Table 1.

Multilevel Interventions Including a Dietary Component to Address Disparities Associated With CVD

Project	Population (Location)	No. of Participants	Intervention Duration	Multilevel Intervention	Dietary Component of the Intervention	Results
CHART (Congestive Heart Failure Redesign Trial: A Pilot Study)124	Low‐income patients hospitalized with heart failure (Chicago, IL)	n=20 Physicians; n=33 patients (23 completed the study)	4 mo	Culturally sensitive, multilevel long‐term care intervention to improve self‐management behaviors by providing patient and provider education; community healthcare worker intervention	Patients received self‐management training for diet by a trained nurse through 11 interactive sessions over a 4‐mo period	Median sodium intake declined (3.5 vs 2.0 g/d; P<0.01)
Heart Healthy Lenoir Project—Lifestyle study125	Patients receiving hypertension care in rural primary care practices (Lenoir County, North Carolina)	339	2 y	Phase 1: improving diet quality and increasing physical activity (6 mo); Phase 2: weight loss intervention for patients with a BMI ≥25 kg/m2 or a lifestyle maintenance intervention for patients with a BMI <25 kg/m2 (6 mo); Phase 3: RCT comparing intensive with less intensive weight loss maintenance intervention for subjects who lost ≥8 lb in phase 2 or lifestyle maintenance intervention for all other subjects (1 y)	See left	Phase 1 (n=251 completed). Substantial improvement in diet score (4.3 units), systolic BP (−6.4 mm Hg; −8.7 to −4.1 mm Hg) that was maintained for 2‐y follow‐up; Phase 2 (n=138): weight change was −3.1 kg (−4.9 to −1.3) for group sessions and −2.1 kg (−3.2 to −1.0) for group/telephone session; Phase 3 (n=24): weight loss was −2.1 (−4.3 to 0.0) and −1.1 kg (−2.7 to 0.4) for the 2 groups, respectively. Outcomes for blacks and whites were similar: there was a substantial improvement in diet and BP, but weight loss was modest
Project Red Chip (Reducing Disparities and Controlling Hypertension in Primary Care)121	Six primary care clinics in predominantly black urban communities (4 were located in medically underserved areas in Baltimore, MD)	3964 Uncontrolled hypertensive patients	3 mo	Multimethod, staged quality improvement intervention (targeting better BP measurement; patient case management; provider education, including audit and feedback and communication skills training)	Patients received 3 care management educational sessions (totaling 120 min), including lifestyle behaviors covered by RDs related to DASH diet, weight loss, and exercise	Those completing all sessions (629 participated in education; 245 completed all 3 sessions) on average reached BP control (mean systolic/diastolic BP, 137/78 mm Hg) and systolic BP was reduced by 9 mm Hg (P<0.001) and 4 mm Hg diastolic BP (P=0.004) greater improvement than nonparticipants; Disparities in systolic and diastolic BP between blacks and whites were no longer present at the end of the study. However, the limited reach indicated that care management alone may not improve BP control and eliminate disparities
ACT (Achieving Blood Pressure Control Together) Study122	Black adults with uncontrolled hypertension in a primary care clinic in a low‐income area (Baltimore, MD)	159	12 mo	1) An educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem‐solving intervention	The community health worker intervention reviewed and reinforced education on high BP, nutrition, and exercise. In the problem‐solving intervention, participants learned about behavioral goals for monitoring their BP and making effective diet and lifestyle modifications for BP control	No results published yet
Proyecto Mercado Fresco (fresh market project)127	Predominantly Latino communities (East Los Angeles, CA, and Boyle Heights, CA)	n=4 Corner stores	2 y	The project used a community‐engaged approach to select, recruit, and convert 4 corner stores to improve access to and awareness of fresh affordable fruits and vegetables. This is a multilevel corner store conversion intervention, which includes having multiple stakeholders, expertise in corner store operations, community and youth engagement strategies, and social marketing campaigns	See left	Improvements were found in perceived healthy food accessibility and perceptions of corner stores. No changes were found, however, in store patronage, purchasing, or consumption of fruits and vegetables
North Carolina Wisewomen Project,123	Low‐income women (31 counties in North Carolina)	n=17 Counties’ health department in the MI group; n=14 in the EI group; n=2148 women screened	6 mo	Expanding an existing cancer screening program to include a CVD screening and intervention program. The enhanced intervention included 3 specially constructed counseling sessions spanning 6 mo using a structured assessment and intervention program tailored to lower‐income women	The counseling sessions included diet and physical activity using a tailored, culturally appropriate, structured assessment and intervention program for patients with lower literacy and low income. The program is known as “A New Leaf”	After 6 mo of follow‐up in the EI health departments, changes in total cholesterol levels, HDL‐C levels, diastolic BP, and BMI were observed (−5.8 mg/dL, −0.9 mg/dL, −1.7 mm Hg, and −0.3 kg/m2, respectively), but were not significantly different from MI health departments. A dietary score that summarized fat and cholesterol intake improved by 2.1 units in the EI group, compared with essentially no change in the MI group
Five Plus Nuts and Beans trial126	Blacks with controlled hypertension from an urban primary care clinic (Baltimore, MD)	123	8 wk	A program providing dietary advice and assistance with grocery ordering, and $30 per week of high‐potassium foods	In the intervention group, known as the DASH‐Plus group, subjects received coach‐directed dietary advice and assistance with weekly online ordering and purchasing of high‐potassium foods delivered by community supermarkets to a neighborhood library	Compared with the control group, the DASH‐Plus group increased self‐reported consumption of fruits and vegetables (mean, 1.4; 95% CI, 0.7–2.1 servings/d); estimated intake of potassium (mean, 0.4; 95% CI, 0.1–0.7 g/d); and urine potassium excretion (mean, 19%; 95% CI, 1%–38%). There was no significant effect on BP

BMI indicates body mass index; BP, blood pressure; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; EI, enhanced intervention; HDL‐C, high‐density lipoprotein cholesterol; MI, minimum intervention; RCT, randomized controlled trial; and RD, registered dietitian.