A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial

Do Personalized Nutrition Interventions Improve Dietary Intake and Risk Factors in Adults With Elevated Cardiovascular Disease Risk Factors? A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Dietary modifications can improve cardiovascular disease (CVD) risk factors. Personalized nutrition (PN) refers to individualized nutrition care based on genetic, phenotypic, medical, behavioral, and/or lifestyle characteristics. PN may be beneficial in improving CVD risk factors, including diet. However, this has not been reviewed previously.

OBJECTIVE

The aim was to evaluate the effectiveness of PN interventions on CVD risk factors and diet in adults at elevated CVD risk.

DATA SOURCES

Six databases were searched for randomized controlled trials published between 2000 and 2023 that tested the impact of PN interventions on CVD risk factors in people at elevated risk.

DATA EXTRACTION

Risk of bias was assessed using the Academy of Nutrition and Dietetics Quality Criteria checklist. Data synthesis of eligible articles included participant characteristics, intervention details, and change in primary CVD risk factor outcomes, including blood pressure (BP), plasma lipids, and CVD risk score, and secondary risk factors, including anthropometric outcomes and diet quality. Random-effects meta-analyses were conducted to explore weighted mean differences (WMDs) in change or final mean values for studies with comparable data (studies with dietary counseling interventions) for outcomes including BP, blood lipids, and anthropometric measurements.

DATA ANALYSIS

Of 7676 identified articles, 16 articles representing 15 studies met the inclusion criteria. Studies included between 40 and 563 participants and reported outcomes for CVD risk factors, including hyperlipidemia (n = 5), elevated BP (n = 3), overweight/obesity (n = 1), and multiple risk factors (n = 6). Risk of bias was low. Results suggested potential benefit of PN on systolic BP (WMD: -1.91; 95% CI: -3.51, -0.31 mmHg) and diastolic BP (WMD: -1.49; 95% CI: -2.39, -0.58 mmHg) and dietary intake in individuals at high CVD risk. Results were inconsistent for plasma lipid and anthropometric outcomes.

CONCLUSION

Results were promising for PN interventions that used dietary counseling on CVD risk factors in at-risk individuals. However, further evidence for other personalization methods is required, including improving methodological quality and longer study duration in future PN interventions.

SYSTEMATIC REVIEW REGISTRATION

OpenScience Framework (https://doi.org/10.17605/OSF.IO/SHVWP).

Potassium - a scoping review for Nordic Nutrition Recommendations 2023

Potassium (K) is an essential mineral that is necessary for normal cell and membrane function and for maintaining both fluid balance and acid-base balance. Potassium is furthermore very important for normal excitation, for example in nerves and muscle. It is widely available in several food products, with the most important dietary sources being potatoes, fruits, vegetables, cereal and cereal products, milk and dairy products, and meat and meat products. Potassium deficiency and toxicity is rare in healthy people, but dietary potassium is associated with other health outcomes. Results from observational studies have shown that a potassium intake above 3500 mg/day (90 mmol/day) is associated with a reduced risk of stroke. Similarly, intervention studies provide evidence that this level of potassium intake has a beneficial effect on blood pressure, particularly among persons with hypertension and in persons with a high sodium intake (>4 g/day, equivalent to >10 g salt/day).

Association of Plant-Based Protein Intake with Cognitive Function in Adults with CKD

Key Points

Higher plant protein intake was associated with higher cognitive scores in people with kidney disease. Future trials are needed to determine whether increasing plant protein intake improves measures of cognition in patients with kidney disease.

Background

Patients with CKD have accelerated cardiovascular and cognitive aging when compared with the non-CKD population. This cognitive decline contributes to excessive rates of physical and functional decline, reduced quality of life, and mortality in the CKD population. Mediterranean diets, a plant-forward diet, have been associated with positive cognitive performance in the general non-CKD population and with some beneficial outcomes in CKD. However, it is still unclear whether plant-based diets are associated with cognitive decline in patients with CKD.

Methods

Using the National Health and Nutrition Examination Survey 2011–2012 and 2013–14 data, we conducted a secondary analysis evaluating the relationship of plant-based and unprocessed plant protein with cognitive outcome measures in eligible participants aged 60 years and older. All data were extracted from the available National Health and Nutrition Examination Survey demographic, questionnaire, examination, and laboratory data. CKD was calculated and defined in participants as urine albumin to creatinine ratio ≥30 mg/g and/or eGFR <60 ml/min. In incremental models, we adjusted for total energy intake, age, sex, race/ethnicity, body mass index, total energy intake, diabetes, hypertension, education, smoking, and alcohol.

Results

Higher plant-based protein above median dietary intakes was significantly associated with higher executive function scores in participants with CKD (P < 0.05). For all patients and in those with CKD, plant-based protein was significantly associated (P < 0.05) with higher composite cognitive scores in nearly all statistical models. Higher unprocessed plant protein was significantly associated (P < 0.05) with higher composite cognitive scores in all categorical models.

Conclusions

Higher plant protein intake was a significant predictor of certain individual and composite cognitive score measures within the general and in the CKD population. Future interventional trials are needed to determine whether increasing plant-based protein intake improves measures of cognition in patients with CKD.

Effects of the DASH diet and losartan on serum urate among adults with hypertension: Results of a randomized trial

Serum urate is a risk factor for hypertension and gout. The DASH diet and losartan independently lower blood pressure (BP); however, their effects on serum urate are understudied. We performed a post-hoc analysis of the DASH-losartan trial, which randomized participants with hypertension in parallel fashion to the DASH diet or a standard American diet (control) and in crossover fashion to 4-week losartan or placebo. Serum urate was measured at baseline and after each 4-week period. Diets were designed to maintain weight constant. We examined the effects of DASH (vs control) and/or losartan (vs placebo) on serum urate, overall and among those with baseline serum urate ≥6 mg/dL, using generalized estimating equations. Of 55 participants (mean age 52 years, 58% women, 64% Black), mean (±SD) baseline ambulatory SBP/DBP was 146±12/91±9 and mean (±SD) serum urate was 5.2±1.2 mg/dL. The DASH diet did not significantly reduce urate levels overall (mean difference -0.05 mg/dL; 95%CI: -0.39, 0.28), but did decrease levels among participants with baseline hyperuricemia (-0.33 mg/dL; 95%CI: -0.87, 0.21; P-interaction=0.007 across hyperuricemia groups). Losartan significantly decreased serum urate (-0.23 mg/dL; 95%CI: -0.40, -0.05) with greater effects on serum urate among adults <60 years old versus adults ≥60 years old (-0.33 mg/dL vs 0.16 mg/dL, P interaction = 0.003). In summary, the DASH diet significantly decreased serum urate among participants with higher urate at baseline, while losartan significantly reduced serum urate, especially among younger adults. Future research should examine the effects of these interventions in patients with hyperuricemia or gout.

Native opportunities to stop hypertension: study protocol for a randomized controlled trial among urban American Indian and Alaska Native adults with hypertension

Introduction

American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics.

Methods

NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake.

Discussion

NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults.

Clinical trials registration

https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.

Evaluation of a Produce Prescription Program for Patients With Diabetes: A Longitudinal Analysis of Glycemic Control

OBJECTIVE

Produce prescriptions have shown promise in improving diabetes care, although most studies have used small samples or lacked controls. Our objective was to evaluate the impacts of a produce prescription program on glycemic control for patients with diabetes.

RESEARCH DESIGN AND METHODS

Participants included a nonrandom enrollment of 252 patients with diabetes who received a produce prescription and 534 similar control participants from two clinics in Hartford, Connecticut. The start of the COVID-19 pandemic in March 2020 coincided with program implementation. Produce prescription enrollees received vouchers ($60 per month) for 6 months to purchase produce at grocery retail. Controls received usual care. The primary outcome was change in glycated hemoglobin (HbA1c) between treatment and control at 6 months. Secondary outcomes included 6-month changes in systolic (SBP) and diastolic blood pressure (DBP), BMI, hospitalizations, and emergency department admissions. Longitudinal generalized estimating equation models, weighted with propensity score overlap weights, assessed changes in outcomes over time.

RESULTS

At 6 months, there was no significant difference in change in HbA1c between treatment and control groups, with a difference of 0.13 percentage points (95% CI -0.05, 0.32). No significant difference was observed for change in SBP (3.85 mmHg; -0.12, 7.82), DBP (-0.82 mmHg; -2.42, 0.79), or BMI (-0.22 kg/m2; -1.83, 1.38). Incidence rate ratios for hospitalizations and emergency department visits were 0.54 (0.14, 1.95) and 0.53 (0.06, 4.72), respectively.

CONCLUSIONS

A 6-month produce prescription program for patients with diabetes, implemented during the onset of the COVID-19 pandemic, was not associated with improved glycemic control.

Association Between County-Level Food Retail and Socioeconomic Environment and Nutritional Quality of Household Food Purchases, 2015

BACKGROUND

About 40 million Americans do not have easy access to affordable nutritious foods. Healthier foods are less likely to be available to those living in rural and/or lower-income communities.

OBJECTIVE

The objective of this study was to analyze the association between nutritional quality of household food purchases and county-level food retail environment; county-level demographic, health, and socioeconomic indicators; and household composition, demographic characteristics, and socioeconomic characteristics.

DESIGN

This study is a secondary analysis of the 2015 Information Resources Inc Consumer Network panel; Purchase-to-Plate Crosswalk, which links US Department of Agriculture nutrition databases to Information Resources Inc scanner data; County Health Rankings; and the Food Environment Atlas data.

PARTICIPANTS AND SETTINGS

A total of 63,285 households, representative of the contiguous US population, consistently provided food purchase scanner data from retail stores throughout 2015.

MAIN OUTCOME MEASURES

Nutritional quality of retail food purchases was assessed using the Healthy Eating Index 2015 (HEI-2015).

STATISTICAL ANALYSIS

Multivariate linear regression analysis was used to simultaneously test the relationship between the main outcome and household-level demographic and socioeconomic characteristics as well as the county-level demographic, health, socioeconomic, and retail food environment.

RESULTS

Household heads who had higher education and households with higher incomes purchased food of better nutritional quality (ie, higher HEI-2015 scores). Also, the association between retail food purchase HEI-2015 scores and the food environment was weak. Higher density of convenience stores was associated with lower retail food purchase nutritional quality for higher-income households and households living in urban counties, whereas low-income households in counties with higher specialty (including ethnic) store density purchased higher nutritional quality food. Both in the full sample and when stratified by household income or county rural vs urban status, no association was found between grocery store, supercenters, fast-food outlets, and full-service restaurant densities and retail food purchase HEI-2015 scores. HEI-2015 scores were negatively correlated with the county average number of mental health days for higher income and urban households.

CONCLUSIONS

The study findings suggest that availability of healthier food alone may not improve healthfulness of retail food purchases. Future studies examining the influence of demand-side factors/interventions, such as habits, cultural preferences, nutrition education, and cost/affordability, on household purchasing patterns could provide complementary evidence to inform effective intervention strategies.

Libraries advancing health equity:a literature review

Purpose

Progress toward health equity is necessary to reduce health disparities, and health literacy is key to achieving this goal. Because libraries provide access to knowledge and insights about their communities, they are effective partners in advancing health equity and implementing programs to reduce health disparities. A literature review on library programs and activities that focus on promoting health equity was conducted.

Design/methodology/approach

A literature review on library programs and activities concerning health equity and social determinants of health was conducted. Relevant literature was identified from searches of databases, library publications and grey literature.

Findings

The authors found 224 eligible sources and many types of libraries advancing health equity. Libraries frame their role in advancing health equity through external programs in three ways: (1) providing access to high-quality health information, (2) delivering health literacy training and resources and (3) connecting their communities with community health services. Libraries also advance health equity by focusing on internal library operations and providing research services focused on cultural humility and competence as they apply to health care.

Originality/value

This literature review will help the National Library of Medicine (NLM) develop a strategy to support libraries advancing health equity through information made available by programs and activities of NLM and the Network of the National Library of Medicine.

Accelerating integration of social needs into mainstream healthcare to achieve health equity in the COVID-19 era

It is known that social inequities result in health disparities in outcomes, highlighted in the coronavirus disease 2019 (COVID-19) pandemic. This commentary discusses the actionable initiatives that have been implemented to address social inequities in healthcare in the United States. The publicly available social needs screening tools and International Classification of Disease Systems-10 Z codes for social determinants of health are introduced. In this context, policies, health system strategies and the larger role of implementation science in recognizing and alleviating the social needs are discussed.

A Systematic Review of Literature on the Representation of Racial and Ethnic Minority Groups in Clinical Nutrition Interventions

The racial and ethnic disparities in diet-related chronic diseases are major concerns. This systematic review examines the extent to which diet-induced changes in health outcomes, such as cardiometabolic, inflammation, cancer, bone health, and kidney function outcomes, etc., have been reported and discussed by race or ethnicity in randomized trials with 2 or more diet arms that recruited both minority and non-Hispanic White groups. Databases (i.e., PubMed, Cochrane Library, and Web of Science) were searched up to August 2021. Thirty-four studies that discussed effects of defined dietary interventions on health outcomes by racial or ethnic minority group compared with non-Hispanic Whites were included in the systematic review (PROSPERO registration number: CRD42021229256). Acute trials and those with 1 diet arm that accounted for race or ethnicity in their analyses and studies that focused on a single racial or ethnic group were discussed separately. Most studies were conducted in Black compared with White adults testing effects of energy restriction, macronutrient modification, sodium reduction, or variations of the Dietary Approaches to Stop Hypertension (DASH) diet on cardiometabolic outcomes. There was limited focus on other minority groups. Evidence suggests greater blood pressure reduction for Black adults compared with Whites particularly with DASH (or similar) diets. Overall, there was limited consideration for group-specific eating patterns and diet acceptability. Overall risk of bias was low. With emerging precision nutrition initiatives that aim to optimize metabolic responses in population subgroups through tailored approaches, it is imperative to ensure adequate representation of racial and ethnic subgroups for addressing health disparities. Factors that help explain variability in responses such as socioecological context should be included and adequately powered. Given the racial and ethnic disparities in chronic diseases, studying the adoption, maintenance, and effectiveness of dietary interventions on health outcomes among different groups is critical for developing approaches that can mitigate diet-related health disparities.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Development and Implementation of a Combined Nurse Care Manager and Community Health Worker Training Curriculum to Address Hypertension Disparities

The use of nurse care managers (CMs) and community health workers (CHWs) has demonstrated effectiveness in supporting improved blood pressure management among racially, ethnically, and socioeconomically minoritized populations. We partnered with a community advisory board (CAB) to develop a CM and CHW training curriculum and team-based collaborative care intervention to address uncontrolled hypertension. The objective of this study was to train CMs and CHWs to implement patient-centered techniques and address social determinants of health related to hypertension control. In partnership with a CAB, we developed and implemented a training curriculum for the CM/CHW collaborative care team. The training improved CM and CHW confidence in their ability to address medical and nonmedical issues that contribute to uncontrolled hypertension in their patients; however, preexisting norms and beliefs among CMs and CHWs created challenges with teamwork. The training curriculum was feasible and well-received. Additionally, the CMs' and CHWs' reactions provided insights to improve future collaborative care training and teamwork.

Advancing Equity in Blood Pressure Control: A Response to the Surgeon General's Call-to-Action

Hypertension is an established risk factor for cardiovascular disease. Although controlling blood pressure reduces cardiovascular and stroke mortality and target organ damage, poor blood pressure control remains a clinical and public health challenge. Furthermore, racial and ethnic disparities in the outcomes of hypertension are well documented. In October of 2020, the U.S. Department of Health and Human Services published The Surgeon General's Call to Action to Control Hypertension. The Call to Action emphasized, among other priorities, the need to eliminate disparities in the treatment and control of high blood pressure and to address social determinants as root causes of inequities in blood pressure control and treatment. In support of the goals set in the Call to Action, this review summarizes contemporary research on racial, ethnic, and socioeconomic disparities in hypertension and blood pressure control; describes interventions and policies that have improved blood pressure control in minoritized populations by addressing the social determinants of health; and proposes next steps for achieving equity in hypertension and blood pressure control.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Short-Term RCT of Increased Dietary Potassium from Potato or Potassium Gluconate: Effect on Blood Pressure, Microcirculation, and Potassium and Sodium Retention in Pre-Hypertensive-to-Hypertensive Adults

Increased potassium intake has been linked to improvements in cardiovascular and other health outcomes. We assessed increasing potassium intake through food or supplements as part of a controlled diet on blood pressure (BP), microcirculation (endothelial function), and potassium and sodium retention in thirty pre-hypertensive-to-hypertensive men and women. Participants were randomly assigned to a sequence of four 17 day dietary potassium treatments: a basal diet (control) of 60 mmol/d and three phases of 85 mmol/d added as potatoes, French fries, or a potassium gluconate supplement. Blood pressure was measured by manual auscultation, cutaneous microvascular and endothelial function by thermal hyperemia, utilizing laser Doppler flowmetry, and mineral retention by metabolic balance. There were no significant differences among treatments for end-of-treatment BP, change in BP over time, or endothelial function using a mixed-model ANOVA. However, there was a greater change in systolic blood pressure (SBP) over time by feeding baked/boiled potatoes compared with control (-6.0 mmHg vs. -2.6 mmHg; p = 0.011) using contrast analysis. Potassium retention was highest with supplements. Individuals with a higher cardiometabolic risk may benefit by increasing potassium intake. This trial was registered at ClinicalTrials.gov as NCT02697708.

A Randomized Pilot Study of DASH Patterned Groceries on Serum Urate in Individuals with Gout

The Dietary Approaches to Stop Hypertension (DASH) diet reduces serum urate (SU); however, the impact of the DASH diet has not been previously evaluated among patients with gout. We conducted a randomized, controlled, crossover pilot study to test the effects of ~$105/week ($15/day) of dietitian-directed groceries (DDG), patterned after the DASH diet, on SU, compared with self-directed grocery shopping (SDG). Participants had gout and were not taking urate lowering therapy. Each intervention period lasted 4 weeks; crossover occurred without a washout period. The primary endpoint was SU. Compliance was assessed by end-of-period fasting spot urine potassium and sodium measurements and self-reported consumption of daily servings of fruit and vegetables. We randomized 43 participants (19% women, 49% black, mean age 59 years) with 100% follow-up. Mean baseline SU was 8.1 mg/dL (SD, 0.8). During Period 1, DDG lowered SU by 0.55 mg/dL (95% CI: 0.07, 1.04) compared to SDG by 0.0 mg/dL (95% CI: −0.44, 0.44). However, after crossover (Period 2), the SU difference between groups was the opposite: SDG reduced SU by −0.48 mg/dL (95% CI: −0.98, 0.01) compared to DDG by −0.05 mg/dL (95% CI: −0.48, 0.38; P for interaction by period = 0.11). Nevertheless, DDG improved self-reported intake of fruit and vegetables (3.1 servings/day; 95% CI: 1.5, 4.8) and significantly reduced total spot urine sodium excretion by 22 percentage points (95% CI: −34.0, −8.6). Though relatively small in scale, this pilot study suggests that dietitian-directed, DASH-patterned groceries may lower SU among gout patients not on urate-lowering drugs. However, behavior intervention crossover trials without a washout period are likely vulnerable to strong carryover effects. Definitive evaluation of the DASH diet as a treatment for gout will require a controlled feeding trial, ideally with a parallel-design.

Effectiveness of Lifestyle and Drug Intervention on Hypertensive Patients: a Randomized Community Intervention Trial in Rural China

BACKGROUND

Strict medication guidance and lifestyle interventions to manage blood pressure (BP) in hypertensive patients are typically difficult to follow.

OBJECTIVE

To evaluate the 1-year effectiveness of lifestyle and drug intervention in the management of rural hypertensive patients.

DESIGN

Randomized community intervention trial.

PARTICIPANTS

The control group comprised 967 patients who received standard antihypertensive drug intervention therapy from two communities, whereas the intervention group comprised 1945 patients who received antihypertensive drug and lifestyle intervention therapies from four communities in rural China.

MAIN MEASURES

Data on lifestyle behaviors and BP measurements at baseline and 1-year follow-up were collected. A difference-in-difference logistic regression model was used to assess the effect of the intervention.

KEY RESULTS

BP control after the 1-year intervention was better than that at baseline in both groups. The within-group change in BP control of 59.3% in the intervention group was much higher than the 25.2% change in the control group (P < 0.001). Along with the duration of the follow-up period, systolic and diastolic BP decreased rapidly in the early stages and then gradually after 6 months in the intervention group (P < 0.001). In the intervention group, drug therapy adherence was increased by 39.5% (from 48.1% at 1 month to 87.6% at 1 year) (P < 0.001), more in women (45.6%) than in men (31.2%; P < 0.001). The net effect of the lifestyle intervention improved the rate of BP control by 56.1% (70.8% for men and 44.7% for women). For all physiological and biochemical factors, such as body mass index, waist circumference, lipid metabolism, and glucose control, improvements were more significant in the behavioral intervention group than those in the control group (all P < 0.001).

CONCLUSION

The addition of lifestyle intervention by physicians or nurses helps control BP effectively and lowers BP better than usual care with antihypertensive drug therapy alone.

Retail Nutrition Programs and Outcomes: An Evidence Analysis Center Scoping Review

As nutrition-related diseases contribute to rising health care costs, food retail settings are providing a unique opportunity for registered dietitian nutritionists (RDNs) to address the nutritional needs of consumers. Food as Medicine interventions play a role in preventing and/or managing many chronic conditions that drive health care costs. The objective of this scoping review was to identify and characterize literature examining Food as Medicine interventions within food retail settings and across consumer demographics. An electronic literature search of 8 databases identified 11,404 relevant articles. Results from the searches were screened against inclusion criteria, and intervention effectiveness was assessed for the following outcomes: improvement in health outcomes and cost-effectiveness. One-hundred and eighty-six papers and 25 systematic reviews met inclusion criteria. Five categories surfaced as single interventions: prescription programs, incentive programs, medically tailored nutrition, path-to-purchase marketing, and personalized nutrition education. Multiple combinations of intervention categories, reporting of health outcomes (nutritional quality of shopping purchases, eating habits, biometric measures), and cost-effectiveness (store sales, health care dollar savings) also emerged. The intervention categories that produced both improved health outcomes and cost-effectiveness included a combination of incentive programs, personalized nutrition education, and path-to-purchase marketing. Food as Medicine interventions in the food retail setting can aid consumers in navigating health through diet and nutrition by encompassing the following strategic focus areas: promotion of health and well-being, managing chronic disease, and improving food security. Food retailers should consider the target population and desired focus areas and should engage registered dietitian nutritionists when developing Food as Medicine interventions.

Community-engaged and community-based participatory research to promote American Heart Association Life's Simple 7 among African American adults: A systematic review

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States and African Americans (AA) have a disproportionately greater burden of CVD as compared to Whites. The American Heart Association (AHA) Life's Simple 7 (LS7) framework outlines goals for attaining ideal cardiovascular health. Yet, there is a lack of evidence summarizing best practices to maximize LS7 attainment. The objective of the present study was to systematically review the extant peer-reviewed literature on community-engaged and community-based participatory research (CBPR) aimed at improving one or more LS7 metrics among AA.

METHODS

PubMed, CINAHL, and Embase databases were searched. We included articles that reported quantitative results for one or more of the following LS7 metrics: physical activity, diet, cholesterol, blood pressure, body mass index, smoking, and glycemia. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age).

RESULTS

Of the 1008 unique studies identified, 54 met inclusion criteria; 27 of which were randomized controlled trials. 50% of studies assessed more than one LS7 metric but only two studies evaluated all seven of the LS7 metrics. No studies had a high proportion of AA males. 40 studies improved at least one LS7 metric at the study end-point. Formative research was used in many studies to guide intervention design. Studies were of varying quality, but overall rated "fair" using a modified approach to the National Institute of Health quality assessment tool.

CONCLUSION

There is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of LS7 metrics among AA. Future studies using rigorous methodology with increased gender diversity and utilizing the AHA LS7 framework are required to establish a validated program to improve LS7 in AAs.

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Barriers, Opportunities, and Challenges in Addressing Disparities in Diet-Related Cardiovascular Disease in the United States

In the United States, cardiovascular disease (CVD) is the leading cause of death and disability. Suboptimal diet quality is responsible for a greater percentage of CVD-related morbidity and mortality than any other modifiable risk factor. Further troubling are the stark racial/ethnic and socioeconomic disparities in diet quality. This represents a major public health concern that urgently requires a coordinated effort to better characterize the barriers to healthy dietary practices in population groups disproportionally affected by CVD and poor diet quality to inform multifaceted approaches at the government (policy), community environment, sociocultural, and individual levels. This paper reviews the barriers, opportunities, and challenges involved in shifting population behaviors, especially in underserved populations, toward healthy dietary practices. It is imperative that public health policies address the social determinants of nutrition more intensively than previously in order to significantly decrease CVD on a population-wide basis.

Ethnicity and Metabolic Syndrome: Implications for Assessment, Management and Prevention

The metabolic syndrome (MetS) is a constellation of cardiometabolic risk factors that identifies people at increased risk for type 2 diabetes and cardiovascular disease. While the global prevalence is 20%–25% of the adult population, the prevalence varies across different racial/ethnic populations. In this narrative review, evidence is reviewed regarding the assessment, management and prevention of MetS among people of different racial/ethnic groups. The most popular definition of MetS considers race/ethnicity for assessing waist circumference given differences in visceral adipose tissue and cardiometabolic risk. However, defining race/ethnicity may pose challenges in the clinical setting. Despite 80% of the world’s population being of non-European descent, the majority of research on management and prevention has focused on European-derived populations. In these studies, lifestyle management has proven an effective therapy for reversal of MetS, and randomised studies are underway in specific racial/ethnic groups. Given the large number of people at risk for MetS, prevention efforts need to focus at community and population levels. Community-based interventions have begun to show promise, and efforts to improve lifestyle behaviours through alterations in the built environment may be another avenue. However, careful consideration needs to be given to take into account the unique cultural context of the target race/ethnic group.

Phylogeography of the Bradyrhizobium spp. Associated With Peanut, Arachis hypogaea: Fellow Travelers or New Associations?

Legume plants have colonized almost all terrestrial biotopes. Their ecological success is partly due to the selective advantage provided by their symbiotic association with nitrogen-fixing bacteria called rhizobia, which allow legumes to thrive on marginal lands and nitrogen depleted soils where non-symbiotic plants cannot grow. Additionally, their symbiotic capacities result in a high protein content in their aerial parts and seeds. This interesting nutritional value has led to the domestication and agricultural exploitation of several legumes grown for seeds and/or fodder for human and domestic animal consumption. Several cultivated legume species are thus grown far beyond their natural geographic range. Other legume species have become invasives, spreading into new habitats. The cultivation and establishment of legume species outside of their original range requires either that they are introduced or cultivated along with their original symbiotic partner or that they find an efficient symbiotic partner in their introduced habitat. The peanut, Arachis hypogaea, a native of South America, is now cultivated throughout the world. This species forms root nodules with Bradyrhizobium, but it is unclear whether these came with the seeds from their native range or were acquired locally. Here we propose to investigate the phylogeography of Bradyrhizobium spp. associated with a number of different wild and cultivated legume species from a range of geographical areas, including numerous strains isolated from peanut roots across the areas of peanut cultivation. This will allow us to address the question of whether introduced/cultivated peanuts associate with bacteria from their original geographic range, i.e., were introduced together with their original bacterial symbionts, or whether they acquired their current associations de novo from the bacterial community within the area of introduction. We will base the phylogenetic analysis on sequence data from both housekeeping and core genes and a symbiotic gene (nif). Differences between the phylogenetic signal of symbiotic and non-symbiotic genes could result from horizontal transfer of symbiosis capacity. Thus this study will also allow us to elucidate the processes by which this symbiotic association has evolved within this group of Bradyrhizobium spp.

Household Cooking Frequency of Dinner Among Non-Hispanic Black Adults is Associated with Income and Employment, Perceived Diet Quality and Varied Objective Diet Quality, HEI (Healthy Eating Index): NHANES Analysis 2007-2010

Home cooking is associated with improved diet quality. Non-Hispanic Blacks, a population with diet-quality related health disparities, report lower home cooking than other racial/ethnic groups. Factors and subsequent dietary outcomes associated with this cooking disparity are relatively unknown. A secondary analysis was performed using demographic and consumer behavior data from the 2007-2010 cycles of the National Health and Nutrition Examination Survey (NHANES) to identify factors associated with household cooking frequency of dinner among Non-Hispanic Blacks. Self-reported dietary data were used to calculate Healthy Eating Index-2010 (HEI-2010) to determine cooking related objective diet quality. Lower income, unemployment, and higher perceived diet quality were significantly associated with higher cooking frequency (p < 0.05). For diet quality, higher vegetable (p = 0.031), lower empty calorie intake (p = 0.002), higher dinner time protein (p = 0.004) and lower dinner time dairy intake (p = 0.003) were associated with cooking. Total HEI scores were associated with higher cooking frequency for middle income (p = 0.007), but not higher or lower income categories (p = 0.306; p = 0.384), respectively. On average, factors associated with cooking frequency were psychosocial, income, and employment related. Objective diet quality as measured by HEI was variable. Future dietary studies among Non-Hispanic Blacks should include cooking, socioeconomic status and perceived diet quality as particularly relevant factors of interest.

Achieving Health Equity in Hypertension Management Through Addressing the Social Determinants of Health

PURPOSE OF REVIEW

The goals of this paper were to examine recent literature on the social determinants of health as they relate to hypertension and cardiovascular disease, and discuss relevance to the practice of emergency medicine.

RECENT FINDINGS

Social determinants of health, defined by the World Health Organization as "the conditions in which people are born, grow, live, work, and age" ( https://www.who.int/social_determinants/thecommission/en/ ) play a complex role in the development of hypertension and cardiovascular disease and the persistence of racial disparities in related health outcomes. Deciphering the independent association between minority status and social determinants in the United States is challenging. As a result, much of the recent interventional work has targeted populations by race or ethnicity in order to address these disparities. There is opportunity to expand the work on social determinants of health and hypertension. This includes exploring innovative approaches to identifying at-need individuals and breaking down traditional siloes to develop multidimensional interventions. New funding and payment mechanisms will allow for providers and health systems to identify and target modifiable social determinants of health at the level of the individual patient to improve outcomes.

Sociodemographic and Kidney Disease Correlates of Nutrient Intakes Among Urban African Americans With Uncontrolled Hypertension

OBJECTIVE

The objective of this study was to determine the association between sociodemographic factors and intakes of 4 nutrients and associations between intakes and markers of kidney disease to identify opportunities to improve outcomes among clinically high-risk African Americans.

DESIGN AND METHODS

We conducted a cross-sectional study of baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension in Baltimore MD. To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio >=30 mg/g.

SETTING AND SUBJECTS

Baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension, were obtained.

METHODS

To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease.

MAIN OUTCOME MEASURES

Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m² or urinary albumin-to-creatinine ratio ≥30 mg/g.

RESULTS

Overall, compared to Institute of Medicine recommendations, participants had lower intakes of magnesium, fiber, and potassium but higher vitamin C intakes. For females, sociodemographic factors that significantly associated with lower intake of the 4 nutrients were older age, obesity, lower health numeracy, and lesser educational attainment. For males, none of the sociodemographic factors were significantly associated with nutrient intakes. Below-median intake was significantly associated with albumin-to-creatinine ratio ≥30 (adjusted odds ratio [95% confidence interval]: 3.4 [1.5, 7.8] for vitamin C; 3.6 [1.6, 8.4] for magnesium; 2.9 [1.3, 6.5] for fiber; 3.6 [1.6, 8.4] for potassium), but not with estimated glomerular filtration rate <60.

CONCLUSION

African Americans with uncontrolled hypertension may have low intakes of important nutrients, which could increase their risk of chronic kidney disease. Tailored dietary interventions for African Americans at high risk for chronic kidney disease may be warranted.

Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Comparison of automated clinical and research blood pressure measurements: Implications for clinical practice and trial design

Discrepancies between clinic and research blood pressure (BP) measurements lead to uncertainties in translating hypertension management guidelines into practice. We assessed the concordance between standardized automated clinic BP, from a primary care clinic, and research BP, from a randomized trial conducted at the same site. Mean single-visit clinic BP was higher by 4.4/3.8 mm Hg (P = 0.007/<0.001). Concordance in systolic BP (SBP) improved with closer proximity of measurements (difference = 2.5 mm Hg, P = 0.21 for visits within 7 days), but not averaging across multiple visits (difference =5.1(9.2) mm Hg; P < 0.001). This discrepancy was greater among female participants. Clinic-based difference in SBP between two visits was more variable than research-based change (SD = 19.6 vs 14.0; P = 0.002); a 2-arm trial using clinic measurements would need 95% more participants to achieve comparable power. Implementation of a bundled standardization intervention decreased discrepancies between clinic and research BP, compared to prior reports. However, clinic measurements remained higher and more variable, suggesting treatment to research-based targets may lead to overtreatment and using clinic BP approximately halves power in trials.

What Is the Evidence Base for a Potassium Requirement?

Increased intake of potassium should be promoted to reduce the risk of cardiovascular disease and stroke and to protect against bone loss, but confidence in recommended intakes depends on the strength of the evidence. All public health recommendations are considerably higher than current average intakes. Evidence on which current potassium intake recommendations for the United States, Europe, and globally have limitations. More recent evidence reviewed by the Agency for Healthcare Research and Quality affirms that more evidence is needed to define specific values for optimal potassium intakes. Potassium requirements undoubtedly vary with a number of factors including energy needs, race, and intake of sodium.

Effects of a Dietary Approach to Stop Hypertension (DASH) Diet Intervention on Serum Uric Acid in African Americans With Hypertension

OBJECTIVE

To examine whether partial replacement of a diet typical of the average American diet with Dietary Approaches to Stop Hypertension (DASH)-related foods in the home environment lowers the serum uric acid (UA) level in individuals with hypertension.

METHODS

We conducted an ancillary study of a randomized trial of African American adults with controlled hypertension from an urban clinic. Participants were assigned to either a control group or an intervention (DASH-Plus) group. DASH-Plus participants received coach-directed dietary advice, assistance with purchasing DASH-related foods ($30/week), and home delivery of food via a community supermarket. Participants in the control group received a DASH diet brochure and a debit card account ($30/week) to purchase foods. Serum UA levels were measured at baseline and after 8 weeks.

RESULTS

Of the original 123 randomized participants, 117 had available serum UA measurements. Seventy percent of the participants were women, the mean ± SD age was 59 ± 9.5 years, and the mean ± SD serum UA level was 6.4 ± 1.7 mg/dl. The DASH-Plus diet did not reduce serum UA levels compared with the control diet (difference in difference -0.01 mg/dl [95% confidence interval -0.39, 0.38]). However, there was a significant trend toward a greater reduction in the serum UA level in participants with higher baseline serum UA levels (P for trend = 0.008). Baseline changes in the serum UA level were inversely associated with changes in systolic blood pressure (P = 0.002), diastolic blood pressure (P = 0.001), and urinary sodium excretion (P = 0.05).

CONCLUSION

Overall, in African American individuals, partial replacement of a typical diet with DASH foods did not lower serum UA levels compared with a control diet. However, there was a significant trend toward a greater reduction in serum UA levels in subjects with higher baseline serum UA levels. Furthermore, changes in serum UA levels were associated with known correlates, suggesting heterogeneity of effects in the treatment and control arms. Future pragmatic studies of consumption of the DASH diet to lower serum UA levels should optimize replacement strategies and enroll individuals with hyperuricemia or gout.

Health and Wellness Coaching Improves Weight and Nutrition Behaviors

Most Americans have an eating pattern inconsistent with the Dietary Guidelines, putting them at risk for obesity and chronic disease. Health and wellness coaching (HWC) for lifestyle behavior change is emerging as a potentially effective tool to prevent and treat chronic disease. A systematic literature review identified 11 randomized controlled trials studying the use of HWC for improving nutrition-related biomarkers and eating behaviors. These trials demonstrate efficacy of HWC across diverse populations and treatment modalities. Almost all (82%) of the trials showed an improvement in at least one outcome. The most commonly studied outcomes were weight, blood pressure, and fruit, vegetable, and fat intake. There are several gaps in the research. The assessment of nutrition-related behaviors can be expanded to include assessment of diet quality and eating patterns associated with chronic disease prevention. Research is needed to evaluate HWC for nutrition-related biomarkers and behaviors in understudied populations with known health disparities. In addition, the health coaching dosage for long-term maintenance of changed outcomes and behaviors is inconsistent or unknown. These gaps will be important to address to determine policies and best practices for future application of HWC.

Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health

The opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. We review scientific evidence from promising interventions focused on the social determinants of health and discuss how such interventions can improve population health and reduce health disparities. We found sufficient evidence of successful outcomes to support disparity-reducing policy interventions targeted at education and early childhood; urban planning and community development; housing; income enhancements and supplements; and employment. Cost-effectiveness evaluations show that these interventions lead to long-term societal savings, but the interventions require more routine attention to cost considerations. We discuss challenges to implementation, including the need for long-term financing to scale up effective interventions for implementation at the local, state, and national levels.

Reporting of Telehealth-Delivered Dietary Intervention Trials in Chronic Disease: Systematic Review

BACKGROUND

Telehealth-delivered dietary interventions are effective for chronic disease management and are an emerging area of clinical practice. However, to apply interventions from the research setting in clinical practice, health professionals need details of each intervention component.

OBJECTIVE

The aim of this study was to evaluate the completeness of intervention reporting in published dietary chronic disease management trials that used telehealth delivery methods.

METHODS

Eligible randomized controlled trial publications were identified through a systematic review. The completeness of reporting of experimental and comparison interventions was assessed by two independent assessors using the Template for Intervention Description and Replication (TIDieR) checklist that consists of 12 items including intervention rationale, materials used, procedures, providers, delivery mode, location, when and how much intervention delivered, intervention tailoring, intervention modifications, and fidelity. Where reporting was incomplete, further information was sought from additional published material and through email correspondence with trial authors.

RESULTS

Within the 37 eligible trials, there were 49 experimental interventions and 37 comparison interventions. One trial reported every TIDieR item for their experimental intervention. No publications reported every item for the comparison intervention. For the experimental interventions, the most commonly reported items were location (96%), mode of delivery (98%), and rationale for the essential intervention elements (96%). Least reported items for experimental interventions were modifications (2%) and intervention material descriptions (39%) and where to access them (20%). Of the 37 authors, 14 responded with further information, and 8 could not be contacted.

CONCLUSIONS

Many details of the experimental and comparison interventions in telehealth-delivered dietary chronic disease management trials are incompletely reported. This prevents accurate interpretation of trial results and implementation of effective interventions in clinical practice.

Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities

Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.

Lifestyle Medicine and the Management of Cardiovascular Disease

PURPOSE OF REVIEW

Evidence has clearly demonstrated the importance of lifestyle factors (e.g., diet, physical activity, smoking) in the development of cardiovascular disease (CVD). Interventions targeting these behaviors may improve outcomes for CVD patients. The aim of this review is to summarize the effects of lifestyle interventions in individuals with established CVD.

RECENT FINDINGS

Most recent trials focused on diet, physical activity, stress reduction, or a combination of these. Findings were mixed, but most interventions improved at least some markers of cardiovascular risk. Few studies measured long-term clinical outcomes, but some suggested a possible benefit of stress reduction and multifaceted interventions on cardiovascular events. The benefits of lifestyle change for CVD patients have been established by decades of evidence. However, further research is needed to determine the optimal intensity, duration, and mode of delivery for interventions. Additional studies with long-term follow-up and measurement of clinical outcomes are also needed.

Environmental biomonitoring of essential and toxic elements in human scalp hair using accelerated microwave-assisted sample digestion and inductively coupled plasma optical emission spectroscopy

Human scalp hair samples were collected and used to assess exposure to toxic elements and essential elements in the state of North Carolina, USA using accelerated microwave assisted acid digestion and inductively coupled plasma optical emission spectroscopy (ICP-OES). The figures-of-merit of the ICP-OES were appropriate for elemental analysis in scalp hair with detection limits as low as 0.0001 mg/L for Cd, good linearity (R² > 0.9978), and percent recoveries that ranged from 96 to 106% for laboratory-fortified-blanks and 88-112% for sample spike recovery study. The concentrations of essential elements in scalp hair were larger than those of toxic elements, with Ca having the highest average concentration (3080 μg/g, s = 14,500, n = 194). Some of the maximum concentrations observed for As (65 μg/g), Ni (331 μg/g), Cd (2.96 μg/g), and Cr (84.6 μg/g) in individual samples were concerning, however. Samples were statistically analyzed to determine the influence of race, gender, smoking habits, or age on the elemental concentrations in scalp hair. Higher concentrations of essential elements were observed in the scalp hair of Caucasians, females, and non-smokers, and the differences were often significant at a 90% confidence level. Several pairs of essential elements, for example Ca-K, Ca-Mg, and Ca-Zn, were strongly correlated in Caucasian hair but uncorrelated in African-American hair. Similarly, essential elements were strongly correlated in female hair but weakly correlated in male hair. Toxic element pairs (As-Cd, As-Se, Pb-As, and Se-Cd) were strongly correlated in the hair of smokers but uncorrelated in that of non-smokers, suggesting that cigarette smoke is a common source of toxic elements in humans.

Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis

BACKGROUND

The long-term management of chronic disease requires the adoption of complex dietary recommendations, which can be facilitated by regular coaching to support behavioral changes. Telehealth interventions can overcome patient-centered barriers to accessing face-to-face programs and provide feasible delivery methods, accessible regardless of geographic location.

OBJECTIVE

This systematic review assessed the effectiveness of telehealth dietary interventions at facilitating dietary change in chronic disease.

DESIGN

A structured systematic search was conducted for all randomized controlled trials evaluating multifactorial dietary interventions in adults with chronic disease that provided diet education in an intervention longer than 4 wk. Meta-analyses that used the random-effects model were performed on diet quality, dietary adherence, fruit and vegetables, sodium intake, energy, and dietary fat intake.

RESULTS

A total of 25 studies were included, involving 7384 participants. The telehealth dietary intervention was effective at improving diet quality [standardized mean difference (SMD): 0.22 (95% CI: 0.09, 0.34), P = 0.0007], fruit and vegetable intake [mean difference (MD) 1.04 servings/d (95% CI: 0.46, 1.62 servings/d), P = 0.0004], and dietary sodium intake [SMD: -0.39 (-0.58, -0.20), P = 0.0001]. Single nutrients (total fat and energy consumption) were not improved by telehealth intervention; however, after a telehealth intervention, important clinical outcomes were improved, such as systolic blood pressure [MD: -2.97 mm Hg (95% CI: -5.72, -0.22 mm Hg), P = 0.05], total cholesterol [MD: -0.08 mmol/L (95% CI: -0.16, -0.00 mmol/L), P = 0.04], triglycerides [MD: -0.10 mmol/L (95% CI: -0.19, -0.01 mmol/L), P = 0.04], weight [MD: -0.80 kg (95% CI: -1.61, 0 kg), P = 0.05], and waist circumference [MD: -2.08 cm (95% CI: -3.97, -0.20 cm), P = 0.03].

CONCLUSIONS

Telehealth-delivered dietary interventions targeting whole foods and/or dietary patterns can improve diet quality, fruit and vegetable intake, and dietary sodium intake. When applicable, they should be incorporated into health care services for people with chronic conditions. This review was registered at http://www.crd.york.ac.uk/PROSPERO/ as CRD42015026398.

Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health

The opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. We review scientific evidence from promising interventions focused on the social determinants of health and discuss how such interventions can improve population health and reduce health disparities. We found sufficient evidence of successful outcomes to support disparity-reducing policy interventions targeted at education and early childhood; urban planning and community development; housing; income enhancements and supplements; and employment. Cost-effectiveness evaluations show that these interventions lead to long-term societal savings, but the interventions require more routine attention to cost considerations. We discuss challenges to implementation, including the need for long-term financing to scale up effective interventions for implementation at the local, state, and national levels.

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

Ultra-long-term human salt balance studies reveal interrelations between sodium, potassium, and chloride intake and excretion

BACKGROUND

The intake of sodium, chloride, and potassium is considered important to healthy nutrition and cardiovascular disease risk. Estimating the intake of these electrolytes is difficult and usually predicated on urine collections, commonly for 24 h, which are considered the gold standard. We reported on data earlier for sodium but not for potassium or chloride.

OBJECTIVE

We were able to test the value of 24-h urine collections in a unique, ultra-long-term balance study conducted during a simulated trip to Mars.

DESIGN

Four healthy men were observed while ingesting 12 g salt/d, 9 g salt/d, and 6 g salt/d, while their potassium intake was maintained at 4 g/d for 105 d. Six healthy men were studied while ingesting 12 g salt/d, 9 g salt/d, and 6 g salt/d, with a re-exposure of 12 g/d, while their potassium intake was maintained at 4 g/d for 205 d. Food intake and other constituents were recorded every day for each subject. All urine output was collected daily.

RESULTS

Long-term urine recovery rates for all 3 electrolytes were very high. Rather than the expected constant daily excretion related to daily intake, we observed remarkable daily variation in excretion, with a 7-d infradian rhythm at a relatively constant intake. We monitored 24-h aldosterone excretion in these studies and found that aldosterone appeared to be the regulator for all 3 electrolytes. We report Bland-Altman analyses on the value of urine collections to estimate intake.

CONCLUSIONS

A single 24-h urine collection cannot predict sodium, potassium, or chloride intake; thus, multiple collections are necessary. This information is important when assessing electrolyte intake in individuals.