Sociodemographic Characteristic of Respondents
Respondents (n = 21) who fulfilled the Harmonised MetS criteria participated in the study. On average participants were 51 (SD = 10.3) years old, ranging in age from 26 to 64. The majority were women (73%), married (73%) and all had equal to or more than a high school education. Slightly less than half 46% were employed full-time. All participants had abdominal obesity according to the Harmonised Criteria (14, 18).
Table 1: Sociodemographic characteristic of study respondents.
| Sociodemographic Characteristic |
No | Item | n | | % |
1 | Age (years) | 21 | 51 ± 10.3 | |
2 | Gender |
| Male | 6 | | 27 |
| Female | 15 | | 73 |
3 | Status |
| Single | 1 | | 4 |
| Married | 15 | | 73 |
| Widow | 3 | | 14 |
| Divorced | 2 | | 9 |
4 | Ethnicity |
| Malay | 20 | | 95 |
| Chinese | 1 | | 5 |
5 | Education |
| Secondary | 5 | | 24 |
| Tertiary | 16 | | 76 |
6 | Occupation |
| Employed | 9 | | 43 |
| Unemployed | 1 | | 5 |
| Business Owner | 6 | | 29 |
| Retired | 5 | | 23 |
7 | Income (MYR) |
| 0–999 | 1 | | 5 |
| 1000–1999 | 2 | | 9 |
| 2000–3999 | 5 | | 24 |
| 4000–5999 | 5 | | 24 |
| 6000–9999 | 4 | | 19 |
| >10,000 | 4 | | 19 |
8 | Metabolic Risk Factors |
| Abdominal Obesity | 21 | | 100 |
| Hypertension | 21 | | 100 |
| Diabetes | 19 | | 91 |
| Dyslipidemia | 7 | | 33 |
| Hypertriglyceride | 9 | | 43 |
9 | Number of risk factors |
| 3 risks | 3 | | 14 |
| 4 risks | 15 | | 72 |
| 5 risks | 3 | | 14 |
Themes
Six strong themes emerged during the analysis of motivation and perceived barriers among adults with MetS. While one theme on perceived threat emerged on further analysis.
Motivations
Theme 1: Weight Gain and Physical Appearances
Participants expressed the changes in lifestyle is highly motivated by the gradual weight gain as they aged. The weight gain decreases their physical appearances resulted in them investing in anti-ageing products and food supplements. However, six participants extended their health monitoring by improving dietary habit and increasing physical activity. One of them said;
“You can eat all the pills but you will see the difference only once you sweat and eat better.”
Weight gain is seen as a health threat as well especially among male respondents. They raised their concern on the worsening knee pain, shortness of breath and constant fatigue. Two of the participants said;
“the tummy has become large until I feel tired carrying it.”
“you know your body is having problem when you have shortness of breath after climbing the stairs and feel extremely sleepy past the afternoon lunch”
While weight gain is a concern, female respondents are more concern on the skin and physical beauty. Observable changes on their skin prompted the female participants to eat better and exercise. One of the respondent said;
“I only started exercising when my dermatologist said it helps to get rid of my wrinkles.”
Theme 2: Personal Experience of Adverse Complication
When being asked about what their view on MetS which accounts to increased risk of cardiovascular diseases and type 2 diabetes mellitus, participants shared their fears of being less healthy, or of being in such poor health that they could not continue in their normal roles, and how disability may affect their life. Four participants told stories of close family and relatives whom they knew who had strokes and rendered paralysed prior to it and how these had limit them. The participants expressed that they did not want their health compromised to the extent that they could not take care of themselves or their families. Hence, they are motivated to change to better. As one of the women said, when talking about all the things she still planned to do in life.
“I’ve made up in my mind but I’m not ready to go yet as I am not sure how to start.”
The following quote is from a participant who shared how providing care for dad who got paralysed prior to stroke attack. Hence it has motivated her to make changes:
“Couple years ago, my father got stroke at 59 years old. Couldn’t move, couldn’t eat, couldn’t do nothing and depend on us (the children) ...it really started all of us thinking and decided to change. Whatever that goes inside my husband and my children mouth is taken care of. It will be too late when we got stroke. Why want to trouble everyone around us because of our bad habits…"
Although several participants acknowledged how fear motivated them to action, two of the participants expressed opposite views indicating that fear alone was not enough to sustain lifestyle changes. One person commented that threat of poor health concerned her, but she didn’t feel threatened enough to change the way she lived.
“If something destined to happen, it will happen, no matter how you take care.”
Theme 3: Good Family and Social Support
The participants were asked about the environment and surrounding that may affects their life choices and habit. Eight of them voiced the need for support when making lifestyle changes. Different individuals expressed different type of support that they need or had received. Three participant talked about family members walking with her daily while another shared walking her dog daily routine. Participants gave examples of how individuals and pets had given primarily positive support. One of participant however shared that her husband prevents her to do the walking because he feels intimidated by her healthy lifestyle. Henceforth, the need to have friends or family support the person in making lifestyle changes was a strong theme. Five comments from participants were:
“I don’t have that support, I get discouraged and then, you know, I stop. If I had somebody to walk with me, I believe I could walk a little bit.”
“I think that, means a lot when you got somebody else that’s in the house that’s take care of food and drinks and conscious about food every day.“
“I always join my neighbour to walk around the neighbourhood. Usually we’ll do it in a group. I feel very moving to go for a walk. My wife and kids are together too. On weekends, we usually have barbeque, get together. It’s that kind of support that makes me feel better about myself.”
If one does not have support it can be especially challenging as evident in this quote from a participant:
“Dieting is hard for a housewife like me. I have to take care of what my husband and my kids want to eat. My husband never cares about his food. I have to cook everything that he likes which is sometimes not a healthy choice. When it comes to exercise, we do it seldom. When my husband feels lazy, my kids will follow him. I usually walk with my neighbour, seldom, once a week.”
“My husband is a jealous type. If he don’t likes it, you better not do it. Like walking and all, he can never see me doing it. Because when I do it and he’s lazy, he feels intimidated.”
Barriers
Theme 4: Healthcare as a business model
There is an intricate relationship between participants and their health care providers. Most of the participants has been visiting Medical Precinct for more than two years. Trusting health care providers was important for them and most of them were told stories of doctors prescribing medications without discussing side effects, why the medications were needed. Five of the participants told that they are more interested on non- pharmacological options such as diet and exercise to reduce the risk of their diseases which however was not being provided by their previous health care providers. Most participants described relatively little or no discussion with health care providers about healthy eating and exercise, and they perceived doctors were rushed during visits.
“I always heard ‘you are what you eat’, but doctors are busy prescribing medications only.”
When asked about nurse or diet counselling, none participants shared experiences either positive or negative impact of the counselling from within the private or public practice offices. They are more interested on the information provided by their medical doctors than other health personnel. Public has to be educated on what roles of each health personnel are playing. Dependency on medical doctor only will result to a long queue in health practices and delayed treatment.
“I don’t think these people (nurse and dietician) understands what is happening inside me. They only speak based on their working manual. That’s why I think it is crucial for doctor to explain more to us.”
Moreover, several participants voiced concerns that some illnesses were being used to financially benefit companies. This led to distrust for most participants, and communication and trust with their health care providers was a concern. One participant commented;
“…sometimes when the doctors prescribed too many medications, they act like they work for the pharmacy.”
Two others commented:
“Doctors will tell all Indian people over 40 or 50 will high blood pressure. I think that is an easy statement for all (vague generalisation).”
“I think doctors give too much medication until five or six different medicines something’s going to cancel out something.”
Some of these statements portrayed a lack of understanding among participants on the diseases and its clinical management. For an instance, MetS itself has five different cardiometabolic risk factors that may require different medications on each case. Henceforth, health care providers should work to build trust and clearly explain their reasons for treatment recommendations as well as the role played by nurse and dietician. All participants viewed good communication and personal contact as building blocks to establish trust in the patient-provider relationship. One gentleman shared about the relationship he had with his former physician;
“...I had a good Chinese doctor friend in a clinic in Sunway...... But he passed away last year. All of my family consult with him before. That kind of doctor is hard to find. He will sit with you and tell you one by one why you need to take your medications. He will tell you to go jogging every morning. He never rushes like a normal doctor especially those in the public government practice.”
Theme 5: Healthy change is hard and expensive
Besides, participants were aware about the details of good dietary habit including food pyramid, food timing and calorie counts but they found it hard to apply it in real life due to the cost of healthier food options, lack of support to practice healthy diet and daily exercise and finally the availability of food may influence participant food choices. Participant however ignored the habit of reading nutrition panel in all processed food that they consumed. 70% of participants reported previous participation in lifestyle intervention focussing on weight loss. Despite that, they suffered decay in healthy habits after six months of the end of intervention due to lack of support from the close surroundings. Besides, the healthy habits are seen as hard and unrealistic to be applied in Malaysia due to availability and affordability of healthier food options, the tedious process of calorie counting, lack of surrounding support on healthy lifestyle behaviour and inadequate knowledge on healthy lifestyle.
One of common comment when participants were asked to rate their healthy life;
“This one is hard to talk about, but I found it’s hard to keep being healthy every day.”
Many participants had made lifestyle changes for a while, but then went back to previous habits. Four participants have previous subscribed for an expensive weight loss program and failed to maintain their weight after 7 months. While, the others commented that the changes introduce into their life is too hard and drastic. They do not know how to manipulate the change to keep it more exciting.
“It’s boring to weight food every day. It feels like a fishmonger in a market.”
“I bought all the weight loss vitamins (supplements) for nearly 10,000 (MYR), it feels slimmer for a while but after a year I feel my body expands.”
For many, it was hard to continue to make life style changes related to healthy eating and increased exercise. The participants really viewed changing eating and physical activity for the long term as a “battle” and something they had to control. One participant pointed out that
“Once you have been off a diet and go back, it’s just harder to go back.”
“Once you started dieting and you fry a piece of chicken, you’re going to fry some chicken every day for a week, and your diet just gone.”
This process of beginning to make changes “getting on track” was viewed as very difficult. Likewise, if participants returned to old habits, it was hard to get “back on track,” eating healthy foods and increasing physical activity. The feelings of discouragement of relapse came through very clearly in all sessions. One participant described getting off track as:
“My problem is common for everyone, I’m going to get up for exercise every morning, which I did initially and after that God knows. And then when I try to schedule it for afternoons and do it for a while, but I always feel tired so I don’t go jogging that day.”
Another participant shared her way of making sure that she gets her exercise:
“I’m always home until lunch, if I’m watching TV then I will cycle, If I can watch TV, I can exercise.”
Participants were asked what it takes to be healthy and most of them answered that they do not know. They see as being healthy is to eat proper food which is more expensive than the easy local food and to be involved in active lifestyle which has the most people gave up. However, two participants give new perspectives on healthy lifestyle;
“Buy a weighing scale and a long mirror. Put it at your bedside. Every day, if you are fat, you can see you are fat.”
“Health lifestyle needs discipline. That’s why a lot of successfully people has a healthy life. They have the discipline to be healthy.”
Theme 6: Cultural influence on food intake
All respondent assume healthy diet is a plate filled with vegetable, organic food and drizzled with olive oils. Most respondent recognised ‘Mediterranean Diet’ as the perfect healthy diet. Thus, most of them feels like they are ‘cheating’ when they eat local foods. Several respondent gave up eating healthily at all because they were told to avoid rice;
“We as Malaysian can never stop eating rice. Make rice healthy and then only tell us to diet.”
A Chinese female respondent claimed her diet to be different than other race. She said;
“We are told what to eat since we are kids. If you are Chinese, you will eat more soup and not eating at night. It’s different than Indian, Malay and any other race in Malaysia.”
However, one respondent said that despite the cultural influence in food choice, the current availability of foods in Malaysia has made choice is the only thing to blame. He mentioned;
“Now you can find most of the food you want to eat, Chinese, Indian, Malay, Italian, French, Japanese, Korean and all. You just need to know which to choose.”
Perceived Threat
Theme 7: Inadequate knowledge on Metabolic Syndrome
In terms of perceived threat and susceptibility, participants were able to identify the components of MetS individually and relate it to the bad lifestyle and dietary habit. For example, high carbohydrate diet towards progression of diabetes and high salt intake that is responsible to cause hypertension. In general, participants were unfamiliar with MetS as a diagnosis. Most were unaware of the term and had not been told by their doctors that their combination of health problems was referred to as “Metabolic Syndrome”.
“we only know about diabetes, high blood pressure and high blood cholesterol. We were only told to eat properly, exercise and eat our medication. Metabolic syndrome is new. If you said it’s the big tummy problem, that’s what I call fat.”
Based on their individual risk factors, participants were aware of the need to make lifestyle behaviour changes to improve their health. In addition, they had knowledge of appropriate behaviours in which they should be engaged. For example, several were aware that the appropriate healthy serving plate concept; Quarter, Quarter and Half (19). However, they expressed a need for skill building to successfully make behaviour changes.