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Research Spotlights: November 2022

Telehealth lifestyle intervention reduces blood pressure, with dietitian support leading to greater improvements in secondary cardiometabolic outcomes

In the U.S., hypertension (high blood pressure) is a significant cause of morbidity and mortality and affects over 120 million adults aged 20 years of age and older. Unhealthy dietary patterns, high sodium intake, low physical activity, and obesity all contribute to the development of hypertension and cardiovascular disease. Interventions that help individuals lower their blood pressure (BP) is challenging in clinical practice, often due to a lack of time and resources. Telehealth interventions that use mobile applications and online programs could be helpful by providing patients with insights about their own data and have the potential to reach patients living in rural areas.

Recently published research supported by NIDDK and others, examined the impact of two different telehealth strategies (minimal remote nonclinical staff support versus remote dietitian support with motivational interviewing) that leveraged online programs and mobile applications to promote healthy behavior change on 12-week changes in 24-hour systolic BP and other measures of healthy lifestyle.

Researchers within the Geisinger Health System conducted a parallel-arm, randomized clinical trial. Patients with elevated BP were identified through their electronic health records, health plan screenings, primary care provider referrals, and self-referrals, and were randomized to one of two conditions: 1) dietitian-led (received weekly calls from the study dietitian and explored participants’ goals and values and set attainable goals) or 2) minimal-support (only received phone contact from a research assistant if they were not entering sufficient dietary data). Across both conditions, participants received the American Heart Association lifestyle guidance and access to web-based applications for meal-logging, materials on promoting weight loss, a diet designed to end hypertension (e.g., increased intake of fruits and vegetables, whole grains, and plant-based proteins), increasing physical activity, setting goals, overcoming barriers, and preventing relapse. At baseline, all participants received a nutrition report based on a food frequency questionnaire that provided personalized suggestions to improve dietary habits that align with national dietary guidelines. Participant goals for both arms included losing 3% of body weight at 12 weeks, consuming a healthier dietary pattern, reducing sodium intake to less than 2300 mg/day, and participating in at least 180 minutes/week of moderate to vigorous physical activity.

For the primary outcome of 24-hour systolic BP, researchers found that participants (n = 187, mean age = 54.6 years) in both arms showed reductions, with no significant differences between arms. However, the dietitian-led arm showed greater improvements in sleep diastolic BP, diastolic BP, and physical activity compared to the minimal-support arm and tended to show greater improvements in dietary quality and weight loss. Participants in the dietitian-led arm also reported greater satisfaction with the research study than the minimal-support arm.

The study findings have some limitations. Although the sample reflected the demographics of the primarily rural area served by the healthcare system, 97% of participants identified as non-Hispanic White, and of relatively high socioeconomic status. Due to the COVID-19 pandemic, the study also shifted to remote research visits and relied upon patient self-report weight and waist circumference and an inability to measure automated office blood pressure for approximately half of the participants.

In summary, remote lifestyle interventions to reduce hypertension show great potential, particularly if they also include clinical staff, such as dietitians. This research highlights the need for more personalized lifestyle interventions to reduce hypertension, and potentially prevent cardiometabolic disease.

Citation:
Chang AR, Gummo L, Yule C, Bonaparte H, Collins C, Naylor A, Appel LJ, Juraschek SP, Bailey-Davis L. Effects of a Dietitian-Led, Telehealth Lifestyle Intervention on Blood Pressure: Results of a Randomized, Controlled Trial. J Am Heart Assoc. 2022 Oct 4;11(19):e027213. doi: 10.1161/JAHA.122.027213. Epub 2022 Sep 29. PMID: 36172955.

Family caregivers face unique challenges caring for discharged COVID-19 ICU patients

Family caregiving can be characterized as providing unpaid care and assistance for a family member or friend’s health, behavioral, and social needs. Around 21% of COVID-19 hospitalized patients required an intensive care unit (ICU) stay for respiratory and cardiovascular complications at the height of the pandemic and necessitated caregiver assistance from family upon discharge. While there was an increase in the amount of family caregivers, there is scarce information about the post-hospitalization family caregiving experience and strategies to best support those transitioning into a caregiving role. Recently published research supported by the NIA, NINR, VA, and others may be one of the first studies to use dyadic (discharged COVID-19 ICU patients and their family caregivers) qualitative data to investigate the adaptive needs of families following an infective condition and ICU discharge. Study results could lead to improved family health outcomes and support needs as well as points of interventions for clinicians.

A secondary analysis was performed using data from the Health Enhanced by Adjusting and Recovering Together (HEART) COVID-19 Recovery project. The HEART study recruited and surveyed dyads of family caregivers and discharged ICU patients who had COVID-19 in the U.S. at the start of the pandemic through October 2020 in southeastern Michigan. Each dyad member (n=32, 16 patients, 16 caregivers) was interviewed remotely by research staff and asked questions related to their experience in providing and receiving care for a severe COVID-19 infection and the recovery period post-hospitalization. Researchers used data from the transcripts to identify and rank 14 themes that clarified the phenomena of adaptation to family caregiving and the application to relevant nursing theory. Additional thematic analysis was performed, narrowing the list to six final themes including (1) engaging the support of family and friends, (2) increased responsibilities to accommodate caregiving, (3) managing emotions, (4) managing infection control, (5) addressing patient independence, and (6) engaging support services.

The findings suggest that the COVID-19 pandemic involved unique challenges for family caregivers such as managing infection control. Isolation and quarantining away from family and friends were extremely stressful for patients and caregivers prior to vaccine rollout due to the highly transmissible nature of COVID-19. Additionally, family caregiver personal health and wellness needs should be prioritized along with relationships outside of the caregiving role. Effective adaptation for family caregiving and positive post-hospitalization care outcomes requires flexibility and sufficient external support and resources, starting with the clinician care team preparing the family prior to discharge for the likely challenges of recovery. When outside social support is adequate, the family caregiver/patient dyads can focus on the needs of the family rather than solely on the needs of patient post-hospitalization improving the overall experience for all.

Citation:
Robinson-Lane SG, Leggett AN, Johnson FU, Leonard N, Carmichael AG, Oxford G, Miah T, Wright JJ, Blok AC, Iwashyna TJ, Gonzalez R. Caregiving in the COVID-19 pandemic: Family adaptations following an intensive care unit hospitalisation. J Clin Nurs. 2022 Oct 19. doi: 10.1111/jocn.16560. Epub ahead of print. PMID: 36262026.

Changing state policy contexts are associated with increasing mortality rates among working-age adults in the U.S. ages 25-64 over the past two decades

Working-age mortality rates among adults in the United States (U.S.) ages 25-64 has increased over the past several decades, resulting in overall stagnation of U.S. life expectancy. Prior research has shown that several factors contributed to rising mortality rates, including noncommunicable diseases (particularly cardiovascular disease), unintentional injuries (e.g., alcohol-induced causes or drug poisonings), and intentional injuries (e.g., suicide). More recent work has shown that increases in U.S. mortality rates are also associated with macro-level influences, including social, political, and cultural factors. Political and policy shifts may have marked impacts on health and well-being, particularly at the state level where policy may determine such factors as education, economic stability, encouragement/discouragement of risky behaviors (e.g., tobacco taxes), access to health care, or employment protections and benefits. To date, the role of U.S. state policy contexts on the changing mortality rates of working-age adults has not yet been addressed. Recently published research supported by NIA has built on past work to investigate how state policy contexts in the past two decades are associated with working-age mortality rates overall among adults 25-64 years of age, and attributable to cardiovascular disease, alcohol-induced causes, suicide, and drug poisoning.

The research team merged state mortality data with state-level policy data to generate datasets for further analysis. Mortality data for this study was accessed through the National Center for Health Statistics’ National Vital Statistics System (1999 to 2019), and both all-cause and cause-specific mortality rates were calculated. Annual state-level contextual data was adapted from past work and examined on eight policy domains known to be factors associated with working-age mortality rates and/or life expectancy—criminal justice, economic taxes, environment, firearm safety, health and welfare, marijuana, labor, and tobacco tax. Each of these domains were assigned a “policy liberalism score” from 0 to 1 (conservative to liberal continuum) for each state-year observation. The researchers used regression models, accounting for sex, and included time-varying covariates, multiple policy domains, fixed effects for states, and lagged analyses to account for lag times between policy changes and potential impacts on mortality rates. Finally, several counterfactual scenarios were modeled in order to estimate lives saved or lost under potential state policy contexts.

Results showed that state policy domains were significantly associated with all-cause mortality rates among both men and women. In particular, all domains with the exception of “health and welfare” were associated with all-cause mortality. Scores that indicated more liberal policy contexts on the environment, gun safety, labor, economic taxes, and tobacco taxes were associated with lower mortality rates, while more conservative scores on marijuana were associated with lower mortality rates. Upon examination of the cause-specific mortality, several significant associations were found between state policy domains and specific causes of death. Those that were especially noteworthy, included associations between: more liberal gun safety and lower cardiovascular mortality, more liberal labor policies and lower alcohol-induced causes of mortality, and more liberal gun safety policies and lower suicide rates. In contrast, more conservative marijuana policies were significantly associated with lower suicide rates among women.

This study has some limitations. First, despite the complex analyses, this study can only report associations, rather than causal relationship between policy domains and mortality. Second, study takeaways are only generalizable to working-age adults between 25-64 years. Third, study models did not include all state policies that may contribute to mortality rates, nor did they include a broad scope of social determinants of health as covariates. Finally, study analyses do not account for interstate migration nor similar trends such as immigration or unemployment rates, all of which may be impacted by state policies as well as overall population health.

In conclusion, the growing “mortality disadvantage” of working-age adults in the U.S. may be partially explained by changing state policy contexts. In particular, more liberal policies that promoted gun safety, environmental protections, labor, progressive taxation, and tobacco control are association with lower all-cause and cause-specific mortality rates among both men and women. Study simulations further suggest that if all states were in a fully-liberal orientation, over 170,000 lives might have been “saved” in 2019, while the scenario in a fully-conservative orientation might have seen over 217,000 lives lost.

Citation:
Montez JK, Mehri N, Monnat SM, Beckfield J, Chapman D, Grumbach JM, Hayward MD, Woolf SH, Zajacova A. U.S. state policy contexts and mortality of working-age adults. PLoS One. 2022 Oct 26;17(10):e0275466. doi: 10.1371/journal.pone.0275466. PMID: 36288322; PMCID: PMC9604945.