The burden of hypertension, chronic kidney disease (CKD), and cardiovascular disease is disproportionately higher in Black Americans. Adherence to the DASH (Dietary Approaches to Stop Hypertension) eating plan is associated with improvements in hypertension and positive outcomes in CKD and cardiovascular disease. However, according to Crystal C. Tyson, MD, MHS, and colleagues, adherence to DASH is low among Americans. Diet counseling has been shown to enhance DASH adherence in Black men and women, resulting in reduction in racial disparities in rates of hypertension control. Nevertheless, adherence to DASH is suboptimal and racial disparities in adherence remain.
There are few data available on the factors contributing to low adherence to DASH in Black Americans. Previous studies have identified possible barriers to adherence, including high costs of healthy food, lack of available and/or accessible healthy food, overaccessibility and convenience of unhealthy food, and discordant cultural influences on food preferences and diet norms. Individuals with CKD may face additional barriers related to the need to restrict some foods that are emphasized in DASH (fruits, vegetables, whole grains, and legumes).
Dr. Tyson et al conducted a qualitative study to examine perceptions about DASH, its cultural compatibility, and barriers and facilitators to adherence to DASH in a cohort of Black adults with CKD. Results were reported in the Journal of Renal Nutrition [2023;33(1):59-68].
The study included focus groups and semistructured individual interviews with 22 Black men and women with CKD from outpatient clinics at a US academic medical center. Thematic analysis was used to examine the transcripts of the audio-recorded interviews. Eligible participants were ≥21 years of age, had CKD stages 3 or 4 (defined as estimated glomerular filtration rate of 30 to 59 mL/min.1.73 m2 or 20 to 30 mL/min/1.73 m2, respectively), and completed an outpatient primary care or nephrology clinic visit between November 2019 and March 2021.
Focus group discussions were held from December 2019 to January 2020 in a private conference room. The discussions lasted approximately 90 minutes and were led by an experienced qualitative moderator. Due to the implementation of COVID-19 restrictions in March 2020, the interviews with participants with CKD stage 4 were conducted via telephone. The telephone interviews lasted approximately 60 minutes and were performed by one of two race-concordant qualitative moderators using the same interview guide that was used during the initial focus group discussions.
All participants were asked semistructured, open-ended questions. They were asked to react to this statement: DASH is not an African American diet because it doesn’t take into account cultural traditions or food preferences. The lack of a definition for African American diet was deliberate.
The final sample size was 22 individuals. Of those, 13 patients with stage 3 CKD attended one focus group discussion involving eight participants or one focus group discussion involving five participants, and nine with CKD stage 4 completed one telephone interview. Of the overall cohort, 13 participants were female, median age was 61 years, and the most commonly reported comorbid condition was hypertension.
A total of 21 participants completed the study questionnaire. Of those, 15 reported having little or no money left to purchase “special things” after paying their monthly bills, and 11 reported only rarely or never having enough money left over to purchase healthy food in a typical month.
Participants’ familiarity with DASH varied from having no prior knowledge about the diet to having heard of it but not in detail. One participant had been a part of the DASH feeding trial and was very familiar with it. After learning about DASH, the participants generally agreed that it was a healthy diet.
The majority of participants felt that DASH was appropriate for patients with CKD; however, three participants, all with stage 4 CKD, mentioned potential conflicts. One felt DASH included too much protein, and another said DASH contained too much potassium, based on receiving advice to restrict those nutrients. The third participant said that his poor appetite, related to his CKD, would make it challenging to consume the amount of food recommended by DASH.
Responses related to the cultural compatibility of DASH were mixed. A few participants felt that DASH did not account for cultural traditions, but indicated that that would not hinder their ability to adhere to the diet. However, most felt DASH to be culturally compatible for reasons that included the possibility to modify traditional recipes into healthful, DASH-friendly versions. The final reaction to the cultural compatibility of DASH was that cultural traditions were irrelevant in areas of health; health needs to take precedence over tradition.
Barriers and Facilitators to Following DASH
Most participants agreed that they had accessibility of healthy foods, but they felt that healthy foods would cost more than their typical dietary pattern. Some felt that because DASH calls for fresh produce, they might face extra trips to the grocery store to replace spoiled food. Participants on fixed incomes or with time constraints indicated those things might make adherence to DASH challenging. However, most participants agreed that the higher costs and extra grocery store trips would be worth the tradeoff of improvements in their health.
Some participants had concerns regarding food preparation and cooking, including worries about cooking ability, not owning proper tools to measure foods, and the inconvenience of having to weigh foods. Strategies to overcome those barriers were having access to simple, easy-to-follow DASH recipes, and learning how to accurately determine serving sizes.
Another perceived barrier to adherence to DASH involved participants’ household responsibilities regarding food. Living with household members with conflicting food preferences and needs was seen as a barrier. Some participants thought living alone would make it easier to adhere to DASH, while some felt living with others would facilitate adherence if the household members were supportive and encouraged efforts to eat healthy foods.
Finally, participants reported that being informed about the benefits of healthy food and adverse outcomes associated with unhealthy foods would serve as motivation to adhere to DASH. Several felt that having willpower and self-discipline would be required to adhere to DASH, while others felt that having external motivation for diet change would facilitate adherence to DASH.
The researchers cited some limitations to the study, including the small sample size restricted to an urban area of a southern state, and the need to conduct individual phone interviews with some participants rather than focus group discussions.
In conclusion, the authors said, “Black adults with CKD viewed DASH as a healthy, culturally compatible diet. Recognizing that diet in Black adults is not uniform, interventions should emphasize person-centered, rather than stereotypically culture-centered approaches to DASH adherence.”
Takeaway Points
- Researchers conducted a study to examine perceptions about the DASH (Dietary Approaches to Stop Hypertension) eating plan among Black adults with chronic kidney disease (CKD) stages 3 to 4.
- The study included 22 Black adults with CKD who received information about DASH and then offered their perceptions of barriers and facilitators to adherence to the diet plan.
- Overall, the participants viewed DASH as a healthy, culturally compatible diet, and indicated willingness to work to overcome barriers to adherence.
