PILOT STUDY
Nutrient-dense, Plant-rich Dietary Intervention Effective at Reducing Cardiovascular Risk Factors for Worksites: A Pilot Study Jay T. Sutliffe, PhD, RD; Joel Fuhrman, MD; Mary Jo Carnot, PhD; Raena Beetham, MS; Madison Peddy
ABSTRACT Context • A worksite provides an excellent opportunity to conduct interventions for health promotion and disease prevention to ameliorate chronic risk factors for disease, such as for cardiovascular disease (CVD). Likewise, nutrient-dense, plant-rich (NDPR) dietary patterns have been shown to be effective at preventing and improving chronic-disease conditions, including CVD. Objective • The study’s aim was to determine the feasibility and effectiveness of an NDPR dietary intervention for worksites to lower CVD risk factors. Design • The study was a 6-wk pilot intervention using a pretest and posttest design. Setting: The intervention was conducted at the Northern Arizona University (Flagstaff, AZ, USA) and sponsored by its Employee Assistance and Wellness Department. Participants • Participants were 35 employees with body mass indexes (BMIs) >25 kg/m2 who were ready and willing to make a lifestyle change, who were not currently participating in a weight loss program, and who were not taking any medications that could increase medical risk or had weight loss as a primary side effect. The average age of
Jay T. Sutliffe, PhD, RD, is an associate clinical professor in the Health Sciences Department at Northern Arizona University in Flagstaff, Arizona. Joel Fuhrman, MD, is a family physician in Flemington, New Jersey. Mary Jo Carnot, PhD, is a professor in the Counseling, Psychology and Social Work Department at Chadron College in Chadron, Nebraska. Raena Beetham, MS, is an admissions officer at Eastern Connecticut State University in Willimantic, Connecticut and was a graduate student at the time of this study. Madison Peddy was an undergraduate research assistant and majoring in Parks and Recreation Management at Northern Arizona University at the time of this study. Corresponding author: Jay T. Sutliffe, PhD, RD E-mail address:
[email protected] 24 ALTERNATIVE THERAPIES, SEP/OCT 2016 VOL. 22 NO. 5
participants was 42.57 y; 91.4% were female, and 80% were Caucasian. Intervention • The intervention used a dietary protocol consisting of the daily consumption of greens, beans, legumes, and a variety of other vegetables, as well as fresh or frozen whole fruits, nuts, seeds, and whole grains. Participants were encouraged to minimize the consumption of refined grains, vegetable oils, processed foods, and animal products. Outcome Measures • The study measured serum lipids, height, weight, waist and hip circumference, waist-to-hip ratio, and blood pressure. Results • Based on paired-sample t tests and Wilcoxon signed-ranks test with a maximum level of P = .05, the intervention resulted in significant changes in weight, BMI, waist and hip measurements, high-density lipoproteins, low-density lipoproteins, and estimated average glucose. Conclusions • The findings favorably revealed that an NDPR dietary intervention that was developed for worksites was an effective approach for reducing CVD risk factors. (Altern Ther Health Med. 2016;22(5):##-##.)
I
n the span of a lifetime, the average person devotes nearly 100 000 hours to his or her employment.1 Thus, the workplace can be an important partner in effective and efficient efforts for health promotion and disease prevention for chronic diseases. The worksite can also be a key contributor to the positive overall physical, mental, and emotional well-being of its workers.2 In the United States and worldwide, chronic disease is a significant burden to economic and health care systems. Chronic disease is projected to continue to increase dramatically in the coming years.3-5 Among the chronic diseases, cardiovascular diseases (CVDs) are the number-1 cause of morbidity and mortality worldwide as well as are very costly.6 Significant evidence continually reveals that many of the chronic diseases are caused by poor lifestyle Sutliffe—Reducing CVD Risk Factors for Worksites
habits that are largely avoidable or can be delayed. Of the modifiable risk factors that contribute to chronic diseases, dietary habits are often considered the most important behavior to address. Numerous studies have shown that nutrient-dense, plantrich (NDPR) diets are effective in reducing risk factors for CVD and other chronic diseases. The NDPR dietary patterns have been proven to be safe and effective in community and clinical applications and have been associated with (1) weight reduction,7,8 (2) lipid normalization and management,8-11 (3) glycemic control in diabetes,12 (4) inflammation reduction,13 (5) a reduction in the perceptions of hunger,14 (6) precautionary approaches for cancer,15 and (7) overall health and longevity.16 In addition, NDPR dietary interventions have also been shown to be an efficient and cost-effective approach to reducing health care costs.17 However, despite the fact that the worksite can serve as an excellent location for dietary interventions focused on a reduction in the risk factors for chronic disease, the NDPR approach in the workplace has been largely underused. The purpose of the current pilot study was primarily to determine the effectiveness of conducting an NDPR intervention at a worksite on a university campus to reduce CVD risk factors. METHODS Participants In the pilot study, a total of 35 employees participated. The mean age was 42.57 years, with a range of 24 to 61 years, and 91.4% were female. Regarding ethnicity, 80% were Caucasian; 8.6% were Hispanic; 5.7% were black; and 5.7% were Native American. Participants were included if they (1) had a body mass index (BMI) >25 kg/m2, (2) were ready and willing to make a lifestyle change, (3) were not currently participating in a weight loss program, and (4) were not taking any medications that could increase medical risk or had weight loss as a primary side effect. Inclusionary criteria included individuals with a BMI of ≥25 kg/m2, individuals ready and willing to make a lifestyle change, and individuals not currently participating in a weight loss program or taking weight loss medications. A total of 39 individuals initially consented to participate in this study but 4 decided not to begin when the study started. Participants were recruited through an email blast to employees, flyers, and Web site promotion by the Department of Employee Assistance and Wellness (EAW) at the Northern Arizona University (NAU) (Flagstaff, AZ, USA). The protocol and design of the study were approved by NAU Institutional Review Board, and all participants provided written informed consent. Procedures Participants attended a 12-hour immersion program prior to commencement of the intervention. The 12 hours consisted of 8 segments or lectures in the course of 2 days in a seminar style. The sessions explained in detail the Sutliffe—Reducing CVD Risk Factors for Worksites
foundational principles of the intervention. Significant portions of each session were dedicated to a discussion of the practical application of the principles as well as to questions and answers. Participants then attended a 1-hour, weekly, group meeting to receive instruction, support, and encouragement; to see a cooking demonstration and participate in a food tasting; and to interact with other volunteers and the research team. The meetings took place during each of the subsequent 6 weeks of the pilot study, excluding week 3 in which the spring break occurred. The NDPR dietary protocol, also called a Nutritarian diet, consisted of foods commonly found in local grocery stores and food markets. The diet was vegetable based, emphasizing daily consumption of greens, beans, legumes, and a variety of other vegetables, as well as fresh or frozen fruits, nuts, seeds, and whole grains. Participants were encouraged to minimize the consumption of refined grains, vegetable oils, and processed foods and to limit animal products to 8 oz. (227 g) or less per week. The Nutritarian diet does not generally emphasize portion sizes or specific caloric intake and is designed to be (1) micronutrient rich (ie, particularly high in plant-derived phytochemicals); (2) nutritionally complete; and (3) hormonally favorable, avoiding carbohydrates with a high glycemic index that could elevate levels of serum insulin. Participants were encouraged to sign up for a complimentary, electronic e-mail service that provided daily email notices from Monday through Friday with health information, recipes, food ideas, and educational materials, including videos, print material, and web site membership. To offer a memorable guide for daily food choices, the participants were provided with the acronym GBOMBS+T. The acronym represents greens, beans, onions, mushrooms, berries, seeds and nuts, plus tomatoes. The use of a multivitamin containing B12, iodine, zinc, and vitamin D was also encouraged as well as the ingestion of a relatively small amount of eicosapentaenoic aciddocosahexaenoic acid (EPA-DHA) from algae to assure consumption of comprehensive and adequate nutrients, given the small amount of animal products recommended by the program. Participants were encouraged to continue their current exercise habits and not to alter their physical activity drastically during the period of the intervention. Participants were also encouraged to notify their primary health care providers to inform them of their intentions to participate in the intervention. They were provided contact information for providers of health services at the worksite in the event that they needed those services. Participants did not receive financial compensation but were eligible for incentives through their EAW, potentially reducing their health insurance premiums. Upon completion of each phase of the study, participants were eligible to receive a set number of points for each aspect of the treatment ALTERNATIVE THERAPIES, SEP/OCT 2016 VOL. 22 NO. 5 25
Figure 1. Nutritarian General Plan and Guidelines Type of Use Food Unlimited
Green vegetables All raw vegetables Nonstarchy vegetables Fresh and frozen whole fruit, with no added sugar Beans and other legumes
Limited daily
Cooked starchy vegetables Whole grains Raw seeds and nuts
Limited weekly
Fish Fat-free dairy Wild meat and fowl Eggs
Rarely
Refined grains Full-fat dairy, including cheese Refined oils and sweets
that corresponded to a reduction in insurance premiums. For the full credit of points, participants were required to complete the entire study successfully. Drawings for gift cards were also made at the weekly meetings to provide an added incentive to attend the meetings. Outcome Measures One week before the immersion training and 1 week following the 6 weeks of the intervention, participants had blood draws after 12 hours of fasting to assess (1) serum lipids—total cholesterol (TC), high-density lipoproteins (HDLs), low-density lipoproteins (LDLs), non-HDLs, cholesterol to HDL (CHOL-HDL) ratio, very low density lipoproteins (VLDLs), and triglycerides; (2) anthropometric measurements—height, weight, waist and hip circumference, and BMI; (3) waist-to-hip ratio (WHR); and (4) systolic blood pressure (SBP) and diastolic blood pressure (DBP). Attendance was measured in total hours of attendance throughout the entire study and recorded each week. Compliance was measured each week by having the participants self-report using a questionnaire, which recorded the percentage of food consumed that adhered to the dietary guidelines of the intervention. Participants wore a wGT3X-BT Monitor, a wrist-worn triaxial accelerometer, from ActiGraph (Pensacola, FL, USA) during a 7-day portion of the intervention, to rule out physical activity as a confounder. The measures included daily axis counts, average counts per minute/per day, and average steps per day to capture and record continuous, high resolution physical activity, and sleep/wake information. This information allows for the tracking of activity and rest periods for each 24-hour period.
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Statistical Analysis SYSTAT software version 13.1 was used for all analyses (Systat Software, Inc, San Jose, CA, USA). An alpha of .05 was used for all determinations of significance. To determine whether significant changes in the outcome measures occurred across time, paired-sample t tests and Wilcoxon signed-ranks tests were used. Wilcoxon tests were used if either or both of the times sampled did not have a normal distribution, based on the Shapiro-Wilk test. Change variables were created for each of the outcome variables to examine the association between change and attendance, diet compliance, and activity level. Because neither the attendance, activity, or compliance variables had a normal distribution based on the ShapiroWilk test, associations were measured using Spearman correlations. RESULTS Anthropometric Measurements Because BMIs, measurements of waists and hips, and WHRs were all normally distributed, nondirectional pairedsample t tests were selected as the appropriate measures of change (Table 1). A significant decrease in BMIs occurred from time 1 to time 2, with the mean change being a decrease of 1.75 inches (4.4 cm), with t = 11.107, df = 34, and P < .001. Significant reductions also occurred in the measurements of participants’ waists, with a mean decrease of 1.89 inches (4.8 cm), t = 7.368, df = 34, and P < .001, and of participants’ hips, with a mean decrease of 1.79 inches (4.5 cm), t = 8.582, df = 34, and P < .001. No significant change occurred, however, in the WHR, with t = 0.964, df = 34, and P = .340. Given that body weight (pounds) were not normally distributed, a Wilcoxon signed-rank test was used to assess change across the 6-week period. The test indicated a significant change from time 1 to time 2, with the time 1 median = 184, the time 2 median = 173.5, z = -5.161, and P < .001. Blood Pressure At time 1, neither SBP nor DBP were normally distributed. A Wilcoxon signed-rank test was used and indicated significant change across time for both the SBP, with z = -3.732 and P < .001, and the DBP, with z = -4.757 and P < .001. Fasting Serum The Shapiro-Wilk tests indicated that all variables did not meet the test of normality required for paired-sample t tests, except for the HDL and eAG. A significant decrease occurred in HDL from time 1 to time 2, with a mean change of 5 mg/dL, t = 4.201, df = 34, and P < .001, and in the eAG, with a mean change of 2.35 mg/dL, t = 2.795, df = 34, and P = .008. The Wilcoxon signed-rank test also indicated significant changes in non-HDL, with z = -4.440 and P < .001, and LDL, with z = -4.575 and P < .001. However, no significant change took place in the CHOL-HDL ratio, with z = -1.050 and P = .294, and VLDL, Sutliffe—Reducing CVD Risk Factors for Worksites
Table 1. Preintervention and Postintervention Outcome Measures
Measure
Normality Test Result (Shapiro Wilk), P < .05
Time 1: Mean ± SD
Time 2: Mean ± SD
t Test
Time 1: Time 2: Median Wilcoxon Median and and Interquartile Signed Ranks Interquartile Range Range Test
188.96 ± 31.86
178.21 ± 29.30
11.164 df = 34 P < .001
Both normal
30.93 ± 4.02
29.18 ± 3.64
11.107 df = 34 P < .001
30.10 5.43
29.00 5.05
Waist (in)
Both normal
39.84 ± 4.27
37.95 ± 4.15
7.368 df = 34 P < .001
40 5.63
38 5.31
Hips (in)
Both normal
45.20 ± 3.73
43.41 ± 3.41
8.582 df = 34 P < .001
44.5 4.94
42.75 5.44
WHR
Both normal
0.883 ± 0.08
0.876 ± 0.084
0.964 df = 34 P < .340
0.900 0.14
0.890 0.12
SBP (mm Hg) Time 1 not normal
125.08 ± 23.86
118.43 ± 10.69
1.81 df = 34 P < .08
128 13.5
118 11.75
Significant z = -3.732 P < .001
DBP (mm Hg) Time 1 not normal
86.23 ± 8.79
79.31 ± 7.22
6.691 df = 34 P < .001
84 10.0
80 10
Significant z = -4.757 P < .001
Weight (lb)
Weight 2 not normal
BMI (kg/m2)
184 32.25
173.5 26.19
z = -5.161 P < .001
TC (mg/dL)
Both not normal
190.14 ± 50.32
170.26 ± 46.25
8.182 df = 34 P < .001
183 42.25
159 42.75
z = -4.940 P < .001
Triglycerides (mg/dL)
Both not normal
114.34 ± 66.55
107.57 ± 61.13
0.947 df = 34 P = .35
104 89.5
92 69.0
z = -0.710 P =.478
CHOL-HDL ratio
Both not normal
3.511 ± 1.48
1.482 df = 34 P = .148
3.3 1.80
3.3 1.75
z = -1.050 P =.294
3.634 ± 1.61
HDL (mg/dL) Both normal
57.34 ± 15.99
52.34 ± 14.13
4.201 df = 34 P < .001
54 18.5
51 16.5
Non-HDL (mg/dL)
Both not normal
132.80 ± 55.21
117.91 ± 49.55
5.871 df = 34 P < .001
135 60.75
105 52.5
z = -4.440 P < .001
LDL (mg/dL)
Both not normal
110.11 ± 46.69
96.49 ± 43.01
5.905 df = 34 P < .001
109 42.25
87 50
z = -4.575 P < .001
VLDL (mg/ dL)
Both not normal
22.86 ± 13.29
21.49 ± 12.24
0.955 df = 34 P = .347
21 18.0
18 14.25
z = -0.772 P =.440
eAG (mg/dL)
Both normal
111.66 ± 9.47
109.31 ± 9.45
2.795 df = 34 P =.008
111 16.25
108 14.0
Abbreviations: BMI, body mass index; WHR, waist-to-hip ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; TC, total cholesterol; CHOL-HDL, cholesterol to high-density lipoprotein; HDL, high-density lipoprotein; LDL, low-density lipoprotein; VLDL, very low density lipoprotein; eAG, estimated average glucose. with z = -0.772 and P = .440. Similarly, no change occurred in triglycerides, with z = -0.710 and P = .478.
Sutliffe—Reducing CVD Risk Factors for Worksites
Attendance and Compliance A significant relationship existed between meeting attendance and 2 of the activity variables, daily axis counts ALTERNATIVE THERAPIES, SEP/OCT 2016 VOL. 22 NO. 5 27
Table 2. Spearman Correlations Between Outcome Variables and Overall Attendance and Overall Dietary Compliance
Overall attendance at meetings Overall compliance Change in weight Change in BMI Change in waist measurement Change in hips measurement Change in WHR Change in SBP Change in DBP Change in TC Change in triglycerides Change in CHOL-HDL Change in HDL Change in non-HDL Change in LDL Change in VLDL Change in EAG
Overall Attendance at Meetings 1.00 .207 .444 .431 -.033 .328 -.144 .172 -.173 .168 -.113 -.197 .355 .024 -.035 -.124 .073
P
