Every year, approximately 795,000 people experience

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1 244 Evidence Supporting the Incorporation of the Dietary Approaches to Stop Hypertension (DASH) Eating Pattern Into Stroke Self-Management Programs: A Review Gayle Satterfield, Jane Anderson, Carolyn Moore ABSTRACT Stroke is a major source of mortality and morbidity in the United States. Nutrition can impact factors that increase the risk of stroke such as hypertension, obesity, elevated blood lipids, and diabetes. The Michael E. DeBakey Veteran s Affairs Medical Center (MEDVAMC) has developed the Self-Management to Prevent (STOP) Stroke Program to help veterans at risk for stroke and stroke recurrence. Patient initial feedback indicated a desire for more in-depth nutrition education in the STOP Stroke program. To address the needs of veterans living some distance from the MEDVAMC, a video teleconference program was developed and modified to include the Dietary Approaches to Stop Hypertension (DASH) diet nutrition concepts. This literature review summarizes the scientific evidence used to support the incorporation of the DASH eating pattern into the MEDVAMC STOP Stroke video teleconference program. Institutions can use this review to support development of similar nutrition education components for other stroke risk management programs. Keywords: DASH diet, lifestyle modification, stroke, stroke education, stroke risk self-management, video teleconference group class Every year, approximately 795,000 people experience a new or recurrent stroke event. Approximately every 40 seconds, someone in the United States has a stroke, and every 4 minutes, someone dies from a stroke. When not included with all cardiovascular events, stroke is the third leading cause of all deaths (Lloyd-Jones et al., 2010), and stroke represents a major source of mortality and morbidity in the United States (Furie et al., 2011). An estimated 6.4 million people over the age of 20 years have experienced a stroke (Lloyd-Jones et al., 2010). Although 15% of strokes are heralded by a transient ischemic attack (TIA), it is difficult to determine the prevalence of TIAs because approximately half of all Questions or comments about this article may be directed to Gayle Satterfield, RD, at gaylerae@gmail.com. She is a graduate student at Texas Woman s University, Houston, TX. Jane Anderson, PhD RN FNP-BC, is an assistant professor of Neurology at Baylor College of Medicine, and Associate Director Nurse Practitioner of the Stroke Center at Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. Carolyn Moore, PhD RD, is an assistant professor at Texas Woman s University, Houston, TX. The V-STOP Stroke Program Pilot Study in which this review was created from is funded by the Veteran Affairs Health Services Research and Development. No other conflicts of interest are declared. Copyright B 2012 American Association of Neuroscience Nurses DOI: /JNN.0b013e patients who experience a TIA do not seek medical attention (Lloyd-Jones et al., 2010). Stroke represents a significant economic burden to individuals with the cost of a stroke averaging $140, 048 (Lloyd-Jones et al., 2010). Overall, in 2010, medical costs associated with strokes were estimated to be $73.3 billion. Each year, among the annual population of individuals who had a stroke in the United States, approximately 17,000 are veterans. It is common for the veteran population to have both modifiable and nonmodifiable risk factors for stroke with one of the biggest stroke risk factor being hypertension, which affects 8.5 million veterans. Numerous studies have shown that stroke risk can be reduced with effective risk factor management (Gordon et al., 2004). Optimal stroke risk reduction requires clinicians and patients to work together (Sacco et al., 2006; Veterans Health Administration DoD, 2003) for effective integration of clinical management with patient education and self-management skills (The Joint Commission, 2005, 2009). Despite being recommended in clinical practice guidelines, education is not routinely provided for patients to develop self-management skills to reduce stroke risk (Doroodchi et al., 2008; Greenlund, Giles, Keenan, Croft, & Mensah, 2002). However, the Joint Commission has recently added self-management support as a measure of quality, which is likely to increase the practice (Department of Veterans Affairs, 2007).

2 Volume 44 & Number 5 & October To address the need for stroke risk reduction, the Michael E. DeBakey Veteran s Affairs Medical Center (MEDVAMC) developed the Self-Management to Prevent (STOP) Stroke Program to help veterans who were at risk for stroke and stroke recurrence. The STOP Stroke Program incorporated a collaborative care model in which patients and providers partner in the management of stroke risk factors. The comprehensive stroke risk reduction program applied the principals of the Chronic Care Model (Wagner, 1998) and other well-established self-management programs (Agency for Healthcare Research and Quality, 2007; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Bodenheimer, Wagner, & Grumbach, 2002; Chodosh et al., 2005; Glasgow, Christiansen, Smith, Stevens, & Toobert, 2009; Warsi, Wang, LaValley, Avorn, & Solomon, 2004). Veterans were involved as decision makers in their own care. They were taught skills to help take on responsibility for the day-to-day management of the multiple chronic health problems that contribute to stroke risk. Patients received stroke education and self-management skills to control stroke risk during the course. Satisfaction with the STOP Stroke Program was high among patients with all (100%) agreeing or strongly agreeing that the program helped them understand the importance of stroke risk factors and self-management to reduce their stroke risk. However, some participants reported that transportation barriers, such as the distance from home to the MEDVAMC and the cost of gasoline, were major limitations to participation in the program. Therefore, a video teleconference (V-Tel) program was created for the VA Community-Based Outpatient Clinics known as the V-STOP Stroke Program. The V-STOP Stroke Program was composed of three group classes for all participants, one individual follow up counseling telephone interview in-between classes, and a clinic visit at the beginning and end of the 6-week program. The topics included developing action plans, checking blood pressure, smoking cessation, diet, exercise, and stress management. The V- STOP Stroke Program was tested through a two-phase pilot study investigating delivery, content, and the feasibility of undertaking a large-scale study of this type of behavioral intervention. However, literature supporting the use of group self-management education classes by V-Tel was lacking. From the early feedback from the first phase of the V-STOP Stroke Pilot Study, there was a significant request from participants for more in-depth nutrition education. Therefore, during the second phase of the pilot study, the class course structure was modified to utilize one entire group class meeting to focus entirely on nutrition. The aim of this article is to review the literature and rational for inclusion of the Because nutrition often affects the major risk factors for both TIA and stroke, effective, in-depth nutrition education could be a significant component of preventive care. nutrition principles and DASH diet into the nutrition class. If the effectiveness of teaching nutrition through V-Tel in group settings could be shown, this information would prove beneficial for developing other programs for rural dwelling older adults in need of health prevention. The Role of Nutrition Nutrition can play a large role in the prevention of stroke and TIA. Nutrition impacts the following major modifiable risk factors for stroke: hypertension, obesity, high blood lipids, and diabetes (Furie et al., 2011). To reduce these modifiable risk factors through healthy eating, veterans were taught in the V-STOP Stroke nutrition class to read nutrition fact labels, to measure appropriate portion sizes, and to apply the principles of the DASH eating pattern. Following the DASH diet has been shown not only to aid in controlling hypertension but also to help in the management of all of the major modifiable risk factors for stroke. DASH Diet The DASH study was a multicenter trial that compared a typical American diet with a diet rich in fruits, vegetables, and low-fat dairy products in combination with a reduction of saturated fat, total fat, and sodium. The study was conducted in adults (mean age, 44 years) with systolic blood pressure of G160 mmhg and diastolic blood pressure of 80Y95 mmhg. All subjects received the control diet for 3 weeks and then were randomly assigned to follow the DASH diet or to remain on the control diet for 8 weeks (Appel et al., 1997). In comparison with the control diet, the DASH diet was low in total fat, saturated fat, cholesterol, and sodium and high in fiber, potassium, magnesium, and calcium (Table 1). The DASH eating pattern was specifically designed to provide six to eight servings of grains; four to five servings of vegetables; four to five servings of fruit; two to three servings of fat-free or low-fat milk products; six ounces or less of meat products; four to five servings of nuts, seeds, or legumes;

3 246 TABLE 1. Nutrient Content of the Control and Dietary Approaches to Stop Hypertension (DASH) Diet Nutrient Control Diet DASH Diet Fat (% total kcal) Saturated 16 6 Monounsaturated Polyunsaturated 8 8 Carbohydrate (% total kcal) Protein (% total kcal) Cholesterol (mg/day) Fiber (g/day) 9 31 Potassium (mg/day) Magnesium (mg/day) Calcium (mg/day) Sodium (mg/day) Note. Values are for diets designed to provide an energy intake of 2100 kcals/day. Based on Appel et al. (1997). two to three servings of fats and oils; and less than five servings of sweets and added sugars per week (U.S. Department of Health and Human Services, 2006). In the initial DASH diet study, 70% of the DASH diet group with untreated hypertension at baseline achieved normal blood pressure by the end of 8 weeks compared with 23% of the control diet group (Conlin et al., 2000). Following the DASH diet resulted in low intakes of total fat, saturated fat, and cholesterol and high intakes of potassium, calcium, magnesium, protein, and fiber (Lin et al., 2007). Effectiveness of Lifestyle Intervention Programs Using the DASH Diet Programs applying behavioral plus diet modifications in free living adults, similar to the V-STOP Stroke Program, have been shown to be effective. The DASH diet when incorporated into a comprehensive lifestyle modification program significantly lowered blood pressure. In the PREMIER Trial (Appel et al., 2003), 810 participants with a mean age of 50 T 8.9 years who had pre- through stage 1 hypertension ( systolic, 120Y159 mmhg or diastolic, 80Y95 mmhg) were randomly assigned to one of 6-month interventions: (a) behavioral lifestyle, (b) behavioral lifestyle with DASH diet, or (c) the advice-only control group. None of the participants regularly took medications to control blood pressure. Both groups with behavioral lifestyle interventions met weekly for group sessions for 8 weeks, then biweekly for 6 months, and then monthly for 12 months. The participants received seven individual counseling sessions throughout the 18 months. Selfmonitoring, goal setting, problem solving, and social support were important aspects of the program. At baseline, 6 months, and 18 months, clinical measurements and 24-hour dietary recalls were performed. The behavioral lifestyle intervention with the DASH dietary patterns was more effective than the behavioral lifestyle intervention group at meeting DASH-specific targets and the daily recommended nutrient intakes. The behavioral plus DASH group had higher fruit, vegetable, and diary intake resulting in higher fiber, vitamin and mineral intake, and a significantly higher mean reduction of 4.3 mmhg in blood pressure. Both intervention groups statistically decreased the prevalence of hypertension compared with the control group (Appel et al., 2003). Challenges to Implementing the DASH Diet The benefits from the DASH diet depend on the ability to make long-lasting dietary changes. Typically, the major challenge is reducing sodium intake because sodium is so prevalent in the food supply due to the overabundance of processed foods (Sacks et al., 2001). Although the DASH diet trials have shown that lowsodium intake can be achieved, studies always note that following sodium reduction guidelines outside of a research setting is difficult (Sacks et al., 2001). Another challenge to the DASH diet is the taste of low-sodium products, which often can be bland. In a study assessing the acceptability of sodium-reduced diets (Karanja et al., 2007), participants were placed on either a DASH diet or a control diet at three levels of sodium intake: high (3.5 g), intermediate (2.3 g), and low (1.2 g). Questionnaires using a 9-point ranking scale assessed the liking and willingness to consume the DASH or control diet. Results indicated that the intermediate level of sodium intake for both the DASH and control diets was the most acceptable (Karanja et al., 2007). Hypertension An estimated 72 million Americans have hypertension defined as systolic blood pressure of Q140 mmhg or diastolic blood pressure of Q90 mmhg(appel et al., 2006). A meta-analyses of randomized control trials show that lowering blood pressure is associated with a 30%Y40% reduction in stroke risk (Furie et al., 2011). Along with medications, weight loss; increased physical activity; decreased alcohol consumption; and increased consumption of fruits, vegetables, and low-fat dairy products have been found to reduce blood pressure levels (Furie et al., 2011).Dietary modifications can be used as an initial treatment before medication is prescribed for patients with stage I hypertension

4 Volume 44 & Number 5 & October (systolic blood pressure, 140Y149 mmhg or diastolic blood pressure, 90Y99 mmhg). Even patients already on medications can lower blood pressure further by diet adjustment (Appel et al., 2006). Benefits of the DASH diet were studied in a randomized controlled trial at various sodium levels with participants who had blood pressure levels above 120/80 mmhg (Sacks et al., 2001). Participants were assigned to eat the typical American diet or the DASH diet for 30 consecutive days. Each group was then randomized to consume high (3.3 g), intermediate (2.5 g), or low (1.5) levels of sodium. Researchers confirmed that blood pressure can be lowered by following the DASH diet or the typical American diet with low-sodium consumption. However, the combined effects of the low-sodium intake and the DASH diet had the greatest impact on blood pressure reduction that was equal to or greater than single-drug therapy (Sacks et al., 2001). Alcohol Consumption Limiting alcohol consumption is a lifestyle intervention associated with decreased blood pressure and thus decreased stroke risk (Furie et al., 2011). A metaanalysis of randomized controlled trials of self-reported reduced alcohol consumption reported by participants decreased systolic blood pressure by 3.3 mmhg and diastolic blood pressure by 2.0 mmhg. This relationship was found to be dose dependent (Xin, Frontini, Odgen, Motsamai, & Whelton, 2001). Additional evidence has suggested that moderate alcohol consumption lowers blood pressure. For this benefit to be realized, men must consume less than or equal to two drinks per day and women should have less than or equal to one drink per day. Portion sizes of one drink are defined as 12 ounces of beer, 5 ounces of wine, and 1.5 ounces of 80 proof distilled spirits (Goldstein et al., 2010). Obesity Obesity defined as a body mass index (BMI) of Q30 kg/m 2 has been shown to be an independent risk factor for cardiovascular disease and premature mortality (Furie et al., 2011). Ideally individuals should strive to achieve and maintain a BMI of G25 kg/m 2 for decreased risk of heart disease (Appel et al., 2006). However, any weight loss, regardless of meeting the BMI goal, can yield positive results. In a meta-analysis of the impact of weight loss on blood pressure reduction, 25 randomized controlled trials with 4,874 participants concluded that a 5-kg weight loss resulted in a decrease in systolic blood pressure of 4.4 mmhg and a decrease of diastolic blood pressure of 3.6 mmhg (Neter, Stam, Kok, Grobbee, & Geleijnse, 2003). The Exercise and Nutritional Intervention for Cardiovascular Health study evaluated the effects of the DASH diet in combination with exercise in 144 overweight or obese (BMI = 25Y40 kg/m 2 ) subjects with elevated blood pressure who were not taking hypertensive medications. The subjects were randomized into three groups: (a) the DASH diet, (b) the DASH diet in combination with a weight management intervention and aerobic exercise, and (c) usual diet as the control. Participants in thedashdietplusweightmanagement group lost on average 8.7 kg over 4 months. The DASH diet alone intervention lost 0.3 kg, and the usual care control group gained 0.9 kg over that same time period. Relative to the control diet, the DASH diet combined with exercise and calorie reduction was effective for helping individuals to lose weight (Blumenthal, Babyak, Hinderliter, et al., 2010). Portion Sizes and Weight Control To follow the DASH diet guidelines, an understanding of the appropriate serving size is key to avoid overconsumption of energy. It is well acknowledged that food portion sizes have grown over the years. This growth can especially be seen in the restaurant industry. Fast food chains offer two to five times larger hamburgers, sodas, and fries today than their original serving sizes. Larger dinner plates are used, as well as larger pans to bake muffins and pizzas. Even new editions of recipe books report fewer serving yields than their identical older edition (Young, 2003). This increase of portion sizes is paralleled by an increase of rates of overweight and obesity, and those with higher BMIs consume larger portions of food (Ledikwe, Ello- Martin, & Rolls, 2005). A review of portion control studies found that many of the participants in these studies reported feeling fuller when they were given larger portions sizes; however, subjects did not adjust their next meal or snack despite having consumed larger portions at the prior meal, suggesting that large portion sizes may not increase satiety. The review concluded that people who have consumed appropriate portion sizes of low-energy dense foods experience successful weight loss/management through increased satiety and hunger control (Ello-Martin, Ledikwe, & Rolls, 2005). Likewise, another study reported that normal weight subjects given meals and snacks in a laboratory-controlled environment for 2 days had significantly sustained reduced energy intakes when decreased portion sizes were given and larger sustained energy intakes when larger portion sizes were offered (Rolls, Roe, & Meengs, 2006a, 2006b). On the basis of these findings of this literature review, the V-STOP Stroke nutrition class incorporated portion control education and utilized food models to reinforce concepts. The veterans participating in the V-STOP Program found use of food models to teach portion control to be particularly helpful.

5 248 High Cholesterol Elevated blood total cholesterol and low-density lipoprotein cholesterol with a decreased high-density lipoprotein cholesterol are associated with an increased risk for stroke. Therapeutic lifestyle modifications to reduce cholesterol are based on decreased consumption of saturated fat and cholesterol in the diet, weight reduction, and increased physical activity (Furie et al., 2011). The previously described Exercise and Nutritional Intervention for Cardiovascular Health study also examined changes in blood lipids of the three study groups. Participants following the DASH diet with the additional weight loss management interventions had significantly lower total cholesterol and triglyceride levels than the other two groups (Blumenthal, Babyak, Sherwood, et al., 2010). Similarly, another study found that the DASH diet improved blood lipid levels. Subject with type 2 diabetes were randomized into the DASH diet or a control group. At the end of 8 weeks, participants following the DASH diet had significantly higher HDL (+4.3 mg/dl) and lower low-density lipoprotein (j17.2 mg/dl) levels compared with the control group. However, the DASH diet did not have an impact on triglyceride levels (Azadbakht et al., 2011). Diabetes Of the population that experiences ischemic stroke, 15%Y33% have diabetes, making diabetes a clear risk factor for stroke (Furie et al., 2011). Evidence has shown that the current guidelines for glycemic control and blood pressure targets should be followed to decrease the risk for complications of diabetes, including heart disease. Compliance with these guidelines is best achieved through management of diet, exercise, oral glycemic drugs, and/or insulin (Furie et al., 2011). Long-term adherence to the DASH diet was studied with 862 participants through assessment of dietary intake using a 1-year, 114-item food frequency interview. At a 5-year follow-up, participants were evaluated for the development of type 2 diabetes and adherence to the DASH diet was reexamined by food frequency interview. When controlled for race and ethnicity, a strong inverse association was found between DASH diet adherence and type 2 diabetes in Whites, but not in other ethnic groups. However, researchers suggested this divergence in the findings for other ethnic groups was likely due to the sample size of minority populations (Liese, Nichols, Sun, D Agostino, & Haffner, 2009). The ENOCORE study also examined the DASH diet s effect on glycemic control. Once again those in the DASH diet plus weight management group had lower fasting glucose blood levels and better insulin sensitivity levels than the other two groups (Blumenthal, Babyak, Sherwood, et al., 2010). In the PREMIER study, the researchers measured insulin sensitivity by glucose tolerance test in 52 of the participants. The group with the behavior intervention and DASH diet had significantly improved insulin sensitivity compared with the advice-only control group. Specifically, the DASH diet group had a 50% increase in insulin sensitivity from baseline over the 6-month intervention period and a 35% greater increase in insulin sensitivity compared with the behavior intervention group. Although the group with behavior-only interventions improved fasting insulin and glucose levels, these levels failed to reach statistical significance (Ard et al., 2004). Likewise, 31 type 2 diabetic subjects who followed the DASH diet for 8 weeks had significant decreased fasting blood glucose by an average of 29.4 mg/dl and reduction of hemoglobin A1C by 1.7% (Azadbakht et al., 2011). Nutrition Facts Labels The nutrition class of the V-STOP Stroke Program included teaching veterans how to read nutrition facts labels. As of May 1994, all manufactured foods need to contain standardized nutrition information under TABLE 2. Impact of Lifestyle Modifications on Blood Pressure Modification Recommendation Systolic Blood Pressure Reduction DASH diet eating plan Consume diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat Weight Maintain BMI 18.5Y24.9 reduction Dietary Reduce dietary sodium intake to no more sodium Alcohol Limit to no more than two drinks per day (men) or 1 drink/day (women) 5.5Y11.4 mmhg (5.5 mmhg for normotensives, 11.4 mmhg for hypertensives) 4.4 mmhg (for 5.1 kg weight loss) 4Y7 mmhg (for reduction by 6 g in daily salt intake) 3 mmhg (for 67% reduction from baseline of 3Y6 drinks/day) Note. Based on Frisoli et al. (2011).

6 Volume 44 & Number 5 & October the Nutrition Labeling and Education Act of Nutrition facts panels are required to display calories, fat, saturated fat, cholesterol, and sodium, based on the reasoning that poor diets are associated with chronic diseases including cardiovascular disease (Variyam, 2008). The frequency that people read nutrition facts and the dietary outcomes associated with nutrition label reading has been investigated through surveys. It was found that out of 1,450 adults, 35.2% usually read the nutrition labels, 20.1% read them often, and 24% read them sometimes, with a high statistically significant association reported with reading nutrition labels and following a low-fat diet (Neuhouser, Kristal, & Patterson, 1999). Likewise, improvement of dietary intake was shown as significant increases in iron and fiber intake from reading nutrition facts although there was no decrease in total fat, saturated fat, and cholesterol intake (Variyam, 2008). Implications for Nursing Practice Research has shown that multiple lifestyle modifications can sustain reduction of blood pressure and thereby impact the risk of stroke and stroke reoccurrence (Table 2). Loss of body weight with concomitant blood pressure reduction appears to have almost a linear relationship (Steven et al., 2001). Diets rich in fruits and vegetables with low-fat dairy products, such as the DASH diet, and low in saturated fat and total fat are independently effective in reducing blood pressure. Decreasing sodium and increasing potassium intake also reduces blood pressure and stroke risk. In addition, a strong linear relationship exists between alcohol and blood pressure with the greatest reduction of blood pressure occurring when alcohol intake is limited to one drink for women and two drinks for men. The benefit of blood pressure reduction may be lost with greater alcohol consumption (Frisoli, Schmieder, Grodzicki, & Messerli, 2011). Through teaching good nutrition habits and encouraging the DASH eating plan, patients can decrease the risk of a debilitating stroke. All patients, whether they are diabetic, overweight, or have elevated blood lipids or hypertension, can benefit from following the DASH eating plan. This literature review provided the rational to expand the nutrition education class and to incorporate the DASH diet into the V-STOP Stroke Program. In the future, this evidencebased review of research can help justify inclusion of nutrition education and the DASH diet into similar stroke risk management programs at other institutions. References Agency for Healthcare Research and Quality. (2007). Patient self-management support programs: An evaluation. Final contract report. Rockville, MD: Author. Appel,L.J.,Brands,M.W.,Daniels,S.R.,Karanja,N.,Elmer,P.J., & Sacks, F. M. (2006). Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. 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