DASH

Supermarket Diet Advice Improves DASH Adherence: SuperWIN

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People who received personalized nutrition education in a series of sessions at their regular grocery store significantly improved adherence to a healthy diet, in a new “first-of-its-kind” study in which scientific researchers partnered with a large supermarket company.

In the SuperWIN study, participants were given individualized advice from supermarket-based dieticians using data on their own buying habits recorded on their supermarket loyalty cards. This was associated with an increased adherence to the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes vegetables, fruits and whole grains while limiting foods that are high in saturated fat, sugar, and sodium and has been shown to lower blood pressure and low-density lipoprotein cholesterol.

One group of patients also received additional education about healthy eating and meal planning through online technologies, and this group showed even better adherence to the DASH diet.

The study was presented at American College of Cardiology (ACC) 2022 Scientific Session by Dylan Steen, MD, adjunct associate professor of medicine at the University of Cincinnati College of Medicine in Ohio.

“The SuperWIN study provides evidence for the benefit of delivering healthy-eating interventions at modern supermarkets and retail-based clinics,” Steen said. “It demonstrates the efficacy of dietary interventions harnessing the physical environment of the supermarket, the retail-based dietitians working within the store, and the purchasing data captured on the store’s loyalty cards,” he added.

The study was conducted in partnership with Kroger, the largest supermarket chain in the United States, which also operates a large chain of pharmacies and health clinics.

Steen said the study was addressing one of the biggest public health problems — unhealthy eating — with an innovative approach. “We need to think about how we can extend the reach of modern healthcare systems into communities and better deliver services right where people are; meet them where they live,” he said at an ACC press conference.

Commenting on the study ay the press conference, Eileen Handberg, PhD, professor of medicine at University of Florida, Gainesville, and immediate past chair of the ACC Cardiovascular Care Team Council, said, “I am amazingly excited about this. There is so much potential here. We have never really taken advantage of the current explosion in retail-based healthcare before.”

Handberg suggested the study had major implications for the primary prevention of cardiovascular disease. “Little kids go shopping with their parents, so you have the ability here to change behavior from children on up if you can change the dynamic of the choices they make in the grocery store,” she said.

In his presentation, Steen noted that despite many longstanding guidelines on healthy eating, about 75% of Americans still have a poor-quality diet. This trial was conducted to see if a new approach could improve that situation. “If we change the environment in which we deliver dietary education, we can make a difference,” he said.  

The SuperWIN trial was conducted in 13 Kroger stores in Ohio and Kentucky. The study enrolled 267 people with at least one cardiovascular risk factor from a primary care network who regularly shopped at one of the study stores. All participants also had to be willing to follow the DASH diet, which was taught at each educational session in the trial.

All participants received one “enhanced” medical nutrition therapy that was guided by the individual’s own dietary intake analytics.

They were then randomly assigned to one of three arms. The control group received no further education. The strategy 1 group received six additional teaching sessions in the supermarket aisles over a 3-month period. Each session was guided by updated individualized purchasing data provided to the dietitian and the participant. 

The strategy 2 group received the same six additional teaching sessions as strategy 1, but they also had some additional teaching on healthy eating and meal planning from a variety of online shopping tools, and nutrition and healthcare apps.  

“The supermarket analytics were automatically collected so the dietitians could tell what each person liked to eat, how much of each product they were buying and how much they were spending,” Steen explained.

COVID hit halfway through the trial, and 20 participants were withdrawn for their own safety as they could no longer visit the stores, but the trial continued with the rest of the participants with enhanced safety precautions. The overall analysis cohort was 247 participants.

The average age of the participants was mid-50s, around 70% were female, and most did not have a history of cardiovascular disease.

Eating habits were assessed by three 24-hour dietary recalls assessed at the start of the study and at 3 and 6 months. The DASH score, which is a measure of adherence to the DASH diet, was calculated from this information. The score can range from 0 to 90, with an increased score showing increased adherence.

In one analysis, the researchers compared the DASH scores from the two intervention groups together with the control group, and in a second analysis they compared the scores in the strategy 2 group with those in the strategy 1 group.

Before the pandemic there was “near 100%” attendance for the six visits over the 3-month study period, which Steen said he thought was “remarkable.” During the pandemic, attendance came down to around 80%.

Results showed that the DASH score increased in all three groups at 3 months, with stepwise increases corresponding to the intensity of the intervention. DASH scores increased by 5.8 points in the control group, by 8.6 points in the strategy 1 group, and by 12.4 points in the strategy 2 group.    

DASH scores significantly differed between the two intervention groups and the control group (P = .02). “This shows that purchasing data–guided in-store tours do increase the efficacy of dietary education,” Steen said.  

The difference in scores between the strategy 1 and strategy 2 groups was also significant (P = .01). “This shows online enhancements increase adherence to the DASH diet even further,” Steen commented

By 6 months, the scores had dropped off a little but were still increased from baseline: by 4.4 points in the control group, 6.6 points in the strategy 1 group, and 8.4 points in the strategy 2 group. “There was again a stepwise increase as the intervention intensified, but there was no longer a significant difference between the interventions and control,” Steen noted.

Secondary endpoints included blood pressure and body mass index. Systolic blood pressure decreased slightly in all three groups: by 2.8 mm Hg in the control group, 6.6 mm Hg in the strategy 1 group, and 5.7 mm Hg in the strategy 2 group. BMI was reduced by 0.2, 0.4 and 0.8, respectively, but the between-group differences were not significant.

Steen noted that this is the first study of its kind to date in which  scientific researchers collaborated with a large supermarket chain. He explained they also involved a primary care network so that healthcare utilization information will be available.

“We can the integrate retail-based healthcare information with traditional healthcare information. And we can start to look at downstream healthcare utilization and cost outcomes as well, which will be important as we start to think how to evolve the healthcare system,” he commented.

“The hope is that we can get more scientists working with more retailers to really drive the evidence to shape the evolution of our healthcare system,” he added.  

Challenges Ahead

Handberg pointed out there would be challenges in reaching the underserved population who do not shop at the major supermarkets. “We need to figure out how to get partnerships across the whole spectrum of grocery stores.”

She also noted that 3 months (the duration of the study intervention) was not much time to change the eating habits of a family. “Interventions may have to be a bit more intensive to get the change in blood pressure and weight that we would want to see.”

She added that she hoped the major grocery store companies will see the opportunities in this approach. “Changing behavior is very complicated, and the key will be how to make people stick with the changes. But grocery stores are smart. They have got us going to their pharmacies, so getting us to see a dietitian is not that much of a stretch.”   

Moderator of the ACC late breaker session at which the study was presented, Pamela Morris, MD, from the Medical University of South Carolina, who is also ACC Annual Scientific Session chair, asked whether the approach could be sustained.  

“I am thinking back to the barber shop study of blood pressure treatment and to my knowledge those PharmDs are no longer in those barbershops, taking blood pressures, counseling patients, and prescribing antihypertensives. So is Kroger maintaining a long-term commitment to providing this education, or how can this be financed over the long term?” she asked.

Steen replied that he believed sustainability to be one of the key strengths of this model. “Retail-based healthcare is exploding in the US. The number of retail outlets offering a comprehensive list of services is going up all the time. These programs exist regardless of whether this trial was conducted or not.”

But Steen stressed that having an evidence base will be critically important.

“Validation is an enormous part of this evolution in retail-based healthcare — not only to figure out what works but also to engage payors and others in the process of supporting these interventions. I think the sustainability is there — it is sort of baked into the model — but research will be a huge part of cementing this in and helping us to understand what we should do.”

Dot-dash-diss: The gentleman hacker’s 1903 lulz.

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A century ago, one of the world’s first hackers used Morse code insults to disrupt a public demo of Marconi’s wireless telegrap.

LATE one June afternoon in 1903 a hush fell across an expectant audience in the Royal Institution’s celebrated lecture theatre in London. Before the crowd, the physicist John Ambrose Fleming was adjusting arcane apparatus as he prepared to demonstrate an emerging technological wonder: a long-range wireless communication system developed by his boss, the Italian radio pioneer Guglielmo Marconi. The aim was to showcase publicly for the first time that Morse code messages could be sent wirelessly over long distances. Around 300 miles away, Marconi was preparing to send a signal to London from a clifftop station in Poldhu, Cornwall, UK.

Yet before the demonstration could begin, the apparatus in the lecture theatre began to tap out a message. At first, it spelled out just one word repeated over and over. Then it changed into a facetious poem accusing Marconi of “diddling the public”. Their demonstration had been hacked – and this was more than 100 years before the mischief playing out on the internet today. Who was the Royal Institution hacker? How did the cheeky messages get there? And why?

It had all started in 1887 when Heinrich Hertz proved the existence of the electromagnetic waves predicted by James Clerk Maxwell in 1865. Discharging a capacitor into two separated electrodes, Hertz ionised the air in the gap between them, creating a spark. Miraculously, another spark zipped between two electrodes a few metres away: an electromagnetic wave from the first spark had induced a current between the second electrode pair. It meant long and short bursts of energy – “Hertzian waves” – could be broadcast to represent the dots and dashes of Morse code. Wireless telegraphy was born, and Marconi and his company were at the vanguard. Marconi claimed that his wireless messages could be sent privately over great distances. “I can tune my instruments so that no other instrument that is not similarly tuned can tap my messages,” Marconi boasted to London’s St James Gazette in February 1903.

That things would not go smoothly for Marconi and Fleming at the Royal Institution that day in June was soon apparent. Minutes before Fleming was due to receive Marconi’s Morse messages from Cornwall, the hush was broken by a rhythmic ticking noise sputtering from the theatre’s brass projection lantern, used to display the lecturer’s slides. To the untrained ear, it sounded like a projector on the blink. But Arthur Blok, Fleming’s assistant, quickly recognised the tippity-tap of a human hand keying a message in Morse. Someone, Blok reasoned, was beaming powerful wireless pulses into the theatre and they were strong enough to interfere with the projector’s electric arc discharge lamp.

Mentally decoding the missive, Blok realised it was spelling one facetious word, over and over: “Rats”. A glance at the output of the nearby Morse printer confirmed this. The incoming Morse then got more personal, mocking Marconi: “There was a young fellow of Italy, who diddled the public quite prettily,” it trilled. Further rude epithets – apposite lines from Shakespeare – followed.

The stream of invective ceased moments before Marconi’s signals from Poldhu arrived. The demo continued, but the damage was done: if somebody could intrude on the wireless frequency in such a way, it was clearly nowhere near as secure as Marconi claimed. And it was likely that they could eavesdrop on supposedly private messages too.

Marconi would have been peeved, to say the least, but he did not respond directly to the insults in public. He had no truck with sceptics and naysayers: “I will not demonstrate to any man who throws doubt upon the system,” he said at the time. Fleming, however, fired off a fuming letter to The Times of London. He dubbed the hack “scientific hooliganism”, and “an outrage against the traditions of the Royal Institution”. He asked the newspaper’s readers to help him find the culprit.

He didn’t have to wait long. Four days later a gleeful letter confessing to the hack was printed by The Times. The writer justified his actions on the grounds of the security holes it revealed for the public good. Its author was Nevil Maskelyne, a mustachioed 39-year-old British music hall magician. Maskelyne came from an inventive family – his father came up with the coin-activated “spend-a-penny” locks in pay toilets. Maskelyne, however, was more interested in wireless technology, so taught himself the principles. He would use Morse code in “mind-reading” magic tricks to secretly communicate with a stooge. He worked out how to use a spark-gap transmitter to remotely ignite gunpowder. And in 1900, Maskelyne sent wireless messages between a ground station and a balloon 10 miles away. But, as author Sungook Hong relates in the book Wireless, his ambitions were frustrated by Marconi’s broad patents, leaving him embittered towards the Italian. Maskelyne would soon find a way to vent his spleen.

One of the big losers from Marconi’s technology looked likely to be the wired telegraphy industry. Telegraphy companies owned expensive land and sea cable networks, and operated flotillas of ships with expert crews to lay and service their submarine cables. Marconi presented a wireless threat to their wired hegemony, and they were in no mood to roll over.

The Eastern Telegraph Company ran the communications hub of the British Empire from the seaside hamlet of Porthcurno, west Cornwall, where its submarine cables led to Indonesia, India, Africa, South America and Australia. Following Marconi’s feat of transatlantic wireless messaging on 12 December 1901, ETC hired Maskelyne to undertake extended spying operations.

Maskelyne built a 50-metre radio mast (the remnants of which still exist) on the cliffs west of Porthcurno to see if he could eavesdrop on messages the Marconi Company was beaming to vessels as part of its highly successful ship-to-shore messaging business. Writing in the journal The Electrician on 7 November 1902, Maskelyne gleefully revealed the lack of security. “I received Marconi messages with a 25-foot collecting circuit [aerial] raised on a scaffold pole. When eventually the mast was erected the problem was not interception but how to deal with the enormous excess of energy.”

It wasn’t supposed to be this easy. Marconi had patented a technology for tuning a wireless transmitter to broadcast on a precise wavelength. This tuning, Marconi claimed, meant confidential channels could be set up. Anyone who tunes in to a radio station will know that’s not true, but it wasn’t nearly so obvious back then. Maskelyne showed that by using an untuned broadband receiver he could listen in.

Having established interception was possible, Maskelyne wanted to draw more attention to the technology’s flaws, as well as showing interference could happen. So he staged his Royal Institution hack by setting up a simple transmitter and Morse key at his father’s nearby West End music hall.

The facetious messages he sent could easily have been jumbled with those Marconi himself sent from Cornwall, ruining both had they arrived simultaneously. Instead, they drew attention to a legitimate flaw in the technology – and the only damage done was to the egos of Marconi and Fleming.

Fleming continued to bluster for weeks in the newspapers about Maskelyne’s assault being an insult to science. Maskelyne countered that Fleming should focus on the facts. “I would remind Professor Fleming that abuse is no argument,” he replied.

In the present day, many hackers end up highlighting flawed technologies and security lapses just like Maskelyne. A little mischief has always had its virtues.

Source:New Scientist

DASH and prevention of kidney stone

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Following a Dietary Approaches to Stop Hypertension (DASH)-style diet may help lower kidney stone risk by increasing urinary citrate and urinary volume, according to the results of a large cohort study reported online September 16 in the Clinical Journal of the American Society of Nephrology.

“We previously observed associations between a …DASH-style diet and large reductions in kidney stone risk,” write Eric N. Taylor, from Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues. “This study examined associations between a DASH-style diet and 24-hour excretions of urinary lithogenic factors.”

The study cohort consisted of 3426 adults with and without nephrolithiasis who were enrolled in the Health Professionals Follow-up Study (HPFS) and the Nurses’ Health Studies (NHS) I and II. A DASH score was calculated from self-reported dietary composition, with higher scores reflecting higher consumption of fruits, vegetables, nuts and legumes, dairy products, and whole grains, and lower consumption of sweetened beverages and red and processed meats. The investigators adjusted 24-hour urinary calcium excretion for age, history of kidney stones, body size, and other factors using analysis of covariance.

For participants in the highest vs the lowest quintiles of DASH score, multivariate-adjusted urinary calcium excretion was increased by 3% in HPFS (P for trend = .12), by 10% in NHS I (P for trend < .01), and by 12% in the NHS II (P for trend = .05). Compared with participants in the lowest quintiles of DASH score, those in the highest quintiles had 4% to 18% higher urinary oxalate (P for trend < .03 for all), 11% to 16% higher urinary citrate (P for trend < .01 for all), and 16% to 32% higher urinary volume (P for trend < .001 for all).

In addition, a higher DASH score was associated with greater urinary potassium, magnesium, phosphate, and pH, and lower relative supersaturations (RSS) of uric acid. Among women only, a higher DASH score was associated with lower RSS of calcium oxalate.

“A DASH-style diet may reduce stone risk by increasing urinary citrate and volume,” the study authors write. “The small associations between higher DASH score and lower RSS suggest unidentified stone inhibitors in dairy products and/or plants.”

Limitations of this study include use of 24-hour urine samples, which prevented identification of associations between a DASH-style diet and potentially important postprandial increases in lithogenic factors such as calcium and oxalate, and which is likely to reflect only short-term dietary intake. In addition, the participants in the study sample were all white, limiting generalizability.

“The higher oxalate content of a DASH-style diet does not lead to large increases in 24-hour urinary oxalate, a finding consistent with our previous reports of only small associations between oxalate intake and both urinary oxalate excretion and incident kidney stone risk,” the study authors conclude. “Overall, we believe our results provide a strong rationale for a randomized trial examining the effect of a DASH-style diet on kidney stone recurrence.”