Metabolic syndrome (MetS) is a cluster of health conditions and risk factors that, when occurring together, increase an individual’s risk of serious health problems such as heart disease, stroke and type 2 diabetes. It is quite common, with more than a third of adults in the United States estimated to be dealing with MetS, according to the American Heart Association. This amounts to about one out of every three Americans, and the actual number could be even higher because some cases may go undetected. Furthermore, as people get older, the chances of having MetS increase significantly. In fact, almost half of those aged 60 and older have it, and it is more prevalent in certain ethnic groups like Black, Hispanic and Native American populations.

Lifestyle modifications are typically the first line of treatment for metabolic syndrome. These include adopting a healthy diet, increasing physical activity, losing weight and quitting smoking, if applicable. Regular exercise, in particular, can help individuals better manage the various risk factors of MetS and minimize its progression. This article outlines strategies for helping your clients with MetS perform exercise safely and effectively.

Early detection and proactive management of metabolic syndrome can significantly reduce the risk of developing the associated health problems and improve overall health and well-being. Regular medical check-ups and discussions with healthcare professionals are essential for those at risk for, or diagnosed with, metabolic syndrome.

Health Conditions Related to Metabolic Syndrome

Metabolic syndrome is concerning because it increases the risk of developing serious health problems, including:

  • Type 2 Diabetes: Individuals with metabolic syndrome are at an increased risk of developing type 2 diabetes. Insulin resistance, a hallmark of metabolic syndrome, can lead to elevated blood sugar levels.
  • Cardiovascular Disease: Metabolic syndrome significantly raises the risk of heart disease and stroke. The combination of high blood pressure, elevated triglycerides, low levels of high-density lipoprotein (HDL) cholesterol and insulin resistance contributes to atherosclerosis (hardening and narrowing of the arteries), which can lead to heart attacks and strokes.
  • Obesity: Excess abdominal fat is a key component of metabolic syndrome. Obesity, especially around the waistline, is a major risk factor for various health issues, including diabetes, heart disease and high blood pressure.
  • High Blood Pressure (Hypertension): Many individuals with metabolic syndrome have high blood pressure, which is a significant risk factor for heart disease and stroke.
  • Abnormal Lipid Profile: Metabolic syndrome often includes high triglyceride levels (a type of fat in the blood) and low levels of HDL cholesterol, which is considered “good” cholesterol. This combination contributes to atherosclerosis.
  • Inflammation: Chronic low-grade inflammation is associated with metabolic syndrome and can contribute to the development of heart disease and other chronic conditions.
  • Non-alcoholic Fatty Liver Disease (NAFLD): Metabolic syndrome is a common risk factor for NAFLD, a condition in which excess fat accumulates in the liver, potentially leading to liver damage and inflammation.
  • Polycystic Ovary Syndrome (PCOS): Women with PCOS often have insulin resistance and are at an increased risk of metabolic syndrome, as well as other health issues such as irregular menstrual periods, infertility and obesity.
  • Sleep Apnea: Metabolic syndrome is linked to an increased risk of sleep apnea, a sleep disorder characterized by breathing interruptions during sleep, which can have negative effects on cardiovascular health.
  • Kidney Disease: Some research suggests that metabolic syndrome may be associated with an increased risk of kidney disease.

It's important to note that not everyone with metabolic syndrome will develop all of these conditions, and the severity of individual risk factors can vary. As mentioned earlier, lifestyle changes, such as improving diet, increasing physical activity and weight loss, are often recommended to manage and reduce the risks associated with metabolic syndrome. Additionally, healthcare providers may prescribe medications to address specific risk factors, such as hypertension or high cholesterol, as needed. Regular check-ups and monitoring are essential for individuals with metabolic syndrome to reduce their risk of complications.

How Metabolic Syndrome is Diagnosed

The specific criteria used to diagnose metabolic syndrome may vary slightly between medical organizations, but it typically includes having three or more of the following factors:

  1. Abdominal Obesity: Excess fat around the waistline, often measured as a waist circumference greater than a certain threshold, which varies by sex. For men it is greater than 40 inches (102 cm) and for women it is greater than 35 inches (88 cm).
  2. High Blood Pressure (Hypertension): Blood pressure consistently at or above 130/85 mmHg or taking medication for high blood pressure.
  3. Elevated Blood Sugar (Hyperglycemia): Fasting blood sugar levels consistently at or above 100 mg/dL or taking medication for high blood sugar.
  4. High Triglyceride Levels: Blood triglyceride levels of 150 mg/dL or higher or taking medication for high blood triglyceride levels.
  5. Low HDL Cholesterol: HDL cholesterol levels below 40 mg/dL for men or below 50 mg/dL for women or taking medication for low HDL.

Common Medication–Exercise Response Interactions and Exercise Program Modifications

The medical management of MetS may consist of a broad range of medications. As a health and exercise professional, understanding the interaction of certain medications with the exercise response and how the exercise program might need to be adjusted is critical. In fact, given the multicomponent risk-factor nature of MetS, my experience suggests that the considerations for medicationexercise response interactions/exercise program modifications for clients with MetS are more pronounced relative to most other conditions and/or diseases. Indeed, some of the most common medications prescribed to Americans are also those likely to be prescribed to clients with MetS, including beta blockers, ACE inhibitors, diuretics and oral hypoglycemics.

Beta blockers function by preventing the binding of epinephrine to receptors in the heart. This results in both decreased resting and exercise heart rate and blood pressure values. The fact that beta blockers attenuate the heart-rate response to exercise means traditional methods for establishing target heart rate (e.g., peak heart-rate method or heart-rate reserve method) are likely to be invalid. Therefore, the most important program design modification for clients taking a beta blocker is to use an alternative method for setting target intensity. The talk test is an excellent option.

Individuals using ACE inhibitors and diuretics have both lower resting and exercise blood pressure values. A primary concern for individuals taking ACE inhibitors and diuretics is that the combination of the reduction in blood pressure from both categories of medications, combined with a naturally occurring post-exercise hypotension, can result in excessive reductions in blood pressure. An easy solution is to add a two- to three-minute cool-down to every exercise.

Oral hypoglycemics are prescribed to control blood glucose levels. Exercise combined with oral hypoglycemics can increase the risk for hypoglycemia (i.e., low blood glucose levels). The most important program modification for clients taking oral hypoglycemics is frequent monitoring of blood glucose values.

The intent of this section is not to be exhaustive in its scope. Rather, it’s to highlight the importance of being aware of medication–exercise response interactions and the exercise program modifications that may be needed for clients who have MetS. It’s also critical to collaborate with the multidisciplinary team of medical providers who manage your client’s health condition and familiarize yourself with other relevant medications and considerations for overall exercise programming.

Exercise Programming for Clients Who Have Metabolic Syndrome

A variety of studies have shown that MetS is inversely associated with physical activity, with more active individuals having a lower incidence of MetS. An individual’s level of cardiorespiratory fitness has also been shown to independently influence the risk of premature mortality in people with increased body weight and/or the presence of MetS.

Because many people with MetS have obesity, exercise programs should follow guidelines for individuals with overweight or obesity [body mass index (BMI) ≥25 kg/m2 and ≥30 kg/m2, respectively]. However, additional factors, such as underlying coronary artery disease, hypertension, dyslipidemia and other risk factors, should be evaluated and considered. Most studies on exercise and MetS have evaluated the effect of various aerobic modes of activity, such as walking, elliptical training and other similar ergometers, and stationary cycling. Some individuals with obesity may be better served by water-based exercise or other forms of non-weight-bearing activities. Furthermore, evidence suggests that engaging in muscular training is linked to a lower prevalence of MetS (Table 1).

Exercise intensity will vary depending on the client’s weight status, overall conditioning and medical profile. Individuals with a lower level of fitness should begin at a lower intensity and gradually progress to moderate levels. Because a primary goal is to burn calories and lose weight, urge clients to aim to exercise five or more times per week. This level of activity, which may consist of both continuous and intermittent activity, may be difficult for some clients to achieve at first, so it can be helpful to create a plan that starts slowly and  builds gradually in both duration and intensity over time.

Alternative Evidence-based Programming for Clients Who Have Metabolic Syndrome

The American Council on Exercise’s educational philosophy, strategy and content is based on the best evidence available in exercise science and behavior-change science. Over the past decade, the research team I lead at Western Colorado University has collaborated with ACE on dozens of sponsored research studies. The following section highlights findings from several of these studies that have significant practical applications as alternative methods of exercise programming for your clients with MetS.

Exercise With a Sauna Suit

In one of our studies from 2016, we quantified the cardiometabolic benefits associated with exercise training while wearing a sauna suit among individuals who had overweight or obesity, as well as MetS and MetS risk factors. Forty-five participants were randomly divided into three groups: (1) a sauna suit group, (2) an exercise alone group and (3) a control group. The individuals in groups 1 and 2 performed progressive exercise programs with similar frequencies, durations and intensities, and that met the recommendations for individuals who have overweight or obesity. The main findings of the study were as follows:

  • The sauna suit group experienced enhanced benefits compared to the exercise alone group in fasting blood glucose (7.7% vs. 2.1% reduction).
  • The sauna suit group saw an 11.7% improvement in VO2max (i.e., cardiorespiratory fitness), compared to a 7.3% improvement in the exercise alone group.

As health and exercise professionals, these findings have important implications. First, it is well known that impaired fasting blood glucose levels are a risk factor for the development of type 2 diabetes. Second, the more pronounced improvements in cardiorespiratory fitness in the sauna suit group is significant, as a growing number of studies are showing that higher cardiorespiratory fitness is inversely related to the development of MetS. As such, for clients with a cluster of cardiometabolic risk factors, improving cardiorespiratory fitness is an important goal to establish for the prevention of MetS.


A 2017 study of 15 adults with MetS and MetS risk factors demonstrated the effectiveness of a six-week Pickleball intervention in positively modifying cardiometabolic risk factors. In particular, we found that blood pressure and HDL cholesterol were significantly improved following the study. Given that both these cardiometabolic parameters are important risk factors for MetS, our findings support Pickleball as an ideal alternative form of exercise for clients with MetS.


The acronym REHIT stands for reduced-exertion high-intensity interval training. In 2018, we conducted a study to determine the effectiveness of an eight-week REHIT program for improving cardiorespiratory fitness and cardiometabolic health in a group of participants with MetS and MetS risk factors. Half of the 32 participants were randomly chosen to follow an eight-week REHIT program, while the other half performed moderate-intensity continuous training (MICT). A CAROL cycle ergometer unit was used to perform REHIT sessions three to four days per week for the duration of the study. The main findings of the study were as follows:

  • The REHIT group saw a positive improvement in the MetS z-score in 75% of the individuals, while the MICT group saw a positive improvement in only 47% of individuals. Moreover, the improvement in MetS z-score was two-fold greater in the REHIT vs. MICT group. The MetS z-score combines a number of cardiometabolic risk factor values into a single score, including blood pressure, circumference measures, blood glucose, HDL cholesterol and triglycerides. 
  • The REHIT exercise group improved their cardiorespiratory fitness nearly twice as much (12.3%) as those who performed traditional, MICT workouts (6.9%)
  • REHIT workouts performed on the CAROL bike were considerably more time efficient. Total weekly exercise time of traditional workouts was 150 minutes, whereas the CAROL workouts took only 41 minutes to complete. This was approximately one-quarter the time commitment of traditional workouts.   

In summary, our findings support REHIT as a time-efficient, alternative form of exercise for clients with MetS.

ACE Mover Method

The ACE Mover Method™ and the associated ACE ABC Approach™ are featured in ACE’s most recent textbook, The Exercise Professional’s Guide to Group Fitness Instruction. The underlying philosophy behind the development of these tools is that the job of an exercise professional entails far more than an understanding of sets, repetitions and exercise programming. Exercise professionals have long recognized that perhaps the most important part of working with their clients centers on the need to empower them to make behavioral changes that can be incorporated into their lifestyles, align with their values and drive meaningful benefits to their health, fitness and overall quality of life.

In a study completed in 2020, we examined the effectiveness of the ACE Mover Method at modifying healthy lifestyle behaviors in a group of individuals with varying degrees of MetS risk factors. All 28 participants completed a 12-week personalized exercise training program based on the ACE Integrated Fitness Training® (ACE IFT®) Model. Half of the participants (the ACE Mover Method group) received an intervention consisting of weekly client-centered sessions featuring the principles of the ACE Mover Method philosophy and ACE ABC Approach in addition to performing the personalized exercise program. These sessions were embedded within the normal exercise routine and personalized to each participant’s unique goals and needs. These conversations were collaborations aimed at positive lifestyle changes. The main findings of the study were as follows:

  • Participants in the ACE Mover Method group experienced statistically significant improvements in all healthy behaviors and lifestyle change categories (i.e., reduced sedentary time, healthy eating and stress reduction) over the course of the 12 weeks.
  • The MetS z-score improvement in the ACE Mover Method group was 5% greater (and statistically significant) relative to the other group.

As mentioned previously, lifestyle interventions are important strategies for managing MetS. The ACE Mover Method is one evidence-based strategy that you can employ as a health and exercise professional to help your clients with MetS to make positive lifestyle behavior changes that are likely to coincide with substantial improvements to their cardiometabolic profile.


Working with clients who have a cluster of cardiometabolic conditions, such as MetS, can be complicated and challenging, yet incredibly satisfying. By appreciating the condition and the influence that certain medications may have on exercise responses, understanding appropriate exercise programming guidelines, and leveraging alternative evidence-based programming when warranted, you can set your clients up for success by helping them perform regular exercise and achieve positive lifestyle behavior changes.

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