Impact of Time in Motion on Blood Pressure Regulation Among Patients with Metabolic Syndrome

Abstract

Purpose of Review

This review assessed recent evidence on the association between objectively measured physical activity from wearable accelerometers and blood pressure (BP) in participants with metabolic syndrome (MetS).

Recent Findings

Results directly related to BP were mixed, with some studies showing positive associations and others showing null results. Importantly, several studies noted that participants with MetS demonstrated greater improvements in components of MetS after engaging in higher amounts of daily physical activity. Although this suggests greater volume of physical activity may be a means to partially mitigate hypertension in those with MetS, it remains unclear whether physical activity or inactivity (i.e., sedentary behavior) is more strongly associated with MetS.

Summary

Although there may be benefit to greater volumes of daily PA among hypertensive patients with MetS, more research is needed to quantify and define the amount of daily activity needed to improve health and refine clinical recommendations. Moreover, although the evidence for improving components of MetS through engaging in physical activity is high, the amount and type(s) of physical activity needed to achieve these benefits is unclear.

Introduction

Hypertension, a primary component of metabolic syndrome (MetS), is highly prevalent in the USA, with recent estimates indicating 50% of adults are classified as hypertensive [1]. MetS is typically defined as the presence of three or more cardiometabolic risk factors including hypertension, abdominal obesity, dyslipidemia, and type 2 diabetes mellitus [2••]. Both observational and interventional research have shown that routine engagement in structured moderate-to-vigorous physical activity (MVPA) plays an important role in managing and curbing the risks associated with hypertension and MetS [2••]. However, lesser known is how time spent moving across all types of daily activities, from planned exercise to walking and other daily tasks, may benefit those with hypertension and MetS.

Traditionally, physical activity has been measured via self-report methods using questionnaires that inquire about time spent engaging in different types of volitional physical activities [3]. However, these questionnaires mainly capture coarse measures of easily recalled activities, creating a potential bias towards routine engagement in physical exercise (e.g., planned activity for health benefits) [4] or more vigorous activities. These biases may potentially underestimate other important aspects of physical activity that encompass different types of movement, including total volume of activity (e.g., active minutes per day, total activity counts or steps per day) or daily patterns of activity (circadian rhythms and transitions between active and sedentary states) [3, 5, 6]. Given the most common types of physical activity in which most adults engage are walking-based activities and tasks associated with daily living, the potential health benefits of routine engagement in such daily activities are largely undefined [7–9].

The advent of wearable devices to measure physical activity provides clinicians and researchers with unprecedented opportunities to define and quantify physical activity and its associated health benefits. Wearable devices range from traditional pedometers to more technologically advanced accelerometers that use sensors to detect accelerations in one-to-three orthogonal planes [10, 11]. Accelerometers span the consumer and research markets and include brands like Fitbit, Applewatch, Garmin, Actigraph, Actiwatch, GENEActiv, and ActivPal [9]. Most research grade models have fairly robust batteries, facilitating continuous, objective assessment of daily physical activity across levels of exertion over multiple days or weeks [9]. In the past decade, the popularity of these devices has exploded in both consumer and research settings, but much of their utility has been limited to assessing compliance with physical activity guidelines or intervention efforts [12, 13•]. Although such compliance measures are important for gauging population health and effectiveness of interventions, these measures vastly underutilize the scope of the data collected by these devices and the potential to more comprehensively understand how the amount of time spent moving is linked with health outcomes. Given the well-established link between movement and health [14–16], a better understanding of the health effects of “time in motion” is warranted.

The purpose of this review is to assess the recent evidence for the effects of objectively measured “time in motion” on hypertension in patients with MetS. Given the rapidly evolving state of wearable technology, we limited our search to the evidence published between 2018 and mid 2021 on the use of wearable devices to assess the impact of physical activity on blood pressure (BP) regulation among patients with MetS.

Methods

Eligibility Criteria

To be included in this review, studies had to be original research articles published within the last 3 years that examined the association between our exposure of interest, objectively measured physical activity, and the outcome variable, blood pressure in participants with MetS. Studies had to include adults (no pediatric participants); present health-related data collected using primary or secondary data collection methods; and have English-language availability. Furthermore, we chose to focus specifically on objective measurement of physical activity in participants using accelerometers. Studies that used only self-reported measures of physical activity were excluded.

Search Strategy

In collaboration with an informationist from the Johns Hopkins Welch Medical Library, we conducted a systematic literature search in Medline (Ovid), Embase, and Cochrane Library on June 21, 2021. The search strategy used controlled vocabulary and keywords to define the concepts of MetS, blood pressure, and physical activity. The full search strategy is available in the supplemental materials. Search results were imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). Duplicates were removed and a dual review process of title/abstract screenings was followed, with each reviewer blinded to the other reviewer’s decision to include/exclude each study; a third reviewer resolved discrepancies. After the initial screening, four team members independently completed a full-text review of the included studies. The decision to include/exclude was based on the pre-specified inclusion criteria.

Data Analysis

Reviewers extracted information from each article, including whether the study population included patients with MetS, MetS components, blood pressure measurement protocol, type and description of wearable device, the role of physical activity in the study, the role of blood pressure in the study, and key findings.

Results

Our initial search yielded 121 articles, three of which were duplicates and removed, resulting in 118 studies that were reviewed for study inclusion. Of the 118 abstracts reviewed, 69 studies were excluded for irrelevant content, leaving 49 studies for full-text review. After full-text review, 23 articles were excluded for the following reasons: full text not available (n = 13), blood pressure not reported (n = 4), wrong patient population (n = 3), or objective physical activity not reported (n = 3). A total of 26 articles were included in this review (Fig. 1).

Fig. 1.

Study screening and inclusion

The included studies ranged from 7 to 2,189 participants: 6 (23%) were interventions, 17 (74%) were cross-sectional analyses, 3 (13%) were longitudinal analyses, and 9 (35%) were secondary analyses of existing datasets. All studies used one or more MetS components in their enrollment criteria and reported objectively measured physical activity and BP (Table 1).

Table 1.

Studies included in the review

Author, year	MetS patients (Y/N) % (N) Study design	MetS criteria	BP measurement (device, if provided)	Wearable device description (manufacturer)	PA description (variable type)	BP description (variable type)	Key findings	PA and BP association
Interventions
Atigan 2021 [38]	Yes 100 (51) Cross-sectional	Three or more of: WC > 88 cm in women, > 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG 1.7 mmol/L; HDL-C < 1.29 mmol/L in women, < 1.03 mmol/L in men; blood glucose ≥ 5.6 mmol/L	Not defined	Pedometer (ECE PEDO)	Pedometer worn over 5 days for 12 weeks (Predictor)	Independent and nested within MetS criteria (Outcome)	All PA groups improved weight, BMI and other anthropometric measures. No difference between PA groups	No changes in BP were observed among the PA groups
Atkas et al. 2019 [17]	Yes 100 (53) Longitudinal	BMI 30–40 kg/m2, elevated BP, elevated fasting plasma glucose, high serum TG, and low HDL-C (cut-points for criteria not stated)	Automated oscillometric device after 5 min of rest	SenseWear armband (BodyMedia Inc., Pittsburgh, PA) Jawbone	Participants were randomized to two arms. Both arms received a 12-week intervention on diet. One arm was given SenseWear and the other arm was not. (Covariate)	Independent and nested within MetS criteria (Outcome)	Both arms of the intervention improved their components of MetS. PA monitoring modestly increased the effect	SBP and DBP decreased after the 12-week intervention. Unclear if the authors compared the difference in BP changes between the two arms
Ormel et al. 2021 [22]	Yes 70 (98) Longitudinal	Three or more of: WC ≥ 88 cm; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg or drug treatment; TG ≥ 150 mg/dL or drug treatment; HDL-C ≤ 50 mg/dL or drug treatment; fasting blood glucose ≥ 100 mg/dL or drug treatment	Assessed after > 5 min of rest	Hip- or wrist-worn GT3XBT accelerometer (ActiGraph, Pensacola, FL, USA)	Occurred during adjuvant endocrine therapy for breast cancer in conjunction with 3 supervised aerobic trainings and 2 resistance trainings per week for 12 weeks (Predictor)	Independent and nested within MetS criteria (Outcome)	Supervised exercise increased the proportion of breast cancer patients adhering to the PA guideline over time. MetS, body composition, health-related quality of life and symptoms improved	No report on PA guideline (≥ 150 min of MVPA per week) and BP association
Pataky et al. 2018 [34]	Yes 88 at baseline (100) 25 at 12 months (20) Longitudinal	SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; TG ≥ 1.7 mmol/l; HDL-C < 1.03 in men and < 1.29 mmol/l in women; fasting glucose ≥ 5.6 mmol/l; WC was pathological in all subjects	Seated position, 3 times using an OMRON 705 cp (OMRON Healthcare Europe, Hoofddorp, The Netherlands)	Lower back-worn Actigraph, AM7164–2.2; (Computer Science and Applications, Pensacola, FL, USA)	Participants engaged in a 12-month weight loss program. Accelerometer was worn over 4 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Body weight decreased in 35 patients, remained stable in 39 patients, and increased in 13 patients. 75% of patients with MetS at baseline were free of MetS at follow-up	No report on total daily PA and BP associations
Shin et al. 2017 [23]	Yes 50 (30) Longitudinal	Three or more of: WC ≥ 88 cm; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L, or drug treatment; blood glucose ≥ 5.5 mmol/L or drug treatment	After 10 min of rest	Pedometer	Wear protocol not defined (Predictor)	Independent and nested within MetS criteria (Outcome)	Participants improved cardiovascular metrics — SBP, DBP, BMI, LDL, TGs, number of MetS components, and 10-year risk estimate from pre-test to post-test. 78% of the MetS participants no longer had MetS at the end of the study	Intervention improved SBP and DBP among all participants. MetS participants had larger reductions in BP than non-MetS participants
Tojal et al. (2020) [43]	Yes 100 (243) Cross-sectional	Three or more of: WC ≥ 88 cm in women, ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L in women, < 1.03 mmol/L in men, or drug treatment; blood glucose ≥ 5.5 mmol/L or drug treatment	Not defined	Wrist-worn GENEActiv accelerometer (ActivInsights Ltd., Kimbolon, UK)	Wear protocol not described (Predictor)	Nested within MetS criteria only (Predictor)	CRF was higher in MetS patients who self-reported greater PA	No report on MVPA or SB and BP associations
Observational Research
Aljuhani et al. 2020 [26]	Yes 38 (39) Cross-sectional	Three or more of: WC ≥ 102 cm; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; TG ≥ 1.7 mmol/L; HDL-C < 1.03 mmol/L; fasting blood glucose ≥ 5.6 mmol/L	Automatic arm digital sphygmomanometer (Omron HEM-7121, Omron Healthcare manufacturing, Japan)	Hip-worn GT3XBT accelerometer (ActiGraph, Pensacola, FL, USA)	Accelerometer worn for 7 consecutive days (Predictor)	Nested within MetS criteria (Outcome)	Low levels of LPA were associated with risk of MetS. No associations between MetS and sedentary tertiles or MVPA	No report on LPA, MVPA, or SB and BP association among those with MetS
Bowden Davies et al. 2019 [29]	Yes 24 (24) Cross-sectional	International Diabetes Federationa criteria	Average of three measures (Dinamap, G & E Medical, USA)	SenseWear armband (BodyMedia Inc., Pittsburgh, PA)	Armband worn over 4 days (Outcome)	Independent and nested within MetS criteria (Outcome)	LPA, MPA, and VPA did not account for differences in metabolic health between individuals. MetS individuals were more sedentary (higher number of and prolonged sedentary bouts)	No report on LPA, MPA, or VPA and BP association within MetS patients
Bueno-Antequera et al. 2018 [40]	Yes 65 (28) Cross-sectional	International Diabetes Federation criteria	Seated position after a 10-min rest period with an electronic monitor (Omron Healthcare Europe BV, Hoofddorp, The Netherlands)	SenseWear armband (BodyMedia Inc., Pittsburgh, PA)	Armband worn for 9 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Light PA was associated with WC. MVPA and total PA were associated with cardiometabolic risk score and WC. Results were attenuated after adjusting for SB and CRF	No report on LPA, MVPA, total PA, or SB and BP association within MetS participants
Colpitts et al. 2021 [18]	Yes 23 (554) Cross-sectional	Three or more of: WC ≥ 88 cm in women, ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L in women, < 1.03 mmol/L in men, or drug treatment; blood glucose ≥ 5.5 mmol/L or drug treatment	Not defined	Waist-worn ActiGraph AM-7164 accelerometer (ActiGraph Corp., Pensacola Fl)	Accelerometer worn for 7 days (Predictor)	Nested within MetS criteria only (Outcome)	Differences in MVPA but not SB were observed among groups (health, MetS diabetes, MetS + Diabetes). The odds of being in the healthy group were associated with MVPA patterns following adjustment for SB	No report on MVPA or SB and BP associations
Edwards et al. (2018) [19]	Yes % and N not defined Cross-sectional	Three of more of: WC ≥ 88 cm in women, ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 150 mg/Dl; HDL-C < 50 mg/dL in women and < 40 mg/dL in men, or drug treatment; blood glucose levels > 100 mg/dL, or drug treatment	Standard sphygmomanometer	Hip-worn ActiGraph 7164 accelerometer (Pensacola, LL)	Accelerometer worn for ≥ 4 days (Predictor)	Nested within MetS criteria only (Outcome)	MVPA and CRF were inversely associated with MetS. A 10 min/day increase in MVPA was associated with 45% reduced odds of having MetS and a 10 ml/kg/min increase in CRF was associated with 43% reduced odds of MetS. Accounting for SB did not influence associations	No report on MVPA or SB and BP associations
Ekblom-Bak et al. 2018 [33]	Yes 27 (180) Cross-sectional	Three or more of: WC ≥ 88 cm in women, ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L in women, < 1.03 mmol/L in men, or drug treatment; blood glucose ≥ 5.5 mmol/L or drug treatment	BP was measured but protocol not defined	GT3X accelerometer (ActiGraph, Pensacola, FL, USA)	Accelerometer worn for 7 consecutive days (Covariate)	Nested within MetS criteria (Predictor)	Participants with MetS had higher odds of having coronary artery calcification. Association was attenuated after further adjustment for SB. Higher fitness was associated with lower odds of coronary artery calcification, but the association was attenuated after adjustment for MVPA	No report on MVPA or SB and BP associations
Galmes-Panades et al. 2019 [31•]	Yes 100 (2189) Cross-sectional	Three or more of: WC ≥ 88 cm in women and ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg or drug treatment; TG ≥ 150 mg/dL or drug treatment; HDL-C < 50 mg/dL in women and < 40 mg/dL in men; fasting glucose ≥ 100 mg/Dl, or drug treatment	Semiautomatic oscillometer (Omron HEM-705CP, the Netherlands) at 5, 10 and 15 min of rest in a seated position	Wrist-worn GENEActiv accelerometer (ActivInsights Ltd., Kimbolon, UK)	Accelerometer worn for 7 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Inactive time (i.e., SB) was associated |with indicators of obesity and MetS. Reallocating 30 min/day of inactive time to 30 min/day of LPA or MVPA was associated with lower BMI, WC, total fat, visceral adipose tissue, HbA1c, glucose, triglycerides, and higher body muscle mass and HDL cholesterol	No report on LPA, MVPA, or SB and BP associations
Jahan et al. 2017 [20]	Yes 26 (38) Cross-sectional	Not defined	Digital sphygmomanometer (Omron HEM-7120)	Pedometer (OMRON HJ-325)	Pedometer worn for 3 consecutive days (Predictor)	Nested within MetS criteria (Predictor)	PA was inversely related signs of MetS. Fewer steps/day and MetS were associated with a greater number of MetS components	No report on pedometer determined PA and BP association among those with MetS
Kong et al. 2021 [21]	Yes 25 (19) Cross-sectional	Three or more of: WC > 88 cm in women, > 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG 1.7 mmol/L; HDL-C < 1.29 mmol/L in women, < 1.03 mmol/L in men; blood glucose ≥ 5.6 mmol/L	Measured by oscillometry after 30 min of rest	Hip-worn accelerometer (Actical; Mini-Mitter Inc., Bend OR)	Accelerometer worn for 7 days (Predictor)	Independent and nested within MetS criteria (Outcome)	Participants with high MVPA showed lower odds of MetS compared to low MVPA	SBP was lower in the middle PA group than in the low PA group. No difference in DBP was observed
Miller et al. 2019 [27]	Yes 9 (7) Cross-sectional	Three or more of: WC ≥ 35 inches for women, ≥ 40 inches for men; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; TG > 110 mg/dL; HDL-C < 50 mg/dL for women, < 40 mg/dL for men; fasting blood glucose > 100 mg/dL	Automated cuff after 5 min of rest (E-Sphyg2; American Diagnostics Corporation, Hauppauge, NY)	Waist-worn GT3XBT accelerometer (ActiGraph, Pensacola, FL, USA)	Accelerometer worn for 7 consecutive days (Outcome)	Independent and nested within MetS criteria (Outcome)	Non-MetS group had lower sedentary time, higher LPA, higher total steps per day, and higher steps per minute compared to MetS group. MPA and VPA did not differ between MetS and non-MetS groups	No report on LPA MPA, VPA, or SB and BP association
Mitchell et al. 2018 [28]	Yes 33–46 depending on definitions (56–77) Cross-sectional	3 definitions: 1. NCEP: Three or more of: WC women > 88 cm, men > 102 cm; BP ≥ 130/90 mmHg or medication; TG 1.7 mmol/L; HDL-C women < 1.29 mmol/L, men < 1.03 mmol/L; fasting glucose ≥ 5.6 mmol/L 2. IDL: Three or more of: WC women > 80 cm, men > 94 cm; BP ≥ 130/85 mmHg or prescribed medication; TG ≥ 1.7 mmol/L or specific treatment; HDL-C, women < 1.29 mmol/L, men < 1.03 mmol/L, or specific treatment; fasting glucose ≥ 5.6 mmol/L, or previous diagnosis of type 2 diabetes mellitus 3. Harmonized: Three or more of: WC women > 80 cm, men > 94 cm; BP ≥ 130/85 mmHg or specific drug treatment; TG ≥ 1.7 mmol/L or specific treatment; HDL-C women < 1.3 mmol/L, men < 1.0 mmol/L, or specific drug treatment; fasting glucose ≥ 5.6 mmol/L, or specific drug treatment	Automated sphygmomanometer after 5 min of rest (Carescape V100; GE Healthcare, UK)	GENEActiv (Activinsights Ltd., UK)	Accelerometer worn for 7 days (Predictor)	Nested within MetS criteria only (Outcome)	Regardless of MetS definition, high SB was associated with higher odds of MetS. Low LPA and low MVPA were associated with higher odds of MetS	No report on LPA, MVPA, or SB and BP associations
Sagawa et al. 2020 [35]	Yes 26 Japanese (63), 38 American (102) Cross-sectional	Three or more of: WC ≥ 102 cm (American), 90 cm (Japanese men); SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; elevated TG ≥ 150 mg/dL; HDL-C < 40 mg/dL; fasting glucose ≥ 100 mg/dL	Automated sphygmomanometer after sitting quietly for 5 min (BP-8800; Colin Medical Technology, Komaki, Japan)	Digiwalker SW-200 pedometer (Yamasa Tokei Keiki Corporation, Tokyo, Japan)	Pedometer worn for 7 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Higher counts of pedometer steps were associated with lower odds of having MetS in both American and Japan participants. In the adjusted model, each 1000 step/day increase was associated with 10% and 13%: lower odds of having MetS among American and Japanese participants, respectively	Pedometer steps/day was not associated with BP
Schilling et al. (2020) [44]	Yes 7 at baseline (7) 8 at follow-up (8) Longitudinal	WC > 88 cm for women and > 102 for men; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; TG > 1.7 mmol/l; HDL-C < 1.0 mmol/l for men and < 1.3 mmol/l for women; blood HbA1c level > 6.1 percent	Seated position with the OMRON M500	Chest-worn ecgMove3 sensors (movisens GmbH, Karlsruhe, Germany)	Accelerometer worn for 7 consecutive days (Covariate)	Independent and nested within MetS criteria (Outcome)	Higher c ardiore spiratory fitness levels were associated with lower MetS risk at follow-up	No report on MVPA and BP associations
Thakkar et al. (2018) [30]	Yes % and N not defined Cross-sectional	Three or more of: WC ≥ 80 cm in women and ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg, or drug treatment; TG ≥ 1.69 mmol/L or drug treatment; HDL-C < 1.29 mmol/L in women and < 1.04 mmol/L in men, or drug treatment; fasting glucose ≥ 5.6 mmol/L or drug treatment	BP was measured but protocol not defined	Actical (Philips Respironics)	Accelerometer worn for at least 4 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Odds of disease and abdominal obesity were higher in the inactive/sedentary group versus the reference group when measured objectively. Within self-report leisure-time groups, elevated odds were observed for the inactive/sedentary group for MetS, obesity, abdominal obesity and elevated TG	No report on MVPA or SB and BP association among those with MetS
Tigbe et al. 2017 [24]	Yes 12 to 18 depending on criteria (13–20) Cross-sectional	Three or more of: WC > 88 cm in women, > 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG 1.7 mmol/L; HDL-C < 1.29 mmol/L in women, < 1.03 mmol/L in men; blood glucose ≥ 5.6 mmol/L	Not defined	Thigh-worn activPAL monitor, PAL Technologies LTD., Glasgow UK	Accelerometer worn for 7 consecutive days (Predictor)	Nested within MetS criteria only (Predictor)	MetS participants were less active, took fewer steps, had shorter stepping duration and spent longer time sitting compared to non-MetS participants	PA and SB were not associated with BP
van der Berg et al. 2017 [32]	Yes 39 (854) Cross-sectional	Three of more of: WC ≥ 88 cm for women, ≥ 102 cm for men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L for women, < 1.03 mmol/L for men; fasting blood glucose ≥ 5.6 mmol/L or drug treatment	Noninvasive blood pressure monitors after 10 min of rest (Omron 705IT; OMRON, Kyoto, Japan)	activPAL accelerometer (PAL Technologies, Glasgow, UK)	Accelerometer worn for 8 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Replacement of SB with standing and stepping was associated with lower odds for MetS and MetS components	Time spent in SB, standing, or stepping was not associated with SBP or DBP
van der Berg et al. [39]	Yes 40 (250) Cross-sectional	Three or more of: WC ≥ 88 cm in women, ≥ 102 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85, or drug treatment; TG ≥ 1.7 mmol/L; HDL-C < 1.30 mmol/L in women, < 1.03 mmol/L in men; fasting blood glucose ≥ 5.6 mmol/L or drug treatment	Mercury sphygmomanometer	Hip-worn GT3XBT accelerometer (ActiGraph, Pensacola, FL, USA)	Accelerometer worn for 7 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Compared to participants who recorded the fewest dynamic sitting minutes, those with more dynamic sitting minutes had lower odds for the metabolic syndrome, lower BMI, and smaller WC	Neither SBP nor DBP differed between quartiles of minutes of dynamic sitting. Being in the highest quartile of dynamic sitting was associated with higher SBP, but not with higher DBP
Zając-Gawlak et al. 2017 [37]	Yes 44 (37) Longitudinal	Three or more of: WC ≥ 88 cm; SBP ≥ 130 mmHg and DBP ≥ 85 mmHg, or drug treatment; TG ≥ 150 mg/dl, or drug treatment; HDL-C < 50 mg/dL, or drug treatment; fasting glucose ≥ 100 mg/dl, or drug treatment	Standard mercury sphygmomanometer	Waist-worn ActiGraph GT1M accelerometer (Manufacturing Technology Inc., FL, USA)	Accelerometer worn for 8 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	Steps/day increased and the risk of MetS decreased from 41 to 12% over time. Women who met step-based guidelines had a higher mean concentration of HDL-C at baseline and follow-up, and a lower concentration of TGs at follow-up. Women who increased their daily steps over 7 years to the recommended steps/day value decreased their TGs. BP was not affected	Number of steps/day was not associated with BP
Zając-Gawlak et al. 2021 [36]	Yes 40 at baseline (24) and 12 at 7-year follow-up (7) Longitudinal	Three or more of: WC > 88 cm; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg; TG ≥ 150 mg/dl; HDL-C < 50 mg/dl; fasting blood glucose ≥ 100 mg/dl	Standard mercury sphygmomanometer	Waist-worn ActiGraph GT1M (Manufacturing Technology Inc., FL, USA)	Accelerometer worn for 8 consecutive days (Predictor)	Independent and nested within MetS criteria (Outcome)	PA (steps/day) increased and risk of MetS decreased from 41 to 12% over 7 years	There was no change for SBP or DBP over 7-year follow-up. There was no difference in SBP or DBP between PA groups
Zisko et al. 2017 [25]	Yes 38 (409) Cross-sectional	Three or more of: WC ≥ 80 cm in women and ≥ 94 cm in men; SBP ≥ 130 mmHg or DBP ≥ 85 mmHg, or drug treatment; TG ≥ 1.7 mmol/L or drug treatment; HDL-C < 1.3 mmol/L in women and < 1.0 mmol/L in men, or drug treatment; fasting glucose ≥ 5.6 mmol/L or drug treatment	No protocol described	GT3XBT accelerometer (ActiGraph, Pensacola, FL, USA)	Accelerometer worn for 7 consecutive days (Predictor)	Nested within MetS criteria only (Outcome)	Participants not meeting the MVPA or VPA recommendations had higher likelihood of MetS compared to those meeting the recommendations. There was no association between MetS and absolute MVPA, MPA or VPA recommendations in the adjusted model	No report on MPA, VPA, or MVPA and BP association among those with MetS

MetS metabolic syndrome, WC waist circumference, BP blood pressure, SBP systolic blood pressure, DBP diastolic blood pressure, HDL-C high-density lipoprotein cholesterol, TG triglycerides, PA Physical activity, LPA Light physical activity, MPA moderate physical activity, VPA vigorous physical activity, MVPA moderate-vigorous physical activity, SB sedentary behavior, BMI body mass index, CRF cardiorespiratory fitness

^aCentral obesity defined as waist circumference with ethnicity specific values (if BMI is > 30 kg/m², central obesity can be assumed, and waist circumference does not need to be measured) plus any two of the following four factors: raised triglycerides (≥ 150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormality), reduced HDL cholesterol (< 40 mg/dL (1.03 mmol/L) in males< 50 mg/dL (1.29 mmol/L) in females or specific treatment for this lipid abnormality), raised blood pressure (systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg or treatment of previously diagnosed hypertension), or raised fasting plasma glucose ((FPG) ≥ 100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes)

Physical Activity Assessment

Physical activity was assessed using a range of wearable devices, ranging from pedometers (n = 4) to research grade accelerometers (n = 22). Physical activity was an exposure in 21 (81%) studies, an outcome in 3 (11%) studies, and a covariate in 2 (8%) studies. Quantification of physical activity mainly focused on achieving or adhering to the recommended physical activity guidelines (min/day of moderate-to-vigorous physical activity or light intensity physical activity) or amount of time spent in sedentary behaviors. The four studies that used pedometers focused on steps per day or steps per minute.

Blood Pressure Assessment

Details on BP measurement varied widely by study. Most described standard protocols that employed seated positioning, with BP measured after several minutes of rest using a digital or manual sphygmomanometer. BP was a stand-alone outcome in 16 (62%) studies, nested within MetS in 7 (27%) studies, and an exposure in 3 (11%) studies.

Key Findings

A summary of each study and its key findings are listed in Fig. 1. Adhering to physical activity guidelines improved body composition, quality of life, cardiovascular fitness, and components of MetS [17–25]. In the observational studies, light physical activity was associated with reduced risk of MetS more often than moderate or vigorous physical activity [26–28]. In several studies, sedentary behaviors were consistently linked with obesity and MetS, independent of physical activity [24, 28–30, 31•, 32, 33]. Among the studies that focused on activity volumes (e.g., steps or activity counts per day), findings noted that higher activity counts per day were associated with lower odds of MetS [35–37].

Among intervention studies, a 12-month exercise intervention demonstrated that 75% of participants with MetS at baseline were free of MetS at follow-up [34]. Furthermore, routine engagement in physical activity was associated with reductions in body weight and attenuation of components of MetS [34]. In a 12-week study of breast cancer patients, supervised exercise increased the proportion of patients adhering to the physical activity guidelines, improving quality of life and MetS symptoms [22]. In a 12-week feasibility study of exercise and diet, all components of MetS improved except waist circumference [17].

Only a few studies directly examined the association between device-measured physical activity and BP as a primary outcome in those with MetS. In studies examining steps per day and sitting time, the results showed that neither steps per day [32, 35, 37] nor time spent sitting was linked with overall BP [32]. Another study found that systolic, but not diastolic, BP was lower in adults with higher activity levels [21]. However, in two studies focused on activity intensity, there was no association between BP and physical activity intensity [36, 38]. Lastly, one study found that engaging in routine physical activity improved systolic BP and diastolic BP among all participants, with those with MetS having a larger reduction in BP compared to those without MetS [23].

Discussion

This review found evidence that among patients with MetS, greater “time in motion” is associated with several health benefits, including improved body composition, reported quality of life, and cardiovascular fitness. The results directly related to BP were mixed, with some studies showing improvements, or positive associations, and others showing null results. Importantly, several studies noted that participants with MetS demonstrated greater improvements in the components of MetS after engaging in higher amounts of daily physical activity, displaying the potential to improve blood pressure and overall health in those with MetS by maintaining or improving physical activity profiles.

It is important to distinguish results by study design. Of the 26 studies included in our review, 20 were observational (17 cross-sectional, 3 longitudinal). Several of these studies identified that sedentary behavior, light-intensity physical activity, and moderate-vigorous intensity physical activity were associated with components of MetS [30, 31•, 40]. Moreover, participants diagnosed with MetS tended to be more sedentary and less physically active than non-MetS participants [18, 24, 27, 29] and low levels of physical activity were associated with increased MetS risk [19, 21, 26, 28]. Furthermore, although results suggest greater volume of physical activity may be a means to partially mitigate hypertension in those with MetS [21], it remains unclear whether physical activity or inactivity (i.e., sedentary behavior) is more strongly associated with MetS [26, 31•, 32, 33, 40]. Further research is needed to disentangle these associations and refine behaviors related to active and sedentary time as targets for intervention.

With respect to the current physical activity guidelines, those not meeting the recommended levels for adults had higher odds of MetS and a greater number of MetS components compared to those who were sufficiently active [25, 37]. In terms of activity volume, studies that measured physical activity volumes via pedometers found that fewer steps per day was associated with greater odds of having MetS [35] as well as more individual components of MetS [20]. Collectively, these results suggest there may be benefit to greater volumes of daily PA among hypertensive patients with MetS, but more research is needed to quantify and define the amount of daily activity needed to improve health and refine clinical recommendations.

Conclusions

Although the evidence for the association between MetS and physical activity is high, considerably more research is needed to discern the impact of routine physical activity on blood pressure alone. Moreover, although the evidence for improving components of MetS through engaging in physical activity is high, the amount and type(s) of physical activity needed to achieve these benefits are unclear. To date, much of the research that has used wearable technology has converted the data into intensity categories to better understand the impact of physical activity intensity on MetS and its associated components and health outcomes. However, categorization of physical activity data is subject to misclassification error, due to differences in speed of movement and relative intensity, especially in adults with limited functional ability or aerobic capacity [9, 41]. Furthermore, categorization methods underutilize the rich, continuous data generated by these devices. Continuous assessment of physical activity using wearable technology facilitates assessment of the full spectrum of “time in motion” using metrics like active and sedentary minutes per day on health outcomes, and is easy for patients to monitor and report remotely [13•]. Finally, investigating activity over 24-h periods can illuminate opportunities to improve physical activity and sedentary behavior profiles by highlighting activity nadirs that may provide opportunities for customizable intervention efforts [9, 42]. Combined with the evidence published over the past 3 years highlighted in this review, increasing research in these vital areas will facilitate expansion of physical activity monitoring into clinical practice to improve metabolic health outcomes.