Abstract
Intensive cardiac rehabilitation (ICR) programs are approved by the Centers for Medicare & Medicaid Services based on their expected benefits on cardiovascular disease (CVD) risk factors and health outcomes. However, the impact of outpatient ICR on diet quality, quality of life (QOL), and CVD risk factors has not been assessed prospectively. The aim of this cohort study was to test the hypothesis that patients enrolled in a Pritikin outpatient ICR program would improve diet quality, QOL, and CVD health indices, and that the improvements would be greater than those of patients in traditional cardiac rehabilitation (CR). Patients enrolled in ICR (N=230) or CR (N=62) were assessed at baseline and at visit 24. Diet quality was assessed using the Rate Your Plate (RYP) questionnaire and QOL was assessed via the Dartmouth COOP Functional Health Assessment (COOP) questionnaire. Secondary endpoints included anthropometrics, CVD biomarkers, hemodynamics, and fitness. ICR patients displayed significant improvements at visit 24 vs. baseline in RYP and COOP scores, weight, body mass index (BMI), waist circumference, fat mass, total and LDL-cholesterol, 6-minute walk distance, and grip strength. Patients in ICR had greater improvements in diet quality (P = 0.001), weight (P = 0.001), and BMI (P < 0.001) compared to those in CR. In summary, this prospective study of Pritikin outpatient ICR revealed significant improvements in diet quality, QOL, adiposity, and other CVD risk factors. The improvements in diet quality, body weight, and BMI were greater than those observed with traditional CR.
Keywords: intensive cardiac rehabilitation, diet quality, quality of life, cardiac rehabilitation, cardiac risk factors
Despite significant advances in the treatment of cardiovascular disease (CVD), CVD remains the leading cause of mortality in the United States.(1) Cardiac rehabilitation (CR) has been shown to improve quality of life (QOL), exercise tolerance, and mortality rates significantly.(2) CR generally consists of 36 exercise sessions over approximately 12 weeks. During this time, patients also receive instruction on healthy dietary habits and behaviors to improve psychological well-being, but relatively little time is devoted to these topics in traditional CR.(3) In comparison, intensive cardiac rehabilitation (ICR) consists of 72 sessions, which includes 36 exercise sessions plus 36 educational and group sessions on nutrition, culinary strategies, exercise, health, and stress reduction(3, 4) To our knowledge, prior studies have not yet prospectively evaluated the impact of an outpatient ICR program on diet quality, QOL, and several indices of CVD health. The goal of the current study was to fill this knowledge gap by assessing the impact of an outpatient ICR program on diet quality and QOL prospectively, as assessed by the Rate Your Plate (RYP) questionnaire and the Dartmouth COOP Functional Health Assessment (COOP) questionnaire, respectively. Secondary endpoints included anthropometrics, CVD biomarkers, hemodynamics, and fitness. Changes in these endpoints in the ICR group were also compared with changes in the traditional CR group.
Methods
The study was conducted at the Washington University School of Medicine / Barnes- Jewish Hospital Heart Care Institute in St. Louis, MO. Inclusion criteria were enrollment in cardiac rehabilitation at this center, age > 18 years, and written, informed consent to participate in the research study. Patients were referred to cardiac rehabilitation by their cardiologist as part of routine clinical care; enrollment in traditional CR or ICR was determined primarily by insurance coverage. Patients were enrolled in the study between January 2017 and July 2021. The study was approved by the Institutional Review Board of Washington University School of Medicine.
The Pritikin outpatient ICR program was used in this study. This is one of three ICR programs approved by the Centers for Medicare & Medicaid Services and is based on the Pritikin Longevity Residential Center program. The Pritikin residential program, whose principles guide the outpatient ICR program studied in this project, includes daily aerobic exercise and a high-fiber, low-fat, low-sodium diet(5) that has been associated with numerous health benefits, including improvements in glucose, insulin, lipid levels, blood pressure, and weight.(6, 7) The outpatient ICR program encompasses these principles of healthy dietary habits, exercise, and a healthy mindset. It consists of 36 1-hour sessions focused on exercise plus 36 45- minute education sessions focused on a healthy diet, CVD risk factor reduction, culinary practices, exercise, and a healthy mindset. The education sessions include 18 videos on various topics related to cardiovascular health (e.g., hypertension, metabolic disorders, nutrition labels, dining out, exercise plans, yoga), as well as 8 nutrition workshops, 4 cooking workshops, 3 exercise workshops, and 3 healthy mindset workshops. In addition, patients meet with a registered dietitian at orientation and throughout the program so that dietary recommendations are individualized based on BMI and other health conditions (e.g., diabetes, kidney disease, etc.).
The traditional CR group participated in the same 1-hour exercise sessions as the ICR group. The facility, exercise equipment, and staff were identical across groups. The exercise prescriptions also were equivalent across groups and were individualized for each patient based on cardiorespiratory fitness, physical function, and health status upon enrollment.
Our primary endpoints were changes in diet quality and QOL between baseline and visit 24. Secondary endpoints included changes in anthropometries (i.e., weight, BMI, waist circumference, body fat percentage), CVD biomarkers (lipid profile), hemodynamics (resting heart rate and blood pressure), and physical fitness (6-minute walk test distance, hand grip strength) between baseline and visit 24. The 24th visit was chosen prospectively as the final assessment point based on standard clinical procedures at this cardiac rehabilitation facility.
Diet quality was assessed using the Rate Your Plate questionnaire, a self-completed questionnaire that is used frequently by healthcare providers as a dietary screening, counseling, and educational resource.(8) The RYP questionnaire includes 24 questions, each worth 1, 2, or 3 points, for a total score ranging from 24-72, with higher scores indicating better diet quality. The score is interpreted as follows: 24-40 points indicates that many changes can be made to improve dietary habits, 41-57 points indicates that some changes can be made to improve dietary habits, and 58-72 points indicates that the patient is making healthy dietary decisions.(9) To glean more detailed information about patients’ dietary patterns and nutrient intakes, we categorized the 24 RYP questions into 12 categories based on topic similarity: meat (questions 1, 3, 4, 5, 8), chicken and turkey (question 7), fish (question 6), cooking method (questions 7, 15), eggs and dairy (questions 9, 10, 11, 12), whole grains (question 13), fruits and vegetables (question 14), fat type (questions 16, 18, 19), salt (question 17), snacks (questions 20, 21), desserts (questions 22, 23), and dining out (question 24). For each category, an average score, with a range of 1-3 points, was computed for the questions in that category.
Quality of life was assessed using the Dartmouth COOP Functional Health Assessment. This self-completed questionnaire includes 9 questions, each with a score of 1-5, for a total score of 9 to 45; lower scores represent higher QOL. The questions assess physical fitness, emotions, difficulty with daily activities, difficulty with social activities, general QOL, pain, subjective change in health, overall health, and social support during the previous 4 weeks. The instrument’s reliability and validity have been demonstrated in prior studies.(10–12)
Statistical analyses were performed using R statistical software version 4.2.0. Patients were included in the analyses if they completed the RYP and COOP questionnaires at baseline and visit 24. Baseline characteristics are presented as frequencies (percent of the sample) for categorical variables, which were compared using Chi-squared tests or Fisher’s exact test as appropriate. Continuous variables are presented as mean ± SD and were compared using t-tests. Though some of the variables (e.g. RYP subscores) were not normally distributed, we report the mean and compared group scores using t-test to be in line with the way RYP scores have been analyzed elsewhere in literature(13), and for simplicity and consistence of presentation. We repeated the analyses of non-normally distributed variables using median (interquartile ranges [IQR]) and Wilcoxon tests, with very similar results and conclusions. For each outcome, change was calculated as the follow-up value minus the baseline value. Intra-group changes were evaluated using paired t-tests; inter-group changes were evaluated using two-sample t-tests. To account for potential between-group differences, the results were confirmed in multivariable models. The models evaluated the effect of ICR/CR on the change in outcome from baseline to follow-up. The first model adjusted for age and sex and the second adjusted for age, sex, race, as well as myocardial infarction, percutaneous coronary intervention, and heart failure due to differences in these last three variables between groups at baseline. Exploratory assessment of the association between RYP changes and changes in weight or BMI were made using Pearson correlations.
Results
Our study included 62 patients in CR and 230 patients in ICR. Table 1 includes baseline characteristics, referral diagnosis, co-morbidities, and medications at the initiation of cardiac rehabilitation. Patients in the CR group were younger than those in ICR. In both groups, the majority of patients were white and there were more men than women. Patients in CR were more likely to be referred for heart failure, whereas patients in ICR had higher rates of myocardial infarction and percutaneous coronary intervention. Cardiac medications generally were similar, although patients in CR were more likely to be taking an aldosterone antagonist, while those in ICR were more likely to be taking a statin.
Table 1.
Demographic characteristics and clinical history
| CR (n = 62) |
ICR (n = 230) |
P-value | |
|---|---|---|---|
| Age (years) (mean ± SD) | 66 ± 12 | 69 ± 10 | 0.03 |
| Sex (% of sample) | 0.15 | ||
| Male | 61 | 72 | |
| Female | 39 | 28 | |
| Race (% of sample) | 0.07 | ||
| White | 86 | 93 | |
| Black | 13 | 7 | |
| Other | 2 | 0 | |
| BMI (kg/m2) (mean ± SD) | 30.2 ± 6.3 | 30.4 ± 5.9 | 0.76 |
| Weight (kg) (mean ± SD) | 86.5 ± 22 | 89.8 ± 20 | 0.30 |
| Referral Diagnosis (% of sample)** | |||
| CABG | 13 | 23 | 0.12 |
| Heart failure | 50 | 24 | <0.001 |
| Heart transplant | 3 | 1 | 0.29 |
| Myocardial Infarction | 21 | 34 | 0.04 |
| PCI | 34 | 54 | 0.003 |
| Stable angina | 3 | 6 | 0.54 |
| Valve intervention | 18 | 21 | 0.99 |
| Co-morbidities (% of sample) | |||
| History of smoking | 54 | 50 | 0.10 |
| Diabetes Mellitus | 26 | 23 | 0.78 |
| Hypertension | 71 | 72 | 0.98 |
| Obesity | 44 | 44 | 1.0 |
| Medications (% of sample taking) | |||
| ACE-I, ARB, or Sacubitril/Valsartan | 55 | 53 | 0.94 |
| Aldosterone antagonist | 26 | 8 | <.001 |
| Diuretic* | 40 | 30 | 0.16 |
| Anticoagulant | 58 | 67 | 0.25 |
| Aspirin | 84 | 91 | 0.14 |
| Beta-blocker | 77 | 85 | 0.20 |
| Insulin | 10 | 10 | 1 |
| SGLT2 inhibitor | 2 | 2 | 1 |
| Statin | 71 | 88 | 0.002 |
ACE-I = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention; SGLT2 = sodium glucose co-transporter 2. Data are presented as mean ± SD or percentages, as indicated.
Excluding aldosterone antagonists.
Some patients had more than one referral diagnosis.
Diet quality results are presented in Figure 1. At baseline, there was no difference in diet quality between groups, as reflected by comparable RYP total scores in CR and ICR. At follow-up, patients in ICR had significantly higher diet quality compared to baseline and compared to the CR group. The improvement in diet quality was greater in ICR than in CR (P = 0.001). In the ICR group, RYP scores improved in 90% of patients, did not change in 3%, and worsened in 7%. In the CR group, RYP scores improved in 71% of patients, did not change in 5%, and worsened in 24% (P = 0.0008). Supplementary Figures 1 and 2 show the results of an exploratory evaluation of the changes in RYP categories between baseline and follow-up in CR and ICR, respectively. Patients in ICR had improvements in all 12 RYP categories, with the greatest improvements observed in the category subscores for fruits and vegetables (+0.56 points), fish (+0.50 points), salt (+0.36 points), and meat (+0.33 points).
Figure 1.
Rate Your Plate scores at baseline and follow-up. RYP = Rate Your Plate. Orange = baseline; blue = follow-up. A higher value represents a healthier diet.
QOL results are shown in Figure 2. Importantly, there were no group differences in baseline QOL, based on Dartmouth COOP scores, and both groups improved their QOL comparably with the intervention. In the ICR group, COOP scores improved in 80% of patients, did not change in 7%, and worsened in 13%. In the CR group, COOP scores improved in 71% of patients, did not change in 13%, and worsened in 16% (P = 0.175).
Figure 2.
COOP scores at baseline and follow-up. COOP = Dartmouth COOP Functional Health Assessment. Orange = baseline; blue = follow-up. A lower value represents a higher quality of life.
Table 2 shows the baseline and follow-up values for the secondary endpoints (anthropometrics, CVD biomarkers, hemodynamics, and exercise performance). At baseline, only 2 of the 14 variables were different between groups; patients in ICR had lower triglyceride levels and higher 6-minute walk test distance than those in the CR group. Improvements were observed in both groups by visit 24. Patients in the CR group realized improvements in waist circumference and 6-minute walk distance. Patients in the ICR group had improvements in several endpoints: weight, BMI, waist circumference, fat mass, total cholesterol, LDL-cholesterol, resting heart rate, resting systolic and diastolic blood pressure, 6-minute walk distance, and grip strength. At follow-up, patients in ICR had significantly healthier BMI values compared to CR and had greater improvements in weight and BMI compared to those in CR.
Table 2.
Baseline and follow-up anthropometrics, CVD biomarkers, hemodynamics, and fitness endpoints
| CR (n = 62) | ICR (n = 230) | Change in CR vs. Change in ICR |
|||||
|---|---|---|---|---|---|---|---|
| Baseline | Follow-up | P-value | Baseline | Follow-up | P-value | P-value | |
| Weight (kg) | 86.5 ± 22 | 87.6 ± 21 | 0.68 | 89.8 ± 20 | 88.3 ± 20 | <0.001 | 0.001 |
| BMI (kg/m2)* | 30.2 ± 6.3 | 30.5 ± 6.1 | 0.55 | 30.4 ± 5.9 | 29.9 ± 5.8 | <0.001 | <0.001 |
| Waist (cm) | 102.9 ± 17 | 101.0 ± 15 | 0.03 | 104.9 ± 14 | 102.8 ± 14 | <0.001 | 0.50 |
| Fat Mass (%) | 33.5 ± 8.7 | 32.9 ± 8.7 | 0.23 | 32.5 ± 8.5 | 31.6 ± 8.3 | <0.0001 | 0.44 |
| Total chol. (mg/dL) | 143 ± 34 | 144 ± 40 | 0.86 | 136 ± 32 | 132 ± 29 | 0.002 | 0.20 |
| HDL-C (mg/dL) | 49 ± 16 | 49 ± 16 | 0.69 | 46 ± 13 | 46 ± 12 | 0.71 | 0.60 |
| LDL-C (mg/dL) | 65 ± 24 | 65 ± 28 | 0.83 | 65 ± 26 | 61 ± 24 | 0.001 | 0.28 |
| TG (mg/dL)** | 145 ± 67 | 154 ± 88 | 0.45 | 128 ± 53 | 125 ± 61 | 0.70 | 0.40 |
| HbA1c (%) | 5.9 ± 1.0 | 5.9 ± 0.91 | 0.71 | 5.8 ± 0.9 | 5.9 ± 0.9 | 0.16 | 0.35 |
| Resting HR (bpm) | 77 ± 12 | 75 ± 13 | 0.09 | 76 ± 12 | 73 ± 12 | <0.0001 | 0.61 |
| SBP (mmHg) | 122 ± 16 | 120 ± 17 | 0.33 | 126 ± 18 | 122 ± 14 | <0.0001 | 0.45 |
| DBP (mmHg) | 73 ± 10 | 70 ± 10 | 0.20 | 73 ± 10 | 70 ± 9 | <0.0001 | 0.47 |
| 6MWT (m)** | 443 ± 130 | 493 ± 138 | <0.001 | 478 ± 114 | 532 ± 123 | <0.001 | 0.87 |
| Grip strength (kg)§ | 32 ± 10 | 33 ± 10 | 0.73 | 34 ± 12 | 36 ± 12 | <0.001 | 0.09 |
BMI = body mass index; DBP= diastolic blood pressure; HbA1c = hemoglobin A1c; HDL-C = high-density lipoprotein cholesterol; HR = heart rate; LDL-C = low-density lipoprotein cholesterol; SBP = systolic blood pressure; TG = triglycerides; Total chol. = total cholesterol; Waist = waist circumference; 6MWT = six-minute walk test. Data are presented as mean ± SD.
Significant difference (P<0.05) between groups at follow-up (CR vs. ICR).
Significant difference (P<0.05) between groups at baseline (CR vs. ICR).
Score range 24-72. A higher score represents a healthier diet.
Score range 9-45. A lower score represents better quality of life.
Highest grip strength for each individual was used.
To further evaluate whether group (ICR vs. CR) was an independent predictor of improvements, we used multivariable models that adjusted for covariates. As shown in Table 3, improvements in diet quality and BMI were greater in the ICR group than in the CR group after adjustment for age and sex (Model 1) and after adjustment for age, sex, race, and referral diagnosis (Model 2). These results were consistent with those of the univariate model (data not shown). The ICR group also trended towards greater improvements in total cholesterol compared to the CR group, but these trends did not meet the criteria for significance.
Table 3.
Multivariate models evaluating inter-group differences from baseline to follow-up for selected endpoints
| Model 1 | Model 2 | |||||
|---|---|---|---|---|---|---|
| β Estimate* |
SE | P-value | β Estimate* | SE | P-value | |
| Diet quality (RYP score) | 3.876 | 0.961 | < 0.001 | 3.251 | 1.007 | < 0.001 |
| Quality of life (COOP score) | −0.548 | 0.658 | 0.406 | −.649 | 0.693 | 0.350 |
| BMI (kg/m2) | −0.607 | 0.15 | <0.001 | −.451 | 0.155 | 0.004 |
| Total cholesterol (mg/dL) | −5.33 | 3.034 | 0.080 | −6.00 | 3.288 | 0.069 |
β estimates compare changes in ICR to changes in CR (e.g., a β estimate of 3.9 indicates that the ICR group improved their RYP score by 3.9 points more than the CR group).
Model 1 is adjusted for age and sex.
Model 2 is adjusted for age, sex, race, myocardial infarction, percutaneous coronary intervention, and heart failure.
BMI = body mass index; COOP = Dartmouth COOP functional health assessment; RYP = Rate Your Plate; SE = standard error
In an exploratory analysis, improvements in diet quality were correlated with reductions in weight (r = −0.227, P = 0.0002) and BMI (r = −0.231, P = 0.0001). The correlation between improvement in diet quality and reduction in waist circumference was less strong, but still significant (r = −0.11, P <0.05). These relationships indicate that a healthier diet correlated with weight loss.
Discussion
To our knowledge, this is the first prospective study to demonstrate a positive impact of the outpatient Pritikin ICR program on diet quality and QOL, as well as multiple anthropometric, CVD biomarker, hemodynamic, and exercise performance metrics. Specifically, ICR was associated with higher diet quality and quality of life, decreases in body weight, BMI, waist circumference, adiposity, total cholesterol, resting heart rate and blood pressure, as well as increases in 6-minute walk distance and grip strength after 24 patient visits (comprised of ~48 sessions). The study also demonstrated that the CR group experienced improvements in diet quality, QOL, waist circumference, and 6-minute walk distance after 24 visits (comprised of 24 sessions). Importantly, the improvements in diet quality, weight, and BMI were greater in the ICR group than in the CR group in both univariate and multivariable analyses.
The primary finding in our investigation was that the Pritikin outpatient ICR program resulted in improvements in overall diet quality and in each of the 12 dietary categories included in the RYP questionnaire. Given the demonstrated improvements in health outcomes attributed to diet modifications in patients domiciled at an inpatient ICR program,(7) the efficacy of the outpatient ICR program to increase diet quality is encouraging. These improvements are likely the result of intensive and comprehensive patient education and contact with registered dietitians, a cornerstone of the outpatient ICR program. The improvements in diet quality in the ICR group were independent of age, sex, race, and referral diagnosis. These results extend those of a retrospective analysis of 1,963 patients enrolled in the Pritikin outpatient ICR program by our research group.(14)
In addition to enhanced diet quality, our investigation demonstrates an increase in QOL after ICR. These findings are in line with those from a previous investigation demonstrating that participants in this outpatient ICR program report decreased depressive symptoms and increased cardiac self-efficacy, likely contributing to better QOL.(15) Importantly, the improvement in the COOP scores were noted in both the ICR and CR groups. It is logical to speculate that the exercise component of these programs primarily contribute to this improvement, as it is well-known that participation in an exercise program improves physical, mental, and emotional well-being.(16) Given that both the ICR and CR groups participated in the same exercise program, in the same location, facilitated by the same staff, it is perhaps unsurprising that the benefits on QOL were similar between both groups. The improvements in functional capacity and confidence on the COOP questionnaire likely were a result of enhanced physical ability via exercise training.
A key finding highlighting the efficacy of the outpatient ICR program is the improvement in several anthropometric indices, CVD biomarkers, and hemodynamics. Specifically, participants in ICR experienced a reduction in weight, BMI, waist circumference, % fat mass, lipids, and resting heart rate and blood pressure. These results are reflective of those demonstrated in the inpatient Pritikin ICR program, which supports the idea that adapting the ICR program to an outpatient setting did not result in a loss of efficacy.(17, 18) The reductions in weight and BMI in the ICR group were associated with improvements in diet quality and were greater than those observed in the CR group. The ICR diet and educational programming emphasize unprocessed foods that are low-fat, low-cholesterol, low-sodium, high-fiber, and plant-based. Additional topics include mindful eating and weight management strategies. Several, if not all, of these principles have been demonstrated to be effective in promoting reductions in weight and adiposity.(19, 20) In addition to decreased weight and fat percent, ICR patients displayed reductions in total and LDL cholesterol, an unsurprising outcome given that weight loss and diets low in saturated fat and cholesterol and high in fiber, such as that endorsed by ICR, are effective in lowering cholesterol levels.(21) These benefits were not observed in our CR group, indicating that the ICR diet and its iterative instruction program may be key to the reduction in cholesterol levels.(20, 22) Importantly, lipids improved despite total and LDL cholesterol levels being relatively low in the ICR group prior to the program and 88% of patients taking statins. This is clinically meaningful, as even modest reductions in cholesterol may contribute to CVD risk reductions.(20) The reductions in resting heart rate and blood pressure in the ICR and CR groups are likely attributable to weight loss as well as the exercise training, given the known beneficial effects of weight loss and exercise on hemodynamics.(23) Moreover, since a lower resting heart rate is well-known to be associated with lower CVD risk,(24) the decrease in resting heart rate after ICR should benefit the patients in that group.
Finally, participation in ICR led to significant improvements in physical fitness, as demonstrated by increased 6-minute-walk distance and greater handgrip strength. These findings are clinically meaningful because higher cardiorespiratory fitness and higher handgrip strength have been associated with lower cardiovascular death and all-cause mortality in numerous large-scale epidemiological studies.(25–27) Patients in the traditional CR program (who underwent similar exercise training as the ICR group) also experienced comparable increases in 6-minute-walk distance, demonstrating the efficacy of the exercise training program among patients with varying referral diagnoses and baseline levels of fitness and frailty.(28) Additionally, Baris et al demonstrated that elderly patients who had undergone cardiac surgery displayed an improvement in 6-minute walk distance, which was possibly related to improvement in dyspnea.(29) Thus, it is tempting to speculate that our patients experienced improvement in 6-minute walk scores as a result of enhanced cardiac function and revascularization.
There are limitations to the current study. Patients were not randomized to the CR and ICR groups because this study was conducted in collaboration with a cardiac rehabilitation program as part of routine clinical care; therefore, there is a potential for selection bias, which is also impacted by the Centers for Medicare and Medicaid Services reimbursable diagnoses. We attempted to mitigate this bias by performing multivariable analyses that controlled for baseline characteristics and differences between groups. Future trials that are randomized may provide additional insight that is free of potential referral bias. Additionally, the CR group is smaller than the ICR group and hence the power to detect improvements in the CR group is lower. Nevertheless, the overall sample size of 292 patients is the largest prospective study of the effectiveness of ICR on diet quality, QOL, and several physical measures that reflect cardiovascular health. Finally, performing follow-up assessments at visit 24, in accordance with clinical protocol, may have led to an underestimation of the beneficial effects observed (i.e., more favorable changes may have been observed after 36 visits).
In this first prospective analysis, outpatient ICR was associated with improvements in diet quality, quality of life, adiposity, cardiovascular biomarkers, hemodynamics, and fitness. Importantly, many of these beneficial effects have been linked to improved outcomes in patients with CVD. Moreover, ICR was more effective than traditional CR in improving diet quality, weight, and BMI. Of note, despite the demonstrated benefits associated with CR(30) and ICR, as well as Medicare coverage of ICR since 2010, ICR remains dramatically underutilized and often unavailable.(31)
Supplementary Material
Supplementary Figure 3. Rate Your Plate change (baseline value – follow up value) in each category. Orange = CR; blue = ICR.
Supplementary Figure 1. Rate Your Plate category scores in the CR group at baseline and follow-up. Score range is 1-3 for each category. A higher value represents a healthier diet. Orange = baseline; blue = follow-up. *Significant difference from pre- to post-intervention.
Supplementary Figure 2. Rate Your Plate category scores in the ICR group at baseline and follow-up. Score range is 1-3 for each category. A higher value represents a healthier diet. Orange = baseline; blue = follow-up. *Significant difference from pre- to post-intervention.
Acknowledgements
The authors would like to thank Kristin D. O’Callaghan for her editorial assistance.
Funding:
This study was supported by grants from the Mentors-in-Medicine program at the Washington University School of Medicine and the Foundation for Barnes-Jewish Hospital (Saint Louis, Missouri, USA) and by the following grants from the National Institutes of Health (Bethesda, Maryland, USA): Clinical and Translational Science Award (CTSA) Grant UL1 TR000448, Siteman Comprehensive Cancer Center and NCI Cancer Center Support Grant P30 CA091842, R01 AG060499 (LRP, MWR, SBR), R34HL138253 (LRP, SBR), R61HL155858 and R21 HL145217 (LRP). The funding sources had no role in the study design, collection, analysis and interpretation of the data, in writing the manuscript, or the decision to submit the article for publication.
Footnotes
Disclosures
Dr. Peterson has received an honorarium from the AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation).
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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Supplementary Materials
Supplementary Figure 3. Rate Your Plate change (baseline value – follow up value) in each category. Orange = CR; blue = ICR.
Supplementary Figure 1. Rate Your Plate category scores in the CR group at baseline and follow-up. Score range is 1-3 for each category. A higher value represents a healthier diet. Orange = baseline; blue = follow-up. *Significant difference from pre- to post-intervention.
Supplementary Figure 2. Rate Your Plate category scores in the ICR group at baseline and follow-up. Score range is 1-3 for each category. A higher value represents a healthier diet. Orange = baseline; blue = follow-up. *Significant difference from pre- to post-intervention.