Table of Contents
Abstract
III
Introduction
IV
Literature Review
VI
Heart Disease
7- 10
Diet
10-13
Conclusion
13-14
Methodology
Research Design
Research Protocol
Sample
Instrumentation
Data Collection Procedures
XV
15
16
16
17-18
18
Data Analysis
18-19
References
XX
Abstract
Studies have shown that nutrition and exercise are associated with reducing heart disease
risk factors like high blood pressure and high cholesterol. Studies have also shown that
stress reduction is associated with lower risk of high blood pressure. The purpose of this
study is to determine the effects of an intervention combining diet, exercise and stress
reduction techniques in the secondary treatment of hypertensive heart disease compared
to conventional treatment. The sample used included males and females between the ages
of 35-65 with hypertensive heart disease. The comparable control group had the same
inclusion and exclusion criteria as the intervention group. 20 people were selected for the
experimental group and 20 people were selected for the control group using the simple
random sampling technique. The study design uses a randomized experimental trial. The
study focused on 2 main variables between groups: Blood pressure and stress levels.
Changes within the experimental group were analyzed through paired sample test.
Differences between the experimental and control group were analyzed through
independent samples test.
Introduction
pressure levels. Another objective is to decrease the incidence of cardiac events. The third
objective is to increase overall nutrient intake. The final objective in this study is to
improve overall morale in participants. The primary dependent variable is blood pressure
levels. The secondary dependent variable is stress levels. The independent variable is the
diet, exercise, and meditation intervention.
The hypotheses for the research objectives are directional. Participants following the
multifaceted intervention will decrease their blood pressure to healthier levels. Participants
who receive the intervention will also decrease the incidence of cardiac events. Participants
who follow the intervention will improve their overall nutrient intake as a result of the
nutrition education portion of the intervention. Participants following the multifaceted
intervention will improve in their overall morale significantly more than control participants
who follow traditional treatment.
Literature Review
Heart Disease
Heart disease is the leading cause of death for both men and women in the United States.
As of 2013 26.6 million adults in the United States were diagnosed with heart disease,
this accounts to 11.3% of the adult population. Of the people diagnosed with heart
disease, 611,105 cases lead to mortality in 2014 (CDC, 2013, table 10). The number of
death related to hypertension was 396,675 in 2013; this is a 61.8% increase from the
number of deaths in 2000, which was 245,220. The hypertension-related death rate was
higher for men than women ages 45-84 however, the rate was higher for women than
men over age 85. In 2013, heart disease, stroke, cancer, and diabetes accounted for 54%
of hypertension- related diseases (Center for Disease Control and Prevention, 2015).
Specifically coronary heart disease is the most common type of heart disease in the
United States. High blood pressure is one of the leading risk factors for the development
of coronary heart disease (Centers for Disease Control and Prevention, 2015). According
to the American Heart Association, chronic stress, although not directly shown to cause
high blood pressure, has been shown to lead to unhealthy lifestyle choices that are
associated with high blood pressure. Chronic stress increases the release of the hormone
adrenaline, which increases heart rate and causes blood pressure to rise temporarily
(American Heart Association, 2014). Risk factors for the development of heart disease
include unhealthy lifestyle choices such as poor nutrition, stress, lack of physical
exercise, and tobacco use (American Heart Association, 2014).
educational program. The program included a pre and post health screening for
comparison. The participants were both male and female and did not have diagnosed
heart disease. The results were a decrease in cholesterol levels from an average of
189mg/dl to 159mg/dl. Also an average LDL decreases from 100mg/dl to 81 mg/dl and a
decrease in BMI with a weight decrease that ranged from 2 to 10lb. The study concluded
the intervention had significant effect in improving health risks related to the
development of heart disease such as BMI, blood pressure, and cholesterol (Hutchins et
al. 2015).
One major difference in the two studies is the time of treatment. The first study done
by faculty of medicine at the University of Duisburg-Essen used diet, exercise, and
relaxation interventions as a secondary treatment; the second study done by faculty in
Applied Health Sciences at Indiana State University used diet, exercise and relaxation
intervention as a primary treatment. As a secondary treatment the intervention can reduce
the incidence of cardiac events (Cramer et al. 2015). As a primary prevention the
intervention can reduce factors related to the development of heart disease (Hutchins et
al. 2015). Neither study provides information on the specifics of the nutrition counseling
provided or information on the emphasis of the diet intervention. Both studies concluded
the intervention lowered participants systolic blood pressure.
Lifestyle intervention including diet, exercise, and stress reduction techniques were
also concluded to be effective in lowering systolic blood pressure in another study. An
experimental study published by the Academy of Nutrition and Dietetics aimed to
examine the effectiveness of a 6-month lifestyle intervention in achieving improvements
on blood pressure, anthropometric measurements, biological measures, and diet among
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The findings from the three studies explained make it evident that lifestyle interventions
that utilize the three domains of diet, exercise, and stress reduction are effective in
lowering some risk factors related to the development of heart disease and in reducing the
severity of heart disease. Although the study conducted in Hattiesburg, Mississippi was
not aimed towards heart disease specifically, the study did use lifestyle intervention
methods to treat the heart disease risk factor of hypertension. For that reason the study is
applicable to the literature review. The study also compliments the findings of the study
done by faculty in Applied Health Sciences at Indiana State University whose lifestyle
intervention also concluded the reduction in systolic and diastolic blood pressure among
participants.
Diet
Stress is positively associated with high blood pressure; diet interventions are also
associated with blood pressure levels (American Heart Association, 2014). It has been
well established that dietary sodium intake has influential effects on blood pressure. High
sodium intakes exceeding 2,300mg/day are related to higher incidence of hypertension
(Noh, Park, Lee, Oh, Paek, Song, Park, 2015). The authors working in the laboratory of
cardiovascular science, National Institutes of Health in Baltimore Maryland, conducted a
study to test the effects of dietary sodium intake on blood pressure and heart rate. The
sample for the study was 36 healthy normotensive women between the ages of 40 and 70
(Mcneely, Windham, Anderson, 2008). The study placed each participant on a low
sodium diet for 6 consecutive days, and then put the participants on a high sodium diet
for 6 consecutive days. The low sodium diet provided participants with 59 mmol/kg of
sodium per day and the high sodium diet provided participants with 154 mmol/kg of
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sodium per day. Thats equal to 1,356mg/kg/ day of sodium for the low sodium diet and
3,540 mg/kg/day for the high sodium diet (Mcneely, 2008). The results of the study
concluded that mean heart rate on the high salt diet was lower than the mean heart rate on
the low salt diet. Salt sensitive participants experienced significant increase in systolic
blood pressure but not in diastolic blood pressure when on the high salt diet. Limitations
of this study include the short time frame and limited number of participants. The study
only tested Caucasian women over the of 40, and the study took place over 12 days
(Mcneely, 2008).
According to a study published by the Academy of Nutrition and Dietetics, potassium
shows the inverse relationship with blood pressure. In this cross-sectional survey, 24,096
Korean adults both male and female over the age of 19 without history of
antihypertensive medication use were selected for a 42-hour recall dietary assessment
(Noh et. al. 2015). The participants were then categorized into four groups using median
intakes of sodium and potassium. The low sodium/high potassium intake group was used
as the reference group. A multivariate logistic regression was preformed to investigate the
association between the four groups dietary intake and high blood pressure. As a result,
low potassium intake was associated with increased risk of hypertension in Korean adults
regardless of the dietary sodium intake. These results suggest higher potassium intakes
could be a preventative against hypertension (Noh et. al. 2015). A limitation to this study
is the researchers where not able to analyze 24-hour urinary sodium and potassium levels
because they were not able to collect urine samples.
To further support the importance of dietary potassium in patients with heart disease,
another study published by the Journal of the American Dietetic Association, recognized
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inadequate potassium intakes in patients with stable heart failure (Arcand, Floras, Ahmed,
Al-Hesayen, Ivanov, Allard, Newton, 2009). This cross-sectional study was conducted to
determine micronutrient dietary concerns for patients with heart failure in addition to
sodium. The study characterized dietary intake among participants with stable heart
failure and among non-heart-failure participants. The study analyzed two sets of 3-day
food records and 24-hour urinary excretion among 123 patients with heart failure and 58
control patients without heart failure. The participants were both male and female
(Arcand et al. 2009). The average of the control group was 64 and the average age of the
heart failure group was 60. As a result of the analysis, both groups reported similar; mean
sodium intakes. According to the DRI upper limit of 2,300mg/day of sodium, 55% of
patients with heart failure and 52% of the control group were consuming excess sodium
(Arcand et al. 2009). Both groups reported inadequate potassium, magnesium, folate,
vitamin E, vitamin D, and zinc intake. Both groups reported nutritional inadequacy
however patients with heart failure may be at greater risk due to nutritional abnormalities
from heart failure. This study concludes that dietary modifications for patients with heart
failure must be comprehensive and include more than just a focus on sodium restriction,
which emphasizes the importance of dietary counseling for patients with heart disease
(Arcand et al. 2009). Limitations to this work include the basis of nutrient requirements
off of the DRI recommendations for healthy people. Patients with heart failure may need
additional nutrient requirements, which were not accounted for in this study.
Both studies published by the Academy of Nutrition and Dietetics and the Journal of
the American Dietetic Association suggested that patients with heart disease had low
dietary potassium intake regardless of dietary sodium intake. This suggests that
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risk of high blood pressure, what might happen if you combine the two interventions in
the secondary treatment of hypertensive heart disease such as coronary heart disease?
How would this intervention compare to classical treatment like medication? Testing this
hypothesis through an experimental study could advance further research.
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Methodology
Research Design
The purpose of this experimental study is to examine the effects of a diet, exercise, and
meditation intervention as a secondary treatment in male and females ages 35 to 65 with
hypertensive heart disease. The objectives of this study are to decrease blood pressure in
participants with stage 1 hypertension to normal or prehypertensive blood pressure levels.
Another objective is to decrease the incidence of cardiac events. The third objective is to
increase overall nutrient intake. The final objective in this study is to improve overall morale
in participants. The primary dependent variable is blood pressure levels. The secondary
dependent variable is stress levels. The independent variable is the diet, exercise, and
meditation intervention.
The variables being measured in this study are blood pressure levels, incidence of
cardiac events, nutrient intake, and overall morale. To assess blood pressure, blood pressure
measurements will be taken before and after the intervention for comparison. To assess
overall nutrient intake blood profile will be taken before and after the intervention. Specific
nutrients examined will be sodium, potassium, protein, potassium, zinc, and vitamin D.
These nutrients were selected from the nutrient emphasis in recent literature on hypertensive
heart disease. To examine stress levels, and MRI brain scan of the amygdala will be taken
before and after the intervention.
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Research Protocol
Sample
The sample population includes male and females between the ages of 35- 65 with
hypertensive heart disease. Participants must be voluntary and agree to take part in the study
for the entire 12 week intervention period. IRB consent must be obtained before volunteers
can participate. Informed consent will be obtained via email. The comparable control will
have the same inclusion and exclusion criteria as the intervention group. To accurately
compare the two both groups, they must both have hypertensive heart disease. The difference
between the control and experimental group is the control group will follow tradition
treatment such as medication, and the experimental group will follow the multifactited
intervention that include diet, yoga, and mediation.The study will use a simple random
sampling technique among all people within the inclusion criteria in hospitals, schools, and
health care facilities in northeast Pennsylvania. Control and experimental groups will be
determined randomly. 20 people will be selected for the experimental group and 20 will be
selected for the control group, with a total desired recruitment of 40 people. Participants must
have hypertensive heart disease and be diagnosed with stage 1 hypertension that is a systolic
blood pressure between 140-159 and a diastolic blood pressure between 90-99. The included
hypertensive heart diseases are coronary heart disease, ischemic heart disease, heart failure,
and hypertrophic cardiomyopathy. All other heart diseases are excluded from the study to
maintain the focus of the study, which is on hypertensive heart disease specifically.
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Instrumentation
The instrumentation reflects all the parts of the research question. The multifaceted
intervention being tested is aimed to reduce blood pressure, stress, and improve overall
dietary consumption.
Measure blood pressure of both the control group and experimental group before and
after using a blood pressure cuff to assess how effective the intervention was in lowering
blood pressure.
To measure a decrease in stress as a result of the yoga and mediation part of the
intervention, brain scans will be done using an MRI. The brain scans will focus on the
amount of gray matter in the amygdala because this is the region of the brain that is
associated with stress. A decrease in gray matter in the amygdala correlates with a
decrease in stress, therefore the smaller the smaller the amygdala the more stress
reduction has occurred. This instrumentation of measuring stress was preformed in a
previous meditation study published by the frontiers in Human Neuroscience. (Kerr,
Sacchet, Lazar, Moore, Jones, 2013). This instrumentation was used in multiple
randomized clinical trials with people with depression.
To measure nutrient intake a food frequency questionnaire will be administered. This will
focus on measuring the nutrients of interest in this study, which are sodium, protein,
potassium, zinc, and vitamin D. After administering the food frequency questionnaire, my
peers suggest that I separate the never eat and the rarely eat columns. They also had a
little confusion on the instruction. For future reference I will separate the two columns for
never eat and rarely eat and elaborate on the instructions. The limitations of this pre
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test are that my peers who took the pre test are not apart of the target audience for this
study. People of the target audience were not available to take the pretest.
Data Collection Procedures
Before the collection of data from participants will be conducted, participants will
receive a written informed consent form to fill out one week prior to data collection tests.
Data will be collected using paper surveys and measurement tools. Paper surveys will be
administered in the form of a food frequency questionnaire. Measurement tools that will
be used are the MRI and a blood pressure cuff. The MRI will be used to measure stress
levels through brain scans. The primary dependent variable being measured is blood
pressure. The secondary dependent variable being measured is stress levels. The
independent variable is the diet, exercise, and meditation intervention.
Data Analysis
Blood pressure and stress levels are the variables being measured to answer the research
question. Both variables are ratio variables. The variables analyzed using descriptive
statistics are age, gender, and heart condition. The measures of central tendency that will
be used are both the sample mean and the sample mode. The results will be displayed
using a histogram. The variables analyzed using comparative statistics will be blood
pressure and stress level compared pre and post intervention. The research question
requires both independent-samples test and paired samples test. Changes within the
experimental group will be analyzed through paired sample test. Differences between the
experimental and control group will be analyzed through independent samples test. The
variables also require a linear regression test. The relationship between the intervention
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and outcome ratio variables can be visually displaced using a scatterplot. The statistical
program that will be used in SPSS Software.
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References
American Heart Association (2014). Frequently Asked Questions (FAQs) About Stress.
Arcand, J., Floras,V., Ahmed,M., Al-Hesayen,A., Ivanov,J., Allard,J., Newton,G (2009).
Nutritional Inadequacies in Patients with Stable Heart Failure. Journal of the
American Dietetic Association , Vol 109, Issue 11, 1909-1913
Center for Disease Control and Prevention. (2015). Coronary Artery Disease (CAD).
Centers for Disease Control and Prevention, Deaths: Final data for 2013, table 10 (2014).
Centers for Disease Control and Prevention, Hypertension- related Mortality in the
United States, 2000-2013. No 193 (2015).
Cramer,H., Lauche,R., Paul,A., Langhorst,J., Michalsen, A., Dobos,G. (2015). MindBody
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Zoellner ,J., Connell, C., Madson, M., Thomson, J., Landry, A., Fontenot, E., Blakely, V.,
Yadrick, K. (2014). HUB City Steps: A 6- Month Lifestyle Intervention Improves
Blood Pressure among a Primarily African-American Community. Journal of the
Academy of Nutrition and Dietetics, Vol.114, Issue 4, 604-612.