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93https:/e-kcj.orgAUTHORS SUMMARYMetabolic syndrome(MetS)is highly prevalent and is associated with worse cardiovascular outcome.Lifestyle modification is the most effective way to reduce the incidence of cardiovascular complications caused by MetS.Here,we would like to review the effects and specific methods of the 6 lifestyle modifications(weight control,smoking cessation,alcohol drinking in moderation,diet control,exercise and physical activity,and cognitive behavioral therapy)and control of blood pressure,dyslipidemia,and blood sugar based on evidence in the management of MetS.ABSTRACTWith the recent rapid increase in obesity worldwide,metabolic syndrome(MetS)has gained significant importance.MetS is a cluster of obesity-related cardiovascular risk factors including abdominal obesity,atherogenic dyslipidemia,high blood pressure and impaired glucose tolerance.MetS is highly prevalent and strongly associated with an increased risk of developing diabetes and cardiovascular disease,putting a great burden on human society.Therefore,it is very important to reduce MetS risk,which can improve patients Korean Circ J.2022 Feb;52(2):93-109https:/doi.org/10.4070/kcj.2021.0328pISSN 1738-5520eISSN 1738-5555State of the Art ReviewReceived:Sep 28,2021Revised:Nov 8,2021Accepted:Dec 1,2021 Published online:Dec 15,2021Correspondence toSang-Hyun Kim,MDDivision of Cardiology,Department of Internal Medicine,Boramae Medical Center,Seoul National University College of Medicine,20,Boramae-ro 5-gil,Dongjak-gu,Seoul 07061,Korea.Email:shkimmdsnu.ac.krCopyright 2022.The Korean Society of CardiologyThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(https:/creativecommons.org/licenses/by-nc/4.0)which permits unrestricted noncommercial use,distribution,and reproduction in any medium,provided the original work is properly cited.ORCID iDsHack-Lyoung Kim https:/orcid.org/0000-0002-6703-1472Jaehoon Chung https:/orcid.org/0000-0002-3923-2971Kyung-Jin Kim https:/orcid.org/0000-0002-5796-3284Hyun-Jin Kim https:/orcid.org/0000-0002-7885-1695Won-Woo Seo https:/orcid.org/0000-0002-4406-5485Ki-Hyun Jeon https:/orcid.org/0000-0002-6277-7697Iksung Cho https:/orcid.org/0000-0001-5927-5410Jin Joo Park https:/orcid.org/0000-0001-9611-1490Hack-Lyoung Kim,MD1,Jaehoon Chung,MD2,Kyung-Jin Kim,MD3,Hyun-Jin Kim,MD4,Won-Woo Seo,MD5,Ki-Hyun Jeon,MD6,Iksung Cho,MD7,Jin Joo Park,MD6,Min-Ho Lee,MD8,Jon Suh,MD9,Sang-Yup Lim,MD10,Seonghoon Choi,MD11,and Sang-Hyun Kim,MD11 Division of Cardiology,Department of Internal Medicine,Boramae Medical Center,Seoul National University College of Medicine,Seoul,Korea2Division of Cardiology,Department of Internal Medicine,National Medical Center,Seoul,Korea3 Division of Cardiology,Department of Internal Medicine,Ewha Womans University Medical Center,Ewha Womans University School of Medicine,Seoul,Korea4Department of Cardiology in Internal Medicine,Hanyang University Guri Hospital,Guri,Korea5 Division of Cardiology,Department of Internal Medicine,Kangdong Sacred Heart Hospital,Hallym University College of Medicine,Seoul,Korea6 Division of Cardiology,Department of Internal Medicine,Cardiovascular Center,Seoul National University Bundang Hospital,Seongnam,Korea7 Division of Cardiology,Severance Cardiovascular Hospital,Yonsei University College of Medicine,Seoul,Korea8 Division of Cardiology,Department of Internal Medicine,Soon Chun Hyang University Seoul Hospital,Seoul,Korea9 Division of Cardiology,Department of Internal Medicine,Soon Chun Hyang Bucheon Hospital,Soon Chun Hyang University College of Medicine,Bucheon,Korea10Departments of Internal Medicine,Korea University Ansan Hospital,Ansan,Korea11 Division of Cardiology,Department of Internal Medicine,Hallym University College of Medicine,Seoul,KoreaLifestyle Modification in the Management of Metabolic Syndrome:Statement From Korean Society of CardioMetabolic Syndrome(KSCMS)Min-Ho Lee https:/orcid.org/0000-0003-0748-7766Jon Suh https:/orcid.org/0000-0001-9593-8453Sang-Yup Lim https:/orcid.org/0000-0002-3042-6702Seonghoon Choi https:/orcid.org/0000-0002-6524-6090Sang-Hyun Kim https:/orcid.org/0000-0001-8026-1582FundingFinancial support for the preparation of this manuscript was provided by the Korean Society of CardioMetabolic Syndrome.Conflict of InterestThe authors have no financial conflicts of interest.Data Sharing StatementThe data generated in this study is available from the corresponding author upon reasonable request.Author ContributionsConceptualization:Kim SH;Data curation:Kim HL,Chung J,Kim KJ,Kim HJ,Seo WW,Jeon KH,Cho I,Park JJ,Lee MH,Suh J,Lim SY,Choi S;Resources:Chung J,Kim KJ,Kim HJ,Seo WW,Jeon KH,Cho I,Park JJ,Lee MH,Suh J,Lim SY,Choi S;Supervision:Kim HL,Kim SH;Writing-original draft:Kim HL,Chung J,Kim KJ,Kim HJ,Seo WW,Jeon KH,Cho I,Park JJ,Lee MH,Suh J,Lim SY,Choi S;Writing-review&editing:Kim HL,Kim SH.cardiovascular prognosis.The primary and most effective strategy to control each component of MetS is lifestyle change such as losing body weight,keeping regular exercise,adopting a healthy diet,quitting smoking and alcohol drinking in moderation.Many studies have shown that lifestyle modification has improved all components of MetS,and reduces the incidence of diabetes and cardiovascular disease.Here,the Korean Society of CardioMetabolic Syndrome has summarized specific and practical methods of lifestyle modification in the management of MetS in the healthcare field.Keywords:Alcohols;Diet;Exercise;Life style;Metabolic syndrome;SmokingINTRODUCTIONMetabolic syndrome(MetS)is a clinical condition characterized by a clustering of obesity-associated cardiovascular risk factors including abdominal obesity,hypertriglyceridemia,decreased high-density lipoprotein(HDL)cholesterol,high blood pressure,and/or impaired glucose tolerance(Table 1 and Figure 1).1-4)Recognizing and understanding MetS is clinically important because of its high prevalence and potential harmful effects on the cardiovascular system.As the prevalence of obesity gradually increases,the number of patients with MetS is increasing worldwide.5)6)National Health and Nutrition Examination Survey(NHANES)data showed that the overall prevalence of MetS in the United States increased from 32.5%in 20112012 to 36.9%in 20152016.7)According to the data analyzing the Korean National Health and Nutrition Examination Survey(KNHANES),the overall age-standardized prevalence of MetS slightly increased from 21.6%in 2007 to 22.9%in 2018 in South Korea.8)In subjects in their 60s,the prevalence of MetS gradually decreased from 47.5%in 2007 to 41%in 2018,but in 94https:/e-kcj.orghttps:/doi.org/10.4070/kcj.2021.0328Lifestyle Modification in Metabolic SyndromeTable 1.Diagnostic criteria of metabolic syndrome suggested by Korean Society of CardioMetabolic SyndromeRisk factorDefining levelCentral obesityWaist circumferenceMen 90 cmWomen 85 cmTriglyceride150 mg/dLHigh-density lipoprotein cholesterolMen 40 mg/dLWomen 130/80 mmHg)and hypertriglyceridemia(triglyceride 150 mg/dL)by 2030%.53)According to a recent meta-analysis,drinking less than 5 g per day reduced the risk of MetS by 14%,whereas drinking more than 35 g per day increased the risk of MetS by 1.8 times.57)Collectively,light to moderate alcohol consumption has a beneficial effect on MetS components as well as on MetS.The World Health Organization(WHO)recommends limiting alcohol consumption to less than 40 g per day for men and 20 g per day for women.63)Reflecting this in Korea,it is recommended to limit intake to less than 4 glasses of soju for men a day and 2 glasses of soju a day for women.DIET CONTROLThe goal of MetS prevention and treatment is to reduce cardio-cerebrovascular disease and death.Among various prevention strategies,a proper diet plays a crucial role.The type and total amount of fat intake are important.There exists a good correlation between blood lipid concentration and the progression of arteriosclerosis.The consumption of saturated fat in Korea is gradually increasing due to the Westernization of lifestyle.The risk of cardiovascular disease decreases when saturated fatty acids are replaced with polyunsaturated fatty acids.64)65)Trans-fat is mainly found in breads,sweets,and processed foods such as milk and meat.Trans-fat increases total cholesterol and decreases HDL cholesterol.It is also known that eating more than 2%of total calories in trans-fat increases the risk of cardiovascular disease by 23%.65)Therefore,it is recommended to consume unsaturated fatty acids,and minimize trans-fat intake.65)Carbohydrate is converted to glucose in the body and used as an energy source,but after excessive consumption,it is converted to fat,which increases triglycerides and reduces HDL cholesterol.66)67)In particular,it was reported that Koreans consume more carbohydrate and have a stronger association with MetS than in do Westerners.68)Therefore,patients with MetS should reduce carbohydrate intake.Koreans consume 2-to 3-fold amount of salt recommended by the WHO.Excessive intake of sodium increases body fluid content along with blood pressure.69)A low sodium diet may lower blood pressure.70)Although vitamin intake is believed to slow vascular aging through its anti-oxidative effect,there have been few studies confirming the preventive effect of cardiovascular disease through vitamin intake.71)Dietary fibers are not digested and absorbed by the body;however,they can absorb various ingested substances thus can improve hyperlipidemia and prevent constipation.72)However,excessive fiber consumption can interfere with nutrient absorption.The Dietary Approaches to Stop Hypertension(DASH)97https:/e-kcj.orghttps:/doi.org/10.4070/kcj.2021.0328Lifestyle Modification in Metabolic Syndromediet is one developed by doctors and nutritionists to control the diet of hypertensive patients with the aim of eating various nutrients in a balanced manner.It consists of fresh vegetables,fruits,low-fat dairy products,brown rice,whole grains,fish,and lean chicken,which can significantly lower systolic blood pressure.73)EXERCISE AND PHYSICAL ACTIVITYExercise is essential for weight loss along with diet control.74)In addition,exercise has the effect of lowering the risk of cardiovascular disease and increasing life expectancy.75)76)It is clear that there is an inverse correlation between the total amount of moderate-intensity exercise and the incidence or mortality of cardiovascular disease,and these effects become more apparent as the amount of exercise increases.77)It is recommended that at least 150 minutes of moderate intensity exercise(fast walking,biking at least 8 kilometers per hour,active yoga,light swimming,etc.)or more than 75 minutes of high intensity exercise(jogging,running,cycling at least 15 kilometers per hour,tennis,intensive swimming,etc.)every week for the prevention of cardiovascular disease.77)There is also a negative dose-response relationship between physical activity and the prevalence of MetS.78)79)Exercise and increased physical activity not only decrease waist circumference,blood pressure,and body fat mass,but also improve insulin resistance and lipid profiles.75)80)For the primary prevention of obesity,about 150250 minutes of moderate intensity exercise per week,along with an energy equivalent of 1,200 to 2,000 kcal per week,can help prevent weight gain.81)The recommended amounts of physical activity to promote clinically significant weight loss and to prevent weight gain after successful weight loss is 225420 minutes and 200300 minutes per week,respectively.82)Both aerobic and strength exercise are important.Aerobic exercise clearly reduces the risk of cardiovascular disease,75)and resistance exercise not only improves physical function,but also reduces blood glucose and blood pressure.Although resistance exercise alone contributes to body fat loss,the effect on overall weight loss is minimal.83)It has been suggested that combined aerobic and resistance exercise is more effective in controlling blood glucose than aerobic or resistance alone.84)Since exercise alone is less effective in losing weight,it is necessary to combine with an appropriate calorie restriction diet.85)Regular exercise also plays a crucial role in maintaining weight after weight loss.86)The sedentary lifestyle is prevalent in modern society.Energy consumption in this lifestyle is only 1.5 times higher than that during rest(energy consumption during exercise is 10 to 20 times higher than during rest).It has been demonstrated in many studies that this sedentary lifestyle is a major cause of MetS,cardiovascular disease or diabetes.Therefore,it is very important to increase the amount of physical activity and reduce the amount of time sitting in everyday life.75)COGNITIVE BEHAVIORAL THERAPYThe behavior pattern that lasts over a long period of time since childhood is likely to persist even into adulthood.These environmental factors interact with genetic factors to form a lifestyle.In addition,exposure to wrong medical common sense through the advice of non-medical professionals can lead to an improper lifestyle.Therefore,the role of primary healthcare providers who can continuously manage patients is more emphasized in cognitive behavioral therapy to prevent MetS.Medical professionals should build positive relationships with patients consistent in their attitude to behaviors.When patients medical condition,life 98https:/e-kcj.orghttps:/doi.org/10.4070/kcj.2021.0328Lifestyle Modification in Metabolic Syndromeenvironment,knowledge level,experience and interests over a long period of time are widely understood,motivation for appropriate counseling and desirable behaviors tailored to each patient can be successfully achieved and sustained.87)88)It has been suggested that motivational interviewing with doctors is very effective in inducing smoking cessation.44)In addition,if decision-making is shared not only with the patient but also with the neighboring family,this can lead to more continuous and consistent changes.89)Since it is not easy to correct a wrong lifestyle that the patient has maintained for a long time,clinicians should ask whether they are able to follow the decision-making.89)Moreover,if positive changes are seen,clinicians encourage them to maintain and reinforce those behavioral changes.However,since it is necessary to maintain the lifestyle and behaviors that the patient judges to be correct,it is most important to help control and monitor them by themselves.90)Through these positive interactions,the patient must eventually set long-term goals for himself,and based on confidence through changed behaviors,he/she must be able to set new improved goals.BLOOD PRESSURE CONTROLHypertension is one of the most important diseases that threaten global human health.91)According to the factsheet of hypertension published by the Korean Society of Hypertension in 2020,the prevalence of hypertension among Koreans aged 20 years is up to
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