Development, validation, and reproducibility of food group-based frequency questionnaires for clinical use in Brazil : a pre-hypertension and hypertension diet assessment

The Blood pressure control diet is well described; however, it has not been implemented in clinical care, possibly due to the impracticability of the diet assessment in these contexts. In order to facilitate the dietary assessment, we developed and assessed the validity and reproducibility of two food group-based food frequency questionnaires (FG-FFQs), with a one-week (7-day FG-FFQ) and a one-month (30-day FG-FFQ) period of coverage for patients with pre-hypertension or hypertension. In 2010, 155 men and women, 30–70 years old, were invited to participate in a prospective study in two outpatient clinics in Porto Alegre, southern Brazil. The participants responded to two 30-day, two 7-day FG-FFQ, four 24-h dietary recalls, and underwent demographic, anthropometric, and blood pressure assessments. The validity and reproducibility were assessed using partial correlation coefficients adjusted for sex and age, and the internal validity was tested using the intra-class correlation coefficient. The participants were aged 61 ( 10) years and 60% were women. The validity correlation coefficient was higher than r = 0.80 in the 30-day FG-FFQ for whole bread (r = 0.81) and the 7-day FG-FFQ for diet/light/zero soda and industrialized juices (r = 0.84) in comparison to the 24-h dietary recalls. The global internal validity was = 0.59, but it increased to = 0.76 when 19 redundant food groups were excluded. The reproducibility was higher than r = 0.80 for pasta, potatoes and manioc, bakery goods, sugar and cocoa, and beans for both versions. The 30-day had a slightly higher validity, both had good internal validity, and the 7-day FG-FFQ had a higher reproducibility

Self-reported adherence to physical activity recommendations compared to the IPAQ interview in patients with hypertension

Background: Physical activity (PA) is recommended as adjuvant therapy to control blood pressure (BP). The effectiveness of simple recommendations is not clear. We aimed to assess the agreement between self-report of adherence to PA in clinical routine and International Physical Activity Questionnaire (IPAQ) interview and its association with BP control. Methods: A cross-sectional study was conducted with hypertensive outpatients. Adherence to recommendation to PA was assessed by the physician and IPAQ interview. A cutoff of 150 minutes/week was used to classify active or nonactive patients. High sitting time was considered >4 hours/day. A total of 127 individuals (SBP 144.9±24.4 mmHg/DBP 82.0±12.8 mmHg) were included. Results: A total of 69 subjects (54.3%) reported to be active to their physician, whereas 81 (63.8%) were classified as active by IPAQ (6.3% active in leisure time PA). Kappa test was 0.22 (95% CI, 0.06–0.37). The rate of BP control was 45.7%. There was no association with the reported PA assessed by both methods nor with sitting time. Our results demonstrated poor agreement between self-report adherence and IPAQ interview, and neither evaluation was associated with BP control. Conclusion: Our findings underpin evidences that a simple PA recommendation has low association with BP control in clinical settings

Avaliação da associação de consumo de feijão com arroz e pressão arterial em indivíduos hipertensos em tratamento

Diversos estudos têm sugerido uma possível associação entre o consumo de proteínas vegetais e redução de pressão arterial. Feijão consumido com arroz é fonte de proteínas de alto valor biológico que fazem parte do hábito alimentar da população brasileira. Assim, pode ser uma opção a mais de intervenção nutricional para manejo de hipertensão arterial sistêmica (HAS) com provável adesão, visto que, esses alimentos são de fácil disponibilidade. No entanto estudos sobre associação do consumo de feijão com hipertensão são poucos. Assim, o presente estudo tem como objetivos avaliar a associação entre o consumo de feijão e arroz e níveis pressóricos de pacientes em tratamento anti-hipertensivo. Outra intervenção nutricional para controle da HAS é a restrição de sal na dieta, cuja eficácia já foi demonstrada, mas é de difícil adesão. Considerando a importância de avaliar a adesão à restrição de sal e a falta de instrumentos de fácil aplicação na rotina assistencial, outro objetivo dessa dissertação foi realizar a validação do questionário de restrição de sódio dietético (DSRQ) desenvolvido para pacientes com insuficiência cardíaca, em pacientes com hipertensão. Esse questionário pode ser útil para identificação de barreiras e facilitadores dessa recomendação e também orientar o desenvolvimento de intervenções de aconselhamento aos pacientes com hipertensão. Foi realizado um estudo transversal, com pacientes hipertensos em tratamento atendidos no ambulatório de hipertensão e Unidade Básica de Saúde do Hospital de Clinicas de Porto Alegre – HCPA. Foram aplicados três recordatórios alimentares de 24h e coletados dados demográficos, antropométricos, medidas de pressão arterial, dados laboratoriais e prescrição medicamentosa. A associação entre o consumo de feijão e arroz e níveis pressóricos foi avaliada pelo teste de comparação de medianas Man Whitney, ANOVA one way e modelo linear generalizado. Participaram desse estudo 242 pacientes, estratificados em pressão controlada ou não controlada. 113 participantes apresentaram pressão arterial controlada, com pressão arterial sistólica e diastólica de 124,9 ±10,3 mmHg e 75,7 ±8,1 mmHg, respectivamente e 129 apresentaram pressão arterial não controlada com níveis de pressão arterial sistólica e diastólica de 154,3 ±17,4 / 88,5 ±12,8 mmHg. Não houve associação entre o consumo de feijão e arroz e pressão arterial controlada ou não controlada (p=0,975). O consumo de feijão e arroz foi categorizado em quartis e pelo teste ANOVA não foi observado associação significativa entre os quartis e pressão arterial sistólica (p=0,053) e diastólica (p=0,553). A razão de prevalência bruta de PA não controlada para indivíduos que não consumiram feijão e arroz foi de 0,86 (IC95% 0,65 a 1,15; p=0,31). Concluindo, os dados sugerem não haver associação entre o consumo de feijão e arroz com níveis pressóricos em pacientes em tratamento anti-hipertensivo. A validação do DSRQ foi realizada por um estudo metodológico, com 104 pacientes do ambulatório de Hipertensão – HCPA. Foram coletados dados demográficos, medidas de pressão arterial, prescrição medicamentosa e três recordatórios alimentares de 24 horas para estimação do consumo de sódio. O questionário é composto por três subescalas – atitude, norma subjetiva e controle comportamental percebido. A fidedignidade foi avaliada por meio da consistência interna dos seus itens utilizando o coeficiente Alfa de Cronbach. A validade do constructo foi avaliada pela análise dos componentes principais e a validade convergente pela correlação de Spearman. O Coeficiente Alfa de Cronbach foi 0,77 para os 15 itens do questionário; e para as subescalas de atitude, norma subjetiva e atitude comportamental foram de: 0,75, 0,25 e 0,82, respectivamente, após exclusão do item 20. A análise dos componentes principais com extração de três fatores representou 53,5% da variância explicada e resultou em novo agrupamento dos itens nos três componentes da análise fatorial. A correlação de Spearman entre as subescalas e o sódio estimado através do RA24h foi significativa apenas entre a subescala comportamento dependente e sódio estimado (p=0,006). Assim, pode-se concluir que o instrumento apresenta validade e fidedignidade de seu constructo para avaliar as barreiras e atitudes de pacientes hipertensos.Several studies have suggested a possible association between vegetable protein intake and the reduction in blood pressure. Consuming a combination of black beans and rice is part of the Brazilian consumption pattern and is a high-biological-value source. Therefore, it can be an extra nutritional intervention for the management of the hypertension (HT). This mixture presents a high possibility of adherence, once these types of food are easily available. However, there are few studies about the association between the black beans intake and hypertension. Thus, the present study aims to evaluate the association between black beans and rice consumption and the pressure levels of the patients under hypertension treatment. Other nutritional intervention for the HT control is a salt restriction diet, whose efficacy has already been demonstrated, although the adherence to it is difficult. Taking into consideration the importance of assessing the adherence to a salt restriction diet, and the lack of easy-application instruments in the clinic routine of the patients, other goal of this dissertation was to perform the validation of the dietary sodium restriction questionnaire (DSRQ) for patients with hypertension. The DSRQ was developed for heart failure patients. This questionnaire can be useful to identify barriers and facilitators of the salt restriction recommendation, also to guide the development of counseling interventions for patients with hypertension. The cross-sectional study was performed with patients who were under treatment in the outpatient hypertension and the Basic Health Unit of the Hospital de Clínicas de Porto Alegre – HCPA. Three 24 hour food recall (24HR) were conducted and demographic data, blood pressure measures, laboratory data and medication prescription were collected. The association between black beans and rice consumption and the pressure levels was analyzed by the Man Whitney median comparison, one way ANOVA and generalized linear models. 242 individuals participated in this study and they were stratified in two groups: controlled blood pressure group and uncontrolled blood pressure. 113 participants present a controlled blood pressure, showing 124.9 ±10.3 mmHg as the systolic blood pressure result and 75.7 ±8.1 mmHg as the diastolic result. 129 participants presented an uncontrolled blood pressure. As the systolic blood pressure result, it was found 154.3 ±17.4 mmHg, and as the diastolic result, 88.5 ±12.8 mmHg. It was not found any association between the black beans and rice intake and the controlled / uncontrolled pressure levels (p=0.975). The black beans and rice consumption was categorized in quartiles and, by the ANOVA test, no significant association between the quartiles, the systolic blood pressure (p=0,053) and the diastolic (p=0.553) was observed. The prevalence ratio crude controlled BP for individuals who did not consume beans and rice was 0.86 (95% CI 0.65 to 1.15, P = 0.31). In conclusion, the data suggested no association between Black beans and rice intake with the pressure levels of the patients under hypertension treatment. The DSRQ validation was performed through a methodological study, with 104 hypertension outpatient patients of the HCPA. Demographics data, blood pressure measures, medication prescription were collected. Three 24HR was conducted for estimated dietary sodium. The DSRQ is composed of three subscales: attitude, norm subjective and perceived behavioral control. The reliability was assessed by the internal consistency of the items of the questionnaire using Cronbach´s Alpha coefficient. The construct validity was evaluated by the Principal Component Analysis (PCA) test and the convergent validity calculated by the Spearman correlation. The Cronbach´s Alpha coefficient found was 0.77 for the 15-items questionnaire; for the attitude, norm subjective and perceived behavioral control subscales were found 0.75, 0.25 and 0.82, respectively – after the exclusion of the item 20. Extracting three factors of the PCA, explained 53.5% of the variance, and it also resulted in a new arrangement of the three components of the factorial analysis. The Spearman correlation between the subscales and the estimated dietary sodium found by the 24HR was significant only between the dependent behavior subscale and the estimated dietary sodium (p=0.006). Thus, it is possible to conclude that the instrument presents validity and reliability of its construct to evaluate the barriers and facilitators of patients with hypertension

Effectiveness of an education intervention for sodium restriction in patients with hypertension : arandomized controlled trial

Estudos têm demonstrado a eficácia das intervenções não farmacológicas na redução da pressão arterial (PA). No entanto, a adesão à dieta hipossódica é baixa e as intervenções de mudança de comportamento devem promover a motivação e desenvolver habilidades para superar os obstáculos da realização da restrição de sódio. O Dietary Sodium Restriction Questionnaire (DSRQ) foi desenvolvido para avaliar as dificuldades e facilitadores da adesão à dieta hipossódica. O instrumento foi validado para pacientes com hipertensão; porém, não há estudos avaliando seu uso em intervenções educativas e também não há ponto de corte estabelecido para definir adesão. Assim, o presente estudo tem como objetivos avaliar a eficácia de uma intervenção educativa planejada a partir da aplicação do DSRQ em pacientes hipertensos na redução da ingestão de sódio e avaliar a validade de critérios do DSRQ comparado com o sódio urinário. Foi realizado um ensaio clínico randomizado, com alocação dos participantes em dois grupos: (1) grupo de intervenção educativa, com orientações para restrição de sódio e plano alimentar tipo DASH; e (2) grupo controle com cuidados usuais. Em ambos grupos, as sessões foram individuais, mensais, durante seis meses. Foram realizadas monitorização ambulatorial de pressão arterial de 24 horas (MAPA), coleta de sangue e amostra spot de urina, aplicação do DSRQ, avaliação antropométrica e medida de PA. Participaram desse estudo 120 indivíduos, com valores de PA sistólica de 24 horas de 122,3 ± 18,3 mmHg e PA diastólica de 24 horas 72,7 ± 12,7 mmHg. Mais da metade dos participantes relataram já estar seguindo dieta hipossódica, 68,3% no grupo de intervenção e 66,7% no grupo controle. Após o seguimento, os escores da subescala Atitude e Norma Subjetiva aumentaram em ambos os grupos (p = 0,039), os escores da subescala do Controle Comportamental Percebido diminuíram (p = 0,023) e os escores do Comportamento Dependente não apresentou diferença (p = 0,369). O sódio de 24 horas estimado diminuiu em ambos os grupos ao longo do tempo (p > 0,05). A avaliação de sensibilidade e especificidade do DSRQ foi realizada com análise dos dados da linha de base. Foram incluídos no estudo 120 participantes, coletas spot de urina, MAPA, DSRQ, avaliação antropométrica e medida de PA. Foi construída uma curva Receiver Operating Characteristic (ROC) para cada subescala do DSRQ visando determinar um ponto de corte indicativo de baixa adesão à restrição de sódio. A área sob a curva ROC foi 0,463 (IC95%: 0,262 – 0,665) na subescala Atitude e Norma Subjetiva, 0,623 (IC95%: 0,451 – 0,796) na subescala Controle Comportamental Percebido e 0,473 (IC95%: 0,320 – 0,627) na subescala Comportamento Dependente. O DSRQ apresentou acurácia não satisfatória para diagnosticar baixa adesão: ≥ 28,5 para a subescala Atitude e Norma Subjetiva; ≤ 14,4 para a subescala Controle Comportamental Percebido; e ≤ 19,5 para a subescala Comportamento Dependente. Portanto, a intervenção educativa para restrição de sódio com base no DSRQ em pacientes hipertensos não foi eficaz, mas os dois grupos apresentaram redução na ingestão de sódio, sugerindo que o acompanhamento mensal por uma equipe de saúde pode melhorar a adesão do paciente.Even though some studies have already demonstrated the effectiveness of non-pharmacological interventions to reduce blood pressure (BP), low-sodium diet adherence is poor. Such interventions should also aim at behavior change, promoting motivation and developing skills to overcome obstacles to sodium restriction. The Dietary Sodium Restriction Questionnaire (DSRQ) was developed to evaluate difficulties and facilitators to low-sodium dietary adherence. The instrument was validated for patients with hypertension; nevertheless, the efficacy of interventions based on DSRQ and cut-off points for satisfactory adherence have not yet been assessed. Thus, the objectives this study are to evaluate the effectiveness of an education intervention guided by the application of DSRQ in hypertensive patients in sodium intake reduction, as well as to evaluate validity of criteria of the DSRQ compared to urinary sodium. Therefore, a randomized clinical trial was conducted with participants allocated in two groups: (1) education intervention group, with sodium restriction advice and DASH-type diet; and (2) control group with usual care. Both groups were individually treated in monthly sessions for six months. BP was monitored 24-hour; blood and urine spot were collected; DSRQ was applied; BP and anthropometric measurements were performed. A total of 120 individuals participated in this study, with 24-hour systolic BP of 122.3 ± 18.3 mmHg and 24-hour diastolic BP of 72.7 ± 12.7 mmHg. More than half of the participants reported following low-sodium diets previously, 68.3% in the intervention group and 66.7% in the control group. After the follow-up, Attitude and Subjective Norm subscale scores increased in both groups (p = 0.039), Perceived Behavior Control subscale scores decreased (p = 0.023) and Dependent Behavior presented no difference (p = 0,369). In both groups, 24-hour sodium estimated decreased over time (p > 0.05), although no significant differences between groups were showed (interaction p = 0.761). Baseline data analysis was used to assess both sensitivity and specificity of the DSRQ. Urine spot samples were collected to estimate 24-hour sodium, ABPM, DSRQ, anthropometric and BP were measured. Receiver Operating Characteristic (ROC) curve was constructed for each DSRQ subscale to determine best points of sensitivity and specificity to define adherence cut-off points. The area under ROC curve was 0.463 (95%CI: 0.262 - 0.665) for Attitude and Subjective Norm subscales; 0.623 (95%CI: 0.451 - 0.796) for the Perceived Behavioral Control subscale; and 0.473 (95%CI: 0.320 - 0.627) for the Dependent Behavior subscale, suggesting poor accuracy. The DSRQ presented unsatisfactory cut-off point values for adherence: ≥ 28.5 for the Attitude and Subjective Norm subscale; ≤ 14.4 for the Perceived Behavior Control subscale; ≤ 19.5 for the Dependent Behavior subscale. As a conclusion, even though both groups showed sodium reduction, suggesting that a month follow-up provided by a health care team may improve patient adherence, the education intervention proposed by the present aimed at sodium restriction based on DSRQ in hypertensive patients showed no effect