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The dietary habits of Americans are creating serious health concerns, including obesity, hypertension, diabetes, cardiovascular disease, and even some types of cancer. While considerable attention has been focused on calorie reduction and weight loss, approaches are needed that will not only help the population reduce calorie intake but also consume the type of healthy, well-balanced diet that would prevent this array of medical complications.
To design an Internet-based nutrition education program and to explore its effect on weight, blood pressure, and eating habits after 12 months of participation.
We designed the DASH for Health program to provide weekly articles about healthy nutrition via the Internet. Dietary advice was based on the DASH diet (Dietary Approaches to Stop Hypertension). The program was offered as a free benefit to the employees of EMC Corporation, and 2834 employees and spouses enrolled. Enrollees voluntarily entered information about themselves on the website (food intake), and we used these self-entered data to determine if the program had any effect. Analyses were based upon the change in weight, blood pressure, and food intake between the baseline period (before the DASH program began) and the 12th month. To be included in an outcome, a subject had to have provided both a baseline and 12th-month entry.
After 12 months, 735 of 2834 original enrollees (26%) were still actively using the program. For subjects who were overweight/obese (body mass index > 25; n = 151), weight change at 12 months was -4.2 lbs (95% CI: -2.2, -6.2;
We have found that continued use of a nutrition education program delivered totally via the Internet, with no person-to-person contact with health professionals, is associated with significant weight loss, blood pressure lowering, and dietary improvements after 12 months. Effective programs like DASH for Health, delivered via the Internet, can provide benefit to large numbers of subjects at low cost and may help address the nutritional public health crisis.
The dietary habits of Americans are creating serious health concerns. The “obesity epidemic” is the most publicized evidence of the problem, but it is only one aspect. Studies have suggested that better dietary habits can, even with only modest weight loss, prevent or help control a number of expensive, chronic conditions like hypertension, cardiovascular disease, diabetes, and even some types of cancer [
There is a growing need for effective ways to improve Americans’ eating habits, but it is difficult to change dietary habits and maintain those changes. Weight loss studies have shown short-term success but gradual regain of weight in the longer term [
We designed a Web-based program, DASH for Health, to improve nutrition and physical activity habits. The nutrition advice was based on the DASH Diet (Dietary Approaches to Stop Hypertension) [
The DASH for Health program was offered as a free employee benefit to all US-based employees (approximately 12,500) of EMC Corporation, a global information infrastructure company based in Hopkinton, Massachusetts. The program was also offered to all adult household members of these employees. Employees and household members were encouraged to join the online program through a series of email communications from EMC leaders. During a three-week open enrollment period, 3479 subjects enrolled in the program and logged on to the website at least once. At the time of enrollment, we asked enrollees if we could use information that they entered about themselves on the website (eg, weight, blood pressure (BP) levels, food intake) to determine whether the program was providing benefit. This report is based upon the 2834 enrollees (81%) who granted consent.
The project was approved by the Institutional Review Board of Boston University Medical Center.
Enrollees were given access to a personalized, password-protected website.
A view of the program’s homepage as designed for EMC Corporation employees
Based on an enrollee’s gender, age, and activity pattern, algorithms on the website calculated the number of servings of each DASH food group the enrollee should consume each day. Enrollees were encouraged to enter information about themselves on the website such as weight, blood pressure, and 24-hour food recall using a recall instrument which converted common foods into servings of DASH food groups. This DASH recall instrument was designed for this program and was validated against the Block 98.2 Food Frequency Questionnaire (data not shown). The website converted those self-entered data into progress report graphs. Although enrollees had the option of submitting email questions for the investigators to respond to, we designed the program to provide minimal personal contact. The goal was to develop a program which, with only minimal person-to-person interaction, could influence behaviors.
We did not impose any limits or expectations on how enrollees used the website. They were free to select for themselves which articles to read and how frequently to enter information about their weight, blood pressure, or eating habits.
We had three primary outcomes, all measured at 12 months: first, change in weight between baseline and 12 months in subjects who indicated a desire to lose weight on their enrollment questionnaire; second, change in systolic blood pressure (SBP) in those who indicated that they either had high blood pressure or were on blood pressure medications or had been told to watch blood pressure (we defined this as our “High Blood Pressure” group); and third, change in consumption of DASH food groups. Change in diastolic blood pressure (DBP) was a secondary outcome. We also performed exploratory analyses of the relationship between our outcomes and the amount of use of the DASH for Health website.
For weight measurement, we used self-entered weights from the website which may have included weights taken by the subjects themselves or taken in other settings (eg, physician visits). We classified subjects as overweight/obese based on their body mass index (BMI; kg/m2). Similarly for blood pressure, we used self-entered readings which could have been self-measurements or readings taken by others. We did provide recommendations on the website about how to take one’s own blood pressure (seated, left arm, average of two measurements). In addition, the employer, EMC Corp., offered free automated sphygmomanometers (Fore-Care 6400; Forecare Inc., Buffalo Grove, IL) to enrollees with hypertension. Food consumption was estimated from the DASH Online Questionnaire, a 24-hour recall instrument. For weight, blood pressure, and food intake, if there were more than a single entry during the baseline or 12th-month time window, we averaged the entries and used that single value in our analyses. Website use was calculated as the number of log-ons by each enrollee who visited the website (unique users).
For our analyses, we used the data that enrollees self-entered on the website. There was no randomization and no control group. Our analyses do not allow estimation of what the effects of DASH for Health might have been on enrollees who did not enter any data. The baseline data reflect information that enrollees entered on the DASH for Health website during the three-week enrollment period (before the website was delivering any behavior-changing messages), and the “12th-month” data are those entered during weeks 48-52. The number of subjects analyzed for each outcome was determined by the number of subjects who entered data for that outcome during both the baseline and 12th-month time frame. In analyzing website use, we used the number of log-ins over 12 months. Data are displayed as means unless otherwise noted, and indices of dispersion are standard deviation (SD) or 95% confidence intervals (CI) as noted. All analyses were performed with SigmaStat 3.5. Baseline versus 12th-month comparisons were performed with paired
Enrollees were widely distributed geographically, residing in 41 states. They were approximately evenly distributed by gender, and their ages ranged from 18-73 years (average 40.7 years). They were highly educated, with 1845 (66%) having completed college or postgraduate work. Of the subjects, 88% were white, and 74% were married (see
Of the 3479 subjects who enrolled in the program and logged on to the website at least once, 2834 (81%) granted consent to use their data for research purposes. Of these, 735 (26%) were still actively using the website in the 12th month. Their demographics are also shown in
Characteristics of all enrollees at baseline and of those still using the program at 12 months, using self-entered data at time of enrollment
All Enrollees |
Still Active at 12 Months |
|
||
All enrollees | 2834 | 735 | ||
Males | 1568 (55%) | 369 (50%) | .01 | |
Females | 1266 (45%) | 366 (50%) | .01 | |
Average Age (years) | 40.7 | 42.2 | .001 | |
Average Weight (lbs) | 182.7 | 179.8 | .11 | |
|
||||
Grade School | 34 (1%) | 5 (< 1% ) | .23 | |
Some High School | 10 (< 1%) | 1 (< 1%) | .34 | |
Completed High School | 171 (6%) | 35 (5%) | .19 | |
Some College | 733 (26%) | 175 (24%) | .25 | |
Completed College | 1140 (41%) | 307 (43%) | .45 | |
Postgraduate Work | 705 (25%) | 199 (28%) | .22 | |
|
||||
Single | 522 (19%) | 110 (15%) | .03 | |
Widowed | 19 (1%) | 11 (2%) | .03 | |
Married | 2063 (74%) | 548 (76%) | .34 | |
Divorced/Separated | 190 (7%) | 52 (7%) | .72 | |
|
||||
African American | 62 (2%) | 13 (2%) | .48 | |
Native Hawaiian/Pacific Islander | 20 (1%) | 4 (1%) | .63 | |
White | 2470 (88%) | 648 (90%) | .46 | |
American Indian | 7 (< 1%) | 1 (< 1%) | .57 | |
Native American | 13 (< 1%) | 4 (1%) | .76 | |
Hispanic | 67 (3%) | 17 (3%) | .93 | |
Other | 221 (8%) | 51 (7%) | .43 | |
|
||||
Want general health info | 2204 (78%) | 604 (82%) | .01 | |
Weight concerna | 2160 (76%) | 568 (77%) | .54 | |
High Blood Pressureb | 664 (24%) | 195 (27%) | .08 | |
Have diabetes | 98 (3%) | 21 (3%) | .42 | |
Have high cholesterol | 790 (28%) | 206 (28%) | .93 |
a“Weight concern” group includes subjects who indicated they wanted to lose weight.
b“High Blood Pressure” group includes subjects who indicated one or more of the following: have high blood pressure; are taking antihypertensive medications; have been told by doctors to “watch” their blood pressure.
At the end of 12 months, 735 of the original 2834 enrollees (26%) were still actively visiting the website.
Pattern of website use during a 3-week baseline period and then in sequential 4-week periods for 12 months
There were 203 subjects who indicated a desire to lose weight when they enrolled in the program and who entered their weight during the baseline period and during the 12th month of the program. Their average weight change was -3.1 lbs (CI -4.7, -1.5;
Weight change from baseline to 12 months
Baseline weight |
Weight change |
Age |
Males |
Females |
|
All subjects (n = 203) | 187.0 (43.0) | -3.1 (-1.5, -4.7)a | 42.7 (10.0) | 79 (39) | 124 (61) |
BMI > 25 (n = 151) | 202.3 (38.3) | -4.2 (-2.2, -6.2)a | 43.2 (9.9) | 72 (48) | 79 (52) |
BMI < 25 (n = 52) | 142.4 (16.7) | +0.2 (-1.6, +2.0) | 41.6 (10.0) | 7 (13) | 45 (87) |
aWeight change in
A total of 120 subjects entered blood pressure readings on the website during the baseline period and the 12th month (
Blood pressure change
Baseline BP |
Systolic change |
Diastolic change |
Age |
Males |
Females |
|
High Blood Pressure group (n = 62) | 137.3/81.2 | -6.8 (-2.6, -11.0)a | -2.1 (+0.8, -5.0) | 48.6 (7.7) | 32 (52) | 30 (48) |
No High Blood Pressure (n = 58) | 118.0/73.5 | -2.4 (+1.3, -6.1) | -0.2 (+2.4, -2.8) | 41.0 (9.1) | 22 (38) | 36 (62) |
aSystolic change in high blood pressure group:
Mean (+ /- 95% CI) systolic and diastolic blood pressure change at 12 months in high and normal blood pressure groups (the systolic change in the high blood pressure group was significant,
A total of 181 enrollees completed at least one DASH online food questionnaire during the baseline period and the 12th month. The median number of completed questionnaires per enrollee was three during baseline and three during the 12th month. The average age was 42.4 years; 107 were women; 74 were men.
The DASH online questionnaire also provided information on 52 subcategories of these eight main food groups. We performed exploratory analyses to examine changes in these subcategories. There were several significant changes in subgroup consumption. Three categories merit mention. Consumption of carbonated beverages decreased from 9 oz per day to 6.5 oz (
Changes in consumption of the eight main DASH food groups from baseline to the 12th month of DASH for Health (n = 181)
DASH Goals |
Average Baseline |
Average 12th month |
Difference |
|
|
Fruit | 4 | 2.0 | 2.2 | +0.2 | .03 |
Vegetables | 4 | 2.6 | 3.1 | +0.5 | .002 |
Grains | 7 | 4.4 | 4.2 | -0.2 | .04 |
Dairy | 2.5 | 2.1 | 2.0 | -0.1 | .48 |
Meat/fish | 1.5 | 1.9 | 1.9 | 0 | .30 |
Nuts/beans | 0.5 | 0.4 | 0.5 | +0.1 | .76 |
Added fats | 2 | 1.6 | 1.5 | -0.1 | .15 |
Sweets | 0.5 | 1.3 | 1.2 | -0.1 | .13 |
We performed exploratory analyses, relating the amount of website use (measured as number of log-ins over the course of 12 months) versus change in our main outcomes: weight, systolic blood pressure, and consumption of DASH food groups. We divided the sample into two parts based on the median number of log-ins. The median log-in number differed for each outcome, being determined by the number who provided baseline and 12-month data for that outcome. For weight and blood pressure, there were tendencies toward greater effect among those with more log-ins (
Comparison of changes in weight and blood pressure in relation to number of DASH website log-ins (median log-ins for blood pressure group was 50; median for weight group was 40)
≤ Median log-ins | > Median log-ins |
|
|
Systolic BP (mmHg; CI) | -3.9 (-9.9, +2.2) | -9.8 (-15.9, -3.7) | .06 |
Diastolic BP (mmHg; CI) | +0.7 (-3.8, +5.1) | -4.8 (-8.6, -1.0) | .06 |
Weight (pounds; CI) | -1.5 (-3.5, +0.5) | -4.6 (-6.9, -2.3) | .09 |
We have found that an online program that provides weekly educational information, motivational messages, and convenient ways for self-monitoring can lead not just to significant weight loss but also to reduction in blood pressure and to healthier dietary habits.
Our results compare favorably to other programs. In terms of retention in the program, 735 of the original 2834 enrollees (26%) were still using the DASH for Health website after 12 months. Very little has been published about long-term subject retention in lifestyle improvement programs in real-world settings, but, as one example, Finley et al reported that, of > 60,000 enrollees in the Jenny Craig program (not Internet-based), only 6.6% were still retained in the program at 52 weeks [
There are thousands of websites on the Internet that provide nutrition information, including more than 400,000 websites that mention the DASH diet. Most of these websites provide static content and are not true education programs. Those that are actual education programs, such as eDiets.com or Weight Watchers, focus on weight loss, and there is little evidence that they provide long-term benefit. Womble et al assessed the weight loss effect of eDiets.com for 12 months in 23 women [
The Internet has also been used in other ways in research studies. Some investigators have used it as a communication tool between an individual nutritionist and a client (a strategy to extend a nutritionist’s reach to greater numbers of clients). In general, programs with more intense or frequent person-to-person interaction lead to greater retention and health benefits [
We believe that scalability and cost are important considerations when addressing a problem as vast as the eating habits of the roughly 140,000,000 Americans who have nutritionally-related health concerns. The physicians and nurses who form the framework of our health care system do not have the time or, in many cases, the background training to counsel patients about nutrition. Additionally, most health insurance products limit the number of allowable visits with a nutritionist. An approach is needed that can be offered without imposing additional burdens on our health care workers or on our health care budget. The Internet, in our view, could potentially provide such a solution.
There were some limitations to this study. First, we relied totally on self-entered data, with no objective measurements to confirm the self-entered results. Second, we could only assess changes in our outcomes after 12 months in people who were, by definition, still using the website. Even though there were no demographic differences between the 12-month users versus all those who enrolled at baseline, it is likely that this group was highly self-selected: people who continued to use the website for the entire year probably did so, in part, because they were deriving some benefit from the website (as observed by Finley et al [
In summary, we showed that 26% of original enrollees continued to use the Web-based DASH for Health program at the end of one year and that, at one year, those who continued using the program had not only lost weight but also lowered their blood pressure and made healthy changes in dietary habits. While this study does not prove a causal relationship between using the program and achieving healthy changes, the possibility that well-designed, Internet-based programs can produce or aid in achieving important health benefits is encouraging. Programs like this one could play an important part in our efforts to improve the way Americans eat.
We wish to thank Donna Abbadessa and Diana Lehman for their assistance in preparing this manuscript and Jack Mollen, Delia Vetter, Lauri Tenney, and Leslie Berger for their help in introducing this program at EMC Corp. The development of the online DASH dietary questionnaire was supported by a grant form the National Heart, Lung, and Blood Institute (3 01 HL57156-04S2). The development of the DASH for Health program was supported by donations from several companies that produce or promote healthy food products (Cabot Cheese, California Table Grape Commission, ConAgra Foods, Dannon, Diamond Nuts of California, Florida Department of Citrus, Garelick Farms, General Mills, International Banana Association, Minute Maid, National Dairy Council, The Peanut Institute, Sunkist, and SunMaid) as well as donations from EMC Corp. and Stop and Shop supermarkets. DASH for Health™ is a registered trademark.
Dr. Moore is Chairman of e-Havior Change, LLC which owns the copyright to the DASH for Health
body mass index
blood pressure
dietary approaches to stop hypertension
diastolic blood pressure
National, Heart, Lung, and Blood Institute
systolic blood pressure
United States Department of Agriculture