Effects of telephone-based motivational interviewing in lifestyle modification program

on reducing metabolic risks in middle-aged and older women with metabolic syndrome:
A randomized controlled trial

Background: Lifestyle modification is often difficult for middle-aged and older women living
in the community who are at high risk of physical inactivity and metabolic syndrome.
Objectives: To examine the effects of telephone-based motivational interviewing in a
12-week lifestyle modification program on physical activity, MetS, metabolic risks (fasting
plasma glucose, blood pressure, triglyceride, high-density lipoprotein, and central obesity),
and the number of metabolic risks in community-living middle-aged and older women
diagnosed with metabolic syndrome. Research design and method: A randomized controlled
trial was conducted. Recruited were 328 middle-aged and older women from a community
health center in Taiwan. Eligible women medically diagnosed with metabolic syndrome (n =
115) were randomly assigned to one of three groups: The experimental group received an
individualized telephone delivered lifestyle modification program that included motivational
interviewing delivered by an experienced nurse. The brief group received a single brief
lifestyle modification counseling session with a brochure. The usual care group received
standard care. Physical activity was assessed with the International Physical Activity
Questionnaire and metabolic risks were determined by serum markers and anthropometric
measures at pre- and post-intervention. One hundred women completed the study and an
intention-to- treat analysis was performed. Generalized estimating equations were used to
examine the intervention effects.

Results: Women in the experimental group increased physical activity from 1609 to 1892
MET-min/week (b = 846, p = .01), reduced the percentage of diagnosed with metabolic
syndrome to 81.6% (b = _0.17, p = .003), and decreased the number of metabolic risks from
4.0 to 3.6 (b = _0.50, p < .001), compared to the usual care group (4.4–4.6). There was not a
reduction in the percentage of diagnosed with metabolic syndrome in the brief group, but
they had fewer metabolic risks after 12 weeks (mean = 4.0 vs. 4.6, b = _0.2, p = .02)
compared to the usual care group. Conclusions: Motivational interviewing as a component of
an individualized physical activity and lifestyle modification program has positive benefit in
reducing metabolic risks in middle-aged and older women.

What is already known about the topic?

_ Middle-aged and older women are at higher risk of physical inactivity and metabolic
syndrome (MetS).

_ Lifestyle modification and moderate physical activity protect against MetS.

_ Lifestyle modification combined with promoting physi-cal activity through motivational
interviewing increases physical activity, but there is limited evidence to show its effects on
MetS risks, particularly in middle-aged and older women living in community.

What this paper adds

_ For community-living middle-aged and older women with MetS, the individualized
lifestyle modification program by telephone-based motivational interviewing can increase the
amount of their physical activity.

_ The individualized lifestyle modification by telephone-based motivational interviewing is

an effective inter-vention model for reducing prevalence of MetS and MetS risks for
middle-aged and older women.

1. Introduction

Metabolic syndrome (MetS), a constellation of hyper-tension, dyslipidemia, and diabetes risk

factors, is associ-ated with an increased risk of all-cause mortality (Dai et al., 2010; Gami et
al., 2007; W.S. Wang et al., 2012). It has become a widespread health problem affecting
women in many countries including Taiwan. Overall, the prevalence of MetS is higher in
women as compared to men (36.3% in men compared to 56.8% in women). In those countries
studied, including Taiwan, this gender difference emerges in midlife (Hwang et al., 2006; Lin
et al., 2014; Mozumdar and Liguori, 2011; Park and Kim, 2015). Compared to men, women
also tend to have lower cardiorespiratory fitness, which is another risk factor for MetS. In
women physical activity declines with age (American College of Sports Medicine, 2013;
Bauman et al., 2009; Carroll et al., 2000). This puts middle-aged and older women at
increased risk of developing MetS. When reduced physical activity is combined with post-
menopausal status, the risk of developing MetS increases (Fruge´ et al., 2015; Kwas´niewska
et al., 2010; Laaksonen et al., 2002; Park et al., 2003). Despite this increased risk it is
challenging for many women to modify their physical activity to reduce MetS risk. Thus,
testing health promotion strategies that target physical activity for middle-aged and older
women living in community is an important focus for women’s health research. Currently
medication and lifestyle modifications, e.g., diet and physical activity, are recommended to
reduce MetS risk (Chu et al., 2016; Esposito et al., 2013; Grundy et al., 2005). Among the
lifestyle modifications, physical activity is considered the most economical and efficient
(Bassi et al., 2014; Yamaoka and Tango, 2012) in reversing the disease trajectory of MetS
(Boule´ et al., 2001; Grundy et al., 2005). The positive effect of increasing the amount of
physical activity on MetS risks occurs even without dietary modification (Chen et al., 2006;
Touati et al., 2011). In Taiwan where middle aged and older women have a high prevalence
of MetS (43.3%), low levels of physical activity are also found (Bauman et al., 2009; Lin et
al., 2015). Therefore, in this intervention study we targeted middleaged and older Taiwanese
women because of both their risk for MetS and their reduced physical activity. Our purpose
was to test the effectiveness of an individualized lifestyle modification program including
motivational interviewing on physical activity and MetS risks.

2. Literature review

2.1. MetS in middle-aged and older women

MetS is defined as having three or more of the following five risk factors according to the
National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III): (1)
elevated fasting plasma glucose: 100 mg/dl or use of antidiabetic medicines; (2) elevated
blood pressure: _130/85 mmHg or use of antihypertensive medicines; (3) elevated
triglyceride: _150 mg/dl; (4) reduced high-density lipoprotein cholesterol: <50 mg/dl; and
(5) central obesity: waist circumference _80 cm (Grundy et al., 2005). Middle-aged and
older women are less likely to participate in physical activity for health promotion purposes
(Im et al., 2012; Steeves et al., 2015; World Health Organization, 2015), leading to a high
risk of developing MetS (Hwang et al., 2006; Lin et al., 2014; Mozumdar and Liguori, 2011;
Park and Kim, 2015). The literature supports the notion that women, in general, do not
prioritize self-care (McArthur et al., 2014; Pavey et al., 2012; United Nations, 2014). Im et al.
(2012) found that Asian-American midlife women give higher priority to family caregiving
and, as a result, assign physical activity as the lowest priority in their lives. A suggested
scenario is that women in Taiwan as well as other parts of Asia also prioritize family care,
contributing to a sedentary lifestyle (Bauer et al., 2000). Nurses play a crucial role in assuring
women’s health, including telenursing, health education, and community campaigns to
improve the well-being of women. Therefore, targeting the high-risk population (i.e., women)
and providing nurse-led interventions against MetS are essential.

2.2. Lifestyle modification and MetS Previous studies show that reducing

MetS risks through lifestyle modification is linked to health benefits and better
patient-reported outcomes (Boule´ et al., 2001; Nanri et al., 2012; Oh et al., 2010). The
behavioral changes of short-term period lifestyle modification programs for individuals with
MetS have better adher- ence than do those of long-term period programs (Lin et al., 2015).
Fortunately, the literature indicates that a lifestyle modification program of at least 4 weeks
that is especially focused on physical activity can improve MetS risks such as central obesity
and serum lipids in women. This is due to reductions in systemic oxidative stress and
inflammatory biomarkers in women with MetS even without modifications of dietary pattern
(Farinha et al., 2015; Oh et al., 2008). Less is known about the strategies used to sustain those
efforts in community-dwelling adults. Our previous systematic review indicated that
nurse-led lifestyle modification programs of _12 weeks positively influence MetS risks in
adults with MetS (Lin et al., 2014). Although interactive approaches with frequent contact
with individuals who are motivated might make a larger and more lasting impact, the effects
of a nurse-led lifestyle modification through a more aggressive approach (e.g., telephone-
based motivational interviewing) on MetS risks remains unknown, particularly in
middle-aged and older women living in community. Traditional physical activity
interventions using a group-supervised approach have positive benefits (Conn et al., 2003;
Fitch et al., 2006; Mathunjwa et al., 2013); however, it may not be appropriate for those who
have limited access (e.g., unavailable/inflexible time or sched-ule, inconvenient
location/commute) in the community. Individualized approaches, including use of telephone,
website, or mass media, characterized as ‘‘telenursing’’ are quickly being put into place
(International Council of Nurses [ICN], 2013). ‘‘Telenursing,’’ defined as professional
nursing care that involves teaching, persuading lifestyle alteration, and understanding the
impact of diseases and other factors on community-dwelling individuals through
telecommunication technology, may be a useful approach for individualized programs geared
to motivate middle-aged and older women to engage in behavior change (ICN, 2013).

2.3. Motivational interviewing

Improving individuals’ motivation for lifestyle modifi-cation adherence and regular physical
activity is a key factor in reducing MetS risk (Bassi et al., 2014). By enhancing
self-determination motivational interviewing is one of the most efficient strategies to
facilitate decision-making about behavioral change (Miller and Rollnick, 2012). It is designed
as a constructive way to help an individual surmount the challenges of changing behaviors
(Miller and Rollnick, 2012); e.g., smoking cessation, managing diabetes (Chen et al., 2012;
Louwagie et al., 2014), and promoting physical activity (Bennett et al., 2007; Brodie and
Inoue, 2005). It is also reported that telephone-based motivational interviewing has beneficial
effects on self-efficacy for physical activity in persons over age 55 (Lilienthal et al., 2014). It
can be hypothesized that a telephone-based motivational interviewing intervention combined
with an individualized lifestyle modification will improve physical activity and reduce MetS
risks for community-dwelling women (Conn et al., 2003).

3. Aims

Our aim was to examine the effects in middle-aged and older Taiwanese women diagnosed
with MetS of an individualized telephone-delivered motivational inter-viewing lifestyle
modification program, compared to a single brief lifestyle modification counseling session
with a brochure, and usual care.

4. Method

4.1. Study design

A randomized controlled trial with a three parallel-intervention-group design was conducted.

Eligible middle-aged and older women diagnosed with MetS living in community were
randomly assigned to one of three groups: (1) the experimental group, who received an
individualized 12-week lifestyle modification program by motivational interviewing; (2) the
brief group who received a single brief lifestyle modification counseling session with a
brochure on lifestyle modification; or (3) the usual care group. Outcome measures included
weekly physical activity amount, MetS, and MetS risks, as well as the mean number of MetS
risks.

4.2. Participants

Potential participants were recruited by a research assistant from an urban community health
center in Taiwan from March 2013 through June 2013. Those who agreed to participate were
then referred to an endocrinol-ogy/metabolism physician of the local medical center for
screening for MetS. Inclusion criteria were (1) women diagnosed with MetS; (2) aged over
40 years; (3) able to speak and understand Mandarin; (4) able to walk without assistance; and
(5) agreed to be randomized to one of the three groups. Exclusion criteria included a history
of cancer, end-stage renal disease with dialysis, confirmed psychiatric disease, and an
inability to participate due to comorbid neurological and musculoskeletal conditions that
produce moderate-to-severe physical disability.

4.3. Study cohorts and interventions

Eligible women who agreed to participate were randomly assigned to either the experimental
group, the brief group, or the usual care group using sealed opaque envelopes, following
computer-generated random serial numbers. At the outpatient clinic women in the
experi-mental and brief groups each received a single, individual, brief (15–20 min)
face-to-face lifestyle modification counseling session and an educational brochure. The
counseling sessions were performed by an experienced and well-trained nurse/researcher (the
first author, who has more than 10-year experience in both metabolic control and physical
activity training). The educational brochure about lifestyle modification included
informa-tion about MetS (definition, prevalence in women, trends, causes, and health
consequences), and standard manage-ment of MetS based on the guidelines of NCEP-ATP III
and ACSM (American College of Sports Medicine, 2013; Grundy et al., 2005), including diet
control, adequate level of physical activity, and stress coping. The women in the experimental
group then received a 12-week individual-ized lifestyle modification program that focused on
physical activity promotion by telephone-delivered moti-vational interviewing. The usual
care group women received standard care, which maintained their usual lifestyles and routine
follow-up at outpatient clinics (Fig. 1). For example, if women diagnosed with type 2
diabetes, dyslipidemia, or hypertension, they received a one-time follow-up per month to
monitor their condition at outpatient clinics. The lifestyle modification program began with
an individualized education session delivered by the same nurse (the first author), who is an
expert at motivational interviewing, and followed by the 12-week individualized motivational
interviewing that focused on physical activity promotion. Before the 12-week motivational
interviewing began, the experimental group participants’ contemplation of physical activity
participation was assessed. The women were categorized into three stages: (1) no intention to
engage in physical activity, (2) intention to engage in regular physical activity, and (3)
already performing regular physical activity. These stages were used to guide the
motivational interviewing-focused content as shown in Table 1. Each woman started at her
own individual physical activity amount (i.e., time spent in aerobic activities) with the goal of
advancing to perform moderate physical activity per week of at least 150 min or walking at
least 210 min (ACSM, 2013). The women were reminded each week to engage in an
adequate amount of physical activity, to modify undesirable attributes, and were rewarded for
achieving their planned physical activity level. At each session, the goal was to empower
women to strengthen their motivation and commitment, to increase their physical activity
amount using the brochure timetable, and to address any questions or concerns by telephone.

Diagram dan tabel

The motivational interviewing was delivered in 15– 30 min telephone calls once per week,
according to the participants’ preferred schedule for 12 weeks. The core elements of
motivational interviewing include empowerment, support, respect, assertiveness,
nonjudgment, and empathy were applied during the intervention (Miller and Rollnick, 2002).
The motivational interviewing was implemented following a protocol designed by the
research team (research project investigator, motivational interviewing implementer, the
endocrinologist, and rehabilitation physician) and based on the standard elements of
motivational interviewing to ensure the veracity of the motivational interviewing delivered.
To establish a trusting relationship between the participant and the researcher, a
conversational approach was used. Motivational interviewing techniques utilized included
asking permission, eliciting/evoking change talk, exploring importance and confidence,
open-ended statements supporting self-efficacy/self-confidence, reflective listening,
normalizing, decisional balancing, deploying discrepancies, readiness-to-change ruler,
affirmations, advice/feedback, summaries, and therapeutic paradox (Miller and Rollnick,
2002, 2012).

4.4. Measures

Eligible women who agreed to participate were invited to the local medical center for pre-
(baseline) assessment. Data were collected using structured interviews with questionnaires,
blood analyses, and anthropometric-measures. The self-reported data (questionnaire:
demo-graphics and lifestyle factors) and anthropometric measures (waist circumferences)
were collected by a separate research nurse, blinded to the group assignment. Questionnaires
included demographics (age, menopausal status, educational level, marital status, occupation)
and lifestyle factors including current alcohol consumption (yes/no), current smoking
(yes/no), and dietary patterns (weekly frequency of breakfast and night-snacking
con-sumption) (Al-Naimi et al., 2004; Deshmukh-Taskar et al., 2012). After 12 h of
participant fasting, the blood samples were collected by trained phlebotomists, who were
blinded to the participants’ group membership.

4.4.1. Physical activity

 The participants’ weekly physical activity was assessed by a research nurse using the
International Physical Activity Questionnaire (IPAQ)-short form, Chinese version, which has
well-established reliability and validity (Liou et al., 2008). This 7-item instrument measures
time (min) of physical activity including housework, transportation, leisure activity, and
moderate-to-vigorous-intensity phys-ical activity for the past 7 days. The physical activity
amount per week of the study was computed and calculated by the same research nurse, as
the sum of walking, moderate-intensity physical activity, and vigor-ous-intensity physical
activity for the past 7 days. The IPAQ scores expressed as ‘‘MET-minutes/week’’ were
calculated as the MET level (i.e., walking = 3.3 METs, moderate-intensity physical activity =
4.0 METs, vigorous-intensity physical activity = 8.0 METs) multiplied by minutes of activity
per week (Craig et al., 2003).

4.4.2. Mean number of MetS risks

The five MetS risks, based on the NCEP-ATP III guideline (Grundy et al., 2005) including
elevated fasting plasma glucose, elevated blood pressure, elevated triglyceride, reduced
high-density lipoprotein (HDL) cholesterol, and central obesity, were identified via blood
samples and anthropometric measurement. The mean number of MetS risks was tabulated for
comparison purposes. Having three or more MetS risks was defined as MetS. The plasma
glucose, triglyceride, and HDL cholesterol were analyzed using an enzymatic assay (Yellow
Spring Glucose Analyzer, YSI, Yellow Springs, OH, USA) and a chemistry analyzer
(Olympus, AU680, BC, Asia/Pacific). The coefficients of variation for the internal quality
controls were under 1%. Blood pressure was obtained after the participant had been seated
quietly for 3–5 min, using an electronic blood pressure monitor device (Terumo, ESP2000,
Tokyo, Japan). Waist circumference was measured while the participant was standing, at the
end of a normal expiration, using a soft

anthropometric tape at the midpoint between the iliac crest and the lowest rib, typically at the
level of the umbilicus. The means of two times measures of blood pressure and waist
circumference were used for analysis. The numbers of MetS risks ranged from 0 to 5.

4.5. Sample size

Sample size estimation was based on our previous study with a medium-to-small effect size
(Lin et al., 2015). With an effect size of 0.25 for the outcome of expected reduction in
percentage of women diagnosed with MetS, an alpha set at 0.05, and a power of 0.80, each
group required 34 women (Cohen, 1992). We recruited 38–39 participants in each group to
account for a 10–15% loss to follow-up.

4.6. Ethical consideration

Institutional review board approval (TSGHIRB: 1-101- 05-073) was obtained from
Tri-Service General Hospital in Taiwan. All participants gave written informed consent when
they were invited to join the study and were assured that their participation was entirely
voluntary and that they could withdraw at any time.

4.7. Data analysis

Statistical analyses were performed by SPSS version 16.0 (SPSS Inc., Chicago, IL).
Descriptive statistics including means and standard deviation (SD) and percentage (%) for the
study participants were presented. Analysis of vari-ance, paired t-test, Wilcoxon signed rank,
and chi-square test were used to compare the pre-intervention differences among the three
groups. Generalized estimating equations (GEE) for longitudinal data/repeat measures were
used to estimate the intervention effects of the three groups by significant interaction of group
and time (group _ time) (Liang and Zeger, 1986). When evaluating the effects of the
intervention on percentage of diagnosed with MetS, MetS risks, and mean number of MetS
risks, the models were adjusted for lifestyle covariates (i.e., alcohol consumption, smoking
habits, regular weekly breakfast frequency, and regular weekly late-night-snack frequency).
All of the statistical analyses were two-tailed and considered significant at p < .05.

5. Results

5.1. Baseline characteristics of participants

Three hundred and twenty eight (328) women were initially approached. Of these 28 women
declined to participate due to lack of time and anticipated discomfort from venipuncture, and
185 were excluded. Of those excluded participants, 90.8% (n = 168) did not meet the criteria
of MetS, 5.4% (n = 10) had a history of cancer, 2.2% (n = 4) had a confirmed psychiatric
disease, and 1.6% (n = 3) were identified as having moderate-to-severe physical disability.
The remaining 115 participants with confirmed MetS and who met the other inclusion criteria
were randomly assigned: 38 (33%) to the experimental group, 38 (33%) to the brief group,
and 39 (34%) to the usual care group, respectively. Of the 115 randomized participants, 100
(87%) com-pleted all data collection: 34 in the experimental group, 32 in the brief group, and
34 in the usual care group. The reasons for missed visits, including withdrawal from the study
(n = 1) and loss to follow-up (n = 14), at the 12-week assessment are presented in the Flow
Diagram (Fig. 1). The last-observation-carried-forward method of data imputation was used
for intent-to-treat analysis. Hence, 115 participants were included in the data analysis. Table
2 presents the demographic, lifestyle factors, and the baseline stage of physical activity
among the three groups. The baseline physical activity amount, MetS, MetS risks, and
number of MetS risks among the three groups are shown in Table 3.

5.2. Outcome evaluation

Physical activity. The descriptive and univariate analysis of outcome evaluation are shown in
Table 3. Women in the usual care group decreased their overall physical activity amount as
well as their amount of moderate-intensity activity and walking. In the brief group there were
no significant changes in physical activity amount, total physical activity, moderate-intensity
physical activity, and walking decreased (except for vigorous-intensity physical activity).
Although the amounts of all types of physical activity increased in the experimental group,
statistical significance was not reached. MetS and MetS risks. In the experimental group,
after the 12-week motivational interviewing intervention, the percentage of diagnosed with
MetS and one of the MetS risks (central obesity) decreased (100–81.6%, p = .01; 84.2–
63.2%, p = .03) at 12 weeks; while both the brief group and the usual care group had no
change in the percentage of diagnosed with MetS and MetS risks (Table 3). Moreover, the
experimental group had a significant decrease in the mean number of MetS risks (4.0–3.6, p =
.002) after 12 weeks, while a significant increase in the usual care group (4.4–4.6, p = .003),
with no changes occurring in the brief group (4.0–4.0, p = .57). GEE analyses. The
effectiveness of the lifestyle modifi-cation by telephone-based motivational interviewing on
physical activity amount and metabolic risks based on GEE analyses are shown in Table 4.
The significant group _ time interaction for physical activity revealed that women in the
experimental group had a greater increase in physical activity at 12 weeks than did those in
the usual care group (b = 846, p = .01). Moreover, women in the experimental group had a
significant increase in moderate-intensity physical activity, compared to the usual care group
(b = 337, p = .02). No differences in physical activity amount were found in the brief group
compared to the usual care group, as well as in the experimental group compared to the brief
group. The significant group _ time interaction for percentage of diagnosed with MetS and
each MetS risk revealed that after adjusting for lifestyle factors of women in the experimental
group there was a significant reduction in percentage of diagnosed with MetS (b = _0.17, p =
.003), reduced HDL cholesterol (b = _0.18, p = .01), and central obesity (b = _0.23, p =
.001), compared to the usual care group. Compared to the brief group, women in the
experimental group also had a significant reduction in percentage of diagnosed with MetS (b
= _0.17, p = .02), reduced HDL cholesterol (b = _0.15, p = .03), and central obesity (b =
_0.16, p = .03). The percentage of diagnosed with MetS and all of the MetS risks in the brief
group revealed no significant decrease compared to the usual care group. The mean number
of MetS risks in the experimental group at 12 weeks decreased significantly, compared to the
usual care group (b = _0.5, p < .001) and the brief group (b = _0.3, p = .002). Although the
mean number of MetS risks did not change in the brief group, there was a significant
reduction compared to the usual care group (b = _0.2, p = .002).

6. Discussion

The study demonstrates that an individualized lifestyle modification program provided by a

nurse-delivered, telephone-based motivational interviewing program improves weekly
physical activity amount, especially moderate-intensity physical activity, and reduces MetS
risks for middle-aged and older Taiwanese women living in community. These results add to
the literature demon-strating that engagement in moderate physical activity may protect
against the development of MetS and that lifestyle modification reduces MetS risks (Fruge´ et
al., 2015; Lin et al., 2015). Furthermore, our results are consistent with prior research
demonstrating that motivational interviewing increases physical activity (Wadden et al.,
2011). The success of this telephone-based motivational interviewing approach provides
evidence for an individualized strategy to enhance physical activity adoption and
maintenance. We hypothesize that an individualized motivational interviewing approach
increases an individual’s motivation to overcome perceived barriers, increase self-care skills,
and most importantly strengthen their willpower to engage in and maintain their healthy
lifestyle (Connelly et al., 2013). The lifestyle modification program focused mainly on
physical activity promotion by motivational interviewing and may be used as one of the
effective models for clinical evidence-based nursing practice for middle-aged and older
women with MetS. As our study revealed, even though the increased vigorous-intensity
physical activity and walking behaviors in the experimental group did not reach statistical
significance, women in both the brief and usual care groups decreased their total physical
activity, particularly moderate-intensity physical activity and walking behaviors, after 12
weeks. As such, a larger sample may have revealed statistically significant differences among
the groups. Additionally, our intervention had positive effects (tebel 1,2) on two specific
MetS risks (i.e., high-density lipoprotein cholesterol and central obesity), which is consistent
with previous studies (Fitch et al., 2006; Oh et al., 2008, 2010). In our participants, a 12-week
intervention did not reduce some other MetS risks (i.e., elevated fasting plasma glucose,
elevated blood pressure, and elevated triglyceride), perhaps due to the large proportion of
individuals taking medications for treating MetS risks (X. Wang et al., 2012). Even though
the values of these three MetS risks showed improvement, they were still considered MetS
risks as defined by the NCEP-ATP III. Serum lipid levels may not change with a lifestyle
modification program without diet modifications. We conjecture that combining the program
with aggressive diet control would have better effects on triglyceride levels (Asemi et al.,
2014). The individualized lifestyle modification and reinforcement strategies delivered via
telephone-based motivational interviewing were effective for women living in community. It
may be that this approach is effective in persuading individuals to confront their own health
behaviors (Bennett et al., 2007; Miller and Rollnick, 2002; West et al., 2007). As a result of
motivational interviewing, women become more active perhaps because their confidences
about self-management are increased. In addition, the motivational interviewing may have
helped to support individuals’ struggles for change during difficulty, and facilitate
decision-making for behavioral change (Miller and Rollnick, 2002; Wadden et al., 2011).
Although women in the brief group did not change their physical activity level they did have
reductions in MetS risks, as compared with the usual care group. These results are consistent
with a previous report (Marshall et al., 2003). Brief lifestyle counseling combined with
educational materials may had led to reductions in sedentary time (i.e., watching television,
sitting behaviors), modifications in diet, and enhancement of self-management skills. Based
on continued MetS risks in the usual care group, our data indicate that health promotion
needs to be aggressively promoted for middle-aged and older women. Even the low-cost,
generalizable intervention in the brief group is a potentially useful, population-based strategy
for physical activity promotion. Motivational interviewing using a telephone-based approach
shortens the ‘‘distance’’ between health providers and community-dwelling people,
especially those who have limited access (e.g., unavailable/inflexible time or schedule,
inconvenient location/commute). After participants are motivated, they might not only be
empowered but become aware of how home-based physical activity can be done more
flexibly, at any time, and in other appropriate places. In addition, we confirmed nurse-led
lifestyle modification programs have positive effects on MetS risks (Lin et al., 2014). We can
conjecture that the better outcomes of nurse-led lifestyle modification programs are due in
part to better adherence and a lower attrition rate (Lin et al., 2014; Nanri et al., 2012; Oh et
al., 2010). We recommend that nurse-led lifestyle modification programs be included in
future designs of lifestyle modification programs and that they be integrated into nursing
education in order to expand the role of nursing in healthcare and reduce the burden of MetS
in the community. The results of this study add to the growing body of literature that supports
the expanded role of nursing and telenursing in primary care. Through a telephone-based/
interactive approach with frequency contact might make a larger impact on individuals’
contemplation of behavioral changes. At this time we cannot state that the positive outcomes
were due to ‘empowerment’ of the women in the experimental group to increase self-care
activities. It is important to point out that the study only included women who were interested
in learning and engaging in self-care activities to reduce MetS. Our study has several
limitations that must be considered: First, although the immediate effects after a 12-week
intervention are important, evaluation of long-term follow-up is necessary; and (2) the
geographic region in which this study was conducted may limit its generalizability to other
cultural groups. Thus, the findings must be interpreted with caution, and more rigorous
sampling strategies from multiple sites are recommended. Although we cannot neglect these
study limitations, there are strengths, including the random allocation design, the provision of
individual interventions with a motivational interviewing strategy in an urban community,
and the high rate of study completion by the participants (87%). Our study is the first trial to
test the effectiveness of telephone-based motivational interviewing in a lifestyle modification
program on promoting physical activity and reducing metabolic risks in middle-aged and
older women with MetS. Future studies could focus on biomarkers that might elucidate how
physical activity improves metabolic risks in this population. In addition, the feasibility of
implementing the intervention both in the community and primary care setting would be an
important next step.

7. Conclusion

A nurse-delivered individualized lifestyle modification program focused on physical activity

promotion through motivational interviewing by telephone helps middle-aged and older
women with MetS achieve a clinically meaning-ful increase of physical activity, reduction of
metabolic risks, and consequently a reduction in MetS diagnoses. Based on our results, this
study may be used as one of the reference models for clinicians to share decision-making
with clients based on evidence-based nursing practice and community-based approaches.

7.1. Implications for nursing practice and research

Our study revealed that an individualized lifestyle modification program focused on physical
activity promo-tion by telephone-based motivational interviewing strate-gies to continuously
empower and promote women’s adherence to physical activity was associated with
meaningful changes in health behaviors and with positive benefits for middle-aged and older
women to reverse the status of MetS. More educational efforts should be targeted to include
motivational interviewing for communitydwelling, middle-aged, and older women. Further
studies should be designed to investigate longterm follow-up effects of the 12-week
individualized lifestyle modification program focused on physical activity promotion by
motivational interviewing among middleaged and older women and men with MetS. More
important factors (i.e., perceived barriers, perceived benefits, patient activation, self-efficacy
of physical activity) that may influence individuals’ motivation for participating in physical
activity should be examined. Since healthy diet patterns and increased physical activity have
different effects on body composition, with both contributing to fat loss, further study might
be needed to incorporate diet-pattern modification into future health promotion programs or
to comprehensively assess the diet for changes. Moreover, whether the program actually did
empower the women should be explored, and future studies using focus groups or qualitative
examination of what participants perceived as most helpful are needed.