Faith-based Lifestyle Intervention Program Reduces Metabolic Syndrome in a High-risk Population


 Introduction: The aim of this study was to investigate the effects of a two-week lifestyle intervention on risk factors contributing to metabolic syndrome that incorporated a natural environment with spiritual motivation, plant-based nutrition, personalized physical activity, and health education. Methods: The demographic population included forty-two middle-aged and aged participants of African-American or Afro-Caribbean/Other Afro-descent, considered “high-risk” according to clinical cardiometabolic risk indicators. Results: Based on the stratified analysis, 59.5% and 40.5% were of African-American and Afro-Caribbean/Other Afro-descent respectively, with a mean age of 59.23 ± 11.24 years. The paired t-test indicated that plasma concentrations of glucose ( P = 0.043) and triglyceride ( P = 0.002) post-intervention reduced compared to pre-intervention baselines. In female participants, blood HDL cholesterol concentrations significantly ( P < 0.0001) increased compared to pre-intervention values. Conclusion: This research suggests that the Fit 4 You Retreat lifestyle intervention program significantly reduced cardiometabolic vulnerability in this high-risk middle-aged and aged population.


Introduction
Metabolic syndrome has been rapidly increasing throughout the world, with lifestyle being identi ed as the most signi cant risk contributing to this condition [1,2]. Metabolic syndrome refers to the co-occurrence of several known cardiovascular risk factors, including insulin resistance, obesity, atherogenic dyslipidemia and hypertension [3]. This increase is associated with the global epidemic of obesity and diabetes [4].
Owing to rapid transitions toward high energy intake and sedentary lifestyle in the past few decades, the metabolic syndrome has become a major health challenge globally. The grand problem is that at intervention completion, high-risk participants often face the challenges of compliance and sustainability. Although people are constantly exposed to an abundance of information regarding the bene ts of healthy lifestyles, Americans continue to struggle with obesity, physical inactivity, and inadequate nutrition [5].
Additional studies revealed that certain economically disadvantaged ethnic minorities and elderly populations were at signi cantly higher risk for cardiovascular disease (CVD) due to unhealthy lifestyles. In addition, minority communities were reported to have greater than equal or double the risk for CVD. Compared to other populations, minorities were also at greater risk for other conditions such as hypertension, diabetes, and dyslipidemia with increased potential for obesity, poor nutrition and sedentary lifestyles [5][6][7].
There are speci c determinants used to diagnose the metabolic syndrome. In this study, we used the National Cholesterol Education Program's Adult Treatment Panel III (NCEP: ATP III)'s de nition to identify the clinical indicators: high-density lipoprotein cholesterol (HDL-C), central obesity, hypertension, high fasting glucose and high triglyceride (TG) values [8,9]. Study subjects were diagnosed as having the metabolic syndrome if he or she had three or more of the following criteria: 1) waist circumference ≥ 90 cm for men and ≥ 80 cm for women; 2) TG ≥ 150 mg/dL; 3) HDL-C < 40 mg/dL for men and < 50 mg/dL for women; 4) blood pressure ≥ 130/85 mmHg; and 5) fasting glucose ≥ 100 mg/dL [3]. Clinicians prefer simple guidelines with which to assess patients and improve management, and the generally accepted de nition for metabolic syndrome prescribed by the NCEP: ATP-III de nition is simple to use and is the preferred standard [6].
People at high risk for metabolic syndrome should manage dietary factors in conjunction with exercise. The basic principle for nutritional management is that the intake of saturated fat, trans-fats and cholesterol is low, the consumption of simple sugars is reduced, and the consumption of fruits, vegetables and whole grains is increased, resulting in positive outcomes which have been demonstrated through various studies [10,11].
In the current literature, research ndings indicated that in the United States, there have been persistent racial and ethnic disparities in CVD morbidity and mortality. National efforts have given attention to reducing these disparities; but the cause of long-term health disparities remains unknown [12]. A number of community-based interventions have consistently emerged in research literature with moderate success. Considering a different approach, this intervention incorporated cultural and religious sensitivity in order to design a faith-based component as one of the constructs for lifestyle health success. Numerous commercially designed lifestyle programs have been conducted in minority and ethnic-church congregations but these programs typically do not use faith as a motivating factor for lifestyle health behavioral change. Therefore, this study was designed incorporating faith engagement as a key fundamental motivation of lifestyle change.
Health behavior research in the African-American/Afro-Caribbean community suggests a strong correlation between health and religious beliefs. A qualitative study conducted with members of an African-American church community in South Carolina, identi ed faith as an enabler to increase physical activity [13]. Within the African-American/Afro-Caribbean community faith is an essential part of the culture, therefore programs that address this component have a greater potential for a positive impact on behavioral change [14]. Extensive research within this cultural context indicates that faith-based initiatives have typically utilized trained lay personnel or health professionals to promote health risk prevention in the church/community-based setting.
The objective of this study was to examine the validity of the Fit 4 You Retreat Lifestyle Intervention program. This intervention integrates the unique elements of the African-American/Afro-Caribbean culture like faith and gospel music with health principles such as plant-based nutrition, physical activity, and health education to enhance compliance and reduce risk factors associated with metabolic syndrome.

Design
This multi-faceted, two-week intervention incorporates spiritual motivation (prayer, meditation, and music), plant-based nutrition, a natural environment, personalized physical activity, and health education to reduce cardiometabolic risk factors. This paper evaluates a culturally sensitive, faith-based lifestyle intervention designed to reduce indicators for metabolic syndrome and addresses the gap in the literature regarding the unique needs of the African-American/Afro-Caribbean community. This study was approved by Sahmyook University's institutional review board (SYUIRB# 2011-015) and conducted during the two-week summer session of the Fit 4 You Retreat, July 8-22, 2012.

Participants
The Fit 4 You Retreat is located on the campgrounds of the Allegheny East Conference of Seventh Day Adventists in Boyertown, Pennsylvania, USA. Sixty-seven individuals started the program but, some were only "one-week" participants who did not complete the entire two-week retreat and were therefore excluded, yielding a nal count of forty-two individuals.

Procedure and measures
The objective of this lifestyle intervention was to promote physical, mental, social, and spiritual wellness. Attendees' meals were plant-based (vegan). Participants followed a daily schedule of physical activity, seminars, behavioral health training, and faith-based activities to promote holistic health. In order to achieve the most comprehensive level of lifestyle training, health education instruction introduced the Fit 4 You Retreat concept of lifestyle modi cation. In order to establish baseline values, a comprehensive metabolic panel assessment was taken which included fasting lipid and glucose blood pro les.
Participants were required to fast after the evening meal served at 6 PM for supper on the day of arrival (sunday) until baseline blood levels were drawn the following morning at 6 AM. During the rst week, consultation appointments were scheduled, and initial assessments were reviewed by an on-site medical professional. The medical and tness teams reviewed performance and clinical parameters to determine participant placement in one of the tness training groups that were arranged by activity level.
A variety of health seminars and educational lectures were provided during the morning sessions throughout the week.
Professionals from both the health and medical disciplines provided a wide variety of lectures and presentations featuring topics like: functional exercise, depression and anxiety, cancer prevention, heart disease, diabetes prevention, and nutrition.
Retreat participants were encouraged to research and present (as a team or individually) one of the principles of lifestyle health during the lunch hour. The Fit 4 You Retreat concept of lifestyle change was taught throughout the program. Faithbased devotional sessions were presented during breakfast and after supper. Additional activities included a variety of therapeutic modalities like art, music, and massage therapy.
The daily menu had an average of 887 calories (fat 23.4 g, total carbohydrates 149.4 g, protein 35.45 g, dietary ber 39.6 g, sodium 1,918 mg) per meal. Breakfast, lunch and a light supper were served daily at ve-hour intervals prepared by the kitchen staff under the supervision of certi ed vegan/vegetarian chefs (Table 1)

Results
The socio-demographic pro le for quali ed participants is shown in  Based on the strati ed analysis, 59.5% and 40.5% were of African-American and Afro-Caribbean/Other Afro-Descent respectively, with a mean age of 59.23 ± 11.24 years (years ± SD). Over fty percent of study participants were married in contrast to 47.7% who were single, divorced, widowed, living with a partner or otherwise classi ed as unknown. The socioeconomic range was based on USD from ≤$2,999 per month to >$5,000 with educational variables split between high school/college and graduate/post graduate matriculation. Employment status was nearly equal between employed (52%) and non-employed (48%). The majority of the participants self-reported as belonging to some form of faith or denomination.
Participants were from urban and rural communities both in the US, and the Caribbean. Table 3 delineates the general characteristics and health related variables of the study subjects according to pre-intervention analysis. The concentration of glucose in the blood was signi cantly (P < 0.018) higher in women compared to men.
However, there were no signi cant differences in the other parameters according to the gender of the subjects in the diagnosis of the metabolic syndrome. Participation in the camp for two weeks improved with regard to the other parameters. Paired t-test results showed that plasma concentrations of glucose and TG were reduced post-intervention compared to pre-intervention analysis (Table 4).
On the other hand, there was no signi cant difference in systolic blood pressure (SBP), diastolic blood pressure (DBP), waist circumference, and HDL.  Table 5 shows the ratio of subjects with metabolic syndrome diagnostic risk factors pre and post retreat intervention. The bene cial effects of the program were signi cant based on the fact that glucose (P < 0.0001), TG (P = 0.024), and HDL levels (P = 0.0001) for females were signi cantly improved at the conclusion of the experiment compared to pre-intervention assessments. The proportion of subjects with normal fasting glucose and TG was signi cantly higher at the end of the program according to the metabolic syndrome index de ned by the NCEP: ATP-III than prior to the intervention. However, there was no signi cant difference in SBP, DBP, waist circumference and HDL for males.

Discussion
In addition to the natural environment and demographics, the study design included socioeconomic strata that in uence health behavior outcomes. Public health research literature indicates that both socio-demographics and economics signi cantly impact mortality and lifestyle outcomes. In a 10-year longitudinal study it was concluded that variables such as employment status, income, education, occupation, race, and marital status all affected mortality [15]. The clearly demonstrated positive effects of integrated lifestyle on cardiovascular risk reduction laid the foundation for early lifestyle adoption research which focused on e cacy analysis but later trended toward implementation and increased proliferation [16]. According to comparative studies evaluating physical activity and exercise, lifestyle combined with diet normalizes glucose and regulates weight. The author postulates that "lifestyle intervention" probably has different meanings for the patient, nurse practitioner, health educator or physician and that physical activity interventions differ from the broader concept of lifestyle modi cation which might include smoking cessation, dietary changes, and stress reduction [16].
Emerging research is now investigating the link between faith, religion, and behavioral health. Within the African-American community, health behaviors are strongly in uenced by faith [13]. The socio-demographic pro le for this study group During the tenure of the program, consultation appointments were scheduled, and initial assessments were reviewed by an on-site medical professional. As a result of these consultations and greater personal understanding, study subjects indicated an intention to have their risk factors evaluated on a regular basis. Participants were also encouraged to take their results back to their private practitioners as a means of establishing and maintaining bene cial health behavior goals.
This research provided potentially important clinical information concerning metabolic syndrome and its prevention. These ndings demonstrated a positive in uence on the reduction of cardiometabolic risk factors in this high-risk population.
Metabolic risks reductions were observed for all indicators with the exception of SBP, DBP and waist circumference for men.
The overall ndings suggest that a multi-faceted approach for lifestyle intervention may offer promising results in risk factor reduction for CVD and stroke in both men and women in this high-risk population. According to recent research by Weng et al. [22], the evidence concluded that "Elevated AST/ALT ratio is signi cantly associated with increased risk of developing CVD in men but not women". However, the ratio does not confer any additional bene ts over established CVD risk prediction tools in the general population but may have clinical utility in certain subgroups.
Consequently, elevated liver enzyme levels may assist clinicians in detecting lifestyle related conditions resulting in nonalcoholic fatty liver disease or additional organ malfunction. The participant pro les' liver enzymes remained within normal range while serum protein levels changed slightly. This observation may be due to the dietary impact of the plant-based diet and the liver's role in detoxifying the system. Additionally, the intervention program's exercise and physical activity regimens most likely had a favorable effect. Lifestyle research reports that sustained compliance is a common issue post intervention. Although the scope of the study did not include these statistics, some participants reported poor compliance after returning home with regard to health behavioral change, more reported sustained change in at least two to three areas of lifestyle modi cation.
The Fit 4 You Lifestyle intervention program was highly effective in signi cantly reducing risk factors associated with metabolic syndrome. However, additional emphasis has been considered regarding mental and emotional barriers to success that challenge health behavioral change.