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O R I G I N A L R E S E A R C H

Supporting cardiovascular risk reduction in overweight and obese hypertensive patients through DASH diet and lifestyle education by primary care nurse practitioners Julie Jarl, DNP, MSN, FNP-BC (Family Nurse Practitioner)1, 2, Jerlyn C. Tolentino, MA (Research Facilitator)1, Kathy James, DNS, APRN, FAAN (Associate Professor)2, Mary Jo Clark, PhD, RN (Professor)2, & Margaret Ryan, MD, MPH (Head of Clinical Research)1

1 Naval Hospital Camp Pendleton, Camp Pendleton, California 2 Hahn School of Nursing and Health Science, University of San Diego, San Diego, California

Keywords Dietary practices; hypertension; lifestyle;

obesity; nurse practitioners.

Correspondence Margaret Ryan, MD, MPH Head, Clinical

Investigation Program Naval Hospital Camp

Pendleton, H200 Room 4179 Camp Pendleton,

CA 92055. Office: 760-719-3593;

Cell: 858-342-5786; Fax: 760-725-1015;

E-mail: [email protected]

Received: 13 December 2012;

accepted: 25 February 2013

doi: 10.1002/2327-6924.12124

Disclosure The views expressed in this article are those of

the authors and do not necessarily reflect any

official policy or position of the Department of

the Navy, Department of Defense, or the United

States (U.S.) Government. No external funding

source supported this project.

Copyright statement This is a U.S. Government work prepared by

authors who are federal employees in

performance of their official duties. Title 17 USC

105 provides that copyright protection is not

available for any work of the U.S. Government.

Abstract

Purpose: To describe an intervention among overweight and obese hyperten- sive patients, encouraging Dietary Approaches to Stop Hypertension (DASH) diet and lifestyle changes, designed and led by a primary care nurse practitioner (NP). Data sources: A pre- and postintervention quasi-experimental time-series design was implemented over 2 months. Intervention included three group classes and two individual counseling telephone calls. Forty-five hypertensive patients enrolled, with a mean age of 55 years and mean initial BMI of 32. Twenty-six (58%) completed the program. Standard instruments (Rapid Eat- ing Assessment for Patients [REAP] and Partners in Health [PIH] question- naires) were used to evaluate diet and lifestyle factors before and after the program. Conclusions: Participants had statistically significant improvements in diet and lifestyle scores on both REAP and PIH questionnaires, as well as statistically significant weight loss (average 3.6 pounds lost) over the 2-month intervention period. Implications for practice: This NP-led primary care intervention on diet and lifestyle showed early success in improving the health of overweight and obese hypertensive patients. Investment in NP-led diet and lifestyle counseling should be considered among high-risk patients in the primary care setting.

Introduction

Hypertension is a leading risk factor for cardiovascular disease, and a major cause of costly morbidity and mor- tality (Heidenreich et al., 2011). Although hypertension should be considered a modifiable risk factor, recent anal- yses suggest that more than half (53.5%) of the estimated 66.9 million adults with hypertension in the United States may have poorly controlled hypertension (Valderrama et al., 2012). Obesity and hypertension are often linked in

adults (Francischetti & Glenelhu, 2007). The challenges of healthy weight control have emerged as a growing public health crisis; as of 2007, more than 30% of U.S. adults may be considered obese and no state had achieved the U.S. Healthy People 2010 objective of reducing the prevalence of obesity to less than 15% of the adult popu- lation (Sherry, Blanck, Galuska, Dieta, & Balluz, 2010).

Opportunities may be available in the primary care setting to better address both hypertension and obe- sity. Nearly 90% of U.S. adults with poorly controlled

498 Journal of the American Association of Nurse Practitioners 26 (2014) 498–503 Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

J. Jarl et al. Supporting cardiovascular risk reduction

hypertension have a usual source of health care, have health insurance coverage, and have received health care in the previous year (Valderrama et al., 2012). This suggests potential missed opportunities by individuals, healthcare providers, and healthcare systems to improve cardiovascular disease prevention. Promoting healthy lifestyles, through diet, physical activity, and weight con- trol, is an aspect of most strategies to improve hyper- tension control in the clinical setting (Glynn, Murphy, Smith, Schroeder, & Fahey, 2010). Nonetheless, the ac- tual value of time-intensive counseling by primary care providers to reduce cardiovascular disease risk is not well established nor well accepted (Moyer, 2012).

Nurse practitioners (NPs) may be uniquely positioned to focus on counseling and preventive services in the primary care setting. This study evaluated whether an NP-led intervention, including counseling about diet and lifestyle, had a measurable impact on the health of a chal- lenging group of hypertensive patients who were also overweight or obese. The intervention included educa- tion about the low-sodium Dietary Approaches to Stop Hypertension (DASH) diet (Blumenthal et al., 2010), and standard assessments of dietary and lifestyle changes, as well as weight loss, over a 2-month period.

Methods

This study was reviewed and approved by the Navy Medicine West Institutional Review Board (IRB) and was conducted in compliance with all applicable federal regu- lations governing the protection of human subjects in re- search (IRB #NHCP.2011.0101). We asked adult patients who were overweight or obese with a medical diagno- sis of chronic hypertension to participate in the study. We collected data on their self-reported diet and exer- cise habits, capacity to manage their condition, and height and weight metrics to calculate body mass index (BMI), before and after completing the patient education pro- gram.

The patient education program, developed by a fam- ily medicine NP, took place between September 7, 2011 and November 2, 2011. The program instructed patients on the DASH diet over three 45-min in-person group classes (held on September 7, October 5, and Novem- ber 2, 2011). Two 20-min individual telephone consults were conducted with participants by the NP between the group classes. Educational materials were compiled from the National Heart, Lung, and Blood Institute (USDHHS- NHLBI, 2006). Packets of all information presented in each class were distributed to all participants.

Participants completed the Rapid Eating Assessment for Patients (REAP) survey before and after the education

sessions. REAP is a 31-item survey that assesses the pa- tient’s diet and physical activity level. REAP has excellent test–retest reliability (r = .86, p < .0001) and adequate reliability and validity to be used in a primary care set- ting for nutrition assessment and counseling (Gans et al., 2006). This questionnaire takes approximately 10 min to complete. It includes 27 questions that assess intake frequency of sodium, whole grains, calcium-rich foods, fruits and vegetables, fat, saturated fat and cholesterol, sugary beverages and foods, alcoholic beverages, and physical activity. These questions are scored as follows: 1 = usually/often, 2 = sometimes, or 3 = rarely/never. As per standard scoring algorithms, if a question is skipped or answered “not applicable,” then the answer is coded as “rarely/never.” Three additional “yes/no” questions ad- dress concerns with shopping for food, food preparation, and special diets. A final question provides an estimate of readiness for behavior change on a 5-point scale (5 = “very willing” to 1 = “not at all willing”). The total REAP score was computed using the 27 scale questions for a possible total of 81 points. Three questions on the REAP (questions 2, 23, and 24) assessed sodium intake specif- ically, and were analyzed individually to determine how participants managed their sodium intake. Physical activ- ity was measured by responses to questions 26 and 27 on the REAP.

The Partners in Health (PIH) scale was used to as- sess patients’ knowledge and behaviors related to self- management of their chronic health condition (Petkov, Harvey, & Battersby, 2010). This 12-item questionnaire has been shown to have good internal consistency (Cronbach’s alpha = 0.82) and good construct validity (Petkov et al., 2010). The PIH scale was used to assess patient self-management knowledge and behavior over time. The PIH takes about 5 min to complete and is scored on a 9-point (0–8) scale, with 0 being the worst and 8 be- ing the best response. A total score was computed for a possible total of 96 points.

BMI was calculated using height and weight measured at baseline and at the end of the third educational session. The NHLBI’s BMI classification was used to define over- weight and obese patients. BMI between 25.0 and 29.9 was considered overweight and BMI >=30.0 was consid- ered obese.

Statistical analysis was performed using SPSS for Win- dows, version 10 (SPSS Inc., Chicago, IL). Descriptive statistics and frequencies were computed to describe pa- tients’ ability to manage their condition, diet, and ex- ercise habits. A paired-samples t-test was performed on BMI, PIH, and REAP scores collected before and after the intervention among participants who completed the program.

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Supporting cardiovascular risk reduction J. Jarl et al.

Table 1 Demographic characteristics of patients who did and did not complete the education program

Participants who Participants who

completed the did not complete

program (n = 26) the program (n = 19) Characteristics number (%) number (%)

Age in years

Mean (range) 57 (44–73) 51 (23–69)

Initial BMI (mean and range) 31.5 (25.2–43.9) 34.0 (25.2–48.3)

Gender

Male 12 (46) 5 (26)

Female 14 (54) 14 (74)

Race/ethnicity

White non-Hispanic 16 (62) 8 (42)

Other 10 (38) 11 (58)

Education

Less than a college degree 16 (62) 12 (63)

College degree or higher 10 (38) 7 (37)

Employment

Employed 13 (50) 10 (53)

Not currently employed 13 (50) 9 (47)

Military affiliation

Family member 13 (50) 14 (74)

Retiree 13 (50) 5 (26)

0

9

18

27

36

45

54

63

72

81

Average REAP Score

Before Education After Education

Figure 1 REAP scores before and after DASH diet education program, among participants who completed the program.

Results

There were 45 eligible patients who consented to be in the study. Of these, 26 (58%) completed the program. Table 1 shows the characteristics of the patients who did and did not complete the education program. Most of the participants who completed the study were female, white (non-Hispanic), and had less than a college education (Table 1). Participants who completed the program did not have statistically significant differences in pre-BMI, pre-REAP, or pre-PIH scores from those

Table 2 Sodium intake before and after the education program, based on questions from the REAP scale

Before education After education

REAP questions N (%) N (%)

In an average week, how

often do you eat four or

more meals from sit-down

or take-out restaurants?

Usually often 5 (19) 1 (4)

Sometimes 3 (12) 5 (19)

Rarely/never 18 (69) 20 (77)

In an average week, how

often do you eat

high-sodium processed

foods like canned soup or

pasta, frozen/packaged

meals (TV dinners, etc.),

chips?

Usually often 6 (23) 0 (0)

Sometimes 10 (38) 10 (38)

Rarely/never 10 (38) 16 (62)

In an average week, how

often do you add salt to

foods during cooking or at

the table?

Usually often 6 (23) 2 (8)

Sometimes 8 (31) 5 (19)

Rarely/never 12 (46) 19 (73)

who did not complete the program. However, those who completed the program were significantly older compared to those who did not complete the program (mean age of 58 years compared to mean age of 51 years, p = .002).

Figure 1 shows that the average REAP score after completing the program was significantly higher com- pared to the average REAP score before starting the pro- gram (mean 64.5 compared to mean 57.5, p = .001). Table 2 presents the number of participants whose sodium intake improved based on responses to select questions on REAP. Similarly, based on responses to physical activity questions on REAP, participants reported greater physical activity after they completed the program (Table 3).

Figure 2 shows that the average PIH score after com- pleting the program was significantly higher compared to the average PIH score before starting the program (mean 79.2 compared to mean 72.7, p = .01). Higher PIH scores correspond to higher perceptions of self-reported knowl- edge and self-efficacy in managing health.

Figure 3 shows the average BMI before and after the education program, among participants who completed the program. Overall, 20 (77%) participants lost weight over the 2-month period, and participants lost an average

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J. Jarl et al. Supporting cardiovascular risk reduction

Table 3 Physical activity habits before and after the education program, based on questions from the REAP scale

Before education After education

REAP questions N (%) N (%)

In an average week, how

often do you do less

than 30 total minutes

of physical activity 3

days a week or more?

Usually often 7 (26) 4 (15)

Sometimes 6 (23) 5 (19)

Rarely/never 13 (50) 17 (65)

In an average week, how

often do you watch

more than 2 h of

television or videos a

day?

Usually often 14 (54) 11 (42)

Sometimes 10 (38) 11 (42)

Rarely/never 2 (8) 4 (15)

0

16

32

48

64

80

96

Average PIH Score

Before Education After Education

Figure 2 PIH scores before and after DASH diet education program, among participants who completed the program.

of 3.6 pounds by the end of the program. A paired t-test found that BMI was statistically significantly (p < .001) lower at the end of the program (mean 31.0) than at the start of the program (mean 31.5).

Discussion

The goal of this study was to assess the impact of an intervention, developed and led by a primary care NP, to improve healthy lifestyles in overweight and obese patients with hypertension. The DASH diet is endorsed by the NHLungBI and by the American Heart Associa- tion as an example of healthy dietary intake for weight

20

25

30

35

BMI

Before Education After Education

Figure 3 Average BMI before and after the DASH diet education program, among participants who completed the program.

and blood pressure control (Harnden, Frayn, & Hod- son, 2009). This study demonstrated the value of pro- moting evidence-based practice to improve clinical out- comes in primary care, consistent with prior study results (Titler, 2010). Our results suggest that a patient education program in a primary care setting based on the DASH diet can be successfully implemented over a 2-month span.

This study has some unique features, as very few stud- ies associated with the use of the DASH diet implemented a survey instrument such as the PIH to assess patients’ knowledge and behaviors related to self-management of their chronic health conditions. Although our educa- tion program was focused on diet, it may be considered provocative that improvements in diet were associated with other improvements in understanding and manage- ment of hypertension. Improvements in activity, inde- pendent of any dietary changes, were demonstrated on both PIH and REAP instruments. This may be consistent with other successful models of nurse-led empowerment strategies for hypertensive patients (Chang, Fritschi, & Kim, 2012).

Most prior studies on DASH diets, such as the Premier study, used dietary recall to identify patients’ eating pat- terns pre- and postintervention (Elmer et al., 2006). Our study was similar, assessing dietary recall through the use of the REAP survey, and showing significant improve- ment in overall dietary habits. Because a primary focus of the DASH diet is daily sodium intake, we also ex- amined sodium intake more specifically. While current dietary guidelines recommend that hypertensive patients reduce sodium intake to <1500 mg/day, it may not be possible to achieve a very low sodium diet that is

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Supporting cardiovascular risk reduction J. Jarl et al.

otherwise nutritionally adequate when most supermar- ket and restaurant food selections have high sodium con- tent (Maillot & Drewnowski, 2012). Our results did not quantify sodium intake in milligrams per day; however, we were able to demonstrate promising and statistically significant reductions in self-reported sodium intake among program participants.

Weight and BMI reductions have been demonstrated among other patients adhering to the DASH diet. The ENCORE (Blumenthal et al., 2010) 5-year study demon- strated weight reductions of 0.3 kg to 8.7 kg. A recent summary of eight trials that applied the DASH diet from 30-day to 3-year duration demonstrated varying degrees of weight reduction, including an average 1.0 kg weight loss over a 9-week trial (Hedayati, Elsayed, & Reilly, 2011). Our results with this NP-led intervention were similar, or perhaps slightly more promising, with an av- erage 1.5 kg weight loss over an 8-week period. Follow- up of this and other intervention cohorts will be im- portant to determine if weight loss was continued or maintained.

Our study included telephone contact from the NP to each participant at two times, between the group education sessions. While other studies have demon- strated the benefit of telephone contact for supporting management of hypertension over more than a decade (Friedman et al., 1996; Svetkey et al., 2009), such in- terventions are time- and resource-intensive. Further study may be valuable in defining the timing, length, and content of this kind of contact to optimize pa- tient engagement. Some of the most promising research in this area leverages newer technology to keep pa- tients engaged in the care of their chronic conditions (Piette et al., 2012).

The strengths of our study include its simplicity and reliance on standard measures of outcomes, includ- ing REAP and PIH. Furthermore, conducting the study within a single family medicine clinic allowed for con- sistency of application of the intervention. Overall re- sults of this study compare favorably to other programs using the DASH diet. Of the 45 patients consented and enrolled in the study, 26 (58%) completed the program with a mean 3.6 lb weight loss. Evaluating outcomes over a 2-month period demonstrated relatively rapid value to participants. Limitations of the study include its mod- est sample size, including participants who were likely to be more motivated patients. Reasons for noncomple- tion by 42% of original participants were not assessed, but likely relate to motivation. Nonetheless, the statisti- cal significance of changes in such a small sample may be considered promising. Our study did not assess the long- term value of the intervention, although follow-up as- sessments of the study participants are planned.

In an era of limited healthcare resources, debate con- tinues about the value of clinician-led behavioral educa- tion in improving patient health. The U.S. Preventive Ser- vices Task Forces cite insufficient evidence to recommend routine clinic-based lifestyle education among lower risk patients (Lin, O’Connor, Whitlock, & Beil, 2010; Moyer, 2012). This highlights the importance of this project, and similar studies, in informing policymakers and providers on these challenging issues. We demonstrated that this NP-led education intervention was associated with some promising short-term success among patients who chose to participate. Further study is clearly needed to identify the factors that are most efficiently and effectively associ- ated with sustained success and, perhaps most challeng- ing, what factors might motivate more patients to engage in healthier lifestyles.

Conclusion

The current obesity–hypertension crisis in the United States imposes a significant burden on society and health- care costs. It is critical that both patients and the health- care industry recognize obesity as a disease. As the number of people with obesity and hypertension in the general population increases, there is a greater need for research in this area. Attaining and maintaining healthy lifestyles is clearly challenging but may be essential to successfully address chronic conditions like obesity and hypertension. This project revealed how a clinical NP-led DASH diet intervention may be applied to effectively ed- ucate motivated overweight and obese patients with hy- pertension and improve their health.

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