18 Effect of Participation with Accompanying Household Member in the Complete Health Improvement Program in Appalachia

Copyright © 2019 Dhatri Kotekal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Intensive therapeutic lifestyle modification programs, such as the Complete Health Improvement Program (CHIP), reduce cardiovascular disease (CVD) risk factors. However, there are little data on how participation in CHIP with a household member can affect CVD biomarkers. This study focuses on the benefit of joint participation of household members in CHIP in order to have a better outcome in improving CVD risk factors compared with lone or individual participation. Data from 20 CHIP classes offered from 2011 to 2015 in Athens, Ohio, where each class was conducted over 2-4 months, consisting of 16-18 sessions, were collected. Body mass index (BMI), blood pressure, fasting glucose, and lipid profiles were measured before and near the completion of each class. A statistically significant greater reduction in BMI (p = 0.003) in those who attended with a household member compared to those who attended as individuals was found. CHIP has some effect on various CVD risk factors for those who attend intensive therapeutic lifestyle modification programs with an accompanying household member. Hence, encouragement of participation with a family member or a “buddy” may be prudent, especially if weight reduction is a key program participation goal. Further evaluation of the “buddy effect” involving both of those residing in the same household and those who do not but nevertheless provide mutual support is warranted.

1. IntroductionCardiovascular disease (CVD) is the leading cause of death in the United States [1]. Risk factors for CVD include dyslipidemia, hypertension, smoking, elevated body mass index (BMI), and diabetes [2–4]. Intensive therapeutic lifestyle modification programs (ITLMP) have been effective in improving CVD biomarkers and risk factors [5–7]. One well-studied ITLMP is the Complete Health Improvement Program (CHIP), which has demonstrated short-term effectiveness in improving many CVD risk factors [8, 9].The Appalachian region of the United States has consistently been associated with high morbidity and mortality resulting from chronic diseases such as CVD and diabetes, lack of access to health care, and higher rates of uninsured people [10]. Prior studies have demonstrated that CHIP was effective in reducing CVD risk factors in an Appalachian population [11, 12]. In spite of the growing literature on ITLMP and CVD risk factors, there is a paucity of studies evaluating the effect of participation with an accompanying household member.Household members may express similarities in lipid profiles due to genetic factors and similar living environments [13]. Furthermore, the resemblance in the physical health profile characteristics in systolic blood pressure and BMI of a family predisposes the development of similar CVD risk factor patterns [14]. Family can influence positive changes, such as increased physical activity seen in spouses participating together in lifestyle change programs [15]. A study evaluating environmental versus genetic influence of acquiring CVD in family members has shown that environment plays a significant role in developing CVD risk factors [16].This study aimed to see if better CVD risk factor outcomes were achieved by participating in an ITLMP with a household member as compared to attending alone. It was hypothesized that participation with an accompanying household member would be associated with better outcomes than participation alone.2. Methods2.1. Study ParticipantsParticipants attended CHIP classes offered from 2011 to 2015 in Athens, Ohio, a rural Appalachian college town. For recruitment, the program was promoted via the local media, health care providers, and churches. Participants came from varied socioeconomic backgrounds. As part of the registration process for CHIP, participants were asked to sign a consent statement to allow the use of their deidentified aggregated data for research purposes. They were informed that their choice to opt out of participation would not alter their eligibility to participate in CHIP. Data were stored on password-protected devices with restricted access to only approved CHIP administrators and study investigators. Approval for the study was obtained from Live Healthy Appalachia, the local CHIP administrator, and the Ohio University Institutional Review Board.2.2. CHIP DescriptionThe CHIP intervention consisted of 16 to 18 two-hour group sessions that were provided over 4 to 8 weeks. A typical session consisted of an instructional video, group discussion, cooking demonstrations, and an exercise component [9]. The goal of CHIP was for participants to consume plant-based whole foods, such as minimally processed vegetables, fruits, whole grains, legumes, and nuts. This was done through fostering self-care and awareness of lifestyle habits. Specifically, overall dietary fat was to be kept below 20% of total calories, daily intake of sugar less than 10 teaspoons, salt intake less than 2000 mg, cholesterol below 50 mg, and fiber intake 35 to 40 grams. Stress management techniques were taught and encouraged for daily use. Daily exercise of at least 30 minutes of moderate activity or 10,000 steps measured using a pedometer was encouraged. Strength training and resistance exercises were encouraged for 20-30 minutes, 2-3 days per week.2.3. Data Collection and ReportingDemographic data were collected as well as status of participation with a household member (sharing the same physical address) or alone, as an individual participant, without a household member. Biomedical assessments were made at baseline and before session 12, near the end of the program. Assessments included a lifestyle questionnaire to evaluate dietary and exercise habits as well as current illnesses and medications, weight, height, pulse rate, and blood pressure. BMI was calculated as weight in kilograms divided by the square of height in meters with a normal range considered as 18.5-24.9, overweight 25.0-29.9, and obese category 30 or above [17]. Blood was collected via venipuncture by trained phlebotomists to determine total cholesterol (TC), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglyceride (TG), and fasting blood glucose (GLU) levels. The data were entered into a password-protected Microsoft Access based database at the Live Healthy Appalachia office.2.4. Statistical AnalysisActual and percentage changes in the biomarker outcome variables during the CHIP program were computed. Participation in the program as an individual or alone (without a household member) or with an accompanying household member was the variable of interest. These were considered two independent groups defined as “Individual” for those who participated in the lifestyle program solely on their own and “Household” for those who participated with an accompanying member of their household. Data from both participating household members were used in the study analysis such that each household member was considered an independent participant in the “Household” group. Independent samples t-tests were conducted to compare differences between those attending with a household member (Household) and those attending alone (Individual) with respect to the mean changes in their biomarker outcomes. All differences were considered statistically significant if p ≤ 0.05.3. ResultsThe demographic characteristics of the CHIP participants in this study are shown in Table 1. In all, 512 people participated in the program over the period under study. Of this, 66.4% participated as an individual, or alone, while 33.6% participated with an accompanying household member. The average age of all the participants was 53.19 (±12.6 standard deviation (SD)) years with a range of 19 through 82 years.