Abstract
Background
Dietary intake is an important modifiable risk factor for cardiovascular disease.
However, to our knowledge, there are no systematic reviews of nutrition interventions
in the context of cardiovascular disease prevention and management within rural communities.
This is important to investigate, given the unique geographic, social, and contextual
factors associated with rurality.
Objective
Our primary objective was to systematically assess evidence on the effectiveness of
randomized controlled trials to improve dietary intake in the context of cardiovascular
disease prevention and management in rural communities.
Methods
Nine electronic databases were searched from inception to June 2020, including MEDLINE,
The Cochrane Library, Embase, Emcare, PsycINFO, Scopus, Rural and Remote Health, CINAHL,
and AMED. Randomized controlled trials that reported results of interventions with
adult, rural populations and measured change in dietary intake compared to usual care,
alternative intervention, or no intervention controls were included. Included randomized
controlled trials were also assessed according to the TIDieR (Template for Intervention
Description and Reporting) checklist and RE-AIM (reach, effectiveness, adoption, implementation,
maintenance) framework.
Results
Thirteen articles reporting results of randomized controlled trials were identified.
Included articles reported a range of nutrition interventions and measured 18 dietary
intake outcomes. Most studies (n = 10) demonstrated effectiveness in altering at least
1 dietary intake outcome, including fruit and/or vegetable (n = 9), fiber (n = 2),
Dietary Risk Assessment score (n = 2), energy, dairy, carotene, vitamin C and sodium
(all n = 1). However, there was wide variation in the reporting of intervention components
(according to the TIDieR checklist) and impact (according to RE-AIM framework), resulting
in difficulty interpreting the “real-world” implications of these results.
Conclusions
Through this systematic review, we found limited evidence of improvement in dietary
intakes due to nutrition interventions in the context of cardiovascular disease prevention
and management in rural communities. Fruit and/or vegetable intakes were the most
frequently reported dietary intake outcomes, and most likely to be improved across
the included studies. Included studies were generally not well reported, which may
hinder replication by clinicians and consolidation of the evidence base by other researchers.
Given the substantial burden of cardiovascular disease experienced by those living
in rural areas of developed countries, additional high-quality nutrition research
that acknowledges the complexities of rural health is required.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the Academy of Nutrition and DieteticsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Cardiovascular diseases fact sheet. World Health Organization.(Published 2017. Updated 17 May 2017)http://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvdsDate accessed: July 18, 2018
- National Health and Nutrition Examination Survey (NHANES) public use data files. Centers for Disease Control and Prevention.https://www.cdc.gov/nchs/nhanes/Date accessed: August 20, 2020
- Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): A prospective cohort study.Lancet. 2020; 395: 795-808
- The burden of cardiovascular diseases among US states, 1990-2016.JAMA Cardiol. 2018; 3: 375-389
- Dietary and policy priorities for cardiovascular disease, diabetes, and obesity: A comprehensive review.Circulation. 2016; 133: 187-225
- Beyond established and novel risk factors: Lifestyle risk factors for cardiovascular disease.Circulation. 2008; 117: 3031-3038
- Relationship between healthy diet and risk of cardiovascular disease among patients on drug therapies for secondary prevention: A prospective cohort study of 31 546 high-risk individuals from 40 countries.Circulation. 2012; 126: 2705-2712
- Dietary Patterns and Cardiovascular Disease Outcomes: An Evidence Check rapid review brokered by the Sax Institute for the National Heart Foundation of Australia.Sax Institute, 2017
- Association between healthy eating patterns and risk of cardiovascular disease.JAMA Intern Med. 2020; 180: 1090-1100
- Dietary patterns and cardiovascular disease.Proc Nutr Soc. 2013; 72: 407-411
- Australian Dietary Guidelines.National Health and Medical Research Council, 2013
- 2015-2020 Dietary Guidelines for Americans.US Department of Health and Human Services, 2015
- A comparison of the modelled impacts on CVD mortality if attainment of public health recommendations was achieved in metropolitan and rural Australia.Public Health Nutr. 2020; 23: 339-347
- Nutrition Across the Life Stages.Australian Institute of Health and Welfare, 2018
- Diet, Nutrition and the Prevention of Chronic Diseases.World Health Organization, 2003
- A cross-sectional study on health differences between rural and non-rural US counties using the County Health Rankings.BMC Health Serv Res. 2015; 15: 441
- Rural inequalities in the australian burden of ischaemic heart disease: A systematic review.Heart Lung Circ. 2017; 26: 122-133
- Quantifying the role of modifiable risk factors in the differences in cardiovascular disease mortality rates between metropolitan and rural populations in Australia: A macrosimulation modelling study.BMJ Open. 2017; 7e018307
- Patients' knowledge of their chronic disease: The influence of socio-demographic characteristics.Aust Fam Physician. 2013; 42: 411
- Impact of rurality on health practices and services: Summary paper to the inaugural rural and remote health scientific symposium.Aust J Rural Health. 2009; 17: 49-52
- Profile of the Australian dietetic workforce: 1991–2005.Nutr Diet. 2006; 63: 166-178
- Geographic variations in cardiovascular health in the United States: Contributions of state-and individual-level factors.J Am Heart Assoc. 2015; 4e001673
- Cost and affordability of healthy food in rural South Australia.Rural Remote Health. 2012; 12: 1938
- Associations of the local food environment with diet quality—A comparison of assessments based on surveys and geographic information systems: The multi-ethnic study of atherosclerosis.Am J Epidemiol. 2008; 167: 917-924
- Reducing cardiovascular disparities through community-engaged implementation research: A National Heart, Lung, and Blood Institute workshop report.Circ Res. 2018; 122: 213-230
- A systematic review of published interventions for primary and secondary prevention of ischaemic heart disease (IHD) in rural populations of Australia.BMC Public Health. 2016; 16
- Reduced or modified dietary fat for preventing cardiovascular disease.Cochrane Database Syst Rev. 2011;
- Dietary advice for reducing cardiovascular risk.Cochrane Database Syst Rev. 2013; 3: CD002137
- Effectiveness of dietetic consultation for lowering blood lipid levels in the management of cardiovascular disease risk: A systematic review and meta-analysis of randomised controlled trials.Nutr Diet. 2019; 76: 199-210
- Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide.BMJ. 2014; 348: g1687
- Use of RE-AIM to address health inequities: Application in a low-income community health center-based weight loss and hypertension self-management program.Transl Behav Med. 2013; 3: 200-210
- RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review.Front Public Health. 2019; 7: 64
- Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.Ann Intern Med. 2009; 151: 264-269
- Member Countries. Organisation for Economic Co-Operation and Development.https://www-oecd-org.ezproxy.newcastle.edu.au/about/members-and-partners/Date accessed: September 17, 2019
- Defining rural at the US Census Bureau.American Community Survey and Geography Brief. US Census Bureau, 2016
- Rural, Regional and Remote Health: A Guide to Remoteness Classifications.Australian Institute of Health and Welfare, 2004
- Adding the Modified Monash Model variable for Remoteness classification. Published 2016.https://www.alswh.org.au/images/content/pdf/InfoData/Data_Dictionary_Supplement/DDSSection5_ModMonashMod.pdfDate accessed: January 17, 2019
- Guidelines on Defining Rural Areas and Compiling Indicators for Development Policy. Food and Agriculture Organization of the United Nations, 2018
- Guidelines for the Management of Absolute Cardiovascular Disease Risk. National Vascular Disease Prevention Alliance, 2012
- Primary prevention of cardiovascular disease: New guidelines, technologies and therapies.Med J Aust. 2013; 198: 606-610
- 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2019; 74: e177-e232
- Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study.Lancet. 2004; 364: 937-952
- Dietary biomarkers: Advances, limitations and future directions.Nutr J. 2012; 11: 109
- The RE-AIM framework for evaluating interventions: What can it tell us about approaches to chronic illness management?.Patient Educ Couns. 2001; 44: 119-127
- How to Use The Evidence: Assessment and Application of Scientific Evidence.National Health and Medical Research Council, 2000
Endnote X9 [computer program]. Version 2. Clarivate Analytics; 2019.
Covidence [computer program]. Version 1521. Covidence; 2019.
- Fidelity to and comparative results across behavioral interventions evaluated through the RE-AIM framework: A systematic review.System Rev. 2015; 4: 155
- Evidence Analysis Manual. Academy of Nutrition and Dietetics.(Published 2016)https://www.andeal.org/evidence-analysis-manualDate accessed: September 17, 2019
- Effects of a home-based intervention on diet and physical activity behaviours for rural adults with or at risk of metabolic syndrome: A randomised controlled trial.Int J Behav Nutr Phys Act. 2016; 13: 13
- Promoting heart health in rural women.J Rural Health. 2013; 29: 248-257
- Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: A randomized controlled trial.Clin Rehabil. 2010; 24: 822-830
- Effectiveness of tailored lifestyle interventions, using web-based and print-mail, for reducing blood pressure among rural women with prehypertension: Main results of the Wellness for Women: DASHing towards Healthclinical trial.Int J Behav Nutr Phys Act. 2014; 11: 148
- Blood pressure change in a free-living population-based dietary modification study in Japan.J Hypertens. 2006; 24: 451-458
- A pilot randomized controlled trial of a telenutrition weight loss intervention in middle-aged and older men with multiple risk factors for cardiovascular disease.Nutrients. 2019; 11: 229
- Influencing cardiovascular health habits in the rural, deep south: Results of a cluster randomized trial.Health Educ Res. 2019; 2: 200-208
- A randomized controlled trial of a public health nurse directed treatment program for rural patients with high blood cholesterol.Prev Med. 2003; 36: 340-351
- The StrongWomen–Healthy Hearts program: Reducing cardiovascular disease risk factors in rural sedentary, overweight, and obese midlife and older women.Am J Public Health. 2009; 99: 1271-1277
- Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial.Int J Behav Nutr Phys Act. 2019; 16: 91
- A cluster randomized trial of a community-based intervention among African-American adults: Effects on dietary and physical activity outcomes.Prev Sci. 2020; 21: 344-354
- A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: The Southeast Cholesterol Project.Arch Fam Med. 1997; 6: 135-145
- Effectiveness of a nutrition intervention with rural low-income women.Am J Health Behav. 2007; 31: 35-43
- A randomised controlled trial of a physical activity and nutrition program targeting middle-aged adults at risk of metabolic syndrome in a disadvantaged rural community.BMC Public Health. 2015; 15: 284
- Process evaluation of the Albany Physical Activity and Nutrition (APAN) program, a home-based intervention for metabolic syndrome and associated chronic disease risk in rural Australian adults.Health Promot J Austr. 2017; 28: 8-14
- Cookin’Up Health: Developing a nutrition intervention for a rural Appalachian population.Health Promot Pract. 2006; 7: 252-257
- Heart disease and stroke statistics—2020 update: A report from the American Heart Association.Circulation. 2020; 141: E139-E596
- Nutrition education for cardiovascular disease prevention among low income populations—Description and pilot evaluation of a physician-based model.Patient Educ Couns. 1992; 19: 5-18
Bess K, Young T, Carthron D, et al. Intergrating Intervention Mapping & CBPR Principles to Adapt a Multi-Component EBI in a Rural African American Community. Paper presented at: APHA 2017 Annual Meeting & Expo, November 4-8, 2017; Atlanta, GA.
- Social-ecological perpectives on health.in: Stone G. Cohen F. Adler N. Health Psychology—A Handbook. Jossey-Bass, 1979: 523-547
- Factors related to cardiovascular disease risk reduction in midlife and older women: A qualitative study.Prev Chronic Dis. 2008; 5: A06
- With every heartbeat is life: A community health worker's manual for African Americans.National Institutes of Health, Published 2007https://www.nhlbi.nih.gov/files/docs/resources/heart/aa_manual.pdfDate accessed: September 20, 2020
- National Heart Lung and Blood Institute.Published 2012https://www.nhlbi.nih.gov/health/educational/healthdisp/pdf/resources/CHWI_MyHealthHabits_Pre_EN.pdfDate accessed: October 6, 2020
- A brief dietary assessment to guide cholesterol reduction in low-income individuals: Design and validation.J Am Diet Assoc. 1991; 91: 1385-1390
- The Fat and Fibre Barometer, a short food behaviour questionnaire: Reliability, relative validity and utility.Aus J Nutr Diet. 2000; 57: 33-39
- Performance of a short tool to assess dietary intakes of fruits and vegetables, percentage energy from fat and fibre.Public Health Nutr. 2004; 7: 1097-1106
- Evaluation of 2 brief instruments and a food-frequency questionnaire to estimate daily number of servings of fruit and vegetables.Am J Clin Nutr. 2000; 71: 1503-1510
- Using secondary 24-hour dietary recall data to estimate daily dietary factor intake from the FLASHE study dietary screener.Am J Prev Med. 2017; 52: 856-862
- Use and reliability of the World Wide Web version of the Block Health Habits and History Questionnaire with older rural women.J Nutr Educ Behav. 2002; 34: S20-S24
- Serum biomarker-based validation of a self-administered diet history questionnaire for Japanese subjects.J Nutr Sci Vitaminol (Tokyo). 2000; 46: 285-296
- Self-administered diet history questionnaire developed for health education: A relative validation of the test-version by comparison with 3-day diet record in women.J Epidemiol. 1998; 8: 203-215
- Validity of a self-administered diet history questionnaire for assessment of sodium and potassium.Jpn Circ J. 1998; 62: 431-435
- A data-based approach to diet questionnaire design and testing.Am J Epidemiol. 1986; 124: 453-469
- The associations of fruit and vegetable intakes with burden of diseases: A systematic review of meta-analyses.J Acad Nutr Diet. 2019; 119: 464-481
- Healthy dietary patterns for preventing cardiometabolic disease: The role of plant-based foods and animal products.Curr Dev Nutr. 2017; 1 (cdn.117.001289)
- Changes in diet quality scores and risk of cardiovascular disease among US men and women.Circulation. 2015; 132: 2212-2219
- Better diet quality scores are associated with a lower risk of hypertension and non-fatal CVD in middle-aged Australian women over 15 years of follow-up.Public Health Nutr. 2020; 23: 882-893
- Why is changing health-related behaviour so difficult?.Public Health. 2016; 136: 109-116
- A cholesterol intervention program for public health nurses in the rural southeast: Description of the intervention, study design, and baseline results.Public Health Nurs. 1999; 16: 156-167
- Healthy diet in Canadians of low socioeconomic status with coronary heart disease: Not just a matter of knowledge and choice.Heart Lung. 2011; 40: 156-163
- How diet modification challenges are magnified in vulnerable or marginalized people with diabetes and heart disease: A systematic review and qualitative meta-synthesis.Ontario Health Technol Assess Ser. 2013; 13: 1-40
- Rural and remote food environments and obesity.Curr Obes Rep. 2015; 4: 46-53
- How dietary evidence for the prevention and treatment of CVD is translated into practice in those with or at high risk of CVD: A systematic review.Public Health Nutr. 2017; 20: 30-45
- Understanding the impact of rural weight loss interventions: A systematic review and meta-analysis.Obes Rev. 2019; 20: 713-724
- Rural physical activity interventions in the United States: A systematic review and RE-AIM evaluation.Int J Behav Nutr Phys Act. 2019; 16: 140
- How widespread are the use of frameworks and theories in applid health promotion research in rural and remote places? A review of programs targeted at cardiometabolic risk factors.Rural Remote Health. 2015; 15
- Qualitative approaches to use of the RE-AIM framework: Rationale and methods.BMC Health Serv Res. 2018; 18: 177
- Nutrition care process and model: ADA adopts road map to quality care and outcomes management.J Am Diet Assoc. 2003; 103: 1061-1072
- The dietetic workforce distribution geographic atlas provides insight into the inequitable access for dietetic services for people with type 2 diabetes in Australia.Nutr Diet. 2020; 77: 121-130
- Dietetic staffing and workforce capacity planning in primary health care.Can J Diet Pract Res. 2018; 79: 181-185
- A national view of rural health workforce issues in the USA.Rural Remote Health. 2010; 10: 1531
- Adapting an evidence-based cardiovascular disease risk reduction intervention to rural communities.J Rural Health. 2019; 35: 87-96
- Adapting an evidence-based cardiovascular disease risk reduction intervention to Urban American Indians.J Health Care Poor Underserved. 2019; 30: 618-636
Biography
L. Kocanda is a PhD candidate, Department of Rural Health, Faculty of Health and Medicine, The University of Newcastle, Tamworth, NSW, Australia, School of Medicine and Public Health, Faculty of Health and Medicine, Priority Research Centre for Physical Activity and Nutrition, Priority Research Centre for Health Behaviour, The University of Newcastle, Callaghan, NSW, Australia, and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
Biography
K. Brain is a research academic, Priority Research Centre for Physical Activity and Nutrition and School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia.
Biography
J. Frawley is a research assistant, Department of Rural Health, Faculty of Health and Medicine, The University of Newcastle, Tamworth, NSW, Australia, and School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia.
Biography
T. L. Schumacher is a clinical teaching and research academic, Department of Rural Health, Faculty of Health and Medicine, The University of Newcastle, Tamworth, NSW, Australia, School of Medicine and Public Health, Faculty of Health and Medicine, Priority Research Centre for Physical Activity and Nutrition, Priority Research Centre for Health Behaviour, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia, and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
Biography
J. May is director, Department of Rural Health, Faculty of Health and Medicine, The University of Newcastle, Tamworth, NSW, Australia, and School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia.
Biography
M. E. Rollo is a research fellow, Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia, and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
Biography
L. J. Brown is an advanced accredited practicing dietitian, Department of Rural Health, Faculty of Health and Medicine, The University of Newcastle, Tamworth, NSW, Australia, School of Medicine and Public Health, Faculty of Health and Medicine, Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia, and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
Article info
Publication history
Published online: July 08, 2021
Accepted:
May 26,
2021
Received:
November 12,
2020
Footnotes
Supplementary materials: Figure 1 is available at www.jandonline.org
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT L. Kocanda undertook this research as partial requirement for the degree of PhD (Medicine) with the University of Newcastle and is supported by an Australian Government Research Training Program Scholarship. Staff affiliated with the University of Newcastle Department of Rural Health are funded under the Australian Government’s Rural Multidisciplinary Training Program.
Identification
Copyright
© 2021 by the Academy of Nutrition and Dietetics.
