New online care from dietitians helps control weight

SEATTLE—A rich chocolate cake is tempting you, but where is a dietitian when you need one?

The e-Care for Heart Wellness study sought to solve this problem. In the study, Group Health patients who were overweight and had hypertension were more likely to have lost 10 pounds in six months if they had secure online access to a dietitian than if they received only information and usual care. The American Journal of Preventive Medicine published the e-Care study.

"One patient said, 'It's like having a dietitian in your pocket,'" said Beverly B. Green, MD, MPH, a family doctor at Group Health, an associate investigator at Group Health Research Institute, and an assistant clinical professor in family medicine at the University of Washington (UW) School of Medicine. "The patients really loved this intervention—and having access to a dietitian to work with them toward a healthier lifestyle."

In addition to team-based care led by a dietitian, the patients in the intervention group were given a home blood pressure monitor, a scale, and a pedometer. They each had one in-person visit with a dietitian where, together, they created a plan to reduce their heart risk, including the Dietary Approaches to Stop Hypertension (DASH) diet, with eight to 10 servings of vegetables and fruits per day. The DASH diet is not about eating less food, just more of the right food, Dr. Green said, quoting a patient who said: "All those fruits and vegetables kept me full and less likely to eat something I might regret later."

The visit to the dietitian was followed by planned follow-up by secure messaging (through Group Health's website for patients) to report their blood pressure, weight, and vegetable and fruit intake—and to receive ongoing feedback. When appropriate, the dietitians also encouraged patients and their doctors to consider changes to their hypertensive and lipid-lowering medication dosages.

Of the 90 people who completed six-month follow-up, the 44 who had been randomly assigned to receive dietitian e-care had higher rates of patient satisfaction and of use of Group Health's secure messaging than did the 46 assigned to education and usual care. Although blood pressure and heart risk trended lower in the intervention group, the differences weren't significant—unlike their weight.

"Heart disease and stroke are the number-one cause of death in the United States, but they don't have to be," Dr. Green said. "If people had better control of their heart risk factors such as blood pressure and cholesterol, and we could prevent or decrease obesity, we could cut the number of heart deaths in half." And that's just what she's been trying to do, by shifting health care from the doctor's office to where people live: in their homes—and online.

In a previous large randomized controlled trial, called e-BP (Electronic Blood Pressure) and published in JAMA, Dr. Green showed that when people checked their blood pressure at home and received Web-based care from pharmacists, they were nearly twice as likely to get their blood pressure under control (under 140/90 mm Hg)—and cost-effectively, without office visits. In that study, the emphasis was on following standard guidelines to boost doses, switch, and combine hypertension drugs. Although the pharmacists helped patients set lifestyle goals, weight loss was not statistically significant. That's why Dr. Green launched the e-Care study.

Next steps, since this study proved the intervention is feasible? Combining the e-Care and e-BP studies, which were both based on the Chronic Care Model. "We're planning a larger randomized controlled trial, where we will tailor the e-care for the patients who have hypertension," Dr. Green said. "We'll pair each patient with either a pharmacist or a dietitian, depending on their individual needs."

The National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) funded this research: grant RC1HL100590, trial registration number NCT01077388.

Dr. Green's coauthors were Sheryl L. Catz, PhD, a professor of health care innovation and technology at the Betty Irene Moore School of Nursing at the University of California–Davis and an affiliate investigator at Group Health Research Institute; and Paul A. Fishman, PhD, Jennifer B. McClure, PhD, and Robert Reid, MD, PhD, senior investigators, Andrea J. Cook, PhD, an associate investigator, and Melissa L. Anderson, MS, a senior biostatistician, at Group Health Research Institute. Drs. Cook, Fishman, McClure, and Reid also have joint appointments at the UW Schools of Medicine and Public Health.

American Journal of Preventive Medicine

The American Journal of Preventive Medicine is the official journal of the American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in prevention research, teaching, practice, and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. Of particular emphasis are papers that address the primary and secondary prevention of important clinical, behavioral, and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. Papers on health services research pertinent to prevention and public health are also published. The journal also publishes official policy statements from the two co-sponsoring organizations, review articles, media reviews, and editorials. Finally, the journal periodically publishes supplements and special theme issues devoted to areas of current interest to the prevention community.

Group Health Research Institute

Group Health Research Institute does practical research that helps people like you and your family stay healthy. The Institute is the research arm of Seattle-based Group Health Cooperative, a consumer-governed, nonprofit health care system. Founded in 1947, Group Health Cooperative coordinates health care and coverage. Group Health Research Institute changed its name from Group Health Center for Health Studies in 2009. Now celebrating its 30th anniversary year, the Institute has conducted nonproprietary public-interest research on preventing, diagnosing, and treating major health problems since 1983. Government and private research grants provide its main funding.

---

---