The Healthy Heart Program Lowers Heart Disease Risk in a Rural County

Coronary heart disease (CHD) remains the leading cause of death in the United States (U.S. Department of Health and Human Services, 1996), despite decreases in CHD mortality over the past few decades (American Heart Association, 1994; Hunink, et al., 1997). The prevalence of CHD has led to an increased interest in and need for prevention programs.

The National Cholesterol Education Program (NCEP) and Healthy People 2000 recommend public health or community approaches for reducing CHD risks (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 1993; Health and Human Services, 1990). Since their beginning in the 1970s, community prevention projects have provided insight into effective approaches to reduce the risks associated with CHD (Brownson, et al., Pawtucket Heart Health Program Writing Group, 1996; Carleton, Lasater, Assaf, Feldman, & McKinlay, 1995; Croft, et al., 1994; Farquhar, Fortmann, & Maccoby, 1990; Luepker, et al., 1994; Shea, Basch, Wechsler, & Lantigua, 1996; Stern, Farquhar, Maccoby, & Russell, 1976).

The Healthy Heart Program is a smaller, community-based program developed in 1979 to educate people about CHD and its risks. Evaluation of the Healthy Heart Program provided some evidence of its capacity to reduce CHD risks, but the long-term effectiveness of the program was not established (Anderson & Gunn, 1981; Lopez & Anderson, 1991). The purpose of the present study was to evaluate the effectiveness of the Healthy Heart Program on lowering heart disease risk through positive changes in knowledge, attitudes and behaviors and to determine if those changes could be maintained over a period of time, with three follow-up assessments.

Program Participants and Leaders

Eighty-three adults from Logan County, Colorado, were recruited for the Healthy Heart Program through advertisements in a newsletter distributed in the local hospital, Sterling Regional Medical Center, and throughout the community. There were nine Healthy Heart Program sessions offered over a period of four years from 1985 to 1989. Seventy-eight people completed the intervention sessions, each of which consisted of five weekly, two-and-a-half hour classes. The starting size of the intervention groups varied from six to 14 persons.

Participants were recalled by telephone and a written reminder for three follow-up assessments given in March 1988, 1989, and 1990 to evaluate the long-term effectiveness of the Healthy Heart Program. Fifty-five participants attended one or more of the follow-up assessments, each taking place during one morning session. This is an approximate 70 percent response rate. Drop-outs had moved out of Logan County, did not obtain blood lipid profile tests prior to the first class, had time conflicts, or did not express interest. However, baseline information was comparable to those who completed at least one of the follow-up periods.

An Extension agent from Logan County and a registered dietitian were trained as Healthy Heart Program leaders and followed The Program Leader's Manual for each class. The Guide was used as a step-by-step manual for the participants. Both the Extension agent and the registered dietitian were present at all classes and follow-up assessments, all of which were held at the Sterling Regional Medical Center.

The Intervention and Follow-up Assessments

Topics covered in the five classes of the Healthy Heart Program were (a) heart disease and risk, body assessment, food records; (b) fats, cholesterol, diet analysis and recipe modification; (c) calories, salt, sugar, fiber, new issues and nutrition labeling; (d) nutrient density, RDA's, dietary guidelines; and (e) a celebration potluck where the participants brought foods they made using modified recipes. Three-day food records were collected early in the intervention (the second class) to assure that the diet would be representative of normal food intakes and not influenced by the intervention. Dietary analyses of the food records were handed back to the participants and discussed at the last class. Intervention pre-tests and post- tests were given at the first and last class, respectively. All of the nine Healthy Heart Program sessions included these same components.

Each of the three follow-up assessments included (a) a fasting blood test and blood pressure reading taken by hospital personnel; (b) an educational breakfast meeting, (c) a three-day food record; (d) a 13-item questionnaire designed to give information on the activities and background of each participant; and (e) a follow-up test, identical to the intervention pre- and post-tests given during the five week intervention session. Before each follow-up assessment, three-day food record sheets were mailed to each participant, to be completed on the three days before the follow-up assessment. Dietary analyses of the food records were mailed to participants after the follow-up session.

Evaluation Tests

Evaluation tests, measuring participants' attitudes, knowledge and locus of control, were given to all participants in the interventions and included a 54-item intervention pre-test in the first class, a 50-item intervention post-test in the last class, and a 50-item follow-up test in each follow-up assessment. All tests were identical, with the exception of the intervention pre-test that included four items for demographic information on gender, age, education, and marital status. These self- administered questionnaires had been tested for content validity with a panel of health professionals and for internal consistency with Cronbach's alpha (Lopez & Anderson, 1991). The tests were scored separately for attitude, knowledge, and locus of control.

Dietary Intake

Dietary intake was measured using a three-day food record during the intervention and again at the follow-up periods. A Logan County registered dietician reviewed the food records and a Colorado State University student entered the data, using the computer program, Nutrifit (1980). Total kilocalories, percent of total kilocalories as fat, percent of total kilocalories as saturated fat, dietary cholesterol, sodium, and fiber were the dietary variables of focus for the study.

Physiological Measurements

A fasting blood sample was drawn for serum lipid measurements by a nurse at the Sterling Regional Medical Center at the first class and at the follow-up assessments. Body weight and systolic and diastolic blood pressure measurements were also taken by the nurse at this time, using instruments from the hospital. The blood was analyzed for serum total cholesterol, HDL cholesterol and serum triglycerides by the same hospital laboratory, that was certified by the American Board of Pathology, for all of the Healthy Heart Program sessions and follow-up assessments. LDL cholesterol (American Dietetic Association, 1992) and a risk ratio of serum total cholesterol to HDL cholesterol (American Heart Association of Colorado, 1996) were calculated.

Statistics

All data were analyzed using the SAS System (SAS Institute, Inc.; 1989-92). "Baseline" refers to participant data collected during the intervention sessions. Participants were grouped into three follow-up groups, according to the number of years since they had completed the Healthy Heart Program; (a) less than two years since completion; (b) two to three years since program completion; and (c) three or more years since program completion.

A randomized block design, two-way analysis of variance was used to determine differences within the Healthy Heart Program intervention sessions and follow-up groups. By blocking on individuals, subject differences were adjusted and comparisons could be made across the intervention and three follow-up groups. Following ANOVA, least significant difference t-tests were used to determine pair-wise differences between the intervention and the three follow-up groups. Data are expressed as least squares mean plus or minus the standard error of the least squares mean, unless otherwise noted. The level of significance was set at p<.05.

The maximum sample size of the intervention group was 67 individuals. Likewise, the maximum sample size of the follow-up of up to two years was 29, the follow-up of two to three years was 60, and the follow-up of three or more years was 37. Take note that some of the same participants appear in more than one of these follow-up groups. Sample sizes of the intervention and each of the follow-up groups may vary for evaluation tests, dietary intake and physiological measurements since all of the participants were not compliant in completing all of the items within each of these categories.

Program Participants

Of the 83 adults from Logan County who originally enrolled in the Healthy Heart Program, 58 were female and 25 were male. The mean age of the participants at the start of the program was 50 years, plus or minus 11 years (SD), with ages ranging from 22 to 74 years.

Evaluation Tests

As indicated in Table 1, attitude and knowledge scores on the intervention post-test and the follow-up tests were significantly higher than the intervention pre-test (p<.001). Locus of control scores did not differ significantly between the intervention pre-test, intervention post-test and follow-up tests.

Dietary Intake

Participants' dietary intake is described in Table 2. Total kilocalorie intake increased significantly from the intervention to the follow-up of three or more years (p<.001). Percent of total kilocalories as fat was significantly lower than the intervention (mean SEM : 351) in the follow-up up to two years (301), in the follow-up two to three years (311), and the follow- up three or more years (271). Percent of kilocalories from saturated fat, polyunsaturated fat, and monounsaturated fat all decreased significantly from the intervention to the follow-up of three or more years only. Dietary cholesterol (mg) decreased significantly from the intervention (27611) to the three follow- up groups (19821, 21113 and 17518, respectively). Fiber increased significantly from the intervention in the follow-up of up to two years (p<.01) and the follow-up of two to three years (p<.001). Fiber intake was not significantly different from baseline in the follow-up of three or more years since program completion.

Physiological Measurements

As illustrated in Table 3, blood cholesterol (mmol/L) decreased significantly (p<.05) from baseline (6.000.10) to the follow-up of three or more years (5.500.15), but did not change from baseline to the follow-up of up to two years (6.050.10) or the follow-up of two to three years (5.800.10). HDL cholesterol did not differ significantly between baseline and follow-up. Blood triglycerides also did not change from baseline to follow- up. LDL cholesterol (mmol/L) decreased significantly (p<.001) from baseline (4.250.15) to the follow-up of two to three years (3.550.10) and the follow-up of three or more years (3.150.15), although there was no change from baseline to the follow-up of up to two years (4.05 0.15). Risk ratio was calculated from serum total cholesterol divided by HDL cholesterol, both in mg/dL. Risk ratio is reported this way for more accuracy since changing to mmol/L required rounding the values for serum total cholesterol and HDL. Risk ratio decreased significantly (p<.001) from baseline (5.230.21) to the follow-up of two to three years (220.16) and the follow-up of three or more years (3.840.24), but not to the follow-up of up to two years (5.070.26).

Systolic blood pressure also decreased significantly from baseline to the follow-up of two to three years (p<.001) and to the follow-up group of three or more years (p<.01). Diastolic blood pressure decrease significantly from baseline to the follow -up of up to two years (p<.05) and the follow-up of two to three years (p<.01), but not to the follow-up of three or more years. Body weight did not differ significantly between the intervention and the follow-up of up to two years, but did decrease significantly (p<.01) from the intervention to the follow-ups of two years or more.

The long-term effectiveness of the Healthy Heart Program was determined using changes in participant knowledge, attitude, and standard locus of control. Assessments included intervention pre- and post-tests and follow-up tests. Changes in participant behavior were noted using dietary and physiological measures. The Healthy Heart Program had a positive effect on participant behavior, similar to that found in the Stanford Five-City Project (Young, et al., 1996).

The attitude scores from the Healthy Heart Program increased from the intervention pre-test, to the intervention post-test, and the follow-up tests. In a survey of 606 cardiac patients in New England, Southern California and the Midwest, the attitude of the majority of the patients was one of belief that diet is very important in the treatment and prevention of heart disease, yet the average knowledge score on a nutrition quiz was less than 50%, a score that would be expected from just chance guessing (Plous, Chesne, & McDowell, 1995). The average intervention pre- test knowledge score for the Healthy Heart Program participants was also less than 50%, but after the Healthy Heart Program, mean intervention post-test and follow-up knowledge scores were above 59%. Participants retained the knowledge they had gained after the Healthy Heart Program.

Unfortunately, as with the Stanford study, the Healthy Heart Program did not show any significant treatment effect to increase self-efficacy, or locus of control, similar concepts relating to a person's belief about his/her ability to control or change his/her life (Young, Haskell, Taylor, & Fortmann, 1996). On the other hand, the participants' locus of control scores did not decrease either. The mean age of the Healthy Heart Program participants was considerably lower than a larger study of older persons whose locus of control decreased as they aged (Goldsteen, Counte, & Goldsteen, 1995).

The mean locus of control score for the participants in the Healthy Heart Program was already quite high at the start of the intervention so that significant increases over the course of the intervention and follow-up assessments may not be realistic. The fact that the participants enrolled in the Healthy Heart Program suggests that they felt they had some control over their health outcomes.

Many of the dietary changes in the Healthy Heart Program participants were positively directed toward lower heart disease risk. Many reports and studies point to the importance of dietary intervention in reducing the risks of CHD (Baer, 1993; Expert Panel, 1993; Fortmann, Taylor, Flora, & Winkleby, 1993; Gambera, Schneeman, & Davis, 1995; Geil, Anderson, & Gustafson, 1995; Oyster & Thompson, 1996; Posner, Cupples, Gagnon, & Wilson, 1993; Posner, et al., 1995; USDHHS, 1990).

As noted in the results, the participants experienced many healthy changes in line with recommendations by the Dietary Guidelines for Americans, the NCEP, and Healthy People 2000 (Expert Panel, 1993; Kennedy, Meyers, & Layden, 1996; USDHHS, 1990). Some explanation for the high mean values for fiber intake in the follow-ups of up to three years may spring from the "oat bran craze" taking place in the late 80s and early 90s. Many of the participants reported eating oatmeal and oat bran in their food record in these follow-up groups. It may be possible that the "oat bran craze" had started to fade by the follow-up of three or more years since program completion when the fiber intakes returned closer to baseline again.

At the start of the intervention and in all of the follow-up groups, serum total cholesterol fell in the borderline-high range of 5.2 to 6.2 mmol/L as identified by the NCEP (Expert Panel, 1993) and was significantly lower than the intervention in the follow-up of three or more years. Although the Healthy Heart participants HDL cholesterol did not change significantly from baseline to the follow-ups, HDL cholesterol values were above 0.9 mmol/L, the level at or above which the NCEP does not consider a risk factor for CHD (Expert Panel, 1993). In fact, HDL cholesterol levels were closer to 1.6 mmol/L, which is considered to be a negative risk factor for CHD by the NCEP (Expert Panel, 1993).

The Pawtucket Heart Health Program, a community-based educational program in Rhode Island, did not result in any significant changes in blood pressure over an eight-to-nine year period (Carleton et al, 1995). The Healthy Heart Program evaluation did result in significant changes in blood pressure over the course of the follow-up assessments. There was a significant decline in systolic blood pressure from the intervention to the follow-ups of two or more years and a significant decline in diastolic blood pressure from the intervention to the follow-ups of up to three years. Mean blood pressure never exceeded 140/90 mm Hg for the intervention or the follow-ups, the level at or above which the NCEP identifies as hypertension (Expert Panel, 1993).

Data from the Framingham Heart Study and the National Health and Nutrition Examination Survey II suggested that a 2 mm Hg reduction in diastolic blood pressure could result in a 6% decrease in risk for CHD (Cook, Cohen, Herbert, Taylor, & Hennekens, 1995). In the follow-ups of up to three years, there was about a 4 mm Hg drop in diastolic blood pressure from the intervention. The Healthy Heart Program participants lost weight and decreased their sodium intake over the course of the follow- up assessments. These favorable lifestyle changes may have contributed to the decreases in blood pressure in the follow-up groups (Cutler, 1995; Herbert, et al., 1995).

Despite such favorable results from this evaluation of the Healthy Heart Program, it would be too optimistic not to point out one obvious and important limitation of the study. There was no control group. Using each subject as his/her own control was one possibility, but this would have less statistical power than group data. Previous studies of the Health Heart Program could possibly serve as comparisons for the present evaluation, but these studies were earlier and would not reflect the secular trends which took place during the present study (Anderson & Gunn, 1981; Lopez & Anderson, 1991). Results of the Minnesota Heart Health study and others suggest that secular trends may have had an impact on the Healthy Heart Program participants (Fortmann et al., 1993; Giles, et al., 1993; Luepker et al, 1994; Murray, 1995; Posner et al., 1995).

Findings from this evaluation provide evidence that small, community-based group nutrition education programs may reduce CHD risks through positive changes in participants' attitudes, knowledge and behaviors and that those changes may be maintained over time. The apparent long-term effectiveness of this program clearly supports the pivotal role of Extension agents in teaching in the community and in working with health professionals, such as dietitians, to delivery quality education that can truly make a difference.

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