Socioeconomic barriers to healthy eating, particularly food insecurity, are a major reason for poor blood pressure control and hypertension complications. Healthy diet patterns have been shown to improve health. Unfortunately, food insecurity makes it difficult for individuals to maintain healthy diet patterns. This pragmatic randomized trial will compare two food insecurity interventions (a healthy food subsidy versus a delivered food box), with or without lifestyle support delivered by community health workers, for 6 versus 12 months duration. Key outcomes include blood pressure, food insecurity, and other patient reported outcomes.
Socioeconomic barriers to healthy eating, particularly food insecurity ("insufficient or uncertain access to enough food for an active, healthy life") are a major reason for poor blood pressure control, and hypertension complications. Healthful dietary patterns, such as a Mediterranean (Med)-style diet, improve blood pressure control and reduce cardiovascular risk, risk for other chronic diseases, and premature mortality. However, food insecurity incentivizes individuals away from healthful diet patterns, resulting in wide disparities in diet-related diseases such as hypertension. Though two major ways to address food insecurity are commonly proposed-- providing subsidies for healthy food and home delivery of healthy food boxes--investigators do not know which will have the greater effect. Further, as these interventions cannot be provided indefinitely, investigators need to determine whether adding an intervention to support healthy lifestyle change, such as a culturally-tailored Med-style diet intervention, can lead to improved health even after provision of the food insecurity intervention ends. Thus, the study team proposes to conduct 2x2x2 factorial design randomized trial to compare two food insecurity interventions, with or without a lifestyle support intervention that provides culturally tailored Med-style dietary pattern education, disease self-management support, and navigation to community resources for health related social needs, over 2 different time periods. To realize the vision of "food as medicine" to promote equity in clinical care, the study team has drawn on an extensive background of previously tested programs to create the novel multi-component interventions that will be tested in this trial. This novel intervention focuses on lowering blood pressure and addressing food insecurity. Specifically, participants will be separately randomized to receive 1) a food subsidy versus home delivery of a healthy food box, and 2) a structured lifestyle support intervention, delivered by community health workers and supervised by a registered dietitian versus usual care for 3) either 6 or 12 months. The proposed study will be conducted in central NC, enrolling 1400 participants with a history of hypertension and food insecurity. Six months after the end of each participant's intervention, investigators will re-assess study outcomes to evaluate for sustained effects.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
525
Food subsidy for 6 months
Food subsidy for 12 months
lifestyle support intervention delivered by community health workers for 6 months
lifestyle support intervention delivered by community health workers for 6 months
Twice monthly delivery of healthy food for 6 months
Twice monthly delivery of healthy food for 12 months
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, United States
Duke University
Durham, North Carolina, United States
Office-based Systolic Blood Pressure at Month 6
Systolic blood pressure recorded at office-based healthcare visits
Time frame: 6 months
Office-based Systolic Blood Pressure at Month 12
Systolic blood pressure recorded at office-based healthcare visits
Time frame: 12 months
Office-based Systolic Blood Pressure at Month 18
Systolic blood pressure recorded at office-based healthcare visits
Time frame: 18 months
Office-based Diastolic Blood Pressure at Month 6
Diastolic blood pressure recorded at office-based healthcare visits
Time frame: 6 months
Office-based Diastolic Blood Pressure at Month 12
Diastolic blood pressure recorded at office-based healthcare visits
Time frame: 12 months
Office-based Diastolic Blood Pressure at Month 18
Diastolic blood pressure recorded at office-based healthcare visits
Time frame: 18 months
Ambulatory Systolic Blood Pressure at Month 6
Systolic blood pressure recorded outside the healthcare system.
Time frame: 6 months
Ambulatory Systolic Blood Pressure at Month 12
Systolic blood pressure recorded outside the healthcare system.
Time frame: 12 months
Ambulatory Systolic Blood Pressure at Month 18
Systolic blood pressure recorded outside the healthcare system.
Time frame: 18 months
Ambulatory Diastolic Blood Pressure at Month 6
Diastolic blood pressure recorded outside the healthcare system.
Time frame: 6 months
Ambulatory Diastolic Blood Pressure at Month 12
Diastolic blood pressure recorded outside the healthcare system.
Time frame: 12 months
Ambulatory Diastolic Blood Pressure at Month 18
Diastolic blood pressure recorded outside the healthcare system.
Time frame: 18 months
Combined (Office-based and Ambulatory) Systolic Blood Pressure at Month 6
Systolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 6 months
Combined (Office-based and Ambulatory) Systolic Blood Pressure at Month 12
Systolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 12 months
Combined (Office-based and Ambulatory) Systolic Blood Pressure at Month 18
Systolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 18 months
Combined (Office-based and Ambulatory) Diastolic Blood Pressure at Month 6
Diastolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 6 months
Combined (Office-based and Ambulatory) Diastolic Blood Pressure at Month 12
Diastolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 12 months
Combined (Office-based and Ambulatory) Diastolic Blood Pressure at Month 18
Diastolic blood pressure recorded either inside or outside the healthcare system.
Time frame: 18 months
Food Insecurity Score at Month 6
Food Insecurity Score. Score ranges from 0-10, with higher scores indicating greater food insecurity.
Time frame: 6 months
Food Insecurity Score at Month 12
Food Insecurity Score. Score ranges from 0-10, with higher scores indicating greater food insecurity.
Time frame: 12 months
Food Insecurity Score at Month 18
Food Insecurity Score. Score ranges from 0-10, with higher scores indicating greater food insecurity.
Time frame: 18 months
Health-Related Quality of Life Score as assessed by Patient-Reported Outcomes Measurement Information System (PROMIS)-14 at Month 6
The Patient-Reported Outcomes Measurement Information System(PROMIS)-14 includes seven health related quality of life domains (Physical Functioning, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, and Pain), and the pain domain has two subdomains (interference and intensity). Raw scores, except pain intensity, are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on physical function indicates better functioning, whereas a higher score on depression indicates more severe depressive symptoms. Will report overall score and scores for each domain. From these data investigators will also calculate a PROMIS-Preference (PROPr score) (PROPr scores range from -0.022 (worst) to 1.0 (best)).
Time frame: 6 months
Health-Related Quality of Life Score as assessed by Patient-Reported Outcomes Measurement Information System (PROMIS)-14 at Month 12
The Patient-Reported Outcomes Measurement Information System (PROMIS) -14 includes seven health related quality of life domains (Physical Functioning, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, and Pain), and the pain domain has two subdomains (interference and intensity). Raw scores, except pain intensity, are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on physical function indicates better functioning, whereas a higher score on depression indicates more severe depressive symptoms. Will report overall score and scores for each domain. From these data investigators will also calculate a PROMIS-Preference (PROPr score) (PROPr scores range from -0.022 (worst) to 1.0 (best)).
Time frame: 12 months
Health-Related Quality of Life Score as assessed by Patient-Reported Outcomes Measurement Information System (PROMIS)-14 at Month 18
The Patient-Reported Outcomes Measurement Information System (PROMIS)-14 includes seven health related quality of life domains (Physical Functioning, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, and Pain), and the pain domain has two subdomains (interference and intensity). Raw scores, except pain intensity, are transformed using the T-score metric based on the item response theory calibrations in which scores have a mean of 50 and standard deviation of 10 for the general population in the US. A higher PROMIS T-score implies more of the concept being measured; i.e., a higher PROMIS score on physical function indicates better functioning, whereas a higher score on depression indicates more severe depressive symptoms. Will report overall score and scores for each domain. From these data investigators will also calculate a PROMIS-Preference (PROPr score) (PROPr scores range from -0.022 (worst) to 1.0 (best)).
Time frame: 18 months
Diet Quality at Month 6
Diet Quality as assessed by Brief Dietary Assessment Scale. This score is comprised of 3 sections (or subscales) used to assess dietary patterns. Subscales are scored independently. The subscales are: Vegetables, Fruit, Whole Grains, and Beans subscale (range 0 - 20), Drinks, Desserts, Snacks, Eating Out, and Salt subscale (range 0- 20), and Fish, Meat, Poultry, Dairy, and Eggs subscale (range 0-10): Total score equals the sum of the 3 subscales. For subscales and total score, higher scores indicates better diet quality.
Time frame: 6 months
Diet Quality at Month 12
Diet Quality as assessed by Brief Dietary Assessment Scale. This score is comprised of 3 sections (or subscales) used to assess dietary patterns. Subscales are scored independently. The subscales are: Vegetables, Fruit, Whole Grains, and Beans subscale (range 0 - 20), Drinks, Desserts, Snacks, Eating Out, and Salt subscale (range 0- 20), and Fish, Meat, Poultry, Dairy, and Eggs subscale (range 0-10): Total score equals the sum of the 3 subscales. For subscales and total score, higher scores indicates better diet quality.
Time frame: 12 months
Diet Quality at Month 18
Diet Quality as assessed by Brief Dietary Assessment Scale. This score is comprised of 3 sections (or subscales) used to assess dietary patterns. Subscales are scored independently. The subscales are: Vegetables, Fruit, Whole Grains, and Beans subscale (range 0 - 20), Drinks, Desserts, Snacks, Eating Out, and Salt subscale (range 0- 20), and Fish, Meat, Poultry, Dairy, and Eggs subscale (range 0-10): Total score equals the sum of the 3 subscales. For subscales and total score, higher scores indicates better diet quality.
Time frame: 18 months
Food/ medication trade-offs at Month 6
Single item-indicators of trading off medication for food or food for medication. An affirmative response indicates the presence of a trade-off.
Time frame: 6 months
Food/ medication trade-offs at Month 12
Single item-indicators of trading off medication for food or food for medication. An affirmative response indicates the presence of a trade-off.
Time frame: 12 months
Food/ medication trade-offs Month 18
Single item-indicators of trading off medication for food or food for medication. An affirmative response indicates the presence of a trade-off.
Time frame: 18 months
Diet self-efficacy at Month 6
Diet Self-Efficacy as assessed by cardiac diet self-efficacy scale. Scores range from 16 to 80 with higher scores indicating greater self-efficacy.
Time frame: 6 months
Diet self-efficacy at Month 12
Diet Self-Efficacy as assessed by cardiac diet self-efficacy scale. Scores range from 16 to 80 with higher scores indicating greater self-efficacy.
Time frame: 12 months
Diet self-efficacy at Month 18
Diet Self-Efficacy as assessed by cardiac diet self-efficacy scale. Scores range from 16 to 80 with higher scores indicating greater self-efficacy.
Time frame: 18 months
Physical Activity Levels at Month 12
Assessed by the International Physical Activity Questionnaire(Short Form). Higher scores indicate higher levels of physical activity.
Time frame: 12 months
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