DASH for HealthShruti SharmaNTR 5502: Nutritional AssessmentMarch 2011

Topics•Purpose of the tool•Explanation to patients•History or development of the tool•Plausible or purported mechanism•Safety of use•Who is it for?•Case studies, testimonials and methods of

marketing•Literature review•Patient Selection•Conclusion

Purpose of the Tool•To improve your eating and exercise habits• It allows people with busy lifestyles to learn

information about food, food preparation, eating out, losing weight and getting fit

• Information is posted on a weekly basis•You can create your own page to track your

progress in such areas as weight, blood pressure and exercise

•You have to subscribe to the site for either 3 or 6 month increments ranging from $39-69

http://www.dashforhealth.com/pages/public/dashforhealthbasics.php

Explanation to Patients• The site does a good job of letting patients know

that it simply offers guidelines and ways to monitor personal progress

• For specific medical concerns, such as interactions of certain foods with medications, referral to a pharmacist or medical doctor is suggested

• “our nutrition advice is based on the DASH diet, which is a well-balanced way of eating that is consistent with general nutrition guidelines”

• Based on your height, weight, gender, age and activity level you can find suggestions that will help you achieve your goals

http://www.dashforhealth.com/pages/public/exerciseadvice.php

Explanation to Patients (contd.)

•Weekly articles written by the staff are posted for viewing once you log in

•Some of the services provided include a “your stuff” page where participants can track their progress, create shopping lists, or even listen to a servings tutorial

•Archives are available to look up previous articles

•“DASHified” Recipes are also provided

http://www.dashforhealth.com/pages/public/exerciseadvice.php

History of the Tool

•Based on the DASH Diet ▫“Dietary Approaches to Stop

Hypertension”

•Originally designed to prevent and/or treat hypertension

•It is now recommended for all American adults (USDA Dietary Guidelines, 2005)

Moore, T.J., et al. 2008.

Plausible Mechanism•An algorithm uses the person’s gender,

age, and activity level to calculate the number of servings from each of the eight DASH food groups the person should consume daily

•The goal being that patients will practice the suggestions made and consume the recommended servings of each food group and incorporate these changes until goals are met

•Thus, weight loss, changes in blood pressure and learning to make healthier food choices occurs

Moore, T.J., et al. 2008.

Plausible Mechanism

•Eight food groups are used to guide individuals’ eating habits:▫Fruits▫Vegetables▫Low-fat dairy▫Meat/fish/poultry▫Grains▫Nuts/legumes▫Sweets▫Added fats

Moore, T.J., et al. 2008.

Safety of Use

•Safety concerns for the long term use of the DASH Diet is not an issue for most.

•The diet is more of a guideline for how to eat for your activity level and offers a way for individuals to live healthier lifestyles.

•However, as with any diet and exercise routine participants should seek counsel with their health care provider to ensure that contraindications do not exist with any of their medications or health conditions

Moore, T.J., et al. 2008.

Who is the DASH Diet for?

•It is applicable to the general population, not only overweight, obese or hypertensive individuals.

• It was originally designed for hypertensive patients as a means for treatment but has now become more of a guideline for how individuals can become healthier while achieving decreases in their blood pressure and weight.

Moore, T.J., et al. 2008.

Marketing Methods• The site is littered with comments indicating

who has profiled the DASH diet plan and user testimonials

• “The Archives of Internal Medicine shows that the DASH diet helps prevent heart attack and strokes in women.”

• “recommended by the American Heart Association, in the USDA Dietary Guidelines”

• “featured in the U.S. High Blood Pressure Guidelines.”

http://www.dashforhealth.com/pages/public/testimonials.php

Marketing Methods• On the website, 8 testimonials are published,

including one by Dr. Henry Domke (Missouri)• “I'm renewing my membership with DASH for

HealthTM because it works. The DASH diet is without a doubt the best diet for people (like me) who have high blood pressure. I suggest it to all my patients who have high blood pressure, and even many of those who don't. The DASH for HealthTM website has practical suggestions for how to fit this diet into your busy life. This is not a passing fad, but the real thing. I also find the "Your Stuff" monitoring features helpful for keeping track of where I have been. It is rewarding to refer to the graphs to monitor my progress.”

http://www.dashforhealth.com/pages/public/testimonials.php

Literature Review

•There are many articles available discussing the role of the DASH diet

•Some of the populations studied include:▫Older adults with or at risk of

cardiovascular disease▫Individuals with metabolic syndrome

•Studies have also analyzed the response rates and validity of internet based questionnaires

Apovian, C.M. et al., 2010., Moore, T.J., et al. 2008, and Stopponi, M.A., et al., 2009.

Literature Review

•Types of studies:▫Randomized control trials (RCTs)▫Retrospective, quasi-experimental design▫Cost analysis▫Prospective study▫Cross-sectional study

Methodology problems

•More studies include a predominantly White, educated population with a higher ratio of female participants

•Patient selection in order to increase ethnic diversity, such as increasing the number of Hispanics and African Americans being recruited

•Language barriers; using English only programs

Stopponi, M.A., et al., 2009.

Sample and duration•In the literature available, the sample

sizes varies from hundreds to thousands of individuals

•The duration of studies ranges from 4 weeks to 12 months

•Participants were recruited in various ways:▫Based on employment ▫Health insurance carrier▫Mass mail outs▫Spouses of participants

Apovian, C.M. et al., 2010., Moore, T.J., et al. 2008, and Stopponi, M.A., et al., 2009.

Conclusion

•Overall, the literature states the further research needs to be conducted to include a more diverse population base; in order to generalize the results

•The outcomes of the internet-based programs are promising and appear to change the behaviors of patients in order to reach dietary goals

Stopponi, M.A., et al., 2009.

Literature Review – Moore example

• Weight, Blood Pressure, and Dietary Benefits After 12 Months of a Web-based Nutrition Education Program (DASH for Health): Longitudinal Observational Study. Moore, T.J., et al. 2008

• This study used three outcome measures; change in:▫Weight▫Systolic blood pressure (SBP)▫Consumption of DASH food groups

• Diastolic BP (DBP)was a secondary outcome• The relationship between the changes in outcome

measure scores and use of the DASH for Health website was also analyzed

Moore, T.J., et al. 2008.

Moore, T.J. et al., 2008• Food consumption was estimated based on the DASH

online questionnaire, a 24 hr recall • Website use was tracked based on the number of times

a person logged on• Weight and BP was self entered• Groups were not randomized and no control group was

used• The researchers did not estimate the effects possible

on people who failed to enter data online• Baseline information was collected in the initial 3

weeks and a 12 month follow up during weeks 48-52• Analysis was done using SigmaStat 3.5; using

confidence intervals of 95%, paired t-tests or Wilcoxon signed rank tests, p-values were considered significant if less than 0.05

Moore, T.J., et al. 2008.

Moore, T.J. et al., 2008• Subjects were from 41 states, equal numbers of

each gender were used aged 18-73 years• 3479 subjects initially enrolled• 88% were White, 74% Married, and 66% had a

college or postgraduate degree• Most common reasons to enroll were “weight loss”

and “general health information”• 25% were concerned about BP or cholesterol levels• 81% consented to their information being used for

research; 26% of those remained at 12 months and were:▫mostly women, either married or widowed with some

singles; most were interested in “general health information”

Moore, T.J., et al. 2008.

Moore, T.J. et al., 2008

•Conclusion of the article:▫Fruit and vegetable intake increased significantly▫Consumption of grain products decreased▫Weight and BP decreased by 12 months▫Thus, the DASH diet and exercise can result in a

healthier lifestyle, weight loss and improved cardiovascular health

•Outcomes related to a greater number of log ins:▫Weight lowered▫Blood pressure lowered▫Fruit consumption was the only dietary change

linked with greater log ins

Moore, T.J., et al. 2008.

Moore, T.J. et al., 2008 - Study Limitations• Participants were not randomized• A control group was not used• The selection of patients in the study by Moore, et al.

(2008) was based on interested individuals working at the EMC Corporation and their spouses

• Participation was voluntary• Information was self-entered by participants• 12 month outcomes could only be calculated for those who

were still using the site at the time• Reasons for dropping out were not recorded, biasing the

outcomes to appear more favorable• People who did not lose weight or lower their BP may not

have continued for the 12 months• Food selection and exercise routines were not

standardized for all participantsMoore, T.J., et al. 2008.

Patient Selection•It is applicable to the general population,

not only overweight, obese or hypertensive individuals.

•Limitations to the use of online programs:▫Ease of access to the internet▫Logging onto the site regularly▫Level of education▫Socioeconomic status▫Age▫Standardized serving sizes

Apovian, C.M. et al., 2010., Moore, T.J., et al. 2008, and Stopponi, M.A., et al., 2009.

Conclusion•Thus, the DASH Diet, which includes an

increased intake of fruits and vegetables, a reduction in sodium intake and regular exercise can benefit those with, and at risk of cardiovascular concerns, such as hypertension and overweight individuals.

•“For overweight or obese persons with above-normal BP, the addition of exercise and weight loss to the DASH diet resulted in even larger BP reductions, greater improvements in vascular and autonomic function, and reduced left ventricular mass.” (Blumenthal, J.A., et al., 2010)

Apovian, C.M. et al., 2010., Blumenthal, J.A., et al., 2010, Moore, T.J., et al. 2008, Shenoy, S.F., et al., 2010, and Stopponi, M.A., et al., 2009.

Conclusion

•It is a simple online tool to guide and modify the food consumption behaviors of patients.

•Patients can be guided to its use in the office and then requested to bring print outs of their information for follow up visits. This allows the clinician to track the patient’s progress.

References• Apovian, C.M., Murphy, M.C., Cullum-Dugan, D., Lin, P.H., Gilbert, K.M., Coffman,

G., Jenkins, M., Bakun, P., Tucker, K.L. and Moore, T.J. (2010). Validation of a web-based dietary questionnaire designed for the DASH (Dietary Approaches to Stop Hypertension) diet: the DASH Online Questionnaire. Public Health Nutr; 13(5):615-622. Doi: 10.1017/S1368980009991996.

• Blumenthal, J.A., Babyak, M.A., Hinderliter, A., Watkins, L.L., Craighead, L., Lin, P.H., Caccia, C., Johnson, J., Waugh, R., and Sherwood, A. (2010). 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: the ENCORE study. Arch Intern Med; 170(2):126-35. Retrieved from: http://archinte.ama-assn.org/cgi/content/full/170/2/126

• Dash For Health. Retrieved from: http://www.dashforhealth.com/• Moore, T.J. Alsabeeh, N., Apovian, C.M., Murphy, M.C., Coffman, G.A., Cullum-

Dugan, D., Jenkins, M. and Cabral, H. (2008). Weight, Blood Pressure, and Dietary Benefits After 12 Months of a Web-based Nutrition Education Program (DASH for Health): Longitudinal Observational Study. J Med Internet Res; 10(4):e52. Doi: 10.2196/jmir.1114.

• Shenoy, S.F., Poston, W.S.C., Reeves, R.S., Kazaks, A., Holt, R.R>, Keen, C.L., Chen, H.J., Haddock, C.K., Winters, B.L., Khoo, C.S.H., and Foreyt, J.P. (2010). Weight loss in individuals with metabolic syndrome given DASH diet counseling when provided a low sodium vegetable juice: a randomized controlled trial. Nutr. J; 9:8. Doi: 10.1186/1475-2891-9-8.

• Stopponi, M.A., Alexander, G.L., McClure, J.B., Carroll, N.M., Divine, G.W., Calvi, J.H., Rolnick, S.J., Strecher, V.J., Johnson, C.C., and Ritzwoller, D.P. (2009). Recruitment to a randomized web-based nutritional intervention trial: characteristics of participants compared to non-participants. J.Med Internet Res; 11(3):e38. Doi: 10.2196./jmir.1086.