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LETTER |
Correspondence: Requests for reprints should be sent to Ken Resnicow, PhD, Rollins School of Public Health, Emory University, 1520 Clifton Rd, Atlanta, GA 30322 (e-mail: kresnic{at}sph.emory.edu).
My coauthors and I appreciate Din's comments. An interesting concern she raised is that we could have better "put our results into perspective by relating the amount of clinical change to the degree of prevention of disease or risk factor modification." Din points out, on the basis of the findings of several prospective observational studies,1–4 that the net relative increase of approximately 1 serving per day of fruits and vegetables in the intensive intervention group could result in a significant beneficial effect on disease outcomes.
Projecting potential morbidity or mortality effects from our intervention is complicated by several factors. First, as Din notes, our primary outcome was assessed only 1 year from baseline. The extent to which the behavioral changes observed would be maintained beyond this relatively short follow-up is unclear. Moreover, even if the change was fully maintained, it is likely that the impact on disease outcomes would be modest. Joshipura et al.1 estimated that for 1 healthy middle-aged adult to avoid a coronary heart disease event, 1443 persons would have to increase their consumption of fruits and vegetables by 1 serving per day for 12 years. Finally, the studies cited are observational in nature, and the extent to which changing fruit and vegetable intake improves disease prognosis in healthy individuals is not well understood.5
With regard to her question as to whether the intervention may have had differential effects on persons with prior disease, we conducted new analyses and found that baseline disease status did not interact with the intervention.
Din raises several other important points, including the need for longer-term follow-up in health promotion intervention studies and the need to include physiological outcomes in such studies. She mentions the benefits of conducting research in Black churches and the importance of including the full socioeconomic spectrum of African Americans in public health research. We are currently conducting a study that focuses on changing diet and physical activity habits among African American adults recruited through Black churches.6
References
1.
Joshipura KJ, Hu FB, Manson JE, et al. The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med.2001;134:1106–1114.
2.
Liu S, Manson JE, Lee IM, et al. Fruit and vegetable intake and risk of cardiovascular disease: the Women's Health Study. Am J Clin Nutr.2000;72:922–928.
3.
Joshipura KJ, Ascherio A, Manson JE, et al. Fruit and vegetable intake in relation to risk of ischemic stroke. JAMA.1999;282:1233–1239.
4. Gillman MW, Cupples LA, Gagnon D, et al. Protective effect of fruits and vegetables on development of stroke in men. JAMA.1995;273:1113–1117.[Abstract]
5. de Lorgeril M, Salen P. Modified Cretan Mediterranean diet in the prevention of coronary heart disease and cancer. World Rev Nutr Diet. 2000;87:1–23.[Medline]
6. Resnicow K, DiIorio C, Blisset D, Braithwaite RL, Perisamy S, Rahotep S. Healthy body/healthy spirit: a church-based nutrition and physical activity intervention. Health Educ Res. In press.
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