M. Mattfeldt-Beman

Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II

Approximately one fourth of the U.S. adult populationnearly 50 million peoplehas hypertension (1, 2). Taking a broader perspective, more than half of the adult population has higher than optimal blood pressure (1), defined as systolic blood pressure greater than 120 mm Hg and diastolic blood pressure greater than 80 mm Hg (2). These persons are at significantly increased risk for cardiovascular disease and stroke (3). Although pharmacologic treatment for hypertension significantly reduces morbidity and mortality from cardiovascular diseases (4, 5), long-term pharmacologic therapy can have undesirable side effects and requires the expense of continuing medical supervision. Furthermore, pharmacologic therapy is not usually initiated when blood pressure is higher than optimal yet below diagnostic thresholds for hypertension. Thus, lifestyle interventions for primary prevention and initial treatment of high blood pressure remain a vital strategy for controlling this highly prevalent condition (2). Weight loss has been shown to reduce blood pressure in overweight hypertensive patients (6-9) and in overweight persons with high-normal blood pressure (10-12). Two reviews of randomized trials of weight reduction to reduce blood pressure examined the results of nine studies (13, 14). Most of these trials were small, only one had more than 500 participants (11), and most had short-term follow-up (1 year or less). Only three studies had follow-up of 3 to 5 years (8, 10, 11). Compared with controls, weight loss averaged nearly 7 kg in the short-term trials and approximately 3 kg in the three longer-term trials. In almost all trials, systolic blood pressure and diastolic blood pressure were reduced in the intervention groups. Since these reviews were published, the Trials of Hypertension Prevention (TOHP) Phase I reported mean weight reduction of 3.9 kg at 18 months in 564 overweight participants with high-normal blood pressure, resulting in significant decreases in systolic blood pressure and diastolic blood pressure compared with a usual care control group (12, 15). To investigate whether nonpharmacologic interventions can prevent hypertension over the long term, TOHP II was initiated. This was a randomized, controlled trial examining the effects of weight loss and dietary sodium reduction, alone and in combination, in reducing blood pressure in overweight adults with high-normal diastolic blood pressure (16). This target population is at high risk for hypertension as they age. The primary outcome paper from this trial (17) provided only a brief overview of the effects of weight loss on blood pressure. Here, we provide more detailed analysis of weight loss and blood pressure in TOHP II. Of special interest are the long-term effects of weight loss on blood pressure, the magnitude of the doseresponse relationship at 36 months, the effect of patterns of weight loss on blood pressure, and the predictors of weight loss and blood pressure response. Methods Participants Participants in TOHP II were overweight adults with nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg. Other eligibility criteria included age 30 to 54 years and a body mass index of 26.1 to 37.4 kg/m2 for men and 24.4 to 37.4 kg/m2 for women, approximately 110% to 165% of ideal weight (18). Principal exclusion criteria were current treatment with medications that might affect blood pressure, clinical or laboratory evidence of cardiovascular disease, diabetes mellitus, renal insufficiency (serum creatinine concentration 150 mol/L [ 1.7 mg/dL] for men and 132 mol/L [ 1.5 mg/dL] for women), and current or planned pregnancy. Detailed descriptions of recruitment and participant characteristics have been published elsewhere (19, 20). The study was reviewed and approved by the institutional review boards at all nine TOHP centers and the coordinating center, and all participants signed informed consent forms. Design Eligible participants were randomly assigned with equal probability to one of four groups: weight loss only, sodium reduction only, combined weight loss and sodium reduction, or usual care (controls). Measurements Age, sex, ethnicity, and years of education were obtained by questionnaire. Baseline blood pressure measurements were taken at three screening visits, each separated by 7 to 45 days. At each visit, three readings of systolic blood pressure and diastolic blood pressure were obtained and averaged. Certified staff obtained measurements in seated participants by using a Hawksley random-zero sphygmomanometer (21). Body weight was measured to the nearest 0.2 kg (0.5 lb) by using a calibrated balance-beam scale; participants wore indoor clothing (without shoes). Blood pressure and weight were measured every 6 months after randomization to the end of follow-up at 36, 42, or 48 months, depending on randomization date. Clinic staff who were blinded to study group assignment made these assessments. Blood pressure measurements were obtained during a single visit at all follow-up points except for 18 and 36 months, when measurements were taken at a series of three visits approximately 1 week apart. Multiple measurements were taken at 18 and 36 months to provide a more precise assessment of average blood pressures at these primary outcome points. Dietary intake was assessed by 24-hour recall, and physical activity was assessed by questionnaire. Intervention Participants assigned to the weight loss intervention group sought to lose at least 4.5 kg (10 lb) during the first 6 months of the intervention and to maintain their weight loss for the remainder of the trial. A brief description of the intervention methods is presented here; a more detailed description has been published elsewhere (22). The intervention started with an individual counseling session, followed by 14 weekly group meetings led by dietitians or health educators. After this 14-week intensive phase, participants attended six biweekly group meetings and then monthly group meetings. Beginning in the 18th month, participants were offered a variety of options to keep them involved in the intervention, including individual counseling sessions and special group sessions focused on selected weight loss topics. The intervention focused on self-directed behavior change (behavioral self-management), nutrition education, information on physical activity, and social support for making and maintaining behavior changes. Specific behavior change techniques included self-monitoring (food diaries and graphs of minutes of physical activity per day), setting explicit short-term goals and developing specific action plans to achieve those objectives, and developing alternative strategies for situations that trigger problem eating. The dietary intervention focused on reducing caloric intake by decreasing consumption of excess fat, sugar, and alcohol. Keeping daily food diaries was emphasized for monitoring intake and assessing progress. With experience, the participants determined the caloric intake that produced moderate weight loss for them. It was suggested that men not consume less than 1500 kcal/d and women not less than 1200 kcal/d. Weight loss of more than 0.9 kg (2 lb) per week was discouraged. The physical activity goal was to gradually increase activity to 30 to 45 minutes per day, four to five days per week. Exercise intensity was moderate, approximately 40% to 55% of heart rate reserve, and consisted primarily of brisk walking. Statistical Analysis Baseline characteristics of the weight loss and usual care groups were compared overall and by sex by using t-tests for means and chi-square tests for proportions. Although weight and blood pressure data were collected every 6 months, special efforts were made to achieve high follow-up rates at 18 and 36 months; at each of these two time points, nine blood pressure readings were collected over three visits and were averaged. For participants prescribed antihypertensive medication, follow-up blood pressure for all subsequent visits was taken to be the last study blood pressure before therapy was started. Participants receiving medications that affect blood pressure for reasons other than hypertension or who became pregnant were treated as missing at that visit. We used two-sample t-tests to compare changes in weight and blood pressure from baseline in the weight loss intervention and usual care groups overall, by sex, by ethnicity, and by sex and ethnicity. The effects of the intervention in terms of changes in weight and blood pressure were examined overall and in subgroups defined by sex, ethnicity, and sex and ethnicity. Subgroup differences were tested by using terms for the interaction of treatment group with sex and with ethnicity in multiple linear regression models. Regression analyses were also used to analyze the doseresponse relationship between change in weight and change in blood pressure, overall and within sex and ethnicity subgroups. Differences in dose response were tested by using interaction terms in linear regression models. All regressions were adjusted for age and baseline weight. We also adjusted for baseline blood pressure in the blood pressure regression models. Change in blood pressure was also examined in relation to quintile of weight loss. Quintiles were computed by using the distribution of weight change in the weight loss intervention group. Additional multiple regression analyses were performed in which weight loss participants were categorized according to patterns of weight loss at 6 and 36 months. The PROC MIXED function of SAS software (SAS Institute, Inc., Cary, North Carolina) was used to perform repeated-measures analyses that tested differences over time by pattern of weight loss. Cox proportional-hazards models were used for survival analyses, with onset of hypertension as the outcome. Results Baseline Findings The baseline characteristics of participants assigned to th

Trials of Hypertension Prevention, phase II structure and content of the weight loss and dietary sodium reduction interventions

Identifying effective, nonpharmacologic means of preventing or significantly delaying the onset of hypertension would be a major advance in the primary prevention of cardiovascular disease. In the first phase of the Trials of Hypertension Prevention (TOHP I), adults with high-normal diastolic blood pressure were randomly assigned to one of seven nonpharmacologic interventions. Only weight loss and reduction of dietary sodium proved to be effective strategies for reducing blood pressure. The second phase of TOHP (TOHP II) will test the effectiveness of weight loss, reduction of dietary sodium, and their combination of lowering blood pressure and preventing the onset of hypertension over a 3- to 4-year follow-up period. This article describes the three interventions used in TOHP II, methods used to maintain continued participation in this long-term trial, and protocol enhancements designed to maximize intervention effectiveness.

Effectiveness of Individual Versus Group Counseling for Clients with Hypercholesterolemia

Abstract The development and implementation of effective and cost-effective nutrition and lifestyle intervention programs plays an important role in the treatment of clients with hypercholesterolemia. Since the majority of nutrition education research has focused on individual counseling, this poses the question as to whether there are measurable differences between individual and group counseling methods for clients with hypercholesterolemia. The purposes of this multidisciplinary project were to: 1) compare individual versus group counseling methods using percentage changes in serum cholesterol, knowledge and behavior scores, and satisfaction level as measures of effectiveness; and 2) complete a cost-effectiveness analysis for both interventions. One hundred thirty-one adults with hypercholesterolemia (total cholesterol ≥200mg/dL) were randomly assigned to either individual (n=66) or group (n=65) counseling programs. A standardized five-week cholesterol education program was presented by the same team of counselors (Registered Dietitian and Clinical Nurse Specialist) in both interventions. Participants had their pre- and post-counseling serum cholesterol measured, completed pre- and post-knowledge and behavior questionnaires, and responded to a post-satisfaction questionnaire. Students paired t-test and analysis of variance were used to detect significant changes within each intervention strategy and compare the two counseling methods. Both intervention methods yielded a significant (P .05) differences between group and individual counseling for any of the effectiveness measures. The program benefits and potential savings outweighed the program costs in both interventions; however, group counseling was determined to be more cost-effective. Results of this study indicate that: 1) group education is just as effective as individual counseling in reducing serum cholesterol, improving knowledge, and changing behavior and 2) a multidisciplinary team can provide effective and cost-effective nutrition and lifestyle counseling that can reduce coronary heart disease risk and promote client satisfaction.

Dietary Iron: Adolescent Athletes’ Knowledge, Attitudes, and Dietary Intake

Abstract Iron-deficiency anemia can affect the athletic and academic performance of adolescent athletes. To determine contributors to iron-deficiency among adolescent athletes, the relationships between knowledge and attitudes and intake of dietary iron were evaluated. Non-athletes served as a comparison. A total of 210 adolescent subjects from six high schools provided data for at least one of the analyses by completing food frequency questionnaires and surveys regarding their activity levels and knowledge and attitudes about dietary iron. Information, including hemoglobin screening results, was collected at American Red Cross blood drives. Athletes and non-athletes were not significantly different in knowledge or attitudes about dietary iron or in dietary iron intake. Thirty-four percent of the students had dietary iron intakes below two-thirds of the RDA. Nearly six percent of students did not pass the hemoglobin screening. Knowledge and attitudes regarding dietary iron were not significantly related to dietary iron intake or hemoglobin status. Fifty-three percent of those who had heard about dietary iron before cited the classroom as the source of the information they received. Results of this study suggest that strategies to increase dietary iron intake among adolescents should occur in the classroom and focus on reducing potential barriers to healthy eating including a lack of time, self-discipline, and sense of urgency for good nutrition, as well as unavailability of nutritious foods at schools and at home.

Relationship Between Diabetes Knowledge, Glycemic Control, and Associated Health Conditions

Objective. The purpose of this study was to identify any existing relationship between diabetes knowledge and glycemic control, as well as possible associations with patient health, among patients with type 2 diabetes. Design and Methods. This qualitative study used a validated multiple-choice test (the Michigan Diabetes Knowledge Test) to assess diabetes knowledge among 17 hospital patients between the ages of 18 and 75 years with type 2 diabetes and a recent (within 3 months) A1C laboratory value. Participants also provided information about their diabetes self-care habits, previous diabetes education, and diabetes-related secondary health conditions. Results. The average diabetes knowledge score was 8.4 of 14 (60%), and the average A1C was 9.3%. Thirteen participants had previously received diabetes education, whereas four participants had never received diabetes education. The participants who had not received education scored 15.3% lower on the diabetes knowledge test and had an average A1C 0.89% higher than those who had received previous education. Although this difference was not statistically significant, it is clinically relevant. There was a significant association between diabetes knowledge and presence of retinopathy (P = 0.03). Conclusion. Diabetes self-management education and support is a crucial component of diabetes care. There is a considerable need for diabetes education strategies to improve self-management of diabetes and thereby improve outcomes and decrease the costs of diabetes-related care. There is also a need for efforts to ensure regular vision screenings for individuals with type 2 diabetes.

Do Schools in North Carolina have Policies that Promote Nutrition for School Age Children

Abstract The purpose of this study was to determine the extent school districts in North Carolina have policies that promote nutrition for school age children and the degree to which these policies were consistent with the Center for Disease Controls (CDC) GuidelinesforSchoolHealthProgramstoPromoteLifelongHealthyEating . School food service directors of each public school district in North Carolina (N=117) were surveyed by questionnaire at the annual state conference. Those who were unable to attend were surveyed by mail and a total useable response of n=106(92%). Only 24.5% of the school districts had a coordinated nutrition policy and none of these were consistent with all of the CDC guidelines. Those having comprehensive nutrition policies were more likely to have individual policies for fund raising (p

Putting Interns in Contact with the Community: The Family Surveillance Project

Abstract The changing health care environment challenges educators to expand learning opportunities into the community and to place primary focus on prevention and rehabilitation. A community project, which has proven to be very valuable, is the family surveillance project. The purpose of this project is to get students involved with typical public health clients and familiar with the agencies/programs. Working with community affiliates, families are identified, screened, and assigned to students for a semester. During the students first home visit, they complete a demographic questionnaire, a household description, a domicile description, a health habits questionnaire, a pantry survey and a listing of current program(s) participation. Subsequent visits are made to become more familiar with the family, refine evaluations of the familys needs, provide nutrition education, and monitor changes that may affect needs. Students keep a log of their visits and turn this in at the end of the semester as part of a report describing their assessments, the results of their assistance, and recommendations for future programs. In addition, the students present an oral report for class discussion. The nutrition care process model is used as the basis for the oral reports and targets the development of the students clinical reasoning skills. Students’ understanding of the programs available to clients has vastly improved. Rather than merely repeating definitions and acronyms, students can now discuss the strengths and shortcomings of the programs, assess unmet client needs, and make recommendations for new programs or changes to existing ones. Exit evaluations with students after completion of the internship have been 100% in favor of continuing the project. It has proven to be a real “eye opener” for them and given them a new respect for their clients.

Status of Hospital Foodservice Training Programs and Turnover Rates

Abstract Hospital foodservice departments have experienced higher than desirable turnover rates for at least twenty years. This study was designed to determine if the turnover rates were related to, or effected by, status of training programs. A randomized sample of 400 hospitals was chosen from a national listing to be surveyed for this information. The 28-item double pilot-tested survey was addressed to foodservice directors for completion and return. The survey asked questions regarding: presence of a training program, budget for training, qualifications of trainer/educators, components of the training programs, department demographics and turnover rates. By studying possible reasons for higher turnover rates and possible relationships to certain variables, foodservice administrators can propose departmental programs that may actually reduce future operating costs by reducing the high cost of turnover. Our results indicated no significant difference between groups in which training was provided, number of hours spent training, inclusion of performance appraisals, or budget for training. However, a significant difference in turnover was seen between groups of departments that had been under the same structure for 18 years or greater. Those departments whose management structure had remained unchanged for more than 18 years, had higher turnover rates.

Registered Dietitians' Use of Multiple Skills

Abstract LEARNING OUTCOME: To determine the need for multiple skills as perceived by members of the American Dietetic Association. One thousand registered dietitians were randomly selected from the American Dietetic Associations membership. Two hundred thirty six (23.6%) completed the 12 page survey. Data provided by the participants were evaluated to determine: 1.) the need for multiple skills, 2.) the impotence and ranking of practice area tasks identified by the Future Search Conference as well as additional possible tasks, 3.) the importance of certification for each task, and 4.) the grouping of skills assessed to be important for securing future dietetic jobs. The skill groups examined were research, education, managing material resources, managing financial resources, managing facilities, marketing services and products, managing human resources, providing programs to the population and providing care to individuals. Using descriptive statistics, registered dietitians overwhelmingly (97.6%) perceived the need for multiple skills. For every Future Search Conference practice area, respondents identified additional tasks and skills needed. Within each practice area an average of 87.0% of the respondents felt there was a need for certification(s). The skill groups were analyzed according to what the respondents felt they would not do, what they are currently doing, and what they logically could do. Results of this study indicate that the skills currently used and those that could logically be used (in rank order) were as follows: education (75.%), research (72,4%), managing human resources (70.7%), marketing services and products (68.6%), provide care to individuals (67.6%), and manage financial resources (53.5%).