1. Determinants and Consequences of Adherence to the Dietary Approaches to Stop Hypertension in African- American 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

2. 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

3. Purpose Determine characteristics that suggest better adherence to DASH diet Determine the association between the level of adherence and reduction in blood pressure

4. ENCORE 16 week randomized clinical trial 144 participants ▫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

5. ENCORE Assessments Clinic BP Ambulatory BP Cardiopulmonary function Retrospective food frequency 4 day food diary

7. 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

8. DASH Adherence Score CategoryServings /day Score Grains>71 5-60.5 <50 Vegetables>41 2-30.5 <20 Fruits>41 2-30.5 <20 Dairy>21 10.5 Meat, poultry, fish<21 30.5 >40 Nuts, seeds, and dry beans >41 2 to 30.5 <20 CategoryServing s/day Score % kcal from fat<271 28 -290.5 >300 % kcal from saturated fat <61 7-80.5 >90 Sweets<51 6-70.5 >80 Sodium (mg)<24001 2400- 3000 0.5 >30000

9. 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

10. 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

11. 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)

15. 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

16. 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

17. Application to Practice Consideration to cultural influences, food preparations, perceptions Modification to “soul foods” Community participation

18. Questions?

19. 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.

20. 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.