In Japan’s project, counseling was offered during evening hours and on holidays in some areas and, there was a significantly large effect on health improvement [46].
4.5.
Scheme for future evaluation
The effectiveness of the project will be evaluated by analyzing changes in the prevalence of metabolic syndrome and the changes in risk factors of metabolic syndrome, based on the results of a re-examination of all subjects who completed the 12-month program. The change in the prevalence of metabolic syndrome will be measured against the baseline prevalence using the Generalized Estimating Equations (GEE) model. The rate of numerical change for each risk factor will also be analyzed based on the results of the re-examination using analysis of covariance (ANCOVA). In addition, the same methods mentioned above will be used to evaluate the subjects’ extent of lifestyle modification, which is the ultimate goal of this program. Because it is not possible to create a control group to compare the effects of the program, the project will measure changes in prevalence, levels of metabolic syndrome, and the rate of lifestyle modifications in participants who were unable to fully participate in the program. Demographic information such as age, sex, education, economic level, and place of residence for subjects who did and did not fully participate in the program will be analyzed using a chi-square test or t-test to understand why some subjects fully participated and others did not.
5.
Conclusions
The SMESY project is the first metropolitan-wide lifestyle intervention program for people with metabolic syndrome conducted in South Korea. The project has resulted in significant improvements to the risk factors of metabolic syndrome. Increased public participation for the project is
diabetes research and clinical practice 101 (2013) 293–302
expected to lead to great positive changes in the health of Seoul citizens.
Conflict of interest The authors declare that they have no competing interests.
Ethics Approval of the project was obtained from the Institutional Review Board of the Korean University Medical Center and all participants provided written informed consent.
Acknowledgements This project was supported by a grant from the Seoul Metropolitan Government.
references
[1] McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270(18):2207–12. [2] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367(9524):1747–57. [3] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global burden of disease and risk factors. Washington, DC: Oxford University Press; 2006. [4] World Health Organization. Preventing chronic disease: a vital investment. Available online at http://www.who.int/ chp/chronic_disease_report/order_form.pdf. [5] Puska P. Fat and heart disease: yes we can make a change – the case of North Karelia (Finland). Ann Nutr Metab 2009;54(Suppl. 1):33–8. [6] Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, et al. 10-Year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374(9702):1677–86. [7] Lindstrom J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, et al. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003;26(12):3230–6. [8] Nikki M, Sara A, Aliceon B, Mike S. The Norfolk diabetes prevention study (Norfolk DPS). Psychol Health 2011;26:270–1. [9] Kohro T, Furui Y, Mitsutake N, Fujii R, Morita H, Oku S, et al. The Japanese national health screening and intervention program aimed at preventing worsening of the metabolic syndrome. Int Heart J 2008;49(2):193–203. [10] Kang HY, Lim SJ, Suh HS, Liew D. Estimating the lifetime economic burden of stroke according to the age of onset in South Korea: a cost of illness study. BMC Public Health 2011;11:646. [11] Hong KS, Kim J, Cho YJ, Seo SY, Hwang SI, Kim SC, et al. Burden of ischemic stroke in Korea: analysis of disability-adjusted life years lost. J Clin Neurol 2011;7(2):77–84.
301
[12] Yoon SJ, Bae SC, Lee SI, Chang H, Jo HS, Sung JH, et al. Measuring the burden of disease in Korea. J Korean Med Sci 2007;22(3):518–23. [13] Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/ National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112(17):2735–52. [14] Grundy SM, Brewer Jr HB, Cleeman JI, Smith Jr SC, Lenfant C. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004;109(3):433–8. [15] Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005;28(7):1769–78. [16] Simmons RK, Alberti KG, Gale EA, Colagiuri S, Tuomilehto J, Qiao Q, et al. The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation. Diabetologia 2010;53(4):600–5. [17] Grundy SM, Hansen B, Smith Jr SC, Cleeman JI, Kahn RA. Clinical management of metabolic syndrome: report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation 2004;109(4):551–6. [18] Singh RB, Singh NK, Rastogi SS, Mani UV, Niaz MA. Effects of diet and lifestyle changes on atherosclerotic risk factors after 24 weeks on the Indian Diet Heart Study. Am J Cardiol 1993;71(15):1283–8. [19] Anderssen SA, Hjermann I, Urdal P, Torjesen PA, Holme I. Improved carbohydrate metabolism after physical training and dietary intervention in individuals with the ‘‘atherothrombogenic syndrome’’, Oslo Diet and Exercise Study (ODES). A randomized trial. J Intern Med 1996;240(4):203–9. [20] Watkins LL, Sherwood A, Feinglos M, Hinderliter A, Babyak M, Gullette E, et al. Effects of exercise and weight loss on cardiac risk factors associated with syndrome X. Arch Intern Med 2003;163(16):1889–95. [21] Poppitt SD, Keogh GF, Prentice AM, Williams DE, Sonnemans HM, Valk EE, et al. Long-term effects of ad libitum low-fat, high-carbohydrate diets on body weight and serum lipids in overweight subjects with metabolic syndrome. Am J Clin Nutr 2002;75(1):11–20. [22] Fappa E, Yannakoulia M, Pitsavos C, Skoumas I, Valourdou S, Stefanadis C. Lifestyle intervention in the management of metabolic syndrome: could we improve adherence issues? Nutrition 2008;24(3):286–91. [23] Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285(19):2486–97. [24] Yoon YS, Lee ES, Park C, Lee S, Oh SW. The new definition of metabolic syndrome by the international diabetes federation is less likely to identify metabolically abnormal but non-obese individuals than the definition by the revised national cholesterol education program: the Korea NHANES study. Int J Obes (Lond) 2007;31(3):528–34. [25] Lee SPH, Kim SM, Kwon HS, Kim DY, Kim DJ, Cho GJ, et al. Cut-off points of waist circumference for defining abdominal obesity in the Korean population. Korean J Obes 2006;15(1):1–9. [26] National Health Institution. Your guide to lowering your blood pressure with DASH; 2006 available online athttp:// www.nhlbi.nih.gov/health/public/heart/hbp/dash/ new_dash.pdf.
302
diabetes research and clinical practice 101 (2013) 293–302
[27] US Department of Health and Human Services. 2008 physical activity guidelines for Americans; 2008 Available online athttp://www.health.gov/PAGuidelines. [28] Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption – II. Addiction 1993;88(6):791–804. [29] Kim SS, Gulick EE, Nam KA, Kim SH. Psychometric properties of the alcohol use disorders identification test: a Korean version. Arch Psychiatr Nurs 2008;22(4):190–9. [30] Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 1993;12(5):399–405. [31] Chandler MA, Rennard SI. Smoking cessation. Chest 2010;137(2):428–35. [32] Beaglehole R, Yach D. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Lancet 2003;362(9387):903–8. [33] Lim S, Shin H, Song JH, Kwak SH, Kang SM, Yoon JW, et al. Increasing prevalence of metabolic syndrome in Korea: the Korean National Health and Nutrition Examination Survey for 1998–2007. Diabetes Care 2011;34(6):1323–8. [34] Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988–1994. Arch Intern Med 2003;163(4):427–36. [35] Choi J, Se-Young O, Lee D, Tak S, Hong M, Park SM, et al. Characteristics of diet patterns in metabolically obese, normal weight adults (Korean National Health and Nutrition Examination Survey III, 2005). Nutr Metab Cardiovasc Dis 2012;22(7):567–74.
[36] Ruderman NB, Schneider SH, Berchtold P. The metabolically-obese, normal-weight individual. Am J Clin Nutr 1981;34(8):1617–21. [37] Ruderman N, Chisholm D, Pi-Sunyer X, Schneider S. The metabolically obese, normal-weight individual revisited. Diabetes 1998;47(5):699–713. [38] Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 1981;282(6279):1847–51. [39] World Health Organization. 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available online at http:// www.who.int/publications/2009/9789241597418_eng.pdf. [40] Leviton LC, Snell E, McGinnis M. Urban issues in health promotion strategies. Am J Public Health 2000;90(6):863–6. [41] Sniehotta FF, Schwarzer R, Scholz U, Schuz B. Action planning and coping planning for long-term lifestyle change: theory and assessment. Eur J Soc Psychol 2005;35(4):565–76. [42] Park HS, Cho SI, Song YM, Sung J. Multiple metabolic risk factors and total and cardiovascular mortality in men with low prevalence of obesity. Atherosclerosis 2006;187(1):123–30. [43] Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns 1995;26(1–3):139–44. [44] Glasgow RE, Anderson RM. In diabetes care, moving from compliance to adherence is not enough. Something entirely different is needed. Diabetes Care 1999;22(12):2090–2. [45] Williams GC, McGregor HA, Sharp D, Levesque C, Kouides RW, Ryan RM, et al. Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial. Health Psychol 2006;25(1):91–101. [46] Imai H. Methods for maximizing of the effectiveness of the Special Health Guidance. National Institute of Public Health in Japan; 2010 [in Japanese].