Physical Activity in Cardiometabolic Disease: Comparison
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Please note this is a comparison between Version 2 by Camila Xu and Version 1 by Martin Heine.

Cardiometabolic disease begins with insulin resistance and then progresses to the clinically identifiable high-risk states of metabolic syndrome and prediabetes, before it leads to type 2 diabetes (T2DM) and cardiovascular disease (CVD). In low-to-middle-income countries (LMICs), the burden attributable to non-communicable disease (including CVD and T2DM) increased from 37.8% of total disability-adjusted life years (DALYs) in 1990 to 66.0% in 2019, with a similar pattern in upper-middle-income countries as well. Cardiometabolic disease imposes a large financial burden on patients and households, while increasing vulnerability to poverty.

  • physical activity
  • diabetes
  • cardiovascular disease
  • metabolic syndrome
  • qualitative review
  • systems thinking

1. Introduction

Prevention of cardiometabolic diseases, including T2DM and CVD, includes maintaining a healthy weight, eating healthily, avoiding tobacco use, and being physically active [5][1]. Countries where the burden of disease is shifting rapidly are struggling to deliver primary and secondary preventative interventions [6][2]. Public health approaches are failing to address the crucial risk factors (such as physical inactivity) globally [6][2], while interventions focused on individual lifestyle modifications are largely absent due to intricate and complex resource constraints [7,8,9,10,11][3][4][5][6][7]. While high-income countries bear a larger proportion of the economic burden (80% of economic cost), LMICs have a larger proportion of the disease burden (75% of DALYs) [12][8]. To effectively address the burden of physical inactivity in LMICs, in relation to the increasing burden of cardiometabolic disease, it is imperative that we understand the drivers of physical inactivity (along with the other risk factors), from a primary and secondary preventative point of view. The World Health Organisation (WHO) physical activity and sedentary behaviour guidelines development group argues that there is a specific need for more studies in LMICs that aim to identify how various sociodemographic factors (e.g., age, sex, and socioeconomic status) inform physical activity or modify the health effects of physical activity in an attempt to address global health disparities [13][9].

Depending on the design, studies may be informed by preconceived conceptual frameworks for behaviour change (e.g., Theory of Planned Behaviour). While such conceptual frameworks have helped to clarify (physical activity) behaviour, they have been criticised for their often linear and phased perceptions of behaviour, which are insensitive to environmental influences [14,15][10][11]. Emerging health behaviour models using the Socio-Ecological Framework (which includes social factors, policy, and environmental factors) or Complexity Theory may be more conducive to the complex nature of behaviour [15][11], particularly in resource-constrained settings. Quantitative methods have been used widely to identify determinants of and factors associated with physical activity. Such studies provide clear quantitative evidence for the relationship between physical activity and a select number of potential determinants (e.g., the relationship between physical activity and built environment). Albeit valuable, these studies may be limited in their scope and comprehensiveness when accounting for the complexity of aspects associated with physical activity within a single study design.

Alternatively, qualitative studies may provide better insight into the real-world challenges and experiences related to physical activity, unrestricted by prior variable selection. Neither existing qualitative nor quantitative research has been able to fully capture the complex system of physical activity behaviour. However, qualitative research may help to develop an understanding of the people, the practices, and the policies behind the mechanisms and interventions [16][12].

2. Discussion

In the literature, behavioural change theories such as the Social Cognitive Theory (SCT), the Theory of Planned Behaviour (TPB), Self-Determination Theory (SDT), and the Transtheoretical Model (TTM) have been dominant approaches in understanding the determinants and correlates of physical activity [14,15][10][11]. These theories have generally viewed change as a linear, deterministic process based on the interaction of cognitive factors such as knowledge, intention, attitudes, beliefs, and efficacy and intention [65][13]. Although the utilisation of these theories has informed our understanding of the psychological factors and mechanisms that influence physical activity behaviour [14][10], physical inactivity remains one of the most important health problems of our time [66][14]. It has become clear that behaviour, and behaviour change, are a complex phenomenon, influenced by multiple factors [14][10]. In this sense, socio-ecological models of health behaviour that focus on individual, social, policy, and environmental-related factors may be particularly useful in aiding our understanding of physical activity. As a complex system, a socio-ecological framework sees behaviour as the result of direct, indirect, and interactive influences from factors of multiple levels of the system [15][11]. Similarly, the findings of this study point toward the multiple interactions, across multiple levels of the person’s ecological system, contributing to an environment (both internal and external to the individual) that either enables or restricts physical activity participation. In line with a systems thinking approach, physical activity behaviour may be influenced by an almost infinite combination of barriers and facilitators [65][13]. However, the identification of recurrent patterns may be used to develop targeted interventions.
Throughout this review, there were several factors that, in quantitative research, could be classified as effect modifiers and/or confounders yet which were challenging to account for in this qualitative meta-synthesis. Some transpired more explicitly, such as gender, whereas others were less tangible, such as temporal aspects or “geographical context”. With respect to the temporal nature of physical activity behaviour, people would describe a social and physical upbringing in which physical inactivity was implicit—cumulative exposure to various risk factors in conjunction with a potential epigenetic predisposition [67,68][15][16]. Geographically, barriers such as safety/violence, air pollution, neighbourhood walkability, and access to physical activity programs appear more prevalent factors in urban settings [69,70][17][18]. Conversely, the role of manual labour and subsistence farming in rural settings may affect the relative (perceived) value of physical activity in risk reduction or secondary prevention. Hence, in particularly in rural areas, the role of physical activity in the primary and secondary prevention of cardiometabolic disease may not be so explicit, and other risk factors may be more prevalent [71,72,73][19][20][21]. The impact of changing context (e.g., urbanisation) on physical activity did not reflect explicitly in the factors identified, despite compelling evidence that, for instance, urbanisation or migration impact physical activity participation [74,75,76][22][23][24]. The impact of time has not been fully captured in any of the prevailing models of behaviour [14][10]. Finally, women appeared more at risk for physical inactivity (particularly in relation to prevailing family roles impacting employment and power dynamics) and appeared to report more barriers to physical activity in relation to safety, cultural or religious norms, and stigmatisation. In this light, there may be a case for a gender-specific approach in addressing physical activity in contexts where this is applicable [77][25].

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