Full text of DOI:10.1080/07315724.2002.10719241

This article was downloaded by: [Stony Brook University]
On: 26 October 2014, At: 01:37
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer
House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of the American College of Nutrition
Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/uacn20
Diet and Exercise Habits of Patients with Diabetes,
Dyslipidemia, Cardiovascular Disease or Hypertension
a
c
ab
Marian L. Neuhouser PhD, RD , Debra L. Miller PhD , Alan R. Kristal DrPH , Matt J.
a
c
Barnett MS & Lawrence J. Cheskin MD
a
Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (M.L.N.,
A.R.K., M.J.B.), Seattle, Washington
b
Department of Epidemiology and Program in Nutritional Sciences, University of
Washington (A.R.K.), Seattle, Washington
c
Division of Gastroenterology, Johns Hopkins University School of Medicine (D.L.M.,
L.J.C.) Baltimore, Maryland
Published online: 19 Jun 2013.
To cite this article: Marian L. Neuhouser PhD, RD, Debra L. Miller PhD, Alan R. Kristal DrPH, Matt J. Barnett MS &
Lawrence J. Cheskin MD (2002) Diet and Exercise Habits of Patients with Diabetes, Dyslipidemia, Cardiovascular Disease or
Hypertension, Journal of the American College of Nutrition, 21:5, 394-401, DOI: 10.1080/07315724.2002.10719241
To link to this article: http://dx.doi.org/10.1080/07315724.2002.10719241
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained
in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of
the Content. Any opinions and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied
upon and should be independently verified with primary sources of information. Taylor and Francis shall
not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other
liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or
arising out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions

Original Research
Diet and Exercise Habits of Patients with Diabetes,
Dyslipidemia, Cardiovascular Disease or Hypertension
Marian L. Neuhouser, PhD, RD, Debra L. Miller, PhD, Alan R. Kristal, DrPH, Matt J. Barnett, MS, and
Lawrence J. Cheskin, MD
Division of Public Health Sciences, Fred Hutchinson Cancer Research Center (M.L.N., A.R.K., M.J.B.), Department of
Epidemiology and Program in Nutritional Sciences, University of Washington (A.R.K.), Seattle, Washington, Division of
Gastroenterology, Johns Hopkins University School of Medicine (D.L.M., L.J.C.) Baltimore, Maryland
Key words: diet therapy, plasma lipids, diabetes, hypertension, cardiovascular disease, dyslipidemia, dietary fat
Objective: The objective of this study was to determine whether free-living individuals diagnosed with
diabetes, dyslipidemia, cardiovascular disease or hypertension follow standard dietary recommendations for
treatment of these diet-modifiable disorders.
Methods: Data are from 1,782 adult men and women who completed an annual clinic visit as part of a large
study of diet and health. Usual dietary intake over the previous month was assessed with a self-administered food
frequency questionnaire. Trained staff obtained a detailed medical history and information on health and exercise
habits, measured height and weight, and collected a fasting blood specimen to measure total serum cholesterol,
triglycerides and carotenoids. Multivariate linear regression was used to test associations of diet-modifiable
chronic diseases with diet and exercise habits.
Results: 42% of the study sample reported at least one diet-modifiable disease or risk factor for disease.
These individuals had higher total serum cholesterol (p Ͻ 0.001) and triglycerides (p Ͻ 0.001) compared to those
without these conditions. Diabetics consumed a greater percent of energy from fat (p Ͻ 0.01), and men with
hypertension consumed a greater percent energy from saturated fat (p Ͻ 0.05) compared to those without these
conditions. There were few other differences in dietary intake between diseased and healthy individuals, and on
average, all participants had diets that were not consistent with recommended guidelines for prevention or
treatment of these diet-modifiable disorders. Forty-six percent of all participants were overweight or obese, and
BMI was significantly higher among participants with at least one diet-modifiable disorder (p Ͻ 0.001). Healthy
and diseased participants exercised about 17 minutes per day, and compared to non-diabetics, persons with
diabetes exercised with 25% less intensity (p Ͻ 0.05).
Conclusion: Participants in this sample with diet-modifiable disorders reported that they are motivated to eat
less fat, but most are still overweight or obese, consume a diet high in fat and low in fruits and vegetables and
engage in very little physical exercise. New strategies are needed to help patients adopt and maintain healthful
dietary practices that will reduce their risk.
intakes and to increase fruit, vegetable, and fiber consumption
INTRODUCTION
[1]. These interventions are intended to normalize lipid levels,
Medical nutrition therapy is an important component of the
treatment for diabetes mellitus, cardiovascular disease, dyslip-
idemia and hypertension. The focus of nutrition therapy for
these conditions includes individual and group instruction to
help patients reduce total fat, saturated fat and cholesterol
stabilize blood glucose, lower blood pressure and maintain or
reduce weight. Substantial evidence suggests that these dietary
approaches to disease prevention and treatment are successful,
resulting in fewer physician office visits, delay of pharmaco-
therapy, less frequent hospitalizations and reduced incidence of
Address correspondence to: Marian L. Neuhouser PhD, RD, Cancer Prevention Research Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research
Center, 1100 Fairview Ave North, MP-702, P.O. Box 19024, Seattle, WA 98109-1024. E-mail: mneuhous@fhcrc.org.
Dr. Debra L. Miller is currently at Central Soya, Ft. Wayne, Indiana.
This study was supported by the Procter & Gamble Company (Cincinnati, OH).
Journal of the American College of Nutrition, Vol. 21, No. 5, 394–401 (2002)
Published by the American College of Nutrition
3
94

Diet and Exercise in Chronic Disease Patients
disease-related complications [2,3]. For example, the Dietary
Approaches to Stop Hypertension (DASH) trial showed that a
diet high in fruit, vegetables and fiber and low in fat and red
meat effectively normalizes blood pressure [4–6]. Jones et al.
found that a combined weight loss and dietary intervention
were important adjuncts to pharmacotherapy for hypertension
recruited by a random digit dial (RDD) telephone survey in
four U.S. cities (Indianapolis, Baltimore, Minneapolis and San
Diego) from 1996–2000; these four cities were selected based
on their geographic location and minority representation. The
telephone survey collected information about usual fruit, veg-
etable and savory snack consumption, beliefs about diet and
health, and demographics. A random sample of respondents
who completed the telephone survey were invited to attend a
clinic visit where they completed a variety of procedures de-
scribed below. Clinic staff conducted quarterly follow-up tele-
phone calls with participants to monitor changes in diet and
health over a one-year period. At the final telephone call, a
subset of these participants were invited to become part of a
cohort that was followed for an additional two years, with
annual clinic visits and quarterly telephone calls. Of the 2,064
participants who were invited to join the cohort, 1,812 (88%)
completed the second clinic visit and 1,702 (83%) completed
the third clinic visit. The analyses in this report are from 1,782
cohort participants for whom we have complete data from
annual clinic visits conducted between October, 1998 and Oc-
tober, 1999, representing the third clinic visit in Indianapolis
and the second visit at the other sites. The Institutional Review
Boards of the participating institutions approved all procedures,
and participants provided written consent for clinic activities.
[7], while Stevens et al. demonstrated that weight loss alone
results in statistically and clinically significant improvements
in blood pressure [8]. Three recently published studies from a
large randomized trial found that dietary interventions with
prepared meal plans led to weight loss, improvements in blood
lipid and glucose profiles and reductions in plasma homocys-
teine and other indicators of risk for cardiovascular disease,
diabetes and other chronic conditions [9–11]. Finally, hundreds
of dietary intervention studies [12] support the positions of both
the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults and the National Cholesterol
Education Program, which recommend nutrition therapy and
other lifestyle changes as the initial treatment for dyslipidemias
[2].
Despite the evidence supporting the effectiveness of medi-
cal nutrition therapy for persons with diet-modifiable chronic
disease, dietary change and maintenance are difficult, and
many patients do not comply with prescribed recommendations
[13]. For example, at least four published studies have shown
that instead of consuming the suggested 30% or less energy
from fat, patients with type II diabetes mellitus obtain, on
average, 34% to 40% of energy from fat [14]. Similarly, a study
conducted in Japan among 39 patients with mildly elevated
blood pressure found that even modest dietary changes were
difficult to achieve and maintain [15]. Still other investigations
have shown that long-term compliance with dietary regimens to
reduce cardiovascular risk factors is difficult [16–18]. Most of
these data showing either the effectiveness of medical nutrition
therapy or the difficulties with long term compliance are from
randomized trials or feeding studies with intensive protocols.
Thus, an important question for nutrition professionals is the
extent to which free-living patients who have been diagnosed
with diet-responsive disorders follow well-known dietary rec-
ommendations. To investigate this question, we examined the
diet and health practices of free-living individuals who have
been diagnosed with diabetes mellitus, dyslipidemia, cardio-
vascular disease or hypertension, conditions that respond fa-
vorably to medical nutrition therapy.
Medical History
Trained interviewers collected detailed information about
each participant’s medical history by asking: “Has a doctor or
health professional ever told you that you had: diabetes; respi-
ratory disease; cardiovascular disease (i.e., heart attack or heart
problems); eye disease; hypertension; high cholesterol or tri-
glycerides; kidney disease; cancer; gallbladder disease; ulcers;
reflux disease; diverticulitis; irritable bowel; lactose intoler-
ance; or liver disease?” More than one response was permitted,
and for each positive response, interviewers inquired about
current status of the condition and medication use. Because we
were interested in the dietary practices of participants with
diet-modifiable chronic diseases, we restricted analyses in this
report to those conditions known to respond favorably to med-
ical nutrition therapy (cardiovascular disease, dyslipidemia,
hypertension and diabetes).
Dietary Assessment
Nutrient intake was assessed with a 122-item food fre-
quency questionnaire (FFQ) [21], with additional questions on
savory snack foods (potato and tortilla chips, extruded snacks
and snack crackers) [22]. The reference period for the FFQ was
METHODS
“
in the past month.” Participants completed the FFQs at home
Study Design and Participants
and brought them to the clinic where staff reviewed them for
completeness. We derived the nutrient database from the Uni-
versity of Minnesota Nutrition Coordinating Center nutrient
database [23], and the algorithms for analysis are published
elsewhere [24].
Data are from adult participants in the cohort phase of the
Olestra Post-Marketing Surveillance Study (OPMSS). Details
about the design and preliminary results of OPMSS are pub-
lished [19,20]. Briefly, adults aged 18 years and older were
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
395

Diet and Exercise in Chronic Disease Patients
Other Measures
disease, we present these results stratified by gender. All dietary
and serum measures, except percent of energy from fat and satu-
rated fat were log transformed prior to analysis to improve the
normality of their distributions, and we present the back-trans-
formed values in their original units for ease of interpretation. We
excluded 83 (5%) FFQs because the energy intakes were outside
the range considered reliable and acceptable (Ͻ800 kcals/day or
Ͼ5000 kcals/day for males and Ͻ600 kcals/day or Ͼ4000 kcals/
day for females) [30]. In addition, there were three participants
who did not complete an FFQ, leaving n ϭ 1696 for analysis.
Additional models tested associations of these disorders with BMI
and exercise.
To assess participants’ motivations for changing dietary
behavior, we used motivation scales previously tested in a
randomized trial of a self-help intervention that promoted lower
fat and higher fruit and vegetable consumption [25]. A subset
of the questions asked whether participants would eat less fat
for the following reasons: 1) to control a medical problem such
as high cholesterol or diabetes; 2) to prevent cancer or other
diseases; or 3) if a doctor recommended that they do so.
Participants who responded affirmatively to each question were
asked to indicate if this was a “very important,” “somewhat
important” or “mildly important reason to eat less fat.” Fre-
quency and intensity of leisure and work-related physical ac-
tivity was measured with standard questions [26]. To estimate
intensity of physical activity in metabolic equivalents (mets),
we multiplied the reported number of minutes per week spent
in physical activity/exercise by an estimate of metabolic equiv-
alents per exercise session [27]. Height, weight, waist and hip
circumferences were measured using a standardized protocol,
and body mass index (BMI) was calculated as weight (kg)/
RESULTS
Table 1 gives the demographic, lifestyle and health character-
istics of the study population. Sixty-three percent of the study
sample were female, 78.7% were Caucasian, 39.4% had a college
degree and 46.6% were overweight or obese. Twenty-one percent
of the sample were current smokers, which is slightly less than the
national average of 25% of all adults [31]. Chronic disease, or
presence of risk factors for chronic disease (e.g., dyslipidemia),
was common in this cohort, as 42% reported at least one condition
and 16% reported two or more conditions. The most commonly
reported conditions were hypertension (20%) and dyslipidemia
2
height (meters) [28]. Demographic characteristics (age, gen-
der, race, education) were collected during the initial study
recruitment telephone call as noted above.
Blood Collection and Analysis
(22%). Of the 564 participants with high cholesterol or cardiovas-
Phlebotomists used venipuncture to collect semi-fasting
cular disease, 32% reported use of cholesterol-lowering medica-
tions. There were 354 (19.9%) participants with physician-diag-
nosed hypertension, of whom 260 (73%) were using anti-
hypertensive medication (data not shown).
(
Ն 6 hours) blood samples into serum separating tubes, which
were protected from heat and light throughout processing.
Specimens were stored at Ϫ70°C until batch analysis. Total
serum cholesterol and triglycerides were analyzed using enzy-
matic methods [29]. Precision was evaluated using packaged
reagents, pooled human serum and control sera; both interassay
precision and bias were Ͻ 3%. Total serum carotenoids were
assayed by reverse phase HPLC where the interassay CV
ranged from 5.7% to 9.2%. All laboratory assays were com-
pleted by Quintiles Laboratories (Atlanta, GA).
Table 2 gives data on serum cholesterol and triglyceride
concentrations, two biochemical measures of disease risk, as
well as total serum carotenoids, which are biomarkers for fruit
and vegetable intake and a general indicator of a healthy diet.
Compared to participants with no physician-diagnosed medical
conditions, those who reported any condition, diabetes or dys-
lipidemia had statistically significantly higher serum choles-
terol; those with any condition or dyslipidemia had signifi-
cantly higher serum triglycerides. After adjusting for all
potentially confounding variables, there were no differences in
serum carotenoid concentrations between the groups examined.
Although 32% of participants with physician-diagnosed dys-
lipidemia reported use of medication to control the condition,
these participants still had total cholesterol and triglyceride
concentrations that were 0.48 mmol/L and 0.26 mmol/L higher,
respectively, than participants without these conditions. Males
with a history of previous heart attack or heart disease had
significantly lower total serum cholesterol compared to males
without a history of cardiovascular disease.
Statistical Analysis
Multivariate linear regression was used to test associations of
diagnosed risk factors or diseases with biochemical indicators of
disease risk and dietary intake. We used each medical condition
(e.g., diabetes) as the independent variable in separate models to
test whether presence of the condition predicted total serum cho-
lesterol, triglycerides and carotenoids, as well as dietary intake of
energy, percent of energy from fat and saturated fat, cholesterol
and daily servings of fruits and vegetables. These models were
adjusted for variables known to be confounders of these associa-
tions including age, gender, race, education, body mass index and
co-morbid conditions. Because preliminary analyses indicated a
statistically significant interaction of gender with diet among par-
ticipants diagnosed with hypertension and an interaction of gender
with serum measures among those diagnosed with cardiovascular
Table 3 gives nutrient intakes of participants stratified by
diagnosed medical condition. There were few differences in di-
etary intake between persons with and without diet-modifiable
diseases or risk factors, even after statistical adjustment for age,
3
96
VOL. 21, NO. 5

Diet and Exercise in Chronic Disease Patients
Table 1. Demographic, Health and Lifestyle Characteristics of Study Participants
Proportion of Participants with and without Diet-Modifiable Disorders
Characteristic
Total
Disease-Free
57.7
Diabetes
6.3
Heart Disease
Hypertension
19.9
Dyslipidemia
21.7
n
1782
%
16.7
All participants
Age (years)
1
3
5
8–34
5–54
5ϩ
454
845
483
81.9
61.9
27.7
2.0
4.9
12.8
6.8
14.1
30.4
5.5
15.3
41.4
6.6
18.6
41.4
Gender
Male
Female
Race/Ethnicity
Caucasian
African-American
665
1117
56.5
58.5
7.7
5.5
16.1
17.1
21.8
18.7
22.8
21.0
1
1403
226
152
57.5
57.1
61.2
5.5
9.7
8.5
17.2
16.4
11.8
18.4
29.2
19.7
22.9
15.0
20.4
2
Hispanic/Other
Education (years)
Յ12
524
556
702
53.4
55.0
63.1
7.8
7.2
4.4
17.4
19.6
13.8
24.0
21.6
15.4
22.7
23.9
19.2
1
3–15
Ն16
1
,3
BMI
Low normal
High normal
Overweight
Obese
375
560
414
416
69.1
63.2
51.9
45.9
2.4
2.3
7.5
16.5
16.3
15.9
18.3
7.7
14.5
26.6
31.3
15.2
18.6
26.6
26.9
13.2
Current smoker
Yes
No
378
1404
65.1
55.8
6.3
6.3
13.0
17.7
15.6
21.1
18.5
22.6
1
2
3
Cell sizes may vary due to missing values.
Other includes Asian-American, American Indian and mixed race.
2
BMI ϭ body mass index calculated as weight (kg)/height (m) . Females: low normal Ͻ23.1; normal ϭ 23.1–Ͻ27.3; overweight ϭ 27.3–Ͻ32.3; obese ϭ Ն32.2. Males:
low normal Ͻ 24.3; normal ϭ 24.3–Ͻ27.8; overweight 27.8–31.1; obese: Ն31.1 [28].
gender, education, body mass index and co-morbid conditions,
which can strongly confound these associations. Diabetics,
though, consumed 37% of energy from fat, compared to 35%
among nondiabetics, and this difference was statistically signifi-
cant (p Ͻ 0.01). There was modest evidence that persons with
dyslipidemia were attempting to decrease dietary fat; compared to
those without elevated serum lipids; these participants ate less
energy from fat and saturated fat and less dietary cholesterol, but
the differences were statistically significant only for saturated fat
and still exceed standard recommendations. Males with hyperten-
sion consumed significantly more percent energy from saturated
fat (p Ͻ 0.05), with modest differences in total cholesterol and
fruits and vegetables (both p ϭ 0.06) compared to men without
hypertension. We note that in spite of an apparent lack of adher-
ence to dietary practices (e.g., low fat, high fruit and vegetable)
that can improve disease status and long-term prognosis, partici-
pants in this study reported high motivation to alter their diets.
Eighty percent of participants with cardiovascular disease, diabe-
tes, dyslipidemia or hypertension reported that it would be very
important to them to eat less fat in order to prevent serious
diseases; 70% to 75% of participants reported that they would eat
less fat if a physician told them to, and nearly 90% reported that
they would eat less fat if it would help control a medical problem
Associations of BMI and physical activity varied across
chronic medical conditions (Table 4). BMI was statistically sig-
nificantly larger among participants who reported diabetes, dys-
lipidemia or hypertension compared to participants who did not
report those conditions. These estimates were adjusted for age,
gender, race, education and co-morbid conditions. We note that
64% of diabetics, 58% of hypertensives, 56% of those with car-
diovascular disease and 62% of participants with dyslipidemia
reported that they were actively trying to lose weight (data not
shown). Both healthy and diseased participants engaged in very
little occupational and leisure physical activity, with each group
obtaining only 120 and 118 minutes per week (or about 17
minutes per day), respectively. There were large differences in
exercise patterns of diabetics compared to non-diabetics. Partici-
pants with diabetes exercised at 25% decreased intensity (as mea-
sured in metabolic equivalents) compared to non-diabetics.
DISCUSSION
The principal finding from this investigation is that the 42%
of all adults in this nationally conducted study who reported a
history of diabetes, cardiovascular disease, dyslipidemia or
hypertension have poor diet and exercise habits. While medical
(data not shown).
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
397

Diet and Exercise in Chronic Disease Patients
Table 2. Associations of Self-Reported Chronic Disease Conditions with Blood Chemistries
Total Serum
Cholesterol (mmol/L)
Serum Triglycerides
Total Serum Carotenoids
Medical Condition
n
1
1
2
(mmol/L)
(␮mol/L)
Mean Ϯ Standard Error
Any chronic condition or
3
disease
Yes
No
753
1029
4.95 (0.04)***
4.69 (0.03)
1.11 (0.04)***
0.97 (0.03)
0.82 (0.02)
0.84 (0.01)
Diabetes
Yes
No
112
1670
4.58 (0.08)**
4.81 (0.02)
1.07 (0.09)
1.03 (0.02)
0.82 (0.04)
0.83 (0.01)
4
Dyslipidemia
Yes
No
387
1395
5.17 (0.05)***
4.69 (0.02)
1.24 (0.05)***
0.98 (0.02)
0.84 (0.02)
0.83 (0.01)
Hypertension
Yes
No
354
1428
4.76 (0.05)
4.80 (0.02)
1.10 (0.05)
1.01 (0.02)
0.80 (0.02)
0.83 (0.01)
Cardiovascular Disease
Males
Yes
No
107
558
4.62 (0.09)*
4.81 (0.04)
1.07 (0.09)
1.25 (0.04)
0.75 (0.04)
0.78 (0.02)
Cardiovascular Disease
Females
Yes
No
190
927
4.84 (0.07)
4.80 (0.03)
0.89 (0.05)
0.94 (0.02)
0.84 (0.03)
0.87 (0.01)
1
2
3
4
Geometric means, adjusted for age, gender, race, education, body mass index and co-morbid conditions.
Geometric means, adjusted for age, gender, race, education, total serum cholesterol, supplemental beta-carotene intake, body mass index and co-morbid conditions.
Diabetes, cardiovascular disease, dyslipidemia or hypertension.
Physician diagnosed elevated total serum cholesterol or triglycerides.
*
*
*
p Ͻ 0.05, compared to participants without the condition.
* p Ͻ 0.01, compared to participants without the condition.
** p Ͻ 0.001, compared to participants without the condition.
nutrition therapy is widely recognized as an essential compo-
nent of treatment for these diet-modifiable diseases and condi-
tions, our data showed that, compared to participants who are
disease-free, many of the biochemical and physical indicators
of disease risk were worse among these participants, who
should be especially careful about adhering to health and ex-
ercise guidelines. There were few differences in dietary intake
between those with and without chronic disease; except for
dietary cholesterol intake, mean estimates for all study partic-
ipants did not meet the guidelines for either disease prevention
or treatment, namely less than 30% of total energy from fat, no
more than 10% of energy from saturated fat, 300 or fewer mg
of cholesterol and at least five servings of fruits and vegetables
per day [3].
These findings have several important public health impli-
cations. First, there is substantial evidence showing that adher-
ence to dietary recommendations (e.g., low fat, high fruit and
vegetable diet) for diet-modifiable diseases will decrease the
risk of long term disease complications and occurrence of
co-morbid conditions [1–3]. Failure to follow these recommen-
dations places patients at increased risk for progressive disease
and poor prognoses, which are strongly associated with reduced
quality of life, shortened life span and considerable economic
costs. For example, Oster and Thompson estimated that lost
earnings and medical costs of cardiovascular disease alone
amount to tens of billions of dollars per year [32]. Other
published reports have documented the estimated health care
dollars that will be saved by Medicare coverage for medical
nutrition therapy [33], which began January 1, 2002 [34].
Because nutrition professionals are actively working to expand
health insurance coverage of medical nutrition therapy for
people with cardiovascular disease and dyslipidemia, and for
Americans who have diabetes and hypertension but are not yet
covered by Medicare, these findings are especially intriguing
and emphasize the need for these important nutrition services.
An important question for nutrition professionals is the
extent to which we can bridge the large gap between patient
knowledge of the effectiveness of nutrition therapy and the
ability to sustain long-term adherence to a prescribed dietary
pattern. For example, 80% of our participants with diet-modi-
fiable chronic diseases reported that it would be very important
for them to eat less fat in order to prevent serious diseases and
90% stated that they would eat less fat if it would help control
a medical problem. Yet, among these same participants, the
mean percent energy from fat was nearly 35%, and the fruit and
vegetable intake was less than three servings per day. Dietary
change and maintenance are difficult, particularly when it must
be sustained over the course of many years to control a chronic
3
98
VOL. 21, NO. 5

Diet and Exercise in Chronic Disease Patients
Table 3. Associations of Self-Reported Chronic Disease Conditions with Usual Dietary Intake
Energy from
1
Energy
kcal/day)
Energy from Fat
(%)
Cholesterol
(mg/day)
Fruit/Vegetables
(servings/day)
1
Medical Condition
n
Saturated Fat
%)
1
,2
1,2
1,2
(
(
Mean Ϯ Standard Error
Diabetes
Yes
No
112
1670
1529 (59)
1590 (15)
36.8 (0.77)**
34.8 (0.19)
12.5 (0.31)
12.0 (0.08)
216 (12)
198 (3)
2.9 (0.13)
2.6 (0.03)
Dyslipidemia
Yes
No
387
1395
1583 (33)
1587 (17)
34.2 (0.42)
35.1 (0.21)
11.7 (0.17)*
12.1 (0.09)
189 (6)
202 (3)
2.7 (0.07)
2.7 (0.03)
Cardiovascular
Disease
Yes
297
1485
1559 (36)
1591 (16)
34.5 (0.47)
35.0 (0.20)
11.8 (0.19)
12.1 (0.08)
194 (7)
200 (3)
2.6 (0.07)
2.7 (0.03)
No
Hypertension
(male)
Yes
No
145
520
1941 (67)
1808 (31)
36.5 (0.67)
35.2 (0.33)
12.8 (0.27)*
12.1 (0.14)
266 (14)
239 (6)
2.2 (0.09)
2.5 (0.05)
Hypertension
(female)
Yes
No
209
908
1409 (41)
1461 (19)
33.6 (0.60)
34.8 (0.27)
11.6 (0.25)
12.0 (0.11)
168 (7)
178 (3)
2.9 (0.10)
2.8 (0.04)
1
2
Adjusted for age, gender, race, education and co-morbid medical conditions.
Geometric means.
*
*
*
p Ͻ 0.05, compared to participants without the condition.
* p Ͻ 0.01, compared to participants without the condition.
** p Ͻ 0.001, compared to participants without the condition.
Table 4. Associations of Self-Reported Chronic Disease Conditions with Body Mass Index and Physical Activity
1
,2
1
1,3
Medical Condition
n
BMI
Exercise (minutes/week)
Exercise (METS/week)
Mean Ϯ Standard Error
Any chronic disease or
4
condition
Yes
No
753
1029
29.1 (0.2)***
27.6 (0.2)
120 (4.0)
118 (4.0)
569 (23)
573 (20)
Diabetes
Yes
No
112
1670
31.4 (0.6)***
28.0 (0.1)
98 (11)
120 (3)
443 (59)*
580 (15)
Dyslipidemia
Yes
No
387
1395
28.8 (0.3)*
28.0 (0.2)
118 (6)
119 (3)
569 (32)
572 (16)
Cardiovascular Disease
Yes
No
297
1485
27.7 (0.4)
28.3 (0.2)
113 (7)
120 (3)
560 (36)
574 (16)
Hypertension
Yes
No
354
1428
30.2 (0.3)***
27.7 (0.2)
125 (6)
117 (3)
613 (35)
561 (16)
1
2
3
4
Adjusted for age, gender, race, education and comorbid conditions.
2
BMI ϭ Body mass index calculated as weight (kg)/height (meters) .
METS ϭ metabolic equivalents. See text for details.
Diabetes, cardiovascular disease, dyslipidemia or hypertension.
p Ͻ 0.05, compared to participants without the condition.
* p Ͻ 0.01, compared to participants without the condition.
** p Ͻ 0.001, compared to participants without the condition.
*
*
*
disease. While there are very few published studies demonstrat-
ing effective long-term behavioral strategies for dietary change
and maintenance, several investigations are currently underway
to explore these important issues [35]. Moreover, we have
recently shown that women, persons older than 55 years and
well-educated individuals are more likely to be successful with
self-initiated dietary change than those who are male, younger
and without a college education [36]. These findings suggest
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
399

Diet and Exercise in Chronic Disease Patients
that clinicians who work with certain demographic groups may
need to devise new ways to help these individuals change and
maintain their diets to prevent or treat diet-related chronic
diseases.
qualify to obtain reimbursement for these services under the
Medical Nutrition Therapy Act, effective January 1, 2002 [34].
There are several strengths to our study. First, the random
digit dial recruitment strategy allowed us to recruit successfully
a diverse study sample from three large U.S. cities. Second, our
measures of diet and health have been previously validated in
other populations [25,37], and the food frequency questionnaire
has been shown to provide good estimates of usual dietary
intake [21]. Third, all clinic staff were centrally trained and
certified in data collection procedures, and strict quality assur-
ance protocols were instituted and followed at each clinic site.
Finally, the combination of objective measures of blood chem-
istries and body measurements together with reliable self-
reported measures of diet and health provide a fairly compre-
hensive profile of the study participants. There are also
limitations. First, we recognize that these data are observational
in nature, and we are unable to determine whether any changes
in weight or diet have occurred over time or since diagnosis.
However, we note that few participants reported a recent diag-
nosis (11.4% of patients with cardiovascular disease, 16.6%
with hypertension, 20.5% with diabetes and 26.0% with dys-
lipidemia were first diagnosed within the previous year), sug-
gesting that sufficient time had likely elapsed since diagnosis to
permit at least some behavior modification. Second, because
we did not obtain specific information on whether participants
with diet modifiable diseases received nutrition services from a
nutrition professional or physician, we are unable to determine
associations between actual therapy offered and compliance.
Third, our results may not be generalizable to all patients with
diabetes, cardiovascular disease, dyslipidemia or hypertension
because we studied the behavior of participants in an observa-
tional research study who may differ from the general popula-
tion. Longitudinal studies conducted with similar free-living
populations will help to clarify the extent to which patients with
diet-modifiable diseases can successfully modify diet and ex-
ercise habits.
ACKNOWLEDGMENT
This study was supported by the Proctor & Gamble Com-
pany (Cincinnati, OH).
REFERENCES
1
2
. Position of the American Dietetic Association: Medical nutrition
therapy and pharmacotherapy. J Am Diet Assoc 99:227–230, 1999.
. Expert Panel on Detection, Evaluation and Treatment of High
Blood Cholesterol in Adults: Executive summary of the third
report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA
285:2486–2497, 2001.
3. Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deck-
elbaum RJ, Erdman Jr JW, Kris-Etherton P, Goldberg IJ, Kotchen
TA, Lichenstein AH, Mitch WE, Mullis R, Robinson K, Wylie-
Rosett J, St Jeor S, Suttie J, Tribble DL, Bazzare TL: AHA Dietary
Guidelines: Revision 2000: A Statement for health care profes-
sionals from the nutrition committee of the American Heart Asso-
ciation. Circulation 102:22:4–99, 2000.
4
. Conlin PR, Chow D, Miller ER, Svetsky LP, Lin PH, Harsha DW,
Moore TJ, Sacks FM, Appel LJ: The effect of dietary patterns on
blood pressure control in hypertensive patients: results from the
Dietary Approaches to Stop Hypertension (DASH) trial. Am J
Hypertens 13:949–955, 2000.
5. Windhauser MM, Ernst DB, Karanja NM, Crawford SW, Redican
SE, Swain JF, Karimbakas JM, Champagne CM, Hoben KP, Evans
MA: Translating the Dietary Approaches to Stop Hypertension diet
from research to practice: dietary and behavior change techniques.
J Am Diet Assoc 99:S90–S95, 1999.
6
. Moore TJ, Vollmer WM, Appel LJ, Sacks FM, Svetsky LP, Vogt
TM, Conlin PR, Simons-Morton DG, Carter-Edwards L, Harsha
DW: Effect of dietary practices on ambulatory blood pressure:
results from the Dietary Approaches to Stop Hypertension (DASH)
Trial. DASH Collaborative Research Group. Hypertension 34:
472–477, 1999.
CONCLUSION
7
. Jones DW, Miller ME, Wofford MR, Anderson DC, Cameron ME,
Willouoghby DL, Adair CT, King NS: The effect of weight loss
intervention on antihypertensive medication requirements in the
Hypertension Optimal Treatment (HOT) study. Am J Hypertens
We conclude that this examination of the diet and health
practices of free-living individuals with physician-diagnosed
diabetes, cardiovascular disease, hypertension or dyslipidemia
indicates that, while many patients report active engagement in
weight loss regimens and are motivated to eat less fat, most are
still overweight, consume a high-fat, low fruit and vegetable
diet and participate in very little physical activity. New strate-
gies are needed to identify successful methods to help patients
adopt and maintain healthful dietary practices. Finally, clini-
cians should be especially attentive to refer patients with these
diet-responsive medical disorders to qualified nutrition profes-
sionals for treatment and monitoring and to help patients who
1
2:1175–1180, 1999.
8
. Stevens VJ, Obarzanek E, Cook NR, Lee IM, Appel LJ, Smith
West D, Milas NC, Mattfeldt-Beman M, Belden L, Bragg C,
Millstone M, Racsynski J, Brewer A, Singh B, Cohen J, for the
Hypertension Prevention Research Group: Long-term weight loss
and changes in blood pressure: results of the Trials of Hypertension
Prevention, phase II. Ann Int Med 134:1–11, 2001.
9
. Chait A, Malinow MR, Nevin DN, Morris CD, Eastgard RL,
Kris-Etherton P, Pi-Sunyer FX, Oparil S, Resnick LM, Stern JS,
Haynes RB, Hatton DC, Metz JA, Clark S, McMahon M, Holcomb
4
00
VOL. 21, NO. 5

Diet and Exercise in Chronic Disease Patients
S, Reusser ME, Snyder GW, McCarron DA: Increased dietary
macronutrients decrease serum homocysteine concentration in pa-
tients at high risk of cardiovascular disease. Am J Clin Nutr
22. Neuhouser ML, Patterson RE, Kristal AR, Rock CL, Neumark-
Sztainer D, Thornquist MD, Cheskin LJ: Do consumers of savory
snacks have poor quality diets? J Am Diet Assoc 100:576–579,
2000.
7
0:881–887, 1999.
1
0. Metz JA, Stern JS, Kris-Etherton P, Reusser ME, Morris CD,
Hatton DC, Oparil S, Haynes RB, Resnick LM, Pi-Sunyer FX,
Clark S, Chester L, McMahon M, Snyder GW, McCarron DA: A
randomized trial of improved weight loss with a prepared meal
plan in overweight and obese patients: impact on cardiovascular
risk reduction. Arch Int Med 160:2150–2158, 2000.
23. Schakel SF, Buzzard IM, Gebhardt SE: Procedures for estimating
nutrient values for food composition databases. J Food Comp Anal
10:102–114, 1997.
24. Kristal AR, Shattuck AL, Williams AE: Food frequency question-
naires for diet intervention research. In “17th National Nutrient
Databank Conference.” Baltimore: International Life Sciences In-
stitute, pp 110–125, 1993.
1
1
1. Haynes RB, Kris-Etherton P, McCarron DA, Oparil S, Chait A,
Resnick LM, Morris CD, Clark S, Hatton DC, Metz JA, McMahon
M, Holcomb S, Snyder GW, Pi-Sunyer FX, Stern JS: Nutritionally
complete prepared meal plan to reduce cardiovascular risk factors:
a randomized clinical trial. J Am Diet Assoc 99:1077–1083, 1999.
2. Howell WH, McNamara DJ, Tosca MA, Smith BT, Gaines JA:
Plasma lipid and lipoprotein responses to dietary fat and choles-
terol: a meta-analysis. Am J Clin Nutr 65:1747–1764, 1997.
3. Van Horn L, Kavey RE: Diet and cardiovascular disease preven-
tion: what works? Ann Behav Med 19:197–212, 1997.
25. Satia JA, Kristal AR, Curry S, Trudeau E: Motivations for health-
ful dietary change. Pub Health Nutr 4:953–959, 2001.
26. Richarson MT, Ainsworth BE, Jacobs DR, Leon AS: Validation of
the Stanford 7-day recall to assess habitual physical activity. Ann
Epidemiol 11:145–153, 2001.
27. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM,
Strath SJ, O’Brien WL, Bassett Jr DR, Schmitz KH, Emplaincourt
PO, Jacobs Jr DR, Leon AS: Compendium of physical activities:
an update of activity codes and MET intensities. Med Sci Sports
Exer 32:S498–504, 2000.
1
1
4. Rodriguez LM, Castellanos VH: Use of low-fat foods by people
with diabetes decreases fat, saturated fat, and cholesterol intakes.
J Am Diet Assoc 100:531–536, 2000.
28. U.S. Surgeon General: “The Surgeon General’s Report on Nutri-
tion and Health.” Washington DC: US Dept of Health and Human
Services, 1988.
1
5. Korhonen MH, Litmanen H, Rauramaa R, Vaisanen SB, Niskanen
L, Uusitupa M: Adherence to the salt restricted diet among people
with mildly elevated blood pressure. Eur J Clin Nutr 53:880–885,
29. Rock CL, Thornquist MD, Kristal AR, Patterson RE, Cooper DA,
Neuhouser ML, Neumark-Sztainer D, Cheskin L: Demographic,
dietary and lifestyle factors differentially explain variability in
serum carotenoids and fat-soluble vitamin: baseline results from
the sentinel site of the olestra post-marketing surveillance study. J
Nutr 129:855–864, 1999.
1
999.
1
6. Newell SA, Bowman JA, Cockburn JD: Can compliance with
nonpharmacological treatment for cardiovascular disease be im-
proved? Am J Prev Med 18:253–261, 2000.
1
7. Brownell KD, Cohen LR: Adherence to dietary regimens 1: An
overview of research. Behav Med 20:149–154, 1995.
30. Willett W: “Nutritional Epidemiology,” 2nd ed. New York: Oxford
University Press, 1998.
1
8. Metz JA, Kris-Etherton PM, Morris CD, Mustad VA, Stern JS,
Oparil S, Chait A, Haynes RB, Resnick LM, Clark S, Hatton DC,
McMahon M, Holcomb S, Snyder GW, Pi-Sunyer FX, McCarron
DA: Dietary compliance and cardiovascular risk reduction with a
prepared meal plan compared with a self-selected diet. Am J Clin
Nutr 66:373–385, 1997.
31. Centers for Disease Control: Tobacco use—United States 1900–
1999. MMWR 48:986, 988–993, 1999.
32. Oster G, Thompson D: Estimated effects of reducing dietary sat-
urated fat intake on the incidence and costs of coronary heart
disease in the United States. J Am Diet Assoc 96:127–131, 1996.
33. Sheils JF, Rubin R, Stapleton DC: The estimated costs and savings
of medical nutrition therapy: the Medicare population. J Am Diet
Assoc 99:428–435, 1999.
1
9. Kristal AR, Patterson RE, Neuhouser ML, Thornquist MD, Neu-
mark-Sztainer D, Rock CL, Berlin M, Cheskin L, Schreiner PJ:
The olestra post-marketing surveillance study: design and baseline
results from the sentinel site. J Am Diet Assoc 98:1290–1296,
34. Medical Nutrition Therapy Act of 1999. H.R. 4577.
35. The Women’s Health Initiative Study Group: Design of the Wom-
en’s Health Initiative Clinical Trial and Observational Study. Con-
trol Clin Trials 19:61–109, 1998.
1
998.
2
0. Thornquist MD, Kristal AR, Patterson RE, Neuhouser ML, Rock
CL, Neumark-Sztainer D, Cheskin LJ: Olestra consumption does
not predict serum concentrations of carotenoids and fat-soluble
vitamins in free-living humans: early results from the sentinel site
of the Olestra Post-Marketing Surveillance Study. J Nutr 103:
36. Kristal AR, Hedderson MM, Patterson RE, Neuhouser ML: Pre-
dictors of self-initiated, healthful dietary change. J Am Diet Assoc
101:762–766, 2001.
37. Vargas CM, Burt VL, Gillum RF, Pamuk ER: Validity of self-
reported hypertension in the National Health and Nutrition Exam-
ination Survey III, 1988–1991. Prev Med 26:678–685, 1997.
1
711–1718, 2000.
2
1. Patterson RE, Kristal AR, Carter RA, Fels-Tinker L, Bolton MP,
Agurs-Collins T: Measurement characteristics of the Women’s
Health Initiative food frequency questionnaire. Ann Epidemiol
9
:178–187, 1999.
Received July 26, 2001; revision accepted February 25, 2002.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
401