Methods

The study was observational and evaluated the pre- to postbiometric changes of 5,070 subjects who had self-selected to participate in a CHIP program. A total of 176 CHIP programs (mean group size 29, range 3 to 228) were conducted at 136 sites throughout North America from January 2006 to October 2009. The Avondale College human research ethics committee approved the study (approval number 20:10:07).

The CHIP programs were facilitated by volunteer directors, sourced primarily through the Seventh-Day Adventist Church, who had an interest in positively influencing the health of their local community. The volunteers underwent a 2-day training workshop at a cost of $250 per team of 3, during which they received instruction and detailed manuals regarding the program’s philosophy, content, and method. They were then provided with a comprehensive resource package that included all the materials required to deliver the program.

During the 30 days of the program, the participants received comprehensive lifestyle counseling through 16 two-hour group sessions. Each session typically included a 1-hour recorded lecture by an epidemiologically trained lifestyle interventionist (Dr. Hans Diehl), cooking demonstrations, group discussion, and an exercise component. Also incorporated into the program were shopping tours and nutrition workshops. The participants paid a fee of $250 to cover the costs of the biomedical assessments, food samples distributed throughout the program, and resources, including a textbook and supplementary reading.

The program encouraged participants to move toward a whole-food, plant-based diet ad libitum, with emphasis on the consumption of grains, legumes, fresh fruits, and vegetables. Specifically, the program recommended <15% of calories be derived from fat, with <10 teaspoons of added sugar, <5,000 mg of salt (2,000 mg sodium), and <50 mg of cholesterol per day. The participants were also encouraged to consume 2 to 2.5 L (eight 10-oz glasses) of water daily. At least 30 minutes of daily aerobic exercise (or 10,000 steps) was prescribed, and stress reduction techniques were advocated.

The intent of the CHIP program was to nurture intelligent self-care through enhanced understanding of the epidemiology, etiology, and risk factors associated with CVD. The CHIP curriculum included the following topics: modern medicine’s accomplishments and limitations, atherosclerosis, cardiovascular risk factors, smoking, exercise, dietary fiber, cholesterol, plant-based nutrition, obesity, diabetes, hypertension, dyslipidemia, lifestyle and health, behavioral change, and self-worth.

The participants were encouraged to consult their physician throughout the program, because previous experience has demonstrated that it is necessary to modify medication use because of the intervention.

The participants who attended a minimum of 13 of the 16 sessions and completed the pre- and postassessments “graduated” from the program and were encouraged to join a CHIP alumni group, which met monthly to provide ongoing support for the lifestyle changes initiated during the intervention.

Before participating in the CHIP program (baseline) and again at its conclusion (postintervention), the participants’ height, weight, and blood pressure were taken and fasting (12-hour) blood samples were collected. The blood samples were collected by trained phlebotomists and analyzed by local pathology laboratories for determination of the total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and fasting plasma glucose levels. In addition, the participants completed a self-reported medical/lifestyle questionnaire. The questionnaire included demographic data, a brief medical and family history, details of medication use, and various measures of lifestyle habits such as dietary behavior, activity level, rest, and the use of alcohol, caffeine, and tobacco.

The data were entered into a specially developed Microsoft Access program, exported into Microsoft Excel (Microsoft, Redmond, Washington) and then imported into PASW Statistics, version 18 (SAS Institute, Cary, North Carolina), for analysis. The data are expressed as the mean ± SD. The extent of the changes (from baseline to postintervention) in the biometric measures and risk factors, for both the overall and the stratified data, were assessed using paired t tests. The McNemar chi-square test was used to determine the changes from before to after the intervention in the distribution of participants across the various risk factor categories. The participants were classified as having the metabolic syndrome at baseline and after intervention, according to the “harmonized definition,” and a Mantel-Haenszel chi-square test was used to test the assumption that there was no significant difference between the number of participants with the metabolic syndrome from baseline to after the intervention.

Results

The 5,070 participants (mean age 57.2 ± 12.9 years) included 1,694 men (57.8 ± 13.0 years) and 3,372 women (56.9 ± 12.9 years). Of these participants, 210 (4.1%) self-reported a history of myocardial infarction, 111 (2.1%) had undergone bypass surgery, 101 (2.0%) had experienced a stroke, and 439 (8.7%) had a history of cancer.

The mean changes from baseline to after the intervention for all participants combined are presented in Table 1 . Significant reductions were recorded in all the risk factors, with the most notable being in total cholesterol (−11%). High-density lipoprotein cholesterol also decreased after the intervention but not to the same magnitude as total cholesterol, reducing the total cholesterol/high-density lipoprotein ratio from 4.02:1 to 3.89:1 (p < 0.001).

A significant reduction (p < 0.001) was found in the number of participants requiring medication because of the program, with 1,085 participants (21.4%) reporting medication use at the start of the intervention and 879 (17.4%) at its conclusion. The most common medications taken by the participants were to lower cholesterol and/or blood pressure. Of the 102 smokers at baseline, only 64 were still smoking at the end of the 30-day program.

The effect of the intervention on the various risk factors was analyzed further, with the results listed in Table 2 ; the data were stratified by conventional risk factor categories. The National Cholesterol Education Program Adult Treatment Panel III classification system was used to categorize the participants for all risk factors, except total cholesterol, for which the Framingham risk classification was used. The Framingham classification was used for stratification of the cholesterol data, because it includes 5 categories compared to only 3 in the National Cholesterol Education Program Adult Treatment Panel III classification system and thus allowing a more detailed analysis of the effect of the intervention on the highest risk participants.

Table 2

Changes in risk factor levels within 30 days according to initial risk factor classification

Risk Factor	Participants (n)		McNemar Chi-square Test (p Value)	Baseline	After Intervention	Mean Change	% Mean Change	p Value
	Baseline	After Intervention
Body mass index (kg/m 2 )
<18.5	27	33	449 (<0.001)	17.6 ± 0.9	17.5 ± 0.8	−0.1	−0.8%	0.144
18.5–24.9	884	1,086		22.7 ± 1.6	22.3 ± 1.7	−0.5	−2.1%	<0.001
25–30	1,470	1,539		27.5 ± 1.4	26.6 ± 1.5	−0.9	−3.1%	<0.001
>30	2,242	1,965		36.6 ± 6.1	35.4 ± 6.0	−1.3	−3.4%	<0.001
Systolic blood pressure (mm Hg)
<120	1,279	1,866	662 (<0.001)	111.8 ± 9.0	114.5 ± 27.0	2.7	2.4%	<0.001
120–139	1,719	1,788		129.9 ± 5.1	125.2 ± 27.0	−4.7	−3.6%	<0.001
140–160	1,127	743		147.2 ± 5.8	134.3 ± 13.1	−12.9	−8.7%	<0.001
>160	454	182		170.7 ± 11.9	147.3 ± 17.6	−23.3	−13.7%	<0.001
Diastolic blood pressure (mm Hg)
<80	2,619	3,364	560 (<0.001)	72.4 ± 6.9	71.8 ± 8.9	−0.7	−0.9%	<0.001
80–89	1,060	822		84.8 ± 2.3	78.3 ± 7.7	−6.4	−7.6%	<0.001
90–100	688	322		92.9 ± 3.0	82.7 ± 8.4	−10.2	−10.9%	<0.001
>100	210	69		106.2 ± 13.0	87.7 ± 10.3	−18.5	−17.4%	<0.001
Total cholesterol (mg/dl)
<160	631	1,862	1,950 (<0.001)	141.0 ± 18.7	133.2 ± 24.8	−7.8	−5.6%	<0.001
160–199	2,116	1,781		182.5 ± 15.7	165.5 ± 24.4	−17.0	−9.3%	<0.001
200–239	1,261	756		215.6 ± 10.5	188.5 ± 25.5	−27.1	−12.6%	<0.001
240–280	478	183		254.7 ± 10.7	215.2 ± 30.7	−39.5	−15.5%	<0.001
>280	126	30		306.6 ± 27.2	245.9 ± 43.4	−60.7	−19.8%	<0.001
Low-density lipoprotein (mg/dl)
<100	1,453	2,115	1,008 (<0.001)	80.6 ± 15.1	75.3 ± 209.1	−5.3	−6.6%	<0.001
100–129	1,345	1,326		114.6 ± 8.3	102.1 ± 20.2	−12.5	−10.9%	<0.001
130–159	905	588		142.4 ± 8.5	120.1 ± 21.8	−22.3	−15.7%	<0.001
160–190	377	197		172.0 ± 8.2	141.6 ± 27.1	−30.4	−17.7%	<0.001
>190	488	342		273.9 ± 67.9	229.8 ± 73.1	−44.1	−16.1%	<0.001
High-density lipoprotein (mg/dl)
<40	1,316	1,814	539 (<0.001)	34.2 ± 4.8	33.2 ± 7.0	−1.0	−3.0%	<0.001
40–60	2,097	1,912		48.9 ± 5.3	45.0 ± 7.8	−3.8	−7.8%	<0.001
≥60	1,261	948		86.3 ± 29.8	76.2 ± 28.5	−10.1	−11.8%	<0.001
Triglycerides (mg/dl)
<100	3,053	3,232	109 (<0.001)	95.5 ± 29.7	99.7 ± 41.8	4.2	4.4%	<0.001
100–199	753	765		171.9 ± 13.9	158.1 ± 53.0	−13.8	−8.1%	<0.001
200–500	820	663		270.5 ± 62.4	220.1 ± 81.8	−50.3	−18.6%	<0.001
>500	45	11		634.7 ± 114.2	354.8 ± 158.5	−279.9	−44.1%	<0.001
Fasting plasma glucose (mg/dl)
<110	3,716	4,026	265 (<0.001)	90.7 ± 9.9	88.6 ± 10.9	−2.1	−2.3%	<0.001
110–125	390	304		116.1 ± 15.5	106.0 ± 15.5	−10.1	−8.7%	<0.001
>125	525	301		164.0 ± 42.2	131.4 ± 34.5	−32.6	−19.9%	<0.001

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