Adaptation of DASH diet (Dietary Approach to Stop Hypertension) for postpartum nutritional care at primary healthcare

Karina dos Santos Tainá Marques Moreira Gabriella Pinto Belfort Carolina Felizardo de Moraes da Silva Patricia de Carvalho Padilha Denise Cavalcante de Barros Cláudia Saunders About the authors

ABSTRACT:

Introduction:

Postpartum weight retention has been found to predict obesity. However, in Brazil, there’s no national strategy for nutritional care of postpartum woman.

Objective:

This study aimed to adapt DASH diet (Dietary Approaches to Stop Hypertension) for nutritional counseling of postpartum woman, at primary healthcare.

Method:

Methodological study, carried out in 2016, at low-income urban neighborhood in the city of Rio de Janeiro. It was developed in four steps: translation, food and food groups adaptation, identification of geographic and economic access to food and viability evaluation.

Results:

The food groups of original diet were structured to Brazilian dietary pattern. After viability analysis, it was observed that the geographical access of food should be accounted to enable greater adherence. A qualitative and illustrated meal plan was elaborated for nutritional counseling.

Conclusion:

The adapted DASH diet for nutritional care of postpartum woman seems to be according to the Brazilian dietary pattern, maintaining nutritional characteristics that provide the health benefits previously demonstrated. Currently, it’s being used in interventional study in two primary healthcare unities at the city of Rio de Janeiro.

Keywords:
Postpartum period; Diet, Food and Nutrition; Maternal nutrition; Women’s health

INTRODUCTION

Postpartum weight retention is a predictive factor for the development of obesity; therefore, it is recommended that returning to pre-gestational weight should occur within the first year after delivery11. Linné Y, Dye L, Barkeling B, Rössner S. Long-term weight development in women: a 15-year follow-up of the effects of pregnancy. Obes Res 2004; 12(7): 1166-78. https://doi.org/10.1038/oby.2004.146
https://doi.org/10.1038/oby.2004.146...
,22. Rooney BL, Schauberger CW. Excess pregnancy weight gain and long-term obesity: one decade later. Obstet Gynecol 2002; 100(2): 245-52.. However, there is no protocol for nutritional care in primary healthcare, in Brazil, regarding the puerperium.

The Dietary Approaches to Stop Hypertension (DASH) diet was originally proposed for the prevention and treatment of systemic arterial hypertension33. Harsha DW, Lin PH, Obarzanek E, Karanja NM, Moore TJ, Caballero B. Dietary Approaches to Stop Hypertension: a summary of study results. DASH Collaborative Research Group. J Am Diet Assoc 1999; 99(Supl. 8): S35-9. and is currently recommended as a healthy dietary standard by several national44. Sociedade Brasileira de Cardiologia. VII Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2016; 107(3 Supl. 3).,55. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2015-2016. São Paulo: A.C. Farmacêutica; 2016.,66. Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes Brasileiras de Obesidade 2016. 4ª ed. São Paulo: Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica; 2016. and international77. Van Horn L, Carson JA, Appel LJ, Burke LE, Economos C, Karmally W, et al. Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association. Circulation 2016; 134(22): e505-29. https://doi.org/10.1161/CIR.0000000000000462
https://doi.org/10.1161/CIR.000000000000...
,88. American Diabetes Association. Standards of Medical Care in Diabetes - 2017: Summary of Revisions. Diabetes Care 2017; 40(Supl. 1): S4-5. https://doi.org/10.2337/dc17-S003
https://doi.org/10.2337/dc17-S003...
technical-scientific organizations, due to its benefits related to nutritional status and metabolic aspects.

The DASH diet is rich in fruits, vegetables, whole grains and low-fat dairy products, prioritizes consumption of white meats, includes seeds and oilseeds, and limits the consumption of sugar and sweets. The benefits of this diet are attributable to its macro/micronutrient composition, by providing increased amounts of calcium, potassium, magnesium, fiber and unsaturated fatty acids and limited sodium, cholesterol and saturated fatty acids99. Lin PH, Aickin M, Champagne C, Craddick S, Sacks FM, McCarron P, et al. Food group sources of nutrients in the dietary patterns of the DASH-Sodium trial. J Am Diet Assoc 2003; 103(4): 488-96. https://doi.org/10.1053/jada.2003.50065
https://doi.org/10.1053/jada.2003.50065...
.

In view of current recommendations44. Sociedade Brasileira de Cardiologia. VII Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2016; 107(3 Supl. 3).,55. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2015-2016. São Paulo: A.C. Farmacêutica; 2016.,66. Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes Brasileiras de Obesidade 2016. 4ª ed. São Paulo: Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica; 2016.,77. Van Horn L, Carson JA, Appel LJ, Burke LE, Economos C, Karmally W, et al. Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association. Circulation 2016; 134(22): e505-29. https://doi.org/10.1161/CIR.0000000000000462
https://doi.org/10.1161/CIR.000000000000...
,88. American Diabetes Association. Standards of Medical Care in Diabetes - 2017: Summary of Revisions. Diabetes Care 2017; 40(Supl. 1): S4-5. https://doi.org/10.2337/dc17-S003
https://doi.org/10.2337/dc17-S003...
, this dietary pattern seems promising for reducing postpartum weight retention and improving overall health conditions for women. However, adapting the original diet, in order to make it feasible for Brazilians to join it, is considered necessary.

This study aimed to adapt the DASH diet for nutritional orientation of postpartum women, in the context of primary healthcare, in a community in the city of Rio de Janeiro. It was methodological, developed in 2016, based on the work of Whitt-Glover and others1010. Whitt-Glover MC, Hunter JC, Foy CG, Quandt SA, Vitolins MZ, Leng I, et al. Translating the Dietary Approaches to Stop Hypertension (DASH) Diet for Use in Underresourced, Urban African American Communities, 2010. Prev Chronic Dis 2013; 10: 120088. https://doi.org/10.5888/pcd10.120088
https://doi.org/10.5888/pcd10.120088...
, consisting of four stages, described below.

The research was approved by the Research Ethics Committee of Escola Nacional de Saúde Pública Sérgio Arouca (CEP/ENSP), under opinion No. 238/10, Certificate of Presentation for Ethical Assessment (Certificado de Apresentação para Apreciação Ética - CAAE) 0251.0.031.031-10, and registered in the ReBEC under opinion RBR-4t46ry.

METHOD

TRANSLATION

The translation process was carried out by the team of researchers, from the publications of the Dash Collaborative Research Group. The version of DASH diet choosed for adaptation was the one proposed by Windhauser et al.1111. Windhauser MM, Ernst DB, Karanja NM, Crawford SW, Redican SE, Swain JF, et al. Translating the Dietary Approaches to Stop Hypertension diet from research to practice: dietary and behavior change techniques. J Am Diet Assoc 1999; 99(8 Supl.): S90-5., since it also presented strategies for application in clinical practice.

ADAPTING FOOD AND FOOD GROUPS

The foods most consumed by the Brazilian population1212. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: Análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011., which contemplate the nutritional recommendations of the DASH diet, were considered1313. Núcleo de Estudos e Pesquisas em Alimentação da Universidade Estadual de Campinas. Tabela Brasileira de Composição de Alimentos - TACO. 4ª ed. Campinas: Núcleo de Estudos e Pesquisas em Alimentação da Universidade Estadual de Campinas; 2011.. The food groups were reviewed and discussed among the researchers, considering the proposal of the Food Guide for the Brazilian Population1414. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2ª ed. Brasília: Ministério da Saúde; 2014.. The nutritional composition of the foods in the original DASH diet and the items identified as more present in the Brazilian menu were compared.

IDENTIFICATION OF GEOGRAPHICAL AND FINANCIAL ACCESSIBILITY

The main supermarkets in the region were identified, as well as the small local trades and free markets, where the prices of various foods were surveyed1515. Mackenbach JD, Burgoine T, Lakerveld J, Forouhi NG, Griffin SJ, Wareham NJ, et al. Accessibility and Affordability of Supermarkets: Associations With the DASH Diet. Am J Prev Med 2017; 53(1): 55-62. https://doi.org/10.1016/j.amepre.2017.01.044
https://doi.org/10.1016/j.amepre.2017.01...
. Due to problems of violence in the territory in question, most of this survey was carried out using internet resources such as Google Maps®, Google Street View® and supermarket sites located in the perimeter of the community.

FEASIBILITY ASSESSMENT

Educational actions to verify the feasibility of adherence to the DASH dietary pattern were carried out with puerperas at two Primary Care Services in the city of Rio de Janeiro, randomly invited in a waiting room or participants in a group of child care units.

A tasting of foods provided in the adapted DASH diet was offered and the prices practiced in the region were informed. A preview of the educational materials elaborated on the basis of the adapted DASH diet was also presented. Women were invited to answer eight questions on palatability (3), financial (2) and geographical accessibility (1) and understanding of educational materials (2). The Likert Scale was used for the answers, with the options “yes”, “no” and “maybe”. The “yes” answers were considered as approval for the items in question.

The educational actions had participation of 17 puerperas. The approval for palatability, financial and geographical accessibility and comprehension of educational materials was 90, 94, 59 and 100%, respectively.

Due to the result of the criterion “geographical accessibility”, the need for individual evaluation of this item to guide the nutritional orientation should be noted1010. Whitt-Glover MC, Hunter JC, Foy CG, Quandt SA, Vitolins MZ, Leng I, et al. Translating the Dietary Approaches to Stop Hypertension (DASH) Diet for Use in Underresourced, Urban African American Communities, 2010. Prev Chronic Dis 2013; 10: 120088. https://doi.org/10.5888/pcd10.120088
https://doi.org/10.5888/pcd10.120088...
,1111. Windhauser MM, Ernst DB, Karanja NM, Crawford SW, Redican SE, Swain JF, et al. Translating the Dietary Approaches to Stop Hypertension diet from research to practice: dietary and behavior change techniques. J Am Diet Assoc 1999; 99(8 Supl.): S90-5.,1515. Mackenbach JD, Burgoine T, Lakerveld J, Forouhi NG, Griffin SJ, Wareham NJ, et al. Accessibility and Affordability of Supermarkets: Associations With the DASH Diet. Am J Prev Med 2017; 53(1): 55-62. https://doi.org/10.1016/j.amepre.2017.01.044
https://doi.org/10.1016/j.amepre.2017.01...
.

RESULTS

After performing the four steps, the adapted DASH diet was structured as shown in Chart 1.

Chart 1.
Translated and adapted Dietary Approaches to Stop Hypertension (DASH) diet, based on a food plan of 2,000 kcal.

The group “Oilseeds, seeds, beans and peas” was dismembered in “Leguminosae” and “Oilseeds and seeds”, considering that beans is the third most consumed food by Brazilians1616. Souza AM, Pereira RA, Yokoo EM, Levy RB, Sichieri R. Alimentos mais consumidos no Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saúde Pública 2013; 47(Supl. 1): 190s-9s. http://dx.doi.org/10.1590/S0034-89102013000700005
http://dx.doi.org/10.1590/S0034-89102013...
, becoming the main source of the nutrients of this group. “Oilseeds and seeds” have a higher cost, but seeds such as flaxseed and sunflower are found in local commerce with lower costs in relation to oilseeds.

The “Sweets” group was excluded from the adaptation, considering that sugar intake should be avoided and limited to less than 5% of total energy consumption1717. World Health Organization. Guideline: Sugars intake for adults and children. Genebra: World Health Organization; 2015. and that the consumption of sugary and sweet drinks is excessive in the Brazilian population1616. Souza AM, Pereira RA, Yokoo EM, Levy RB, Sichieri R. Alimentos mais consumidos no Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saúde Pública 2013; 47(Supl. 1): 190s-9s. http://dx.doi.org/10.1590/S0034-89102013000700005
http://dx.doi.org/10.1590/S0034-89102013...
. Consumption is present, however, but not as part of the nutritional orientation1414. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2ª ed. Brasília: Ministério da Saúde; 2014..

In relation to the “Meat” group, orientation included eggs, viscera and pork, since they present greater supply offer and lower cost in the markets of the region.

Whole grain bread and rice usually have higher prices. Therefore, roots, tubers and oats are good options, equivalents of the group “Cereals, grains, roots and tubers”.

For individual nutritional guidance, a qualitative and illustrated food plan was elaborated, with six daily meals, without personalized dietary calculation, in line with the proposal of the new Food Guide for the Brazilian Population1515. Mackenbach JD, Burgoine T, Lakerveld J, Forouhi NG, Griffin SJ, Wareham NJ, et al. Accessibility and Affordability of Supermarkets: Associations With the DASH Diet. Am J Prev Med 2017; 53(1): 55-62. https://doi.org/10.1016/j.amepre.2017.01.044
https://doi.org/10.1016/j.amepre.2017.01...
.

CONCLUSION

The adaptation of the DASH diet to nutritional care in the postpartum period seems to be in accordance with the Brazilian food pattern, maintaining the nutritional characteristics that impute the previously studied health benefits. Currently, it is being used in an intervention study conducted in two Primary Care Services in the city of Rio de Janeiro.

References

  • 1
    Linné Y, Dye L, Barkeling B, Rössner S. Long-term weight development in women: a 15-year follow-up of the effects of pregnancy. Obes Res 2004; 12(7): 1166-78. https://doi.org/10.1038/oby.2004.146
    » https://doi.org/10.1038/oby.2004.146
  • 2
    Rooney BL, Schauberger CW. Excess pregnancy weight gain and long-term obesity: one decade later. Obstet Gynecol 2002; 100(2): 245-52.
  • 3
    Harsha DW, Lin PH, Obarzanek E, Karanja NM, Moore TJ, Caballero B. Dietary Approaches to Stop Hypertension: a summary of study results. DASH Collaborative Research Group. J Am Diet Assoc 1999; 99(Supl. 8): S35-9.
  • 4
    Sociedade Brasileira de Cardiologia. VII Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2016; 107(3 Supl. 3).
  • 5
    Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2015-2016. São Paulo: A.C. Farmacêutica; 2016.
  • 6
    Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes Brasileiras de Obesidade 2016. 4ª ed. São Paulo: Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica; 2016.
  • 7
    Van Horn L, Carson JA, Appel LJ, Burke LE, Economos C, Karmally W, et al. Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association. Circulation 2016; 134(22): e505-29. https://doi.org/10.1161/CIR.0000000000000462
    » https://doi.org/10.1161/CIR.0000000000000462
  • 8
    American Diabetes Association. Standards of Medical Care in Diabetes - 2017: Summary of Revisions. Diabetes Care 2017; 40(Supl. 1): S4-5. https://doi.org/10.2337/dc17-S003
    » https://doi.org/10.2337/dc17-S003
  • 9
    Lin PH, Aickin M, Champagne C, Craddick S, Sacks FM, McCarron P, et al. Food group sources of nutrients in the dietary patterns of the DASH-Sodium trial. J Am Diet Assoc 2003; 103(4): 488-96. https://doi.org/10.1053/jada.2003.50065
    » https://doi.org/10.1053/jada.2003.50065
  • 10
    Whitt-Glover MC, Hunter JC, Foy CG, Quandt SA, Vitolins MZ, Leng I, et al. Translating the Dietary Approaches to Stop Hypertension (DASH) Diet for Use in Underresourced, Urban African American Communities, 2010. Prev Chronic Dis 2013; 10: 120088. https://doi.org/10.5888/pcd10.120088
    » https://doi.org/10.5888/pcd10.120088
  • 11
    Windhauser MM, Ernst DB, Karanja NM, Crawford SW, Redican SE, Swain JF, et al. Translating the Dietary Approaches to Stop Hypertension diet from research to practice: dietary and behavior change techniques. J Am Diet Assoc 1999; 99(8 Supl.): S90-5.
  • 12
    Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: Análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.
  • 13
    Núcleo de Estudos e Pesquisas em Alimentação da Universidade Estadual de Campinas. Tabela Brasileira de Composição de Alimentos - TACO. 4ª ed. Campinas: Núcleo de Estudos e Pesquisas em Alimentação da Universidade Estadual de Campinas; 2011.
  • 14
    Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2ª ed. Brasília: Ministério da Saúde; 2014.
  • 15
    Mackenbach JD, Burgoine T, Lakerveld J, Forouhi NG, Griffin SJ, Wareham NJ, et al. Accessibility and Affordability of Supermarkets: Associations With the DASH Diet. Am J Prev Med 2017; 53(1): 55-62. https://doi.org/10.1016/j.amepre.2017.01.044
    » https://doi.org/10.1016/j.amepre.2017.01.044
  • 16
    Souza AM, Pereira RA, Yokoo EM, Levy RB, Sichieri R. Alimentos mais consumidos no Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saúde Pública 2013; 47(Supl. 1): 190s-9s. http://dx.doi.org/10.1590/S0034-89102013000700005
    » http://dx.doi.org/10.1590/S0034-89102013000700005
  • 17
    World Health Organization. Guideline: Sugars intake for adults and children. Genebra: World Health Organization; 2015.

  • Financial support: Fundação para o Desenvolvimento Científico e Tecnológico em Saúde (FIOTEC). Authors Karina dos Santos and Carolina Felizardo de Moraes da Silva received, during the period of study development, másters scholarships funded by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

History

  • Received
    28 July 2017
  • Accepted
    31 Jan 2018
  • Online publication
    25 Apr 2019
  • Issue publication
    2019
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil
E-mail: revbrepi@usp.br