When Melbourne-based physiotherapist and educator Sally Mastwyk MACP came across a PhD project on improving management of metabolic syndrome, offered as a joint scholarship program between La Trobe University and Sheffield Hallam University in the UK, she was intrigued—she had never heard of it.

‘I had to google metabolic syndrome and have a chat to Associate Professor Casey Peiris, who was leading the project,’ says Sally.

‘When I found out what it was, I thought it was a fascinating project.’

Metabolic syndrome is a cluster of metabolic risk factors that, together, raise the risk of a person developing chronic disease, including cardiovascular disease, cancer and diabetes. It is defined by the presence of at least three out of five risk factors: abdominal obesity, hypertension (high blood pressure), elevated triglycerides, lowered high-density lipoprotein cholesterol and elevated fasting glucose (Alberti et al 2009).

Globally, 25 per cent of the adult population has metabolic syndrome and its prevalence increases with age.

However, despite its prevalence and its significance as a public health concern, metabolic syndrome is under-recognised by the healthcare system and opportunities to diagnose and manage it before chronic disease develops are frequently missed.

Sally, whose clinical interest up to this point had been women’s pelvic health, jumped at the chance to be involved in the project.

She says that while the relationship between physiotherapy and metabolic syndrome is not immediately obvious, metabolic syndrome is connected to osteoarthritis, tendinopathy, pain conditions and osteoporosis via the common thread of chronic inflammation.

‘We now know that many people’s osteoarthritis may be driven by chronic inflammation rather than the mechanical load on joints that was originally thought to be the issue.

‘One of the first causes of chronic inflammation is metabolic syndrome.

‘A lot of our other joint issues are also linked to that so they’re tied together,’ Sally says.

Chronic inflammation has been associated with poor diet, sedentary behaviours, poor sleep, stress and numerous other lifestyle factors.

Physical activity, diet and other lifestyle interventions are key components in managing metabolic syndrome and reducing the risk of chronic disease.

‘If you’re treating chronic systemic inflammation by addressing someone’s lifestyle behaviours, it’s not only going to have an impact on resolving the metabolic syndrome and preventing other diseases, but should also improve their outcome for the presenting complaint.’

Sally’s research initially focused on physiotherapists’ knowledge about metabolic syndrome.

Her first study, which surveyed 183 physiotherapists from Australia and England, showed that metabolic syndrome was not on most physiotherapists’ radar—one in four had not heard of it and fewer than one in five knew the risk factors, how many were required for diagnosis or the chronic diseases involved (Mastwyk et al 2024a).

However, the physiotherapists in the study expressed interest in knowing more about metabolic syndrome and agreed that they had an important role to play in prescribing physical activity for chronic disease management.

‘Physios have an opportunity here to help with chronic disease prevention but they also need to be aware that a lot of their clients may have some of these underlying health issues before they get to the point of chronic disease.

‘Physios are actually very well placed to address some of this,’ Sally says.

Previous studies by her PhD supervisor, Casey Peiris, had shown that almost two-thirds of clients in community rehabilitation programs had metabolic syndrome (Peiris et al 2022).

Sally was interested in whether the numbers were similar in private practice clinics, where physiotherapists are often the first point of contact.

Their patients are also younger and do not necessarily have chronic disease or comorbidities.

Researcher Sally Mastwyk says that many physiotherapists are unaware of metabolic syndrome and its management.

Sally offered free health screens to clients at six physiotherapy clinics across metropolitan and regional Victoria, looking at physical activity levels, diet and medical history and performing a physical screen including height, weight and waist circumference.

Clients were asked a series of questions about lifestyle change.

Sally also measured their blood pressure, unless they were already known to have hypertension or to be on anti-hypertensive medication, and conducted an on-the-spot blood test to look at blood glucose and/ or cholesterol in patients who were not already diagnosed with and/or taking medication for high cholesterol/diabetes.

‘To be honest, I was nervous about going out to the clinic.

‘I thought it would be a battle getting people to have a health screen but I was pleasantly surprised by how easy it was—they were happy to have this screen after seeing the physio,’ Sally says.

Sally screened 230 clients in total and of those, 37 per cent—more than one in three—met the criteria for metabolic syndrome (Mastwyk 2024b).

‘The big thing for me was that none of them knew that they had metabolic syndrome so it was going completely unrecognised.

‘It hadn’t been diagnosed for any of them,’ Sally says.

Many of the participants were also not aware that they had hypertension or other risk factors associated with metabolic syndrome.

Of 134 people with hypertension, 56 per cent of them were unaware and not taking medication.

Similarly, 29 per cent of those presenting with elevated triglycerides were unaware and not taking medication.

People with metabolic syndrome were older, more likely to live in a poorer socio-economic area and less physically active than those who didn’t meet the criteria for diagnosis.

Both the clients with metabolic syndrome and those without it felt that lifestyle change was important and were willing to make changes.

Patients who did have risk factors received a copy of their results to take to their GP but that raised another issue, Sally says.

‘I made an assumption that most clients would have a regular GP and would be having health checks, getting their blood pressure and cholesterol checked.

‘I was quite surprised to find that actually many of them weren’t connected with a GP,’ she says.

The findings have led to a follow-up study with 20 of the clients as well as eight of the physios to look at the feasibility of doing health screening in private practice physiotherapy clinics.

‘When I asked the clients what they thought about physios offering health screens in private practice, there was a real appetite for it,’ Sally says.

‘The physiotherapists also felt that the screening was valuable—it opened up hard conversations about lifestyle and clients’ physical activity levels and diet, all things that many physios have trouble raising in conversation.

‘But they saw it as an add-on service rather than part of their usual practice.’

Sally notes that studies have shown that many people believe physiotherapists should provide advice on both physical activity and their general health but physiotherapists are wary of operating outside their perceived scope of practice.

‘There’s a bit of a mismatch at the moment between what the community expects and wants from physio and what physios perceive their role to be.

‘In that first survey, on what physios know about metabolic syndrome, we asked about their role in terms of physical activity and they all said “Physical activity promotion is our bread and butter; we should be doing that”,’ she says.

‘But they were unsure about giving out advice on diet, let alone blood sugar control.

‘There’s this uncertainty, which I think comes from lack of education and training.

‘Physios have not thought about it and that’s what the majority of them said.

‘They’re not managing metabolic syndrome because they don’t know enough and they haven’t had any training in it.’

Sally’s studies to date suggest that physiotherapists want to know more about metabolic syndrome and clients want physiotherapists to talk about it but they are not sure how to have those conversations.

‘They want to be able to help their clients but they need a bit of assistance with how to go about it,’ she says.

‘There’s a real need and a real opportunity for physios to optimise outcomes for clients and help people prevent disease.

‘There was an amazing quote from my first study.

‘One of the physios said, “We don’t know what we don’t know.”

‘And that’s the thing—they don’t.’

Sally has recently completed a co-design project in which a group of private practice physios came together to look at raising awareness of metabolic syndrome across the profession.

The group has developed a webinar and course for professional development, which she intends to finish once her PhD is done.

She also has plans for a similar program to be embedded in entry-level physiotherapy education.

Ultimately, Sally hopes to develop a lifestyle intervention program to address metabolic health, along the lines of the well-known GLA:D programs for osteoarthritis and low back pain, tapping into the interest from private health insurers in investing in health promotion and prevention programs.

‘Our studies are not quite there yet for a good evidence-based program that can be rolled out in physio clinics.

‘We need to do some work in terms of training physios, getting them up to speed and then developing programs and piloting them to show that these programs can work in a physio setting,’ says Sally.

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Course of interest:

The bigger picture: childhood overweight and obesity