Food insecurity and effectiveness of behavioral interventions to reduce blood pressure, New York City, 2012-2013.

INTRODUCTION: Food insecurity is associated with diet-sensitive diseases and may be a barrier to successful chronic disease self-management. To evaluate the impact of food insecurity on blood pressure reduction in a pilot clinical trial, we tested the effectiveness of 2 behavioral interventions for hypertension in people with and without food security. METHODS: A group of 28 men and women with type 2 diabetes and uncontrolled hypertension were randomized to either 1) home blood pressure telemonitoring alone or 2) home blood pressure telemonitoring plus telephone-based nurse case management. The primary outcome was 6-month change in systolic blood pressure. RESULTS: The 2 interventions resulted in modest, nonsignificant blood pressure reductions. Food-secure patients experienced clinically and statistically significant reductions in blood pressure, whereas no significant change was seen among food-insecure patients. CONCLUSION: Screening for food insecurity may help identify patients in need of tailored disease management interventions.

Comparative Effectiveness of a Practice-Based Comprehensive Lifestyle Intervention vs. Single Session Counseling in Hypertensive Blacks.

BACKGROUND: Although the efficacy of therapeutic lifestyle change (TLC) interventions are well proven, their relative effectiveness vs. single-session lifestyle counseling (SSC) on blood pressure (BP) reduction in primary care practices remains largely untested in hypertensive Blacks. The aim of this trial was to evaluate the comparative effectiveness of a comprehensive practice-based TLC intervention (motivational interviewing (MINT)-TLC) vs. SSC on BP reduction among 194 Blacks with uncontrolled hypertension. METHODS: The MINT-TLC arm included 10 weekly group classes on TLC, followed by 3 individual MINT sessions. The SSC group received 1 individual counseling session on lifestyle modification plus print versions of the intervention material. The primary outcome was within-patient change in systolic BP (SBP) and diastolic BP (DBP) from baseline to 6 months. The secondary outcome was BP control at 6 months. RESULTS: Mean age of the total sample was 57 (10.2) years; 50% were women, and the mean baseline BP was 147.4/89.3mm Hg. Eighty-four percent of SSC and 77% of MINT-TLC patients completed the final 6-month assessments. BP declined significantly (P < 0.001) in both groups at 6 months with a net-adjusted systolic BP reduction of 12.9 mm Hg for the SSC group vs. 9.5mm Hg for the MINT-TLC group (P = 0.18); and diastolic BP reduction of 7.6 and 7.2mm Hg for the SSC and MINT-TLC group, respectively (P = 0.79). The between-group difference in proportion of patients with adequate BP control at 6 months was nonsignificant (P = 0.82). CONCLUSION: A significant group difference in BP between the intervention groups was not observed among a sample of hypertensive Blacks. Implementation of the pragmatic single-session intervention and its effects on utilization of healthcare services should be further evaluated. CLINICAL TRIAL REGISTRATION: Trial Number NCT01070056 at http://clinicaltrials.gov/ct2/show/NCT01070056?term=TLC+clinic&rank=1.

Race/ethnicity moderates the relationship between chronic life stress and quality of life in type 2 diabetes.

AIMS: To determine whether chronic life stress is differentially associated with quality of life (QoL) for Blacks vs. Hispanics with type 2 diabetes. METHODS: We assessed self-reported chronic stress and QoL in 125 patients with type 2 diabetes who self-identified as either non-Hispanic Black or Hispanic. Separate cross-sectional two-way interaction models (stress × race/ethnicity) with physical and mental health as outcomes were examined. RESULTS: The two-way interaction predicted mental (b=3.12, P=.04) but not physical health. Simple slopes analyses indicated that under conditions of high stress, Blacks (b=-4.4, P<.001), but not Hispanics, experienced significantly lower levels of mental health. In exploratory analyses, we examined a three-way interaction (stress × race/ethnicity × social support) with physical and mental health as outcomes. Results indicated the three-way interaction predicted mental (b=.62, P=.01) but not physical health. Simple slopes analyses indicated that under conditions of high stress, high levels of social support improved mental health for Hispanics (b=1.2, P<.001), but not for Blacks. CONCLUSIONS: Black patients with type 2 diabetes may be particularly vulnerable to the deleterious effects of high chronic stress. Social support buffers effects of stress on mental health in Hispanics but not Blacks, which suggests differences in the use and/or quality of social support between Hispanics and Blacks. Longitudinal investigations that examine race/ethnicity, stress, social support, and QoL should help clarify the processes that underlie these observed relations.

Overcoming barriers to hypertension control in African Americans.

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients.

A practice-based trial of blood pressure control in African Americans (TLC-Clinic): study protocol for a randomized controlled trial.

BACKGROUND: Poorly controlled hypertension (HTN) remains one of the most significant public health problems in the United States, in terms of morbidity, mortality, and economic burden. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes (TLC) for blood pressure (BP) reduction, the effectiveness of these approaches in primary care practices remains untested, especially among African Americans, who share a disproportionately greater burden of HTN-related outcomes. METHODS/DESIGN: This randomized controlled trial tests the effectiveness of a practice-based comprehensive therapeutic lifestyle intervention, delivered through group-based counseling and motivational interviewing (MINT-TLC) versus Usual Care (UC) in 200 low-income, African Americans with uncontrolled hypertension. MINT-TLC is designed to help patients make appropriate lifestyle changes and develop skills to maintain these changes long-term. Patients in the MINT-TLC group attend 10 weekly group classes focused on healthy lifestyle changes (intensive phase); followed by 3 monthly individual motivational interviewing (MINT) sessions (maintenance phase). The intervention is delivered by trained research personnel with appropriate treatment fidelity procedures. Patients in the UC condition receive a single individual counseling session on healthy lifestyle changes and print versions of the intervention materials. The primary outcome is within-patient change in both systolic and diastolic BP from baseline to 6 months. In addition to BP control at 6 months, other secondary outcomes include changes in the following lifestyle behaviors from baseline to 6 months: a) physical activity, b) weight loss, c) number of daily servings of fruits and vegetables and d) 24-hour urinary sodium excretion. DISCUSSION: This vanguard trial will provide information on how to refine MINT-TLC and integrate it into a standard treatment protocol for hypertensive African Americans as a result of the data obtained; thus maximizing the likelihood of its translation into clinical practice. TRIAL REGISTRATION: Clinicaltrials.gov NCT01070056.