SuperWIN: Supermarket Partnership Improves DASH Diet Score

Interviewer: Michelle L. O'Donoghue, MD, MPH; Interviewee: Dylan L. Steen, MD


April 06, 2022

This transcript has been edited for clarity.

Michelle O'Donoghue, MD, MPH: Hi. this is Dr Michelle O'Donoghue for Medscape. Joining me today is Dr Dylan Steen in Cincinnati. We're at the American College of Cardiology (ACC) 2022 Scientific Session, which is my first conference postpandemic — or I guess we are still in a pandemic.

One of the more interesting trials will be presented by Dylan, looking at a supermarket strategy toward better eating. This is a topic that's near and dear to my heart because I think that diet and diet interventions are often overlooked in cardiology and can be a path forward for many patients in terms of both quality of life and also making meaningful health impacts. Dylan, why don't you start off with what this trial was about and how you got it up and going?

Dylan L. Steen, MD: Nice to see you again after all this time. For decades now, we've had research collaborations between pharmaceutical biotech, the medical device industry, and independent academic investigators. In fact, here at ACC, we're going to see many of these studies presented.

What has been absent are research collaborations with other industries. In this case, we partnered with the Kroger Company, the largest supermarket chain in the US. They also have over 2200 pharmacies and over 225 retail clients. We asked whether we could solve major gaps in the public's adherence to guideline-recommended quality diets by delivering care right in our communities through these supermarkets.

O'Donoghue: We can have, obviously, a whole separate conversation about what the best diet is to follow. It's just really interesting in this era of pharma-sponsored trials to now have a grocery store–sponsored trial

Steen: The retail industry is global, and it sits right in the fabric of every community here. Most retailers now are not just retailers, but sort of a retail-tech hybrid. The possibilities to really deliver care that's consumer-centric, accessible, and convenient is enormous.

SuperWIN Strategies

O'Donoghue: What was the study design for this particular program?

Steen: This was a randomized, active control, parallel efficacy trial. There were three separate arms. The control arm received an enhanced medical nutrition therapy session focused on the DASH diet, which we all know really works for cardiovascular health. That was guided by data, so it was a bit of an enhanced version. Then there were two intervention arms.

In the first intervention arm, called strategy one, participants were brought back for six additional sessions. They were guided in each educational session by their own purchasing data, which we took and refined into sophisticated analytics so that the participant and the dietitian could understand what to do next and get individualized care. Then they were taken into the aisles of the store to learn how to shop better, how to read food labels, and how to make smart decisions.

The third arm was simply the same as the second arm except we added online enhancements. We actually introduced and taught the participants how to shop online; how to get home delivery; and how to use various nutrition apps for meal planning, recipe building, and making healthier purchases. Three arms in total, each with an intensity that was sort of a little bit higher than the other.

O'Donoghue: I think that the third arm is particularly interesting for communities that might not have great access to grocery stores, because the topic of food deserts has been a big one. We know that certain groups have less access to the kind of grocery stores and healthy food choices that we're hoping that they will make.

Steen: You and I see patients with heart failure, and we see patients who are disabled from coronary artery disease. These patients cannot go to the in-store environment and carry their groceries. What we call the "silver surfer" is developing, and this may be the way that we can actually get our patients the kinds of foods they need to stay out of the hospital — to eat those low-sodium diets and keep them out of heart failure. Whereas right now, they have no other alternatives.

O'Donoghue: The reality is, too, that as cardiologists we know that we're supposed to be talking about diet to our patients. That ultimately is a lot of confusion, but it's not just that. There's a limit in terms of how much time any cardiologist has in their outpatient practice to sit down with their patients and walk through what they need to be doing.

We're not always using nutritionists. As you pointed out yourself, our patients who have advanced cardiac disease might not be able to physically get to the grocery store. What are we doing to help them?

Advice at the Point of Purchase

Steen: My analogy always is, "If you want to learn how to swim, you have to get in the pool." What we're doing is taking patients right to where they make their food-related decisions, not just for themselves but also for their families.

If you think about it, this could be spun off in so many different ways — not only the DASH diet but also the Mediterranean diet, and for people who have specific medical conditions like celiac disease, for people who have specific allergies, or for people who want to improve the nutrition of their children. Again, childhood health problems, especially obesity and metabolic disease, are on the rise. This could be a way to get at that as well.

O'Donoghue: What did you find? What were the results of the trial?

Steen: First, each of the three groups, even the enhanced standard of care, had significant increases in their DASH score, which is a measure of adherence to the DASH diet. If the score goes up, that means adherence went up, which is something we want. All three went up not just at 3 months, but at 6 months. That is really remarkable after just a six-session intervention.

Between-group differences in terms of the in-store purchasing guiding strategies did seem to improve DASH score compared to the enhanced control at 3 months. Also, it looked like the online enhancements did improve DASH diet compared to not having online enhancements.

At 6 months, the between-group differences became nonsignificant, but it's worth noting that all three groups still did have improved DASH scores over their baseline when they first entered the trial 3 months after they had finished the intervention.

O'Donoghue: It's really interesting what an impact it can have. Ultimately, I think that maybe the people who are listening to this are wondering, how do we possibly pay for this practically with our patients?

Is the hope that insurers actually will start picking up the cost for more intensive dietary interventions, whether it's through being able to help with online purchases or something along those lines? Where do we go from here?

Steen: I had a mentor who told me one time that if you can show the data, you'll find the dollars. One thing that is remarkable when you look at this field of retail-based nutrition interventions, especially rigorous trials, is the absence of data. This study provides those data. This is something new for payers to look at and say, "OK, here's something we think works and something that we can deliver in communities."

As for what is going to be happening in terms of the cost to the participants, we know retail-based care is cheaper right out the gate. That's one of its big advantages. For things like home delivery, actually there's price deflation. If you look at the industry, home delivery used to cost more and it's slowly going down. My personal belief is that retailers are not going be able to charge for home delivery at all in the future because of competition.

That, of course, benefits the patient, especially those low-income patients who you're speaking of, who may not have adequate access to grocery stores in their communities or may not be able to shop there because of medical limitations.

Call to Collaborate With Retailers

O'Donoghue: Hopefully, the data will continue to accrue in that regard. What are your personal next steps in terms of additional studies you might have in mind?

Steen: I think this could go a couple ways. For the audience, this is a call to action for researchers anywhere in the world to partner with retailers to build these types of collaborations to do their own work. For me, I think it would be interesting to see after we look at SuperWIN, when we slice and dice, where we can cut the fat as well as enhance the efficacy of the interventions, and then test it on a larger level for a potentially longer period of time to see how long these dietary changes last, but then also to see how downstream health outcomes can be affected.

Because we partner with our primary care network in this, we do have full cost and medical use utilization capture in this trial, and it will be something that we look at. There may be some interesting findings there.

Part of the reason we partner with them was that we wanted to show that these types of services can be delivered in an integrated care manner. Nobody wants more fragmentation, but the reality is when you look at the SuperWIN results, you will find that this is a thing that could partner with your primary care clinic, and then again, support the needs of value-based care advancements.

O'Donoghue: I hope that that is where we evolve to. Thank you again for leaving the session before the study. That was a fun conversation.

Steen: Thank you. Lots of great science at this conference!

O'Donoghue: Signing off for Medscape, this is Dr Michelle O'Donoghue.

Michelle O'Donoghue is a cardiologist at Brigham and Women's Hospital and senior investigator with the TIMI Study Group. A strong believer in evidence-based medicine, she relishes discussions about the published literature. A native Canadian, Michelle loves spending time outdoors with her family but admits with shame that she's never strapped on hockey skates.

Follow | Medscape Cardiology on Twitter

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.