metabolic syndrome is a collection of symptoms that leads to increased risk of 
 cardiovascular disease and diabetes .
each risk factor , on its own , may not cause significant 
 health issues , but a combination of these risk factors may lead to serious health 
 implications for an individual .
the framingham offspring study showed that metabolic 
 syndrome contributed to almost half of the population - attributable risk of diabetes , and 
 approximately a quarter of all incidents of cardiovascular disease1 .
the incidence of metabolic syndrome is rapidly increasing in people over the age of 602 .
analysis of data of 6,423 adult men and nonpregnant women , from the 
 third national health and nutrition examination survey ( nhanes iii ) , showed that the 
 age - adjusted prevalence of metabolic syndrome was 34.2% among u.s .
adults , and higher 
 prevalence of metabolic syndrome was noted with increasing age . an endeavor to prevent the 
 increase in the number of metabolic syndrome cases among the elderly is needed . walking is recommended for the elderly because walking is an easy exercise to practice4 .
walking is a simple exercise , which does 
 not require special equipment . as walking
can be performed anywhere regardless of season or 
 weather , compared with other kinds of sports , the practice rate of walking exercise was 
 reported to be the highest for the elderly5 . walking offers the perfect combination of exercise and a feeling of 
 immense satisfaction6 , and a positive 
 effect on body composition and lipid profiles of women aged over 65  years old4 .
nuri et al.7 reported that supervised walking and standard resistance training 
 program can improve metabolic syndrome parameters after 15 weeks .
previous research has focused on exercise as the sole intervention for the elderly with 
 metabolic syndrome8 , 9 . as metabolic syndrome correlates directly with obesity and 
 sedentary lifestyles ,
health education for patients is of significant importance in the 
 self - management of risk factors , such as obesity , high blood pressure , and smoking10 .
self - management is defined as the factor 
 of self - care related to cognitive decision - making in reaction to patients symptoms or 
 signs11 , and it is a very complicated 
 process that requires acute perception and evaluation of subtle changes in an individual s 
 own health condition .
self - management is a term applied to educational programs aimed at 
 teaching the skills needed to carry out medical regimens specific to a disease , guide change 
 in behavior regarding health , and provide emotional support for patients to control their 
 disease and increase their quality of life12 . as self - management encourages the patients to actively take part 
 in managing their illness , patients self - management is closely related to improved health 
 behavior and health status13 .
however , 
 few studies of the effect of both exercise and health education on metabolic syndrome have 
 been performed14 .
therefore , we designed 
 a walking program composed of walking exercise and health education , and conducted walking 
 programs for older adults with metabolic syndrome .
in korea , the majority of studies regarding the effect of exercise on metabolic syndrome 
 have been conducted in health centers in urban regions , and little is known regarding the 
 rural population . in korea , 72% of the rural population do not have access to gym 
 facilities , fitness classes or exercise equipment15 . also ,
therefore , this study introduced a combination of a walking 
 exercise and health education to rural residents to improve their self - management abilities , 
 and to decrease risk factors of metabolic syndrome .
the aim of the study was to determine the effects of a 12-week walking exercise and health 
 education program on self - management and risk factors of metabolic syndrome of older 
 adults .
the participants were 36 older adults aged over 60  years old who volunteered to participate 
 in the walking program at health centers ( fig . 

the inclusion criteria were based on the presence of three or more of the following 
 clinical criteria : wc  90  cm for men and  80  cm for women ; tg levels  
 150  mgdl ; ( 3 ) hdl levels < 40  mgdl for men or < 
 50  mgdl for women ; systolic blood pressure ( sbp )  130 mmhg , or diastolic 
 blood pressure ( dbp )  85 mmhg , or the use of antihypertensive medication ; fasting blood 
 sugar  110  mgdlor the use of anti - diabetic medication or insulin ; and body 
 mass index  25  kg / m .
metabolic syndrome was defined according to the revised 
 national cholesterol education program adult treatment panel iii ( ncep - atp iii ) 
 criteria .  
flow chart of participation selection process the experimental group of 21 people was comprised of rural residents attending 2 health 
 centers in e county .
the control group of 15 people was comprised of persons attending other 
 health centers in e county , which had similar demographic characteristics .
dropout rates in 
 the experimental group and control groups were 14.3% and 13.3% , respectively . at the end of 
 the intervention ,
the experimental group contained 18 rural elderly and the control group 
 contained 13 rural elderly .
table 1table 1 . walking exercise and health educationstageweekwalking exercise * ( 3 times a week)health education ( 12 times)stage 1week 12 km for 30 minutes , 40% of hrmaxintroduction of metabolic syndromeweek 2 3 km for 40 minutes , 40% of hrmaxexercise and posturestage 2week 3 4 km for 50 minutes , 50% of hrmaxproper walkingweek 4 5 km for 50 minutes , 60% of hrmaxnutritionstage 3week 5 56 km for 50 minutes , 60% of hrmaxalcoholweek 6 56 km for 50 minutes , 60% of hrmaxsmokingweek 7 56 km for 50 minutes , 60% of hrmaxdaily stressorsweek 8 56 km for 50 minutes , 60% of hrmaxhigh blood pressureweek 9 56 km for 50 minutes , 60% of hrmaxhigh blood sugarweek 1056 km for 50 minutes ,
60% of hrmaxhigh blood cholesterolweek 1156 km for 50 minutes , 60% of hrmaxobesityweek 1256 km for 50 minutes , 60% of hrmaxrevision of all topics shows the general characteristics of the subjects of this study .
there were no 
 significant differences between the two groups regarding gender , job , educational level , 
 income , and the risk factors of metabolic syndrome .
the experimental group participated in 
 the walking program . the walking program consisted of walking exercise and health education . 

stage 1 
 was the initial stage where subjects walked 23  km for 3040 minutes , while maintaining 40% 
 of maximum heart rate ( hrmax ) in the 1st2nd week .
participants walked 45  km for 50 minutes , while 
 maintaining 50% of hrmax .
stage 3 was the maintenance stage in which participants walked 
 56  km for 50 minutes , while maintaining 60% of hrmax .
the times noted above exclude the 
 warming - up and cooling - down periods . for the warm - up and cool - down sessions , participants 
 performed stretches , and running on the spot for 5 minutes each ( table 2table 2 . demographic characteristics and baseline measures of subjects by groupcategoryitemexperimental ( n=18)control ( n=13)n ( % ) n ( % ) gendermale2 ( 11.1)2 ( 15.4)female16 ( 88.9)11 ( 84.6)occupationfarming12 ( 66.7)7 ( 53.8)none2 ( 11.1)1 ( 7.7)housewife4 ( 22.2)5 ( 38.5)education levelnone ( illiterate)7 ( 38.9)5 ( 38.5)literate1 ( 5.6)2 ( 15.4)elementary or above10 ( 55.6)6 ( 46.2)incomeless than 1 million ( won)12 ( 66.7)10 ( 76.9)more than 1 million ( won)6 ( 33.3)3 ( 23.1)diseasehigh blood pressureyes13 ( 72.2)5 ( 38.5)no5 ( 27.8)8 ( 61.5)diabetesyes8 ( 44.4)5 ( 38.5)no10 ( 55.6)8 ( 61.5)arthritisyes5 ( 27.8)8 ( 61.5)no13 ( 72.2)5 ( 38.5 ) ) .
the experimental group received health education and counseling once a week , 
 regarding dietary principles and disease control .
health education focused on 
 self - management of metabolic syndrome , including hypertension and diabetes mellitus .
health 
 education and counseling were provided 12 times , and lasted 60 minutes per session .
the control group did not participate 
 in other health promotion programs . before we began collecting data , we explained the purpose of this study and received the 
 consent of all of the participants .
this study was approved by namseoul university , and the 
 approval number is research-20121205 .
data were collected to measure participant s general 
 characteristics , self - management , and risk factors of metabolic syndrome .
body measurements 
 were evaluated before and after the 12-week walking program by trained research assistants , 
 and blood tests were conducted by a researcher who was a nurse .
the participant s self - management of their health was assessed using a self - management 
 scale16 .
the self - management scale in 
 this study was composed of 17 items , coded from 1 to 3 , with 1 representing  strongly 
 disagree  , 2 representing  agree  and 3 representing  strongly agree .  the items covered 
 dietary treatment , weight control , drinking , smoking , exercise , sleep , and medication status 
 related to essential metabolic syndrome patients self - care .
one item regarding sleeping , 
 which is closely related to metabolic syndrome , was added in this study .
the revised 
 self - management scale was examined by three experts for content validity .
the reliability ( cronbach s  ) of the 
 instrument was 0.72 in lee16 s study and 
 0.91 in the present study .
subjects height was measured in millimeters using a portable height scale , their weight 
 was measured to an accuracy of 100  g using a digital weight scale ( cass digital , korea ) , and 
 their body mass index ( bmi ) was calculated by dividing weight ( kg ) by height squared 
 ( m ) .
participants blood pressure was measured at the health center after a 30 
 minute rest on the test day . following a 5-minute rest period , arterial blood pressure of 
 the right arm
was measured by a mercury sphygmomanometer while the subject rested in a 
 seated position .
two measurements were taken at each time point and the mean of both the 
 systolic ( sbp ) and diastolic ( dbp ) pressures were recorded for later analyses .
the waist 
 line was measured with a tape measure on the belly button line in a comfortable standing 
 position .
fasting blood sugar , high density lipoprotein - cholesterol ( hdl - c ) , and 
 triglyceride levels were tested by collecting blood after fasting at the baseline , and at 
 the end of the 12-week intervention .
a homogeneity test was used to detect any 
 significant group differences in the demographic data and pretest measures .
group comparisons were made of changes in the outcome variables between pretest and 
 posttest measures to assess the effects of the walking program .
on completion of the 12-week 
 walking program , the experimental group showed a significant improvement in self - management 
 of risk factors of metabolic syndrome ( f=4.61 , p<0.05 ) , which may 
 indicate significantly better self - regulation of health in everyday life than in the control 
 group ( table 3table 3 .
mean group comparisons in score changes in self - management between the pretest 
 and the posttestexperimental ( n=18)control ( n=13)pre - testpost - testpre - testpost - testself - management2.46 ( 0.37)2.65 ( 0.22 ) * 2.16 ( 0.31)2.31 ( 0.35)values are expressed as mean ( sd ) , * p<0.05 ) .
mean group comparisons score changes in the numbers of risk factors of metabolic 
 syndrome between the pretest and the posttestexperimental ( n=18)control ( n=13)pre - testpost - testpre - testpost - testrisk factors of metabolic syndrome total numbers of risk factors4.00 ( 0.97)2.33 ( 0.97 ) * * 4.15 ( 0.80)3.30 ( 0.94)blood sugar130.50 ( 42.67)102.50 ( 28.49)114.31 ( 26.67)107.30 ( 19.33)hdl - c44.83 ( 5.19)54.00 ( 6.87)45.23 ( 9.10)54.15 ( 10.99)triglyceride210.38 ( 115.80)180.88 ( 94.74)241.76 ( 135.54)206.31 ( 99.43)systolic blood pressure157.22 ( 20.80)136.22 ( 15.97 ) * 153.84 ( 17.92)147.00 ( 15.59)diastolic blood pressure90.00 ( 17.14)80.38 ( 13.39)87.38 ( 9.84)84.00 ( 11.08)bmi25.97 ( 3.69)25.00 ( 2.52 ) * 26.60 ( 3.18)27.37 ( 2.94)waist circumference88.46 ( 4.85)87.36 ( 4.47)87.80 ( 6.44)86.31 ( 7.04)values are expressed as mean ( sd ) , * p<0.05 , * * p<0.01 shows that there were some significant differences between the two groups in 
 risk factors of metabolic syndrome on completion of the 12-week walking program . in terms of 
 the number of risk factors of metabolic syndrome , the total number of risk factors of 
 metabolic syndrome differed significantly between the two groups ( f=7.98 , 
 p<0.01 ) , indicating a significantly lower rate of metabolic syndrome in the experimental 
 group than in the control group . in addition , the experimental group reported significantly 
 improved bmi ( f=5.81 , p<0.05 ) and systolic blood pressure 
 ( f=4.16 , p<0.05 ) .
group differences in blood sugar , hdl - c , diastolic 
 blood pressure , and waist circumference were found not to be significant .
in this study , we conducted a 12-week walking exercise and health education program for 
 older korean adults , who showed at least three components of metabolic syndrome .
the 
 experimental group showed a significant improvement in self - management and metabolic 
 syndrome symptoms at the end of the 12-week walking program .
the walking exercise and health education were effective at improving self - management of 
 older adults .
few studies have investigated the direct effect of a walking program on older 
 adults self - management of metabolic syndrome .
chang et al.17 suggested that nurse - led empowerment strategies for hypertensive 
 patients with metabolic syndrome improved metabolic syndrome symptoms and self - management 
 behaviors .
in korea , lee16 found that a 
 self - care program for hypertensive outpatients improved self - management compliance with 
 diet , exercise , regular medication intake , blood pressure , and stress management .
our 
 present study showed that health education could help the elderly with medical management , 
 promote good food habits , help manage negative emotions , reduce alcohol intake , and reduce 
 smoking .
in addition , health education can provide older adults with the necessary 
 knowledge , skills , and confidence to deal with metabolic syndrome - related problems . 

considering that older adults self - management is closely associated with health behavior , 
 it is necessary to incorporate health education in health promotion programs for older 
 adults .
the number of metabolic syndrome risk factors in the experimental group was significantly 
 reduced from 4.000.97 to 2.330.97 .
these findings are consistent with previous studies 
 that have examined the relationship between walking exercise and metabolic syndrome in older 
 adults8 , 18 .
our study confirmed that walking and health education effectively 
 ameliorated the risk factors of metabolic syndrome . considering that metabolic syndrome is 
 related to the prevalence , onset rate , and mortality rate of diabetes and cardiovascular 
 diseases19 , a walking program is 
 recommended for older adults as an effective approach for combating the harmful risk factors 
 of metabolic syndrome . in this study , after performance of the 12-week walking program , the bmi of the 
 experimental group significantly decreased from 25.97  kg / m to 
 25.00  kg / m .
our results are consistent with a previous study , which reported 
 that a 12-week walking program , plus individual motivational sessions , significantly reduced 
 the bmi of thai patients20 .
musto et 
 al.21 found that an active walking 
 group with a pedometer program showed significant reductions in bmi and systolic blood 
 pressure .
these results confirm that walking exercise for older adults is effective at 
 decreasing bmi . in this study ,
systolic blood pressure significantly decreased in the experimental group 
 after the program , therefore , the walking program can be considered an appropriate exercise 
 for reducing blood pressure .
farinatti22 
 reported that systolic and diastolic blood pressures were reduced by 6 and 9 mmhg , 
 respectively , after an aerobic exercise program of 30 minutes walking 3 times a week ; 
 however , stevenson and topp23 reported 
 that systolic and diastolic blood pressures were not significantly changed after elderly 
 subjects performed a low intensity exercise program for 9 months .
this difference is likely 
 due to the selection of study subjects , the length of the exercise program , and the 
 individual characteristics of the elderly subjects . in this study
, there were no significant differences in blood sugar , hdl - c , triglyceride , 
 or waist circumference between the two groups .
although statistically not significant , 
 positive trends in blood sugar and in hdl - c were observed in the exercise group .
the walking 
 program was deemed to be not long enough to reduce blood lipid levels or blood sugar levels . 

koutroumpi et al.24 suggested that 
 moderate - intensity exercise needs to be performed most days of the week to produce favorable 
 changes in blood cholesterol levels . to sum up
, this study provides new evidence linking walking and health education with 
 metabolic syndrome . for effective secondary prevention
, health care providers may use a new 
 strategy and intervention , such as a walking regime and health education for the older 
 adults with metabolic syndrome living in rural areas . in conclusion , a 12-week walking 
 program that combined walking exercise with health education
however , it was difficult 
 to distinguish between the effects of walking exercise and health education based on the 
 experimental design of this study .
further studies are needed to identify the independent 
 effects of walking exercise and health education , and the combination effects of walking 
 exercise and health education on metabolic syndrome in the elderly .
   [ purpose ] the aim of this study was to determine the effects of a 12-week walking 
 program on increasing an individual s self - management and decreasing the risk factors of 
 metabolic syndrome in the older adult population . [ subjects ] a total of 31 older adults 
 participated in this study . 
 eighteen participants in the experimental group and 13 
 controls completed the pretest and posttest measures . 
 a walking exercise and health 
 education were provided for the experimental group . 
 data were analyzed by ancovas to 
 examine group differences . 
 [ results ] at the end of the 12-week study period , the 
 experimental group showed a significant improvement in individuals ability to self - manage 
 their health compared to the control group . 
 also , there were significant differences 
 between the two groups in the total numbers of risk factors of metabolic syndrome , 
 systolic blood pressure and bmi . 
 no significant difference in blood sugar levels , hdl - c , 
 waist circumference , and triglyceride levels were found between the experimental and 
 control group . 
 [ conclusion ] this study revealed that a combination of health education and 
 for walking exercise can lead to improved lifestyle management and reduce risk factors of 
 metabolic syndrome for the elderly population of korea . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION