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November 13, 2018

CCTS Community Engaged Research Pilot Project Partnership Paves the Way
By Rhonda G. Kost, MD, Andrea Ronning, MA, RDN and Kimberly S. Vasquez, MPH

The Administration for Community Living (ACL) of the US Department of Health and Human Services recently announced the awardees for innovative projects that will enhance the quality, effectiveness, and outcomes of nutrition services programs provided by the national aging services network. The project from Carter Burden Network (CBN), a senior services organization with locations in Upper Manhattan and Roosevelt Island, in collaboration with The Rockefeller University (RU) and Clinical Directors Network (CDN) was one of five successful proposals from among 39 eligible applications. The CBN/RU/CDN consortium will receive approximately $500,000 over two years.

Annually, Congress appropriates funds to ACL to support community living, and ACL provides these funds to organizations that conduct research or provide services for older adults and people with disabilities. The executive summary for the grant–Innovations in Nutrition Programs and Services describes the grant as “…a competitive grant awarded under the Older Americans Act (OAA) Title IV authority to increase the evidenced-based knowledge of OAA nutrition providers, drive improved health outcomes for program recipients by promoting higher service quality, and increase program efficiency through innovative service delivery models.” Through this grant program, ACL aims to identify innovative and promising practices that can be scaled across the country and to increase use of evidence-informed practices within nutrition programs. The aims of the RU-CBN-CDN grant entitled, “Improving cardiovascular health through implementation of a DASH-diet-based multi-component intervention with senior services programs serving low income and minority seniors,” were informed directly by the preliminary findings of a pilot project conducted at CBN by the three partnering institutions in the previous two years that demonstrated that hypertension was nearly universal and levels of blood pressure control were low for these seniors.

The CBN, RU, and CDN community-academic collaboration formed in 2016 seemed to be the perfect opportunity to seemed to be the perfect opportunity to satisfy the requirements of this grant. The goal of Rockefeller community/academic partnerships is to foster projects that accelerate translation by fostering teams that develop projects with mechanistic, clinical, and patient-centered aims. Through a series of exploratory discussions to articulate priorities, align aims, and test feasibility, the partners developed a pilot study, “Engaging Carter Burden Center for the Aging in a Community Academic Partnership to Understand the Biological, Environmental and Person-level Correlates of Successful Aging in Place.” The study enrolled 218 clients at two CBN sites in East Harlem for collection of physiological, psychosocial, and nutritional data. 83% of the participants were overweight or obese, 33% reported a history of diabetes, and 84% had uncontrolled blood pressure (BP). The prevalence of uncontrolled BP was startling, and even higher than expected. Cardiovascular Disease (CVD) poses significant health risks for seniors, with two thirds of those aged 60 to 79, and approximately 85% of those 80 and over having one or more forms of CVD. Blood pressure is one of the major modifiable risk factors for cardiovascular morbidity and mortality, with even moderate reductions playing a major role in preventing future cardiovascular events.

CBN, in partnership with RU and CDN, will address seniors’ cardiovascular risk through implementation of a dietary intervention at two of its senior centers - the Leonard Covello Senior Program in East Harlem and the Carter Burden Luncheon Club on the Upper East Side. Senior centers serve as critical resource hubs for seniors, offering a spectrum of health, nutritional, social service, art, and recreational programming. With support from the NYC Department for the Aging (DFTA), which will be a partner in the evaluation, CBN provides over 240,000 meals annually to low income and minority seniors in NYC, many of whom report food insecurity.

The project will implement the National Heart, Lung, and Blood Institute’s (NHLBI’s) Dietary Approaches to Stop Hypertension (DASH) diet through meals provided at senior centers and study the impact of this intervention on blood pressure control. The DASH diet has been tested by two major NHLBI-funded studies, demonstrating its ability to lower blood pressure in as little as 14 days. The diet is largely plant-focused – rich in fruits, vegetables, and nuts, with supplementary inclusion of non-fat and low-fat dairy products, whole grains, poultry, fish, lean meats, and heart-healthy fats. Breakfast and lunch menus at Covello and lunch menus at the Luncheon Club will be adjusted with the help of RU Bionutritionists and the RU chef to be DASH–concordant, while respecting the cultural and taste preferences of clients.

The DASH Diet will be implemented through a multicomponent approach. The intervention will begin with Town Hall meetings, led by the RU Community Engagement Specialist, with CBN participants and staff. The food, diet and cooking concerns that are expressed by the participants at the Town Hall meetings will be reviewed by the RU Bionutritionists and the CBN staff. The Bionutritionists will then work with the CBN chefs to make the menus DASH Diet concordant. The Bionutritionists and chef will provide recipe tasting, recipe demonstrations, and education on the DASH diet. A plate-waste study will be conducted with the assistance of dietetic interns to inform recipe change and minimize waste. Health educators from CDN will provide information and training on BP self-monitoring using automated home blood pressure monitors that will be provided to the participants, as well as the importance of antihypertensive medication adherence, and strategies to help improve medication adherence.

The study plans to recruit and consent 200 participants, all of whom will receive Bluetooth-enabled home blood pressure monitoring kits. They will be trained on how to use the devices and encouraged to take BP readings at home and to share these home readings with their clinicians, thus improving self-monitoring, self-efficacy, and healthcare engagement. There will also be on-site telehealth monitoring of BP and other biometric measures (i.e., pulse, body weight, and blood oxygen saturation). The primary outcome will be the reduction of BP as measured by a reduction in mean systolic BP and increase in hypertension control rates. Seven secondary outcomes will be explored: 1) leverage and growth of a sustainable, multi-stakeholder partnership, 2) implementation of DASH—concordant meals, 3) optimization of client acceptance of the intervention, 4) support of cognitive and behavioral change, 5) provision of positive feedback and enhancement of self-efficacy, 6) enhancement of the value of nutritional service programs by reducing waste, and 7) implementation of a scalable and sustainable monitoring and evaluation system. The partners are currently exploring the possibility of adding mechanistic questions (e.g., biomarkers) that may relate to blood pressure and reflect the impact of the DASH diet on inflammation and cardiovascular disease, which will lead to better understanding of the mechanism of action of the DASH diet.

This study represents a unique combination of community-centered and people-centered care, studied within a comparative effectiveness framework, with embedded mechanistic measures. It comprises a novel, full-spectrum approach to translational research that the RU-CDN Community Engaged Research Core has been developing over the last several years. This research is now being extended to address food insecurity, a key component of the social determinants of health, in partnership with agencies beyond the healthcare delivery system. The outcomes of the DASH Diet intervention will also serve to inform the broader aging services network and the healthcare community about the impact of senior center congregate meal service on health outcomes