Transcript Determinants and Consequences of Adherence to the Dietary

Determinants and Consequences of
Adherence to the Dietary Approaches
to Stop Hypertension in AfricanAmerican and White Adults with
High Blood Pressure: Results from
the ENCORE Trial
DE Epstein, A Sherwood, PJ Smith, L Craighead, C Caccia, PHLin, MA Babyak, JJ Johnson, A
Hinderliter, JA Blumenthal
Journal of Academy of Nutrition and Dietetics. June 2012; 112: 1763-1773
Cassie Castillo
April 17, 2013
Background
• DASH: 7-8 grains, 4-5 fruits/vegetables, 2-3 low fat
dairy, 2 lean meats, 4-5 nuts/seeds/legumes per week,
limited sweets/fat
• DASH diet is an accepted HTN treatment
• Proven effective in controlled environment
• PREMIER study suggested limitation of effectiveness
was adherence
• ENCORE study investigated DASH effectiveness
independent of variables
Purpose
• Determine characteristics that suggest better
adherence to DASH diet
• Determine the association between the level of
adherence and reduction in blood pressure
ENCORE
• 16 week randomized clinical trial
• 144 participants
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BMI 25-39.9
BP: 130-159 and 85-99
Sedentary (less than 3x/week)
> 35 years old
no other comorbidities or hypertension
medications
▫ Physician referrals, community screenings, mass
media advertisements
ENCORE Assessments
• Clinic BP
• Ambulatory BP
• Cardiopulmonary function
• Retrospective food frequency
• 4 day food diary
Treatment Groups
• Usual diet control
▫ Maintain usual diet and exercise regimen
▫ Biweekly weight and BP monitoring
• DASH alone
▫ Weekly 30-45 min small group session with RD
▫ Diet instruction, feedback, buying tips, preparation tips,
goals, action plans, weight status
• DASH plus weight management
▫ Weekly 30-45 min session with RD and psychologist
▫ Weight loss and cognitive behavioral instruction
▫ Supervised 3, 45 min exercise session/week
DASH Adherence Score
Category
Servings
/day
Score
Grains
>7
1
5-6
0.5
<5
0
>4
Vegetables
Fruits
Dairy
Meat, poultry, fish
Nuts, seeds, and
dry beans
Category
Serving
s/day
Score
% kcal from fat
<27
1
1
28 -29
0.5
2-3
0.5
>30
0
<2
0
<6
1
>4
1
2-3
0.5
7-8
0.5
<2
0
>2
1
>9
0
1
0.5
<5
1
<2
1
6-7
0.5
3
0.5
>8
0
>4
0
<2400
1
>4
1
24003000
0.5
2 to 3
0.5
<2
0
>3000
0
% kcal from
saturated fat
Sweets
Sodium (mg)
Statistical Analysis
• General linear models
▫ Compared treatment groups and adherence to
DASH
• Linear regression models
▫ Potential predictors of adherence post treatment
• Analysis of variance
▫ Compared quartiles of adherence and change in
blood pressure
Variables
• Adherence Score (response variable)
Independent variables (predictors of adherence)
• Baseline DASH adherence
• Treatment group
• Ethnicity
• Sex
• Age
• Family income
• Years of education
• Psychosocial variables
Baseline Data
• Higher than recommendations: fat, saturated
fat, cholesterol, sodium
• DASH diet suboptimal in all groups
• DASH diet inversely related to lower income,
younger age, and ethnicity (African American)
Conclusion
• Participants who were able to comply with
DASH guidelines achieved more improvement in
BP
• Addition of exercise and weight loss indicated
larger improvements in BP
• African Americans have overall lower adherence
rates when compared to whites
STRENGTHS
-Multitude of variables considered
-Randomized group distribution
-Applicable to everyday practice
WEAKNESSES
-Ancillary study
-Highly motivated participants with
encouragement
-Additional studies due to inadequate power
Application to Practice
• Consideration to cultural influences, food
preparations, perceptions
• Modification to “soul foods”
• Community participation
Questions?
References
•
Academy of Nutrition and Dietetics. African Americans Less Likely to Adhere to DASH Diet for
Lowering Blood Pressure. Eat Right Academy of Nutrition and Dietetics.
http://www.eatright.org/Media/content.aspx?id=6442471914#.UW3nHKDJBFI. Published
September 19, 2012. Accessed April 6, 2013.
•
Blumenthal JA, Babyak MA, Hinderliter A, Watkins LL, Craighead L. Effects of the DASH Diet
Alone and in Combination With Exercise and Weight Loss on Blood Pressure and Cardiovascular
Biomarkers in Men and Women With High Blood Pressure. Journal of American Medical
Association. 2010;170 (2); 126-135. doi:10.1001/archinternmed.2009.470.
•
Boucher B, Cotterchio M, Kreiger N, Nadalin V, Block T. Validity and reliability of the Block98
food-frequency questionnaire in a sample of Canadian women. Public Health Nutrition. 2006; 9
(1), 84-93. http://www.ncbi.nlm.nih.gov/pubmed/16480538. Accessed April 5, 2013.
•
Epstein DE, Sherwood A, Smith PJ, Craighead L. Determinants and Consequences of Adherence
to the Dietary Approaches to Stop Hypertension Diet in African-American and White Adults with
High Blood Pressure: Results from the ENCORE Trial. Journal of the Academy of Nutrition and
Dietetics. 2012; 112 (11): 1763-73. doi: 1016/j.jand.2012.07.007.
References
•
Heart wire. African Americans less likely to adhere to DASH diet. The heart.
http://www.theheart.org/article/1448245.do. Published September 19, 2012. Accessed April 6,
2013.
•
US National Institute of Health. ENCORE: Exercise and Nutritional Interventions for
Cardiovascular Health. http://clinicaltrials.gov/show/NCT00571844. Published November 8,
2012. Accessed April 6, 2013.