Dietary Approaches to Stopping Hypertension (DASH) Mobile App Study

Danielle Sundermier

Major: Biology with Specialization in Neurobiology

11/10/14

BI 495

Abstract:

Backround: Hypertension refers to the blood pressure in the arteries being too high; this prolonged increased pressure can lead to a variety of medical problems, the most prominent being cardiovascular disease (CVD). While pharmaceutical treatments for hypertension have been introduced, they are often cost-ineffective. The Dietary Approaches to Stopping Hypertension (DASH) eating plan and behavioral change interventions have been shown effective in reducing blood pressure in a more cost efficient way.While these methods are oftentimes more cost-effective, they also have higher amounts of data inaccuracies due to the need for participants to self-report their progress. In our study, we avoid this issue by having our data sent to us objectively from the machines themselves. We believe our intervention will be successful due to the convenient mHealth platform, objective data analysis, and our ability to tailor the intervention to each individual participant.

Goal: We aim to see if our 12-week mHealth-based behavioral change intervention with a primary expected outcome of reducing blood pressure, and a secondary outcome of behavioral changes regarding nutrition and physical activity will be successful. Quantitative success will be measured by objective data sent by blood pressure monitors, and qualitative success will be measured by the comparison of answers on the baseline and closeout questionnaires.

Materials: For this intervention we have created an application for participants to track their diet, weight, blood pressure, and physical activity daily for a period of 12 weeks. Throughout the duration of the study, the participants will also have weekly contact with a health counselor who will communicate with them via phone calls and a text chat to discuss nutrition and physical activity as it pertains to the DASH eating plan.

Methods: Our subjects are between 18-64, use a smartphone, and have been previously been given a diagnosis of either pre-hypertension or hypertension, with 3/6 (50%) of them currently receiving treatment via pharmaceutical methods for hypertension. The subjects were recruited via posters at both BU/BUMC, staff emails sent to BUMC/BMC faculty, craigslist, and the BU Student Link job boards.

Results: The current 6 enrolled participants (16.67% of the 36 eligible and screened participants) have a baseline mean (SD: 13.83) age of 41.83 years, weight (SD: 36.41) of 176.50 lbs, Systolic blood pressure (SD: 6.98) of 125.33 mmHg, and Diastolic blood pressure (SD: 6.72) of 81.33 mmHg.

Conclusion: For successful results we expect a decrease in blood pressure and an improvement in nutrition and physical activity habits. We plan to continue enrollment via the aforementioned methods until we reach a number of 30 active participants.

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Introduction:

Hypertension is a condition in which the pressure, or force, of blood on the artery

walls becomes elevated enough to cause stress to the heart, leading to more serious

cardiovascular problems, the most prominent being Cardiovascular Disease (CVD)

(Mayo Clinic, 2014). Blood pressure is determined by both the cardiac output (CO) of

the heart as well as the total peripheral resistance (TPR) to flow of the blood vessels

(Widmaier et al., 2014). While resistance is more commonly thought to have a greater

impact on blood pressure, it has recently been found that increased CO also induces

Hypertension (Lucking et al., 2014). The American Heart Association considers

Hypertension as a systolic blood pressure above 140mmHg, a diastolic blood pressure of

about 90 mmHg, or as being told twice by a physician that their blood pressure is

elevated (2013). The systolic blood pressure refers to the pressure of the arteries while

the ventricle is in the “contracting” phase; the diastolic blood pressure refers to the

pressure when the ventricle is in the “filling” phase (Widmaier et al., 2014).

Hypertension is categorized into two classes: Primary (Essential) Hypertension

and Secondary Hypertension. The causes for Primary Hypertension are unidentified, but

can oftentimes be attributed to extrinsic or environmental influences, which initiate the

chain of events eventually leading to the chronic increase in pressure. Secondary

Hypertension is when there has been a specific and identified interference that caused the

chronic increase in blood pressure (Folkow, 1982). While less is known about what

causes Primary Hypertension, it is seen more commonly, representing about 90% of

Hypertension cases, while Secondary only represents around 10% (Widmaier et al.,

2014).

According to the 2013 statistical fact sheet for Hypertension, provided by The

American Heart Association, there are 77.9 million Americans who currently have high

blood pressure; this is equivalent to a proportion of 1/3 of Americans. Furthermore, of

these 77.9 million, only 81.5% are aware of their condition, and of those aware of their

condition only 52.5% have it controlled. This means nearly half (47.5%) of those affected

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by Hypertension do not have it controlled. It is estimated that in 2030 the number of

Americans affected by Hypertension will increase by 5.61 million, or 7.2% (of the

current 77.9 million affected) (2013).

The American Heart Association currently estimates that the overall cost of

treating high blood pressure in the United States is $51 billion (2013). The major

pharmaceutical treatments involve blocking Beta-Adrenergic receptors, Angiotensin

Conversion Enzyme (ACE) inhibitors, and Calcium Channel Blockers. These

medications have been shown to be effective in lowering blood pressure, however, their

relative value in comparison to how much they cost is still unclear (Furberg et al., 2002).

In 1995, the average cost for managing Hypertension via pharmaceuticals within the first

year of diagnosis was $947, $575 in the second year, and $420 for all subsequent years

(Odell, 1995).

Though the causes of Primary Hypertension are unknown, evidence has shown

that increased sodium intake corresponds to a subsequent rise in blood pressure (Folkow,

1982). In a proceeding of a briefing from the Nutrition Society, there was a request to

increase the amount of controlled trials that specifically support dietary approaches to

preventing cardiovascular disease (Williams et al., 2013). The Dietary Approaches to

Stopping Hypertension (DASH) eating plan is a nutritional regimen that is supported by

research studies funded by the National Heart, Lung, and Blood Institute (NHLBI). It

places an emphasis on eating vegetables, fruits, and low fat dairy products to increase

potassium, calcium, magnesium, fiber, and protein levels within the body. In contrast, it

discourages sodium, saturated fat, and trans fat intake by limiting sweets, sugary

beverages, and salty foods (NHBLI, 2014). Studies have also shown that the combination

of utilizing the DASH eating plan while minimizing sodium intake to about 50 mmol per

day has the greatest effects on lowering blood pressure (Sacks, 2001). In addition to the

DASH eating plan while maintaining a reduction in sodium intake as a means for

reducing Hypertension, national guidelines recommend the integration of weight-loss and

exercise as a treatment for Stage 1 Systemic Hypertension, equivalent to a blood pressure

of 140mmHg/80mmHg (Moore et al., 2001).

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The effectiveness of the DASH eating plan then raises questions about why it

isn’t more regularly used as a treatment instead of expensive pharmaceutical techniques.

The most probable explanation is because of the intensive self-restraint and self-

adherence associated with maintaining the eating plan, as well as regular exercise. In a

study conducted by Thomas Moore in 2001, he found that an 8-week long behavioral

intervention produced immediate results in lowering blood pressure, which lasted for

around 18 months. But as the time post-intervention increased to 36-months there was a

decrease in the after-effects, which he attributed to waning self-adherence (Moore, 2001).

mHealth is the growing field of Public Health, defined as “medical and public

health practice supported by mobile devices, such as mobile phones, patient monitoring

devices, personal digital assistants (PDAs), and other wireless devices” (World Health

Organization, 2011). With the increasing use and integration of smartphones and

technology in daily life, there has been a subsequent rise in the relevance of mHealth.

This is enhanced by increasing development of health tracking smartphone applications,

and the growth of the “Quantified Self” movement, a movement promoting self-

awareness via daily tracking of habits.

Our project involves the use of an mHealth platform, utilization of a developed

self-tracking application, the aforementioned DASH eating plan and a tailored life-style

change intervention provided to the participant by a trained health counselor. We aim to

see if our 12-week mHealth-based behavioral change intervention will be successful in

producing the primary expected outcome of reducing blood pressure along with a

secondary outcome of positive behavioral changes regarding nutrition and physical

activity. This study serves as a pilot study, and therefore aims to see if there is viable

evidence of effectiveness to continue this research onto a larger scale. While there have

been prior behavioral change interventions related to diet management, as well as

Hypertension, to our knowledge the presence of one that integrates both diet and

Hypertension management with a patient tailored intervention on a mHealth platform is

non-existent.

We have chosen an mHealth platform due to its ability to be easily integrated to

daily life. As of January 2014, 58% of Americans have a smartphone, with 29%

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describing their dependency on their smartphone as “something they could not live

without” (Pew, 2014). The increasing relevance of smartphones in daily life has allowed

for the hypothesis that the intervention will be the most effective on an mHealth platform

because it maximizes participant- counselor accessibility. There has also been prior

evidence proving the effectiveness of mHealth interventions. In a 2014 smartphone based

Diabetes study, the participants were found to have improved management of their

diabetes, as well as increased knowledge of what they should and should not be doing to

manage their disease (Wayne).

We have chosen a participant-tailored approach to the behavioral intervention; the

option to do this was made possible by the aforementioned mHealth platform. A

participant-tailored intervention includes using personalized information, such a patient’s

name, gender, their “perceived barriers,” and their willingness to change their behaviors.

(Quintiliani et al., 2005). It has been shown that “mobile technologies complement health

coaching by enabling patients and coaches to maintain multiple channels of contact via

remote monitoring, voice, and text message communications” (Wayne, 2014). By

allowing constant and personalized interaction, the health counselor will gain a better

understanding of the participant’s personality and can therefore tailor the intervention to

best fit their needs. Apart from its integration with mHealth, tailored interventions have

been proven to be more efficiently remembered by the participant and more relevant to

the participant’s life than non-tailored interventions (Quintiliani et al., 2005).

One of the main barriers in reducing Hypertension is the expensive cost of

pharmaceutical treatments. Therefore, a main goal of the study is to help transform the

DASH eating plan to a cheap, accessible, and universal program to assist those who can’t

afford pharmaceuticals as a method to treating their high blood pressure. The mHealth

platform allows for this because of its immediate and inexpensive patient-intervention

relationship (Wayne, 2014). The main way the participants will receive the intervention is

via phone-calls and an in-app chat function, making it available to virtually all

smartphone users at a minimal cost, provided that their calling and messaging costs are

already paid for in their cell phone bills.

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The primary goal for the study is the reduction of high blood pressure, and the

secondary outcome is to analyze the effectiveness of the behavioral intervention by

tracking the eating, drinking, and physical activity changes of the participants, as well as

any changes in their psychosocial traits. This project has been approved by the

Institutional Review Board at Boston University Medical Center, and contains no

Conflicts of Interest. The procedures of obtaining data as well as storage of data are

HIPPA compliant.

Materials

This study consists of a 12-week mobile application based intervention. For the

12 weeks in which a participant is enrolled, they will be expected to track their diet,

weight, blood pressure, and physical activity. They will also receive bi-weekly

counseling sessions from a health counselor, revolving around different topics in nutrition

and physical activity as they pertain to the DASH eating plan.

For this study we developed a cell phone application, which is compatible with

both the iOS and the Android 4.0 operating systems. This application was developed via

utilization of team members with specializations spanning over a variety of different

fields, such as primary care, computer science, nutrition, and human-computer

interactions (Mann, 2013). The application was designed specifically for use in our study

and is comprised of five main screens: portion tracking, goal setting, progress, resources,

and a chat screen. The application was designed to be simple in its appearance as to

appeal to participants with different ranges of exposure to technology.

The home screen of the application is comprised of the portion-tracking page. On

this screen each food group is shown in a box proportionally sized to the amount of

servings per day that should be consumed. To track their diet, the participant taps the box

of the food group that they just ate, with each tap adding one serving of that food to their

intake for the day. To find the portion size for a specific food group, the participant can

hold down the respective icon and a notification will appear listing its portion size

information. The color of the icon of the food group will change as the number of

servings consumed approaches its daily limit. Once the limit is surpassed the icon will

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turn red. To erase an incorrectly tracked serving, there is a minus sign icon located in the

top left corner of the home screen which allows the participant to quickly delete a serving

size from a particular food group. Once the food intake is recorded for the day, a green

check will appear next to the word “diet” on the top of the home screen.

Throughout their time in the study, the participant will set bi-weekly goals with

the health counselor during their counseling sessions. To view these goals there is a

“goals” screen on the application, which lists all previous goals, as well as current goals.

There is also a screen that allows the participant to graphically see their progress

throughout the study. On this “progress” screen the participant can look at their progress

regarding their weight, blood pressure, physical activity and diet over the course of either

the week, month, or entire duration of the study.

The final two screens on the application comprise of the “resources” screen and

the “chat” screen. The “resources” screen has a library of videos developed by the staff to

help explain some concepts pertaining to the DASH eating plan. For example, there is a

set of videos, which explain portion sizing in each of the different food groups. In

addition to the videos the “resources” page also contains a list of web-links that the health

counselor has deemed as relevant and useful for understanding the basics of the DASH

eating plan. Should the “resources” page not answer the participant’s question; there is

also a chat function within the application, which allows the participant to quickly send

the health counselor any immediate questions they may have.

In addition to the DASH application, a web-based portal was also developed. This

portal is the main storage unit for the data regarding the participant’s weight, blood

pressure, and physical activity. The portal is how the health counselor can monitor the

participant’s progress, input their goals as well as mark prior goals as completed The

portal also allows the health counselor to send messages to the participant.

In order to track their weight, blood pressure, and physical activity, the

participants are given a set of Bluetooth enabled devices. They are given an A&D ProFIT

Precision Personal Health Scale to track their weight, an A&D Easy One Set Blood

Pressure Monitor to track their blood pressure, and a fitbit flex monitor to track their

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physical activity. The fitbit monitor will push data to the DASH application whenever it

is opened via a coding sequence developed by the principle software engineer. In order to

sync the scale and blood pressure cuff, the participant must take their weight or blood

pressure while the application is open. Upon a successful sync the application will pop-up

a notification stating “alert: blue-tooth syncing.” When each category is successfully

synced, a green check mark will show up on the application.

There are three health counselors who are trained in both the DASH eating plan

and in using a technique called “motivational interviewing.” They administer the

intervention to the participants. Each participant is assigned a health counselor, with

whom they have bi-weekly phone counseling (synchronous) sessions with, and bi-weekly

messaging (asynchronous) sessions. In addition to hosting those two types of counseling

sessions, the health counselor is also available to the participant throughout the day via

the chat function within the application.

The intervention itself is tailored to the participant based on their responses on the

baseline questionnaire. This questionnaire utilizes questions pertaining to the

participant’s demographics, their current behavioral habits and their current psychosocial

status. For tracking behavioral habits, we utilized the PrimeScreen dietary screening tool,

which is a proven and reproducible dietary questionnaire which allows the quality of an

individual’s daily food intake to be ranked (Rifas-Shiman, 2000). To assess the

participant’s intake of sugary drinks, we utilized the beverage intake questionnaire, or

BEVQ, which is a proven reliable indicator of daily beverage intake (Hedrick et al.,

2010). The behavior section of the questionnaire also includes questions about the

participant’s sleep quality and how often they participated in physical activity or strength

training. For the psychosocial portion, we utilized the Transtheoretical Model (TTM) of

psychosocial analysis, as well as the Perceived Stress Scale (PSS). The TTM observes the

stages of change that the participant goes through while they are competing the

intervention. The six stages of change associated with TTM are pre-contemplation,

contemplation, preparation, action, maintenance, and termination (Prochaska, 1997). We

also utilized the PSS, which measures both event specific and globalized stress levels in

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participants, and the degree to which everyday situations in life are perceived as stressful

(Cohen, 1983).

The closeout questionnaire is similar to the baseline in that it asks all the same

demographic, behavioral and psychosocial questions. However, it also contains several

questions about the participant’s complacency with the study, such as how often they

spoke with their health counselor, how often they messaged her, how they felt about goal

setting, how helpful the goal setting was, and what they would want to change about the

study. We included these questions to gain perspective on what to change in order to

improve the application and the intervention in the future.

Methods:

Figure 1: The flow of

information in the DASH study, the

participant inputs their data into

the DASH application, which

then gets sent to the

DASH portal for the

counselor to analyze and send

feedback back to the participant

The overall process of a participant going through the DASH study consists of 6 major steps:

Participant

Tracking-Bluetooth-WeightPhysical Activity-Diet

DASH Application

DASH Portal Counselor

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1. Initial recruitment2. Successful initial screening3. Baseline visit to BMC to become officially enrolled in the

study4. 12-weeks of active study participation5. Final visit to BMC6. Data analysis

This study recruited individuals who are between 18-64 years, living in the

greater Boston area, have previously been given a diagnosis of hypertension and own a

smartphone. Participants have been recruited via flyers, advertisements in weekly emails

sent to BUMC/BMC staff, postings on both Study Finder and the ReSPECT registry,

postings on craigslist, and postings on the Boston University job boards website.

Recruitment has currently brought in 36 interested participants, and we have 6 currently

enrolled participants. We plan to continue recruitment until we have had 30 participants

successfully complete the trial. During the recruitment process, if we receive an

interested email from a potential participant we respond to them with a generic email

stating the eligibility requirements, as well as a phone number to call us at if they are

interested in participating.

Once a call is received, or a call is made to an interested participant the initial

phone screening occurs. This phone screening serves as the initial process in determining

eligibility. The participant is asked if they have ever been given a diagnosis of

Hypertension, or if they are currently on Hypertension medication. We ensure that they

have Primary Hypertension and that their high blood pressure is not attributed to a known

cause, such as kidney disease or renal failure. It also questions any other pre-existing

health conditions that could prevent the participant from successful completion of the

study, such as arthritis, which would impair their ability complete the physical activity

portion of the study. It also rules out any women who are pregnant or breast-feeding,

whose consequential hormonal changes could interfere with their blood pressure. Lastly,

it ensures that the potential participant has a smartphone and lives in the Boston area. If a

participant meets the criteria for eligibility from the phone screening they will then be

asked to schedule a baseline visit to come in for official study enrollment. The time

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between their initial phone screening and their baseline visit is normally anywhere

between 2-3 weeks.

The initial baseline visit provides the staff with important information about the

participant; it is conducted in a series of 8 major steps:

1. Informed consent is obtained from the participant2. The participant’s blood pressure is taken to ensure they meet the

requirementsa. Systolic <120mmHg if they are on blood pressure

medicationb. Systolic >120mmHg if they are not on medication

3. The participant takes a guideline questionnaire to ensure eligibility4. The participant takes the baseline questionnaire5. The participant has their baseline weight recorded6. The application is loaded onto the participant’s phone and the

participant is given study devices7. The participant meets with the health counselor and research

assistant8. The participant receives their initial compensation

The baseline visit is the first of two times that the participant is asked to come into the

lab. Upon arrival they are (1) taken through the informed consent document and are asked

if they have any questions about the study. (2) They then have their blood pressure tested

by the research assistant, to ensure eligibility. If they have a normal systolic blood

pressure (<120 mmHg) but have shown proof of their medication they can be enrolled,

otherwise, they must have a systolic blood pressure of at least 120 mmHg, indicating a

diagnosis of pre-hypertension. If their blood pressure is in a dangerous range (>140

mmHg) they are referred to Devin Mann, MD., the primary care physician on staff. Once

their blood pressure is deemed to be in an acceptable range, they are then asked to (3) fill

out a guideline questionnaire; this is separate from the baseline questionnaire mentioned

in the “materials” section. This guideline questionnaire ensures that the participant has

room for improvement in their life pertaining to diet and physical activity. In order to be

eligible they must fall below two of the behavioral guidelines on this questionnaire. Upon

successful completion they are then asked to (4) take the baseline questionnaire, which

gives the health counselor information about their demographics, behaviors, and

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psychosocial traits. After they complete the baseline questionnaire the research assistant

then (5) weighs them to record a baseline weight to input into the application. The

research assistant then (6) collects the participant’s phone to load the application via

Xcode and pairs the Bluetooth devices to the participant’s phone. During this time the

participant (7) meets with the health counselor for the first time to schedule their

counseling sessions. The health counselor will also give the participant information

sheets with instructions on how to use the application, different recommended portion

sizes, and more information about the DASH eating plan. After meeting with the health

counselor the participant will meet with the research assistant for an overview on how to

use the study devices. The participant will also receive an information sheet with

instructions on how to use and sync the devices. (8) The research assistant will also give

the participant their initial compensation of $25.

Over the course of the 12-weeks of the study the participant receives a series of 7

motivational interviewing (MI) sessions with the health counselor. During each

counseling session the participant talks with the health counselor about one of the

following topics:

1. Physical activity2. Fast food3. Drinking4. Physical activity5. Fruits and vegetables6. Cooking 7. Snacking

In their baseline survey, the participant chooses which order they want to talk about each

the topics. However, physical activity is the first topic for every participant. The

counseling sessions are conducted using a technique know as motivation interviewing,

which has been shown effective in studies involving weight loss. It is a counseling

technique that “seeks to resolve ambivalence and increase motivation for change by

eliciting self-motivational statements, or change talk from clients” (Quintiliani et al.,

2008). It includes both “synchronous” interviewing, which refers to interviewing done in

real time, as well as “asynchronous” messaging, which refers to chat messages that the

health counselor sends out. During these counseling sessions, which occur bi-weekly and

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last for around 15-20 minutes, the health counselor focuses on having the participants

reflect on their current habits. She also has them set small, attainable goals in order to

motivate them to change certain daily habits. The goal of these sessions is to have the

participant elicit a want to change. Their phone calls are recorded so that the health

counselor can reflect on them and so that they can be later analyzed for effectiveness. In

addition to these bi-weekly phone sessions, participants will also receive “asynchronous”

messages from the health counselor during the weeks in which there are no scheduled

counseling sessions. These messages are mainly reminders to the participant of what their

goals are and to encourage them to keep working towards them.

While enrolled in the study the participants are expected to track their diet,

weight, blood pressure, and physical activity. They do all of the following directly

through the application. The procedure in which participants track their diet is described

in the “materials” section. Participants are expected to input their diet either after every

meal or at the end of the day. To track their physical activity they are expected to wear a

fitbit fitness monitor daily, either on their wrist or clipped onto their belt. Notifications

about the battery level of the fitbit device are forwarded to the lab staff, and the health

counselor will utilize the chat function in the application to inform the participant of

when to charge it. During the baseline visit the participants are shown how to take their

blood pressure via the A&D monitor that we provide them with. Before enrollment into

the study the participant must demonstrate proficiency recording his/her own blood

pressure. They will be expected to take their blood pressure at least once daily, anytime

throughout the day, utilizing the syncing method described in the “materials” section.

Tracking their weight on the scale follows the same previously mentioned procedure.

They will be expected to record their weight at least daily, utilizing the same syncing

method. The information from the devices automatically gets pushed into the DASH

portal to allow the health counselor to access it. If she sees that they are not inputting

their data on a daily basis, she will either utilize the chat to question their tracking habits

or will bring attention to the issue in their next phone call. Similarly, if she notices that a

participant is tracking their information daily and showing significant improvement, she

can use either of those two functions to praise the participant.

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The final visit is the second time that the participant is asked to come into BMC.

During this visit they return their study devices, have the application deleted from their

phone, complete a baseline questionnaire and receive study compensation. The final

questionnaire, as described in the “materials” section, is similar to the baseline

questionnaire, but also contains questions about the participant’s thoughts on their time in

the study. The final compensation for the study comes in two parts: $50 for returning the

study devices, and $25 for successful completion of the study.

To analyze data we will quantitatively look at the numerical changes in blood

pressure, weight, physical activity, daily food intake, and daily sugary beverages intake.

Qualitative changes will also be measured; this will be done by looking at any changes in

responses to questions regarding the psychosocial models of TTM and PSS on the

baseline questionnaire versus the final questionnaire. The data will be analyzed via

statistics based software, such as SAS. The final blood pressure, weight, and minutes

spent doing physical activity will be averaged and compared to the baseline values. The

food and beverage intake will be scaled, averaged and compared using the scaling

method described in the “results” section. A similar scaling technique will be used for the

psychosocial behavior questions (PSS and TTM), which is discussed in the “results”

section as well.

Results

The following results came from the responses to the baseline survey (supported

by Qualtrics software) that the participants are asked to fill out during their baseline visit.

The 6 participants we currently have enrolled (20% of the total eligible 30

participants, and 16.67% of the total 36 screened participants) have a mean (SD: 13.83)

age of 41.83 years, with the youngest participant being an outlier at 23 years. There is an

equal amount of both males and females (n=3 males, n=3 females). There is also an

equality in the ethnicities the participant identify themselves as, with n=2 (33.33%)

identifying themselves as White, n=2 (33.33%) identifying as Black or African

American, and n=2 (33.33%) identifying as Asian or Pacific Islander. 16.7% (n=1) of the

participants have had 12 years of schooling, and 83.3% (n=5) have had 16+ years. 50%

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(n=3) of the participants are married, and 50% (n=3) are single. 83.3% (n=5) of the

participants are currently working full-time, while 16.67% (n=1) are currently working

part-time.

When asked if there had been a time in the past 12 months when they had been

unable to pay for medication, 83.3% (n=5) responded with no, and 16.67% (n=1)

responded that they had not been prescribed medicine in the past 12 months. None of the

participants have had any food shortages in the past 12 months, and only n=1 (16.67%)

participant responded that they had other health issues apart from Hypertension. n=3

(50%) of participants have been previous tobacco users, and n=3 (50%) have not used

any tobacco products in the past.

When asked about their current exposure to technology all (n=6) of the

participants responded that they use the internet, email, smartphone applications, and

access email on their smartphone at least occasionally. Only n=1 (16.67%) of participants

had previously used their smartphone for health tracking applications, and none (n=0)

were currently receiving any sort of text alert from their doctors.

The mean (SD: 36.41) weight of the participants was 176.50 pounds. The

American Heart Association defines normal blood pressure as <120 mmHg (systolic) and

<80 mmHg (diastolic), with the range for a diagnosis of Pre-Hypertension starting at 120

mmHg (systolic) and 80 mmHg (diastolic). Our participants have a mean (SD: 6.98)

systolic blood pressure of 125.33 mmHg and a mean (SD: 6.71) diastolic blood pressure

of 81.33 mmHg, which is equivalent to a diagnosis of Pre-Hypertension.

Table 1: Characteristics of participants currently enrolled in the DASH study

Characteristic n= 6

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Weight, pounds, mean (SD) 176.50 (36.41)Systolic BP, mmHg, mean (SD) 125.33 (6.98)Diastolic BP, mmHg, mean (SD) 81.33 (6.71)Age, years, mean (SD) 41.83 (13.83)Sex n=6

Male 3Female 3

Race n=6White 2

Black or African American 2Asian or Pacific Islander 2

Level of Education n=612 Years 1

16+ Years 5Marital Status n=6

Single 3Married 3

Current Work Status n=6Working Full-Time 5Working Part-Time 1

Type of Health Insurance n=6Private 5

N/A 1Been unable to pay for medication in the past 12 mo n=6

No 5Not Prescribed 1

Food shortages in the past 12 mo n=6No 6

Internet Usage n=6At least occasionally 6

Other Diagnosed Health Issues n=6N/A 5

High Cholesterol 1Previous Tobacco Use n=6

No previous use 3Prior usage, but not currently 3

Usage of Email n=6At least occasionally 6

Usage of Email/Internet on a Smartphone n=6At least occasionally 6

How often Email is accessed n=6Several times a day 6

Usage of Smartphone to download applications n=6Yes 6

Usage of health tracking applications n=6

Yes 1

No 5

Currently receiving text updates/ alerts from your Doctors n=6

No 6

Currently on high blood pressure medication n=6

Yes 3

No 3

The daily food intake (Table 2a) was recorded and scaled via the PrimeScreen

method proposed by Rifas-Shiman in 2008. This method scales the number of food

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servings by assigning a value based on the number of times they were eaten per week,

and then averages them by the number of participants in the trial (n=6). The same method

was utilized for determining the number of times per day the participants engaged in

certain food behaviors (Table 2a). The assigned values are as follows:

Less than once per week: .03Once per week: .142-4x per week: .43

Nearly daily or daily: 12x+ daily: 2.5

The daily intake of beverages (Table 2c) were recorded and scaled via the BEVQ

questionnaire, developed by Hedrick in 2010. To scale this the values were converted to

the number of times the participant drank the specified beverage each day, and then

multiplied by the number of consumed fluid ounces of the beverage. This value was then

averaged over the value of n=6 to obtain the amount (in fluid ounces) of each beverage

consumed per day. These results are summarized in Table 2c.

Table 2b summarizes the participant’s engagement in physical activity over the

past month. All participants (n=6) have previously participated in physical activity in the

past month, with n=3 (50%) participating in it 1-2 days per week, n=2 (33.33%)

participating in it 3-5 days per week, and n=1 (16.67%) participating in it for more than 5

days a week. When asked for the amount of time each participant engaged in the

aforementioned physical activity, n=3 (50%) participated in it for less than 30 minutes,

n=1 (16.67%) participated in it for between 30-60 minutes, and n=2 (33.33%)

participated in it for 150-250 minutes. When asked about how often each participant

utilized strength training n=4 (66.67%) said never, and n=2 (33.33%) responded with 1-2

times a week.

Table 2d summarizes the participant’s perceived sleep behavior. The participants

had a mean (SD: 7.53) of 11.67 days per month without an adequate amount of rest, and a

mean (SD: 1.10) amount of 7.00 hours of sleep per night

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Table 2: Current behaviors of participants enrolled in the DASH study

Behaviors of participants n=6(2a) Food Intake Number of servings per day

Fruit and Vegetables 1.24Dairy Products 1.95

Whole grain foods .648Pasta, rice, and noodles .593

Baked products .410Beef, pork, or lamb as a main dish .115

Processed meats .067Fish or seafood .133

Fried foods .115

Food Behaviors Number of times per dayAddition of salt to foods .192

Eating out (including fast food) .097Cooking meals at home 1.31

(2b) Participation in physical activity over the past month Yes (n=6)Amount of times per week n=6

1-2 days 33-5 days 2> 5 days 1

Amount of time spend on activity n=6<30 minutes 3

30-60 minutes 1150-250 minutes 2

Amount of times per week strength training n=6None 4

1-2 times 2

(2c) Beverage Intake Number of fluid ounces per dayWater 39.6

100% Juice 1.73Sweetened juice .867

Whole milk .1122% (reduced-fat) milk .030

1% (low-fat) milk .922Regular soft-drinks .354

Diet soft-drinks .541Beers, Ales, Wine Coolers, Non-Alcoholic &Light Beer .097

Wine .193Hard Liquor .030

Energy and Sports Drinks .360Tea/Coffee with cream/sugar 12.6

Tea/Coffee without cream/sugar .667Other 0

(2d) Sleep Behavior Mean (SD)Days in a month without enough rest/sleep, mean(SD) 11.67(7.53)

Hours of sleep in a 24 hour period, mean(SD) 7.00(1.10)

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Table 3a summarizes the participant’s responses to the TTM of psychosocial

traits. The TTM attempts to track the participant’s willingness to change, and is measured

in 6 successive steps: pre-contemplation, contemplation, preparation, action,

maintenance, and termination. n=1 (16.67%) participant stated that they were in the “pre-

contemplation” stage. This is seen as the stage where “people do not intend to take action

in the very near term.” n=1 (16.67%) participant stated they were in the “contemplation”

stage, which is when the participant is willing to change their behavior in the next 6

months. n=2 (33.33%) participants stated they were in the “preparation” stage, where the

participant is expected to be willing to make changes soon (within the next month). n=1

(16.67%) participant stated that they are in the “action” stage, indicating that they have

“made specific, overt modifications in their lifestyles within the past 6 months.” n=1

(16.67%) have stated that they’re in the “maintenance” stage, indicating they have

already “made specific, overt modifications in their lifestyles and are working to prevent

relapse.” The “termination” stage indicates a state of “zero temptation and 100%

efficacy,” n=0 participants stated that they were in this stage (Prochaska, 1997).

Table 3b summarizes the participant’s perception of stress within their life, by

utilizing the PSS. This survey questions how participants feel about managing stress in

their lives by asking four basic questions (Cohen, 1983):

1. In the last month, how often have you felt that you were unable to control the important things in your life?

2. In the last month, how often have you felt confident about your ability to handle you personal problems?

3. In the last month, how often have you felt that things were going your way?

4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Each response was given a numerical value, and these values were averaged over the

number n=6 to get the mean amount of stress perceived by each participant. The values

were assigned based on the scaling below:

Never: 0Almost never: 1Sometimes: 2

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Fairly often: 3Very often: 4

Table 3: Psychosocial characteristics of currently enrolled DASH participants

(3a) Transtheoretical Model (TTM) n=6Pre-contemplation 1

Contemplation 1Preparation 2

Action 1Maintenance 1

(3b) Perceived Stress Scale (PSS) Frequency of feeling (mean, SD)Felt unable to control the important things in their life 1.67(.943)

Felt confident in ability to handle personal problems 2.83(1.34)Felt things were going their way 3.33(.745)

Felt difficulties were piling up so high they could not overcome them

.667(.745)

Discussion

According to the 2013 State Indicator report, provided by the Center for Disease

Control (CDC), the median amount of fruit intake for an adult in Massachusetts is 1.2

servings, while the median vegetable intake is 1.7 servings, averaging to a mean intake of

1.45 servings of fruits and vegetables per day. The mean daily fruit and vegetable serving

within our range of participants was 1.24, indicating a value below the state median. The

recommended amount of grain servings per day is 6-11 servings, whereas our participants

averaged a value below that, of 1.241 (combined grains, pasta, rice, and noodles) servings

per day. The recommended dairy is 2-3 servings per day, our participants were nearly in

this range by averaging a number of 1.95 servings per day (Muñoz, 2014).

According the American Heart Association, “To promote and maintain health, all

healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical

activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic

physical activity for a minimum of 20 min on three days each week” (2007). According

to these guidelines, 50% (n=3) fall below guidelines for the amount of days spent doing

physical activity per week, and 50% (n=3) fall below guidelines for the amount of time

per week spent doing physical activity.

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The National Sleep Foundation recommends anywhere between 7.5-9 hours of

sleep per night, our participants have averaged 7 hours of sleep per night. Sleep could

potentially be an important variable in our reseach because in a study done in 2009 by

Buxton, it was shown that more adequate sleep lead to workers making healthier choices

in regards to their food intake.

The recommendation for the daily fluid ounces of water currently stands at an

amount of 125 ounces for men, and 91 ounces for women. Our participants fell greatly

below this level by consuming around 40 ounces per day. However, our participants

drank less than recommended limit for coffee and tea (obtaining a mean of 13.267 oz

while the limit is around 24 oz). For the intake of sugary beverages, the guidelines

recommend to drink it less than daily, which all of our participants successfully did

(Harvard School of Public Health, 2014).

We believe our study will be effective due to its accessible and cost effective

mHealth platform. If proven effective we hope to integrate the DASH application as an

alternative to pharmaceutical treatments for those who are affected by Hypertension.

Upon completion of the study, if successful, we hope to analyze participant responses on

how to improve the study, and implement those changes. Furthermore, we hope to re-

launch the application on a larger scale and over an extended time period to test its long-

term feasibility. Should this be successful we believe it would be a novel and cost-

effective treatment for Hypertension.

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