February 2010 Issue

Nutrition Education for Heart Health — Interventions That Work
By Maggie Moon, MS, RD
Today’s Dietitian
Vol. 12 No. 2 P. 40

Research is showing that certain strategies, such as communicating dietary advice to adults via the Web, can encourage people to make vital changes to their lifestyle.

As health professionals, RDs can easily name a half-dozen ways to take good care of the heart through diet and lifestyle changes. The good news is that, thanks in part to a whole month dedicated to raising awareness about heart health, most clients can likely do the same. Many could also follow the general tenets of a healthy diet without too much difficulty, including consuming a good amount of fruits, vegetables, whole grains, and lean proteins and a limited amount of saturated fat, trans fat, salt, and added sugars. Penny M. Kris-Etherton, PhD, RD, distinguished professor of nutrition at Penn State University, adds that the health benefits of dietary fiber and omega-3 fatty acids are also gaining recognition.

There is no doubt that awareness is key. RDs know clients are more inspired to change their behavior when they understand why doing so is important. However, behavior change is complex, and motivating clients to take action can be difficult. They must realize why the change is necessary, learn how to make the change, and commit to putting recommendations into action. Nutrition education is an essential component.

Read on for a review of how well people are complying with dietary recommendations targeting heart health and a look at recent interventions aimed at answering this question: When it comes to a heart-healthy diet, what works?

The United States of Noncompliance
According to a recent research article by Henson et al, people have the most difficulty complying with the heart-health–related dietary recommendation to reduce red meat consumption.1 The difficulty of complying was based on self-report and measured using a Rasch model; a regression analysis identified behavior determinants.

Though participants struggled most with cutting back on red meat, for every three people who found limiting red meat difficult, two had trouble meeting the recommended daily intake of fruits and vegetables. The results support Srinivasan’s 2007 finding that Americans would need to drastically change their eating patterns to meet dietary guidelines. For example, Americans would need to eat 80% more fruits and 37% more vegetables.2

The next bit of dietary advice participants found challenging was reducing their intake of negative nutrients such as excess fat and salt. In order of difficulty, the next most challenging foods for people to limit were full-fat dairy, fatty and/or salty snacks, fried foods, and foods that are high in salt.1

Participants complied more easily with some recommendations, such as using oils higher in unsaturated fats (eg, vegetable oils). They also had an easier time controlling salt shaker habits while cooking and at the table. A strong media and political awareness of the dangers of trans fats may have contributed to participants being able to easily avoid foods that contain trans fats. And finally, participants reported choosing to use low-fat cooking methods such as baking, broiling, and steaming.1

The study authors suggest that compliance is easier when the target behavior change involves simple substitutions or changes in cooking habits compared with a potentially larger shift such as limiting red meat intake.1 In addition, when cooking at home, clients can have more control over what they eat and how it’s prepared.

Personal factors also play a part. People were better able to follow dietary advice if they were at least 55 years old, already valued food and nutrition for health, were female, and had cholesterol levels that made them worry about the risk of developing cardiovascular disease.1 Research suggests that the increased risk for developing heart disease is made clearly and personally relevant when people learn they have high blood cholesterol. It’s a strong trigger for clients to make significant lifestyle changes.3

It should be encouraging that one out of every three U.S. adults is acting in favor of heart health. A 2009 data brief from the Centers for Disease Control and Prevention reported that about one third of Americans complied with six or more recommendations out of nine (1999 to 2002 data).4 However, in general, Americans demonstrated low compliance with dietary recommendations. The lowest rated compliance was for meeting daily fruit intake recommendations (about 16%); the highest rated compliance was for having blood pressure checked within two years (more than 90%).

The following is how dietary compliance fared, though none of the results met Healthy People 2010 targets:

• About 16% of adults ate two to four servings of fruit daily.

• Approximately 29% ate three to five servings of vegetables per day.

• Nearly 31% consumed 2,400 mg or less of sodium daily.

• About 42% kept calories from saturated fat intake under 10% of a day’s total energy intake.

As RDs, we stay up-to-date on strategies for helping clients eat right so we can stockpile a variety of tactics to match different situations. Arm yourself with the successful aspects of recent nutrition education interventions.

Adult Strategies
Researchers are field testing a variety of strategies for encouraging Americans to maintain a healthier diet—from peer nutrition education to stand-alone Web-based programs. Despite their diversity, these methods have each enjoyed a measure of success.

With older adults becoming increasingly active in online communities, it’s more feasible to target this group with Web-based nutrition education for chronic disease prevention and treatment.

A longitudinal observational study that leveraged the proven Dietary Approaches to Stop Hypertension (DASH) eating plan tested an Internet-based nutrition education program over a 12-month period. Those who visited the Web site more often experienced greater weight loss and drops in blood pressure.5

The program provided weekly nutrition articles and dietary advice based on the DASH diet to 735 adult volunteers (26% of the original enrollees). With nearly three out of four original participants dropping out, it’s important to remember that results may reflect what’s possible with only the most motivated clients.5

The researchers tracked participants’ food intake online via self-report and measured success based on changes in weight, blood pressure, and quality of food intake at the 12-month mark in comparison to baseline intake. Participants who were overweight (body mass index greater than 25) lost an average of 4.2 lbs (P < 0.001); those with high blood pressure saw systolic blood pressure fall 6.8 mmHg (P < 0.001); and diastolic blood pressure also dropped, but results were not significant (2.1 mmHg, P = 0.16). Overall results showed an increase in fruit and vegetable intake and a decrease in carbonated beverage consumption.

Although Web-based programs do not replace a relationship with a health professional, they may be an additive strategy to help adults successfully follow dietary guidelines.5

Peer-to-peer nutrition counseling can improve general nutrition knowledge, attitudes, and behaviors, as well as diabetes self-management, a common heart disease comorbidity, according to a systematic review of 22 peer-counseling efforts among Latinos, the largest minority group in the United States. Overall, programs aimed at diabetes management improved glycemic control, lipid profiles, blood pressure, knowledge about diabetes, and self-management.6

For example, in a randomized, controlled trial on the Texas-Mexico border, a culturally specific program resulted in a 0.45% decrease in hemoglobin A1c (HbA1c) for the intervention group compared with the control group (P < 0.001). The program included eight weekly two-hour classes, follow-up telephone calls, and biweekly postcards encouraging behavior change. Another program that included seven hours of personalized counseling and individualized case management over one year resulted in a drop in HbA1c of 1.08% (P < 0.01).6

An intervention that involved seven sites across five states (n = 320 people in 223 families) provided weekly group education sessions at community centers over a six-month period. Participants learned through workbooks, picture books, easy-to-read booklets, and videos, as well as follow-up home visits. Based on pretests and posttests, participants improved heart-healthy behaviors such as getting more exercise and losing excess weight.6

Another peer-counseling intervention added goal setting as “homework,” and the results from the 14-week randomized, controlled trial in San Diego County showed improved overall energy intake. The intervention utilized weekly home visits (or telephone calls) and 12 tailored newsletters to reach out to 357 Spanish-speaking participants. They were given homework assignments each week by mail that helped them set behavioral goals for eating right.6

Pediatric Health Promotion
An American Heart Association (AHA) position statement on heart-health promotion in schools helped renew energy for school-based interventions in 2004, and we are now seeing published results from these interventions. Citing epidemiological, clinical, and lab studies, the AHA position paper concluded that primary prevention of cardiovascular disease should start from early childhood, including preschool.7 In particular, the AHA supports the idea of population-based programs that make healthful changes to food and physical activity environments to facilitate healthful behaviors.

An Oregon-based 10-week intervention for the fourth grade called Be a Fit Kid taught children about heart-healthy nutrition. The program had a strong focus on physical fitness, with 40-minute sessions held three times per week. Participants included elementary school children and their parents, who were offered five lessons and nutrition workbooks. The children had weekly 45-minute lessons that encouraged a diet rich in vegetables, fruits, whole grains, low-fat dairy, legumes, and omega-3 fatty acids from foods such as salmon, tofu, and nuts. The curriculum discouraged saturated and trans fats that might be in foods such as red meat, cheese, fried foods, and processed foods. The children were also taught to limit refined carbohydrates found in sugary cereals, white flour products, candy, and soda. The tactical tools included workbooks, food displays, heart models, and nutrition bingo. The children tasted healthy foods each week.8

Compared with a control school that did not receive the intervention, saturated fat and sodium intakes were lower (P < 0.05), nutrition knowledge was higher (P < 0.01), and total and LDL cholesterol were lower (P < 0.01) in the intervention school. In a comparison of preintake and postintake, the fourth-grade children decreased their intake of red meat (69%), cheese (58%), candy (71%), and soda (92%) and increased their intake of vegetables (79%), fruits (88%), grains (76%), water (73%), and healthy fats (59%).

The Be a Fit Kid program is one to watch; since the fourth-grade intervention results were published in early 2009, the program has expanded to a curriculum serving first through fifth grades.8

A school-based program in Mississippi took a simpler approach and asked whether improving fruit and vegetable intake might be as easy as providing fruits and vegetables for free. The pilot program from the Mississippi Department of Education examined changes in children’s attitudes toward, familiarity with, preferences for, and intake of fruits and vegetables in five schools. Free fruits and vegetables were provided for students from kindergarten through 12th grade during the 2004-2005 school year, and results were measured through self-report on pretests and posttests (n = 725), as well as 24-hour recalls (n = 207). Overall, results reflected improvements on all success metrics.9

Predictably, participants at all grade levels reported being more familiar with fruits and vegetables (P < 0.05) than at baseline. However, only those in the eighth and 10th grades increased how much they liked them (P < 0.01). Going deeper, results showed that only fruit intake actually increased. The eighth-grade students were more positive about eating both fruits and vegetables and were confident they could eat more fruit (P < 0.01); these students were also more likely to try a new fruit. The pilot program showed that when making it easy for people to access fruits, preferences for and intake of fresh fruits can increase. Boosting actual intake of vegetables may be more challenging, but getting kids to try the “gateway produce” of fresh fruit is a good start.9

The Challenges
Despite the good progress being made, cardiovascular disease is still widely prevalent. Kris-Etherton touches on some of the challenges: “In part, I think there is lack of knowledge about implementing a healthy diet. Lack of motivation also plays a role.” In addition to personal factors, she notes, “There are so many foods readily available in our environment and social situations that make it challenging to follow all current dietary recommendations.” In fact, many of the school-based interventions named reluctance coming from the school environment itself as one of the major barriers to implementing their programs.

A brief review of recent research shows that a diverse range of approaches to nutrition education can be effective when it comes to modifying diets for heart health. Despite differences in the details of how they get there, interventions work best when theory, research, and practice are all linked. The take-away message is to stay up-to-date on the many ways to successfully help people make healthful dietary changes in order to pick and choose the tools that work best for your clients.

— Maggie Moon, MS, RD, is a nutrition writer and dietitian based in New York City.


1. Henson S, Blandon J, Cranfield J, Herath D. Understanding the propensity of consumers to comply with dietary guidelines directed at heart health. Appetite. 2009. Epub ahead of print.

2. Srinivasan CS. Food consumption impacts of adherence to dietary norms in the United States: A quantitative assessment. Agricultural Economics. 2007;37(2-3):249-256.

3. Panzer M, Renner B. To be or not to be at risk: Spontaneous reactions to risk information. Psychology and Health. 2008;23(5):617-627.

4. Wright JD, Hirsch R, Wang CY. One-third of U.S. adults embraced most heart healthy behaviors in 1999-2002. NCHS Data Brief. 2009;(17):1-8.

5. Moore TJ, Alsabeeh N, Apovian CM, et al. Weight, blood pressure, and dietary benefits after 12 months of a web-based nutrition education program (DASH for Health): Longitudinal observational study. J Med Internet Res. 2008;10(4):e52.

6. Pérez-Escamilla R, Hromi-Fiedler A, Vega-López S, Bermúdez-Millán A, Segura-Pérez S. Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: A systematic literature review. J Nutr Educ Behav. 2008;40(4):208-225.

7. Hayman LL, Williams CL, Daniels SR, et al. Cardiovascular health promotion in the schools: A statement for health and education professionals and child health advocates from the Committee on Atherosclerosis, Hypertension, and Obesity in Youth (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110(15):2266-2275.

8. Slawta JN, Deneui D. Be a fit kid: Nutrition and physical activity for the fourth grade. Health Promot Pract. 2009. Epub ahead of print.

9. Coyle KK, Potter S, Schneider D, et al. Distributing free fresh fruit and vegetables at school: Results of a pilot outcome evaluation. Public Health Rep. 2009;124(5):660-669.