Nutrition Intervention of Groceries for Black Residents of Boston to Stop Hypertension (GoFresh) Among Adults With or Without Treated Hypertension Trial: Rationale, Design, and Evidence to Promote Implementation

Nutrition Intervention of Groceries for Black Residents of Boston to Stop Hypertension (GoFresh) Among Adults With or Without Treated Hypertension Trial: Rationale, Design, and Evidence to Promote Implementation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nutrition Intervention of Groceries for Black Residents of Boston to Stop Hypertension (GoFresh) Among Adults With or Without Treated Hypertension Trial: Rationale, Design, and Evidence to Promote Implementation Kayla M. Ferro, Reva Seager, Kathy McManus, Kristen M. Kraemer, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6222158/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Dec, 2025 Read the published version in Trials → Version 1 posted 5 You are reading this latest preprint version Abstract Background The Dietary Approaches to Stop Hypertension (DASH) Eating Plan is proven to lower blood pressure; however, the original DASH diet involved a set menu of meals prepared in a metabolic kitchen. There is little evidence mapping this dietary pattern to real-world groceries, tailored to a range of cultural preferences and dietary practices. Methods The GoFresh Trial, a parallel-arm randomized, controlled trial, is studying the impact of DASH-patterned, home-delivered groceries on the blood pressure of Black adults living in communities with reduced access to grocery stores. Participants were able to choose DASH-patterned groceries according to their preferences for themselves and up to five family members from local supermarkets. A dietitian assisted participants with grocery selection to ensure that groceries followed a DASH pattern and met potassium/sodium ratio of >2.2 with kilocalories from saturated fat ≤7%. In addition, dietitians provided weekly educational modules on sustainably adopting DASH. Two conceptual frameworks were designed to address five domains related to diet adoption: accessibility and cost, food preparation, social influences, individual beliefs, and cultural adaptations. To support meal preparation, a recipe book and 24 demonstration videos were created in collaboration with Boston chefs to highlight heritage diets like African and Afro-Caribbean. Results Compliance assessments include 24-hour urine paired with 24-hour nutrition recalls, seated blood pressure, and surveys collecting information on food preparation and shopping habits. Conclusion Findings from this study will inform policy related to healthy food access and provide real-world examples of how DASH might be adapted in a real-world context now and in years to come. Trial registration: NCT05121337. Registered on November 16, 2021, at ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/NCT05121337 hypertension medically tailored groceries nutrition DASH diet dietitian Figures Figure 1 Introduction/Background Hypertension is one of the most important modifiable risk factors for cardiovascular disease. 1 Black persons are disproportionately impacted by hypertension and there is strong evidence that diet is a primary mediator of disparities in hypertension among Black adults. 2 Prior work through the Dietary Approaches to Stop Hypertension (DASH) and DASH-Sodium trials demonstrated meaningful improvements in cardiovascular (CVD) risk factors through consuming a low sodium, DASH diet with greater effects among Black adults. 3 , 4 However, translation of these dietary patterns has been challenging for several reasons. First, the original DASH diets were prepared in a metabolic kitchen, and while these meals could theoretically be recreated by consumers in the U.S., they were not commercially available in real-world settings. Moreover, the original DASH meals followed a fixed meal plan based on typical American dietary patterns in the 1990s. This may not be acceptable across multicultural populations or a range of geographic locations throughout the U.S. or internationally. Finally, nutrition insecurity resulting from poor access to healthy foods is a prevalent, significant, and growing barrier to the adoption of healthy eating and the realization of its health benefits. 5 There is increasing recognition of the importance of home-delivered groceries to promote healthy dietary patterns in the U.S. and throughout the world. 6 – 8 Unlike medically-tailored meals, medically-tailored groceries have tremendous potential for adaptation and customization to an extensive range of distinct cultural heritages that can enable translation of DASH principles across cultures and geographic settings. Prior work has demonstrated the importance of cultural adaptation to achieve long-term adherence. 9 Moreover, a number of grocery intervention studies demonstrated improvements in healthy eating by supporting participants’ choice of food. 10 – 12 However, these studies have fallen short of demonstrating direct benefits on blood pressure and related CVD risk factors (e.g., low density lipoprotein cholesterol or markers of glycemia). This may be in part due to the insufficient amount of food replacement provided through prior work or missing key food groups that were important for achieving the full benefits of the DASH diet. Through the GoFresh and GoFreshRx trials, this dietitian-led nutrition intervention aimed to implement a DASH framework for grocery selection in a personalized, person-centered manner that addressed barriers related to accessing DASH groceries and potential gaps in knowledge and skills related to preparing DASH meals. The goal of this manuscript is to describe the design of the intervention with implementation case examples and serve as a guide for practitioners seeking to translate this intervention into real-world clinical encounters. Design Parent study design and population Details of the GoFresh design were published previously. 13 In brief, the GoFresh trials each enrolled up to 176 participants who self-identified as Black or African American, were 18-years or older, and lived in areas characterized by a low concentration of grocery stores in the Boston area. The only difference between GoFresh and GoFreshRx was hypertension treatment status: GoFresh enrolled participants without hypertension medications, while GoFreshRx focused on adults on stable hypertension treatment. All participants were required to have a systolic blood pressure of 120 to <150 mm Hg and a diastolic blood pressure <100 mm Hg based on the average across three screening visits. Participants were excluded if they were taking medications for diabetes, reported severely limited dietary preferences, allergies, or malabsorption, among others. Examples of dietary exclusions included vegan diets, gluten-free due to Celiac Disease or gluten allergy, or unwilling to eat one or more of the seven DASH food groups. Adjustments were made to include vegetarians, as long as they ate nuts/seeds/legumes and dairy (or non-dairy) products in order to achieve a DASH dietary pattern. More details on how the intervention was adapted for vegetarians may be found in the vegetarian case example (Case 1, Supplement Material SM1 ). Non-dairy products were provided for folks with lactose intolerance (Case 2, Supplement Material SM1 ). Assignments The intervention was divided into two arms; A) self-directed shopping and B) dietitian-assisted DASH grocery delivery. The self-directed shopping group (the reference group) received an introduction to the DASH plan and an unrestricted stipend of $500/month (at 4-, 8-, and 12-weeks post randomization). Before each payment, they completed a virtual check-in with their assigned dietitian. Participants randomized to the active intervention, i.e., dietitian-assisted, home-delivered DASH groceries, partook in weekly grocery order calls (GOs) with the dietitian plus a home-delivered grocery order following the DASH Eating Plan. These calls served three purposes: (1) order groceries for the week, (2) assess compliance from the prior week’s order, and (3) allow for education and counseling on fundamentals of the DASH principles. This group was asked to restrict food consumption to the study groceries for the entire 12-week intervention. Two Conceptual Frameworks The intervention sought to address multiple domains related to barriers in adopting the DASH Plan through two proposed frameworks, ‘store-to-door’ and ‘gate-to-plate’ ( See Figure 1 ). GoFresh identified five domains as major contributors to adopting a healthy diet: I) accessibility and cost, II) cooking skills and knowledge, III) social and family influences, IV) individual beliefs and knowledge, and V) cultural adaptation. The ‘store-to-door’ framework, similar to a traditional food-is-medicine approach, focused on both (a) selection of foods that met specific nutrient goals in a manner consistent with participant personal preferences as well as (b) increasing access to healthy foods by using online grocery stores to deliver groceries directly to people’s homes. The “gate-to-plate’ framework focuses on barriers related to the acceptance, preparation, and consumption of healthy foods (Domains II-V). It addresses how to support people to actually consume the DASH groceries, a step past simply receiving them at their door. Some may argue that getting the food to people’s home is the easiest step, however, encouraging acceptance of the foods and actual consumption requires more time and effort, preferably with a nutrition professional. Domains II-V can be seen in practice in Supplement Material SM1. Grocery orders and nutrient information An order sheet was developed to record, track, analyze, and guide the weekly DASH grocery order. It was divided into seven sections for the seven food groups of DASH; fruit, low-fat dairy, protein, fats/oils/spices, vegetables, grains, nuts/seeds/legumes. Energy needs were calculated using the Mifflin St. Jeor equation. 17 After the caloric level was determined, the dietitians used an adapted version of the DASH Eating Plan—Number of Food Servings by Calorie Level from NHLBI ( Table 1 ) to calculate the goal number of servings for the seven DASH food groups selecting the closest calorie level. The table from the NHLBI’s DASH Eating Plan, “Number of Food Servings by Calorie Level” was adapted to approximate the additional kilocalories and servings needed for family members for at least one meal per day ( see Supplement Table ST2 ). The quantity of food was not restricted as part of the intervention and could be adjusted if needed based on feedback from the participants during their weekly GO visit. Aside from the food item name, the order sheet also listed the order unit, servings per unit, serving size, kilocalories, sodium, and potassium per order. These details made it possible to compare grocery orders to nutrient targets and alternative products were suggested to conform with order goals prior to submitting the order. Orders prioritized potassium/sodium ratio and proportion of kilocalories from saturated fat, while attempting to maintain recommended food group servings of the DASH diet. If a participant requested an item not on the order sheet, it was added to the order if it met the following DASH requirements per serving: less than 300 mg of sodium and less than 5g of saturated fat. The flexibility to add products at any time point also supported cultural concordance to their current eating pattern ( Domain 5, Figure 1 ). GoFresh did not send beverages, sweets, salty snacks, or ultra-processed foods. Organic foods were not emphasized though could be sent if requested. Cost was not a factor in grocery orders. Family size was restricted to 6 adults at dinner due to budget constraints, but the cost of the weekly order was not considered. Cookbook and chef collaboration Recipe development was a collaboration between the dietitians and Black chefs in the Greater Boston area to support incorporation of DASH principles into meals. A GoFresh cookbook was provided to all participants randomized to the dietitian-assisted DASH grocery delivery arm at the start of their intervention and given to the self-directed group after completion of their final visit. Chefs prepared a recipe that the dietitian entered into Elizabeth Stewart Hands and Associates (ESHA) Research’s Food Processor 23 (Beaverton, Oregon) to extract a nutrition label. Recipes were required to meet study nutrients targets for sodium (less than 300 mg per serving) and saturated fat (less than 5 grams per serving Applications of the Gate-to-Plate Model Lessons Learned Through ‘The Store to Door’ Framework Online grocery stores with home delivery are becoming increasingly accessible, offering a growing geographic range that now includes areas of Boston where physical grocery stores may be limited or far from residents' homes. These virtual stores provide an extensive variety of products that may not be available in the person’s neighborhood. This accessibility supports personalized meal planning and allows adults to maintain dietary preferences aligned with their ethnic traditions. The goal of the home deliveries was to remove barriers related to accessing DASH-patterned groceries like lack of transportation, cost, and local grocery store availability. The groceries were sent directly to the participant’s home or another convenient location with either Amazon Fresh, Whole Foods, or Instacart. The platform was switched based on participant preference, timing needs of delivery, and the store’s food availability. Delivery times were able to accommodate any work schedule with options in the early morning (before 8AM) and late night (after 10PM) depending on the courier. Multiple store options allowed for greater diversity in food selections. Online grocery shopping has significantly emerged in the last several years 14 and GoFresh is one of the first to use these services on a large-scale, nutrition intervention 13 . With this novelty, some roadblocks emerged such as limited food selection, store availability, and skill/knowledge of the third-party shopper. One common complaint of online grocery stores from GoFresh participants thus far was the unreliability of their shoppers. Poor quality and incorrect items were sometimes selected or substituted, which are amplified in a nutrition study because of the strict dietary guidelines. In addition, online vendors were not consistent with providing complete, accurate nutrition information. This limitation is also reported elsewhere. 15,16 Many times, the dietitians needed to refer to the product company’s website for a complete evaluation of the nutrition label. Culture-specific produce and items were not widely available, such as plantains, yuca, chayote, papaya, fresh collard greens, lima beans, ackee, certain legumes like pigeon peas and lima beans, and barley. The locally owned grocery or corner stores that do sell these products are not regularly available for online shopping. The delivery of the food itself also exposed barriers related to poor packaging, delivery outside the time window, and failure to follow delivery instructions. This presented challenges for families living in multi-family homes or apartment buildings, especially when groceries were not delivered to the correct door. If 25% or more of a food group’s items were missing, a supplemental order was sent with priority placed on high potassium foods. Addressing Barriers Through ‘The Gate to Plate’ Framework General Principles Dietitian counseling was designed to facilitate the ‘gate to plate’ framework by promoting preparation, consumption, and acceptability of groceries. We used motivational interviewing in a person-centered fashion, emphasizing open-ended questions, rolling-with-resistance, reflective listening, and affirmations. Participants had autonomy over weekly grocery selection and meal preparation, enabling adaptation to a wide range of diverse cultural heritages. During the introduction call, dietitians listened to participants’ descriptions of their eating and food preparation customs and worked to mold the DASH plan to their personal pattern. Through Education In addition to the grocery order and counseling, a 12-week curriculum was developed to aid in adherence and understanding of the DASH plan ( Supplemental Table ST1 ). The curriculum was designed to progress from a more informative, teaching style in the first six weeks, to hands on application and strategy building in the latter six weeks. Topics in the first six weeks included principles of the DASH plan, high potassium foods, potassium and sodium’s effect on the body, understanding the nutrition label, and alternatives to salt. It was designed to deliver novel nutrition information to the participants and build their knowledge of healthy eating. The second six weeks focused on practical goal building to foster long-lasting behavior change. For example, topics in the second six weeks included: how to adhere to DASH at social events, make DASH work for the entire family, develop a personalized DASH shopping list, adapt favorite recipes to DASH guidelines, and set goals to help maintain DASH. During week 12, dietitians reviewed a list of resources in the local community where participants can find DASH groceries, including food banks, farmer’s markets, corner stores, grocery stores, and community health centers. Through Domains II-IV: The Gate-to-Plate Framework Domain II: Meal Preparation Preparing DASH-compliant and flavorful meals can be challenging for some. Low sodium diets can be bland for those who rely on salt to flavor their food. Therefore, GoFresh Dietitians encouraged seasoning without salt and instead highlighted herbs and spices to bring out the natural flavors of food. Low sodium was encouraged not only through education, but also by including salt-free seasonings in grocery orders. Limited time for food preparation can be another major barrier. 18 The dietitians addressed this by providing simple recipes and easy-prep tips or semi-prepped grocery items to facilitate uptake (see cases 3, 4, and 5 in Supplement Material ST1 for examples). Domain III: Social and Family Influences Caregiving responsibilities (e.g., children or parents) can reduce time for self-care, including meal preparation, which can be a significant barrier to adopting a healthy diet or maintaining a healthy lifestyle. 19 There can also be peer pressure or social influences when adopting a new diet. 20 To address this barrier, dietitians tailored their recommendations to involve the needs of the family members at home. For example, dietitians included family members in the food preparation and grocery selection and provided flexible scheduling (see practice case 3 in Supplement Material SM1 ). Domain IV: Individual Beliefs and Knowledge Individual beliefs and knowledge can act as barriers to adopting the DASH plan due to misinformation, health perceptions, fear of change, and knowledge gaps (see case 4 in Supplement Material SM1 ). A limited understanding of food’s impact on health can provide limited motivation to adjust eating patterns. Individual beliefs and knowledge were addressed with motivational interviewing (MI) techniques, specifically prioritizing patient autonomy and decision making. Dietitians used the ‘elicit-provide-elicit’ MI strategy to give the participant control over what suggestions were offered to them. 21 This strategy ensured their beliefs were incorporated into the counseling but also gave the dietitian the opportunity to provide other perspectives or information. The didactic modules were used to explain ‘why’ and more important, ‘how’ the DASH plan impacts their health. Domain V: Culture Adaptation of DASH The erasure of culture when discussing diet can alienate participants and in turn decrease the likelihood of diet adoption. As reported elsewhere, culture is a social determinant of health thus dietary guidelines and recommendations need to consider cultural personalization. 22 Adapting the DASH plan to the participant’s style of eating was a major part of ‘the gate to plate’ model. During the first call, the dietitian gathered information on the participant's eating habits and lifestyle, including cooking patterns and food preferences. The dietitian used this information when making food choice suggestions or referenced the cookbook when appropriate. The grocery order sheet was customized to each participant to include frequently ordered DASH-appropriate foods in order to promote autonomy in ordering and respect individual food preferences. By sending groceries instead of meals, participants could order the grocery components that matched their preferences within each DASH category. Lastly, through education modules, recipe adaption strategies were discussed like ingredient swaps for more DASH aligned cuisine components and DASH additions vs. removal of an ingredient were facilitated. Table 2 highlights the DASH principles applied to four cuisines: soul food, Afro-Latin, African Heritage, and Afro-Caribbean. It also highlights high potassium (>250 mg/serving) foods in each of these cuisines with an asterisk. It is important to note that there is extensive diversity even within regional cuisine, so it is best to let the individual steer the decision making. Self-Reported Adherence and Promoting Engagement During weekly calls, participants reported the number of meals and snacks consumed from non-study sources the prior week. These two metrics were used to determine each participant’s intervention adherence score via the following formula: The same formula was used for the percentage of snacks. Notably, this formula only focused on grocery adherence, which may not reflect DASH adherence. While outside foods were discouraged during the study, they could be DASH-compliant using the modules and knowledge gained for informed food decision making. Leftover food from previous orders was also used to assess adherence. If there were many fruits and vegetables left over, then the dietitian dedicated additional counseling time on strategies to increase fruit and vegetable consumption. Adherence data will be published in future papers after the study has completed. Other objective measures of adherence are outlined in Supplement Table ST3 . Conclusion Prior trials demonstrated the ability of a low sodium DASH dietary pattern to improve CVD risk factors, with greater effects among Black adults. 3 , 4 However, there is still a need to address barriers that limit adoption of this healthy dietary pattern in real-world settings. The GoFresh, dietitian-assisted, DASH-patterned grocery intervention allowed for the implementation of DASH in a personalized manner that aimed to address barriers related to accessing DASH groceries and potential gaps in knowledge and skills related to preparing DASH meals. Future work should continue to delineate and address the barriers related to choosing, obtaining, preparing, consuming, and maintaining the DASH plan through grocery selection across the globe. Abbreviations DASH, Dietary Approaches to Stop Hypertension; GO, weekly grocery ordering call; GO#, week number of 12-week intervention; RZ, randomization visit; FV1, follow up visit 1 (3-month mark); FV2, follow up visit 2 (6-month mark); FV3, follow up visit 3 (12-month mark); MI, motivational interviewing Declarations Ethics approval and consent to participate All participants completed in-person, written informed consents prior to enrollment. These trials were approved by the Institutional Review Board at Beth Israel Deaconess Medical Center. Consent for publication Not applicable Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors have no conflicts to disclose. Funding GoFresh and GoFreshRx studies are funded by the American Heart Association grant American Heart Association (AHA) Health Equity Research Network (HERN) on the Prevention of Hypertension (award number 878488) and the National Institute of Minority Health and Health Disparities, R01MD016068, respectively. Dr Turkson-Ocran is supported by the National Heart, Lung, Blood Institute of the National Institutes of Health under award number 3R01HL158622-01S1 Authors' contributions KF was the primary writer of this manuscript. All authors read and approved the final manuscript Acknowledgments The investigators thank the participants who participated in these trials. References Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation . 2024;149(8). doi:10.1161/CIR.0000000000001209 Howard G, Cushman M, Moy CS, et al. 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J Natl Med Assoc . 2011;103(1):36-45. doi:10.1016/S0027-9684(15)30241-8 Tables Table 1: DASH Eating Plan—Number of Food Servings by Weekly Calorie Level Food Group 8400 9800 11200 12600 14000 16000 18200 21700 Grains 28-35 35-42 42 42 42-56 56-70 70-77 84-91 Vegetables 21-28 21-28 21-28 28-35 28-35 30-37 35-42 42 Fruits 21-28 21-28 21-28 28-35 28-35 30-37 35-42 42 Fat-free or low-fat dairy products 14-21 14-21 14-21 14-21 14-21 21 21 21-28 Lean meats, poultry, and fish 21 or less 21-28 or less 21-28 or less 42 or less 42 or less 42 or less 42 or less 42-63 or less Nuts, seeds, legumes 3 per week 3 per week 3-4 per week 4 per week 4-5 per week 6 per week 7 per week 7 per week Fats and oils 7 7 14 14-21 14-21 21 21 28 Table 2: DASH Foods Categorized by Cuisine DASH Food Group Soul Food Latin Heritage African Heritage Afro-Caribbean Fruits Peaches, apples, bananas*, rhubarb*, strawberries, oranges, watermelon, cantaloupe*, honeydew, persimmons Papaya, mango, oranges, avocado*, breadfruit*, star fruit, passion fruit*, melons*, guanabana*, guava*, pineapple, sapote*, bananas*, custard apple*, prickly pear Bananas*, dates*, dried figs*, figs, grapefruit, honeydew, cantaloupe*, lemons, limes, mangos, oranges, papaya, pomegranates, pumpkin puree, tamarind, watermelon Akee, avocados*, bananas*, dates*, dried figs*, figs, grapefruit, guava*, lemons, limes, mangos, honeydew, cantaloupe*, oranges, papaya, pomegranate, pumpkin puree, tamarind pulp*, watermelon Vegetables Collard greens, bell peppers, onions, acorn squash*, yellow squash, zucchini, turnips, turnip greens, beets, beet greens*, okra*, potatoes*, sweet potatoes*, corn, cucumber, tomatoes, mustard greens* Tomatoes, onions, peppers (both sweet and hot), yuca*, batata*, plantains* (both green and ripe), potatoes*, summer squash, pumpkin, chayote, heart of palm, spinach*, collard greens, cabbage*, carrots*, ñame*, tomatillos, corn, yams* Asparagus, beets*, Brussels sprouts*, broccoli*, butternut squash*, red cabbage*, green cabbage, carrots*, eggplant, okra*, onions, bell peppers, radish*, scallions*, acorn squash*, yellow squash, zucchini, jicama, callaloo*, chard*, collard greens, kale*, mustard greens*, plantains*, spinach*, turnip, tomatoes and canned tomato varieties (no salt added), potatoes*, sweet potatoes*, yams*, yuca* Broccoli*, butternut squash*, red cabbage*, green cabbage, carrots*, eggplant, okra*, onions, bell peppers, scallions*, acorn squash*, yellow squash, zucchini, callaloo*, chard*, collard greens, kale*, mustard greens*, plantains*, spinach*, turnip, tomatoes and canned tomato varieties (no salt added) Grains Grits, cornbread, rice, cornmeal, sorghum, millet, wheat breads, pasta Maize (corn), rice, tortillas (flour and corn), pasta, bread, barley, cracked wheat Amaranth, barley, couscous, maize/ corn, rice varieties, sorghum, teff, wild rice, oats Barley, couscous, maize/ corn, oats, rice varieties, wild rice Lean proteins Chicken*, pork*, catfish, shrimp, oysters, crawfish*, turkey, beef*, crab* Chicken*, beef*, pork*, goat*, cod*, salmon*, tuna*, clams*, mussels*, octopus*, sea bass*, shrimp, scallops, squid Chicken*, turkey, eggs, lean beef*, lean pork*, goat*, cod*, haddock*, salmon*, halibut*, shrimp, scallops, canned tuna, canned salmon*, red snapper Chicken*, turkey, eggs, lean beef*, lean pork*, goat*, cod*, haddock*, salmon*, halibut*, shrimp, scallops, canned tuna, canned salmon*, red snapper Dairy Milk*, cheeses Fresh cheese (queso blanco), milk*, crema, yogurt Coconut milk (light), Yogurt, Almond milk, Soy Milk Coconut milk, light Nuts, seeds, and legumes Black eyed peas, red beans*, lima beans*, peanuts*, sesame seeds, cowpeas, pecans* Black beans*, red beans*, lentils*, peanuts*, pigeon peas (gandules)*, coconut*, almonds*, cashews*, pumpkin seeds* Black-eyed peas, butter beans, chickpeas, kidney beans*, lentils*, lima beans*, pigeon peas*, Brazil nuts*, cashews*, coconut*, peanuts*, pecans*, pumpkin seeds*, sunflower seeds* Black-eyed peas, butter beans, chickpeas, kidney beans*, lentils*, lima beans*, pigeon peas*, peas, cashews*, coconut*, peanuts*, pumpkin seeds* Spices and seasonings Hot chiles, vinegar, garlic, molasses, filé powder, paprika, onion powder, garlic powder, oregano, thyme, chicken broth, cinnamon, nutmeg, allspice, ginger Hot chiles, achiote, cilantro, epazote, cumin, oregano, chili powder, cilantro, thyme, ginger, garlic, bitter orange, lime Hot peppers and chilies, no salt added and low-sodium broths, vinegars, bay leaf, cinnamon, cilantro, cloves, coriander, cumin, curry, dill, garlic powder, ginger, mustard, nutmeg, onion powder, oregano, paprika, parsley, peppers, sage, sesame Hot peppers and chilies, no salt added and low-sodium broths, vinegars, bay leaf, cinnamon, cilantro, cloves, coriander, cumin, curry, dill, garlic powder, ginger, mustard, nutmeg, onion powder, oregano, paprika, parsley, peppers, sage, sesame, turmeric *High potassium foods (>250 mg per 100 g) Supplementary Files SupplementMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 03 Dec, 2025 Read the published version in Trials → Version 1 posted Editorial decision: Major revision 10 Aug, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers invited by journal 20 Jun, 2025 Editor assigned by journal 06 Jun, 2025 First submitted to journal 13 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6222158","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":474227126,"identity":"ead66dcd-5f02-4cf4-841b-6ba3aaf92f70","order_by":0,"name":"Kayla M. Ferro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACCeYDIMomgY0hgYGBsQEqysDAjFsLWwKISiNdy2EgSawWyTbmY58rKs7n8bFnJ35g3GGXb3D87MMbDBXWiQ04tEizsSXPPHPmdjEbz9vNEoxnki03nEk3tmA4k45Ti5x8jzFjY9vtxDaJ3G0MjG3MBpINaWwSjG2HcWth4/8M1HIOpqXeQLL/GVDLP9xapNl4mIFaDsC0HDbglwDZ0oBbi2QbmzFjw5lkiF8S244DtTxjtkg4lm6MS4vEMebHjA0Vdnny7bkbP3xsqzZg409jvPGhxloWlxZUkIDBGAWjYBSMglFAFgAAIutSl8JMPGoAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0000-6661-8979","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA","correspondingAuthor":true,"prefix":"","firstName":"Kayla","middleName":"M.","lastName":"Ferro","suffix":""},{"id":474227130,"identity":"83ee2c9e-81bc-4157-acfb-3a87c0d85422","order_by":1,"name":"Reva Seager","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Reva","middleName":"","lastName":"Seager","suffix":""},{"id":474227131,"identity":"6e2ea62a-ad79-44e9-a245-c341f13a3680","order_by":2,"name":"Kathy McManus","email":"","orcid":"","institution":"Harvard Medical School, Boston, MA; Department of Nutrition, Brigham and Women’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kathy","middleName":"","lastName":"McManus","suffix":""},{"id":474227127,"identity":"b25258bc-1bd1-4c90-ab6f-2ffb41a112b9","order_by":3,"name":"Kristen M. Kraemer","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA; Harvard Medical School, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"M.","lastName":"Kraemer","suffix":""},{"id":474227128,"identity":"f4e13588-e99f-4956-80e1-502a151a9e38","order_by":4,"name":"Ruth-Alma Turkson-Ocran","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA; Harvard Medical School, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Ruth-Alma","middleName":"","lastName":"Turkson-Ocran","suffix":""},{"id":474227133,"identity":"e38b4894-404b-484c-b569-1f84f34c38e0","order_by":5,"name":"Jackie Michetti","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Jackie","middleName":"","lastName":"Michetti","suffix":""},{"id":474227132,"identity":"6a8b3397-bf9b-4d52-bc39-9bae7ad20867","order_by":6,"name":"Sofia Allison","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Sofia","middleName":"","lastName":"Allison","suffix":""},{"id":474227134,"identity":"808d13cb-2eac-438b-8dcf-c2ea149ab4c9","order_by":7,"name":"Stephanie L. Fitzpatrick","email":"","orcid":"","institution":"Kaiser Permanente Center for Health Research, Portland, Oregon, USA","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"L.","lastName":"Fitzpatrick","suffix":""},{"id":474227129,"identity":"69dead1d-9140-4e63-a4fd-adb7bdc3baf8","order_by":8,"name":"Stephen P. Juraschek","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA; Harvard Medical School, Boston, MA","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"P.","lastName":"Juraschek","suffix":""}],"badges":[],"createdAt":"2025-03-13 17:59:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6222158/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6222158/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13063-025-09273-z","type":"published","date":"2025-12-03T15:58:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86136248,"identity":"6b831c12-6c54-4734-9c93-8c4f23fb0310","added_by":"auto","created_at":"2025-07-07 07:49:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":166830,"visible":true,"origin":"","legend":"\u003cp\u003eAddressing Barriers to Adopting the DASH Eating Plan\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6222158/v1/f2c395878011a2794ff84c14.png"},{"id":97724663,"identity":"1e6f8ca3-9fc6-4220-b25b-71e34cb3ddef","added_by":"auto","created_at":"2025-12-08 16:13:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":869159,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6222158/v1/1c56f457-4b19-4c42-8909-5c646e387783.pdf"},{"id":86135384,"identity":"3e61b663-0a1b-4f8c-abe0-9d43ff5ec61a","added_by":"auto","created_at":"2025-07-07 07:41:59","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":34877,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6222158/v1/59ece78c3af42d9ee4a79105.docx"}],"financialInterests":"","formattedTitle":"Nutrition Intervention of Groceries for Black Residents of Boston to Stop Hypertension (GoFresh) Among Adults With or Without Treated Hypertension Trial: Rationale, Design, and Evidence to Promote Implementation","fulltext":[{"header":"Introduction/Background","content":"\u003cp\u003eHypertension is one of the most important modifiable risk factors for cardiovascular disease.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Black persons are disproportionately impacted by hypertension and there is strong evidence that diet is a primary mediator of disparities in hypertension among Black adults.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Prior work through the Dietary Approaches to Stop Hypertension (DASH) and DASH-Sodium trials demonstrated meaningful improvements in cardiovascular (CVD) risk factors through consuming a low sodium, DASH diet with greater effects among Black adults.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, translation of these dietary patterns has been challenging for several reasons. First, the original DASH diets were prepared in a metabolic kitchen, and while these meals could theoretically be recreated by consumers in the U.S., they were not commercially available in real-world settings. Moreover, the original DASH meals followed a fixed meal plan based on typical American dietary patterns in the 1990s. This may not be acceptable across multicultural populations or a range of geographic locations throughout the U.S. or internationally. Finally, nutrition insecurity resulting from poor access to healthy foods is a prevalent, significant, and growing barrier to the adoption of healthy eating and the realization of its health benefits.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere is increasing recognition of the importance of home-delivered groceries to promote healthy dietary patterns in the U.S. and throughout the world.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Unlike medically-tailored meals, medically-tailored groceries have tremendous potential for adaptation and customization to an extensive range of distinct cultural heritages that can enable translation of DASH principles across cultures and geographic settings. Prior work has demonstrated the importance of cultural adaptation to achieve long-term adherence.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Moreover, a number of grocery intervention studies demonstrated improvements in healthy eating by supporting participants\u0026rsquo; choice of food.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e However, these studies have fallen short of demonstrating direct benefits on blood pressure and related CVD risk factors (e.g., low density lipoprotein cholesterol or markers of glycemia). This may be in part due to the insufficient amount of food replacement provided through prior work or missing key food groups that were important for achieving the full benefits of the DASH diet.\u003c/p\u003e \u003cp\u003eThrough the GoFresh and GoFreshRx trials, this dietitian-led nutrition intervention aimed to implement a DASH framework for grocery selection in a personalized, person-centered manner that addressed barriers related to accessing DASH groceries and potential gaps in knowledge and skills related to preparing DASH meals. The goal of this manuscript is to describe the design of the intervention with implementation case examples and serve as a guide for practitioners seeking to translate this intervention into real-world clinical encounters.\u003c/p\u003e"},{"header":"Design","content":"\u003cp\u003e\u003cem\u003eParent study design and population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDetails of the GoFresh design were published previously.\u003csup\u003e13\u003c/sup\u003e In brief, the GoFresh trials each enrolled up to 176 participants who self-identified as Black or African American, were 18-years or older, and lived in areas characterized by a low concentration of grocery stores\u003cdel cite=\"mailto:Fitzpatrick,%20Stephanie\" datetime=\"2025-01-12T21:48\"\u003e\u0026nbsp;\u003c/del\u003e in the Boston area. The only difference between GoFresh and GoFreshRx was hypertension treatment status: GoFresh enrolled participants without hypertension medications, while GoFreshRx focused on adults on stable hypertension treatment. All participants were required to have a systolic blood pressure of 120 to \u0026lt;150 mm Hg and a diastolic blood pressure \u0026lt;100 mm Hg based on the average across three screening visits. Participants were excluded if they were taking medications for diabetes, reported severely limited dietary preferences, allergies, or malabsorption, among others. Examples of dietary exclusions included vegan diets, gluten-free due to Celiac Disease or gluten allergy, or unwilling to eat one or more of the seven DASH food groups. Adjustments were made to include vegetarians, as long as they ate nuts/seeds/legumes and dairy (or non-dairy) products in order to achieve a DASH dietary pattern. More details on how the intervention was adapted for vegetarians may be found in the vegetarian case example (Case 1, \u003cstrong\u003eSupplement Material SM1\u003c/strong\u003e). Non-dairy products were provided for folks with lactose intolerance (Case 2, \u003cstrong\u003eSupplement Material SM1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssignments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention was divided into two arms; A) self-directed shopping and B) dietitian-assisted DASH grocery delivery. The self-directed shopping group (the reference group) received an introduction to the DASH plan and an unrestricted stipend of $500/month (at 4-, 8-, and 12-weeks post randomization). Before each payment, they completed a virtual check-in with their assigned dietitian.\u003c/p\u003e\n\u003cp\u003eParticipants randomized to the active intervention, i.e., dietitian-assisted, home-delivered DASH groceries, partook in weekly grocery order calls (GOs) with the dietitian plus a home-delivered grocery order following the DASH Eating Plan. These calls served three purposes: (1) order groceries for the week, (2) assess compliance from the prior week\u0026rsquo;s order, and (3) allow for education and counseling on fundamentals of the DASH principles. This group was asked to restrict food consumption to the study groceries for the entire 12-week intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTwo Conceptual Frameworks\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention sought to address multiple domains related to barriers in adopting the DASH Plan through two proposed frameworks, \u0026lsquo;store-to-door\u0026rsquo; and \u0026lsquo;gate-to-plate\u0026rsquo; (\u003cstrong\u003eSee Figure 1\u003c/strong\u003e). GoFresh identified five domains as major contributors to adopting a healthy diet: I) accessibility and cost, II) cooking skills and knowledge, III) social and family influences, IV) individual beliefs and knowledge, and V) cultural adaptation. The \u0026lsquo;store-to-door\u0026rsquo; framework, similar to a traditional food-is-medicine approach, focused on both (a) selection of foods that met specific nutrient goals in a manner consistent with participant personal preferences as well as (b) increasing access to healthy foods by using online grocery stores to deliver groceries directly to people\u0026rsquo;s homes.\u003cins cite=\"mailto:Fitzpatrick,%20Stephanie\" datetime=\"2025-01-12T21:51\"\u003e\u0026nbsp;\u003c/ins\u003eThe \u0026ldquo;gate-to-plate\u0026rsquo; framework focuses on barriers related to the acceptance, preparation, and consumption of healthy foods (Domains II-V). It addresses how to support people to actually consume the DASH groceries, a step past simply receiving them at their door. Some may argue that getting the food to people\u0026rsquo;s home is the easiest step, however, encouraging acceptance of the foods and actual consumption requires more time and effort, preferably with a nutrition professional. Domains II-V can be seen in practice in \u003cstrong\u003eSupplement Material SM1.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGrocery orders and nutrient information\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAn order sheet was developed to record, track, analyze, and guide the weekly DASH grocery order. It was divided into seven sections for the seven food groups of DASH; fruit, low-fat dairy, protein, fats/oils/spices, vegetables, grains, nuts/seeds/legumes. Energy needs were calculated using the Mifflin St. Jeor equation.\u003csup\u003e17\u003c/sup\u003e After the caloric level was determined, the dietitians used an adapted version of the DASH Eating Plan\u0026mdash;Number of Food Servings by Calorie Level from NHLBI (\u003cstrong\u003eTable 1\u003c/strong\u003e) to calculate the goal number of servings for the seven DASH food groups selecting the closest calorie level.\u003c/p\u003e\n\u003cp\u003eThe table from the NHLBI\u0026rsquo;s DASH Eating Plan, \u0026ldquo;Number of Food Servings by Calorie Level\u0026rdquo; was adapted to approximate the additional kilocalories and servings needed for family members for at least one meal per day (\u003cstrong\u003esee Supplement Table ST2\u003c/strong\u003e). The quantity of food was not restricted as part of the intervention and could be adjusted if needed based on feedback from the participants during their weekly GO visit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAside from the food item name, the order sheet also listed the order unit, servings per unit, serving size, kilocalories, sodium, and potassium per order. These details made it possible to compare grocery orders to nutrient targets and alternative products were suggested to conform with order goals prior to submitting the order.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOrders prioritized potassium/sodium ratio and proportion of kilocalories from saturated fat, while attempting to maintain recommended food group servings of the DASH diet. If a participant requested an item not on the order sheet, it was added to the order if it met the following DASH requirements per serving: less than 300 mg of sodium and less than 5g of saturated fat. The flexibility to add products at any time point also supported cultural concordance to their current eating pattern (\u003cstrong\u003eDomain 5, Figure 1\u003c/strong\u003e). GoFresh did not send beverages, sweets, salty snacks, or ultra-processed foods. Organic foods were not emphasized though could be sent if requested. Cost was not a factor in grocery orders. Family size was restricted to 6 adults at dinner due to budget constraints, but the cost of the weekly order was not considered.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCookbook and chef collaboration\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRecipe development was a collaboration between the dietitians and Black chefs in the Greater Boston area to support incorporation of DASH principles into meals. A GoFresh cookbook was provided to all participants randomized to the dietitian-assisted DASH grocery delivery arm at the start of their intervention and given to the self-directed group after completion of their final visit. Chefs prepared a recipe that the dietitian entered into Elizabeth Stewart Hands and Associates (ESHA) Research\u0026rsquo;s Food Processor\u003csup\u003e23\u003c/sup\u003e (Beaverton, Oregon) to extract a nutrition label. Recipes were required to meet study nutrients targets for sodium (less than 300 mg per serving) and saturated fat (less than 5 grams per serving\u003c/p\u003e"},{"header":"Applications of the Gate-to-Plate Model","content":"\u003cp\u003e\u003cstrong\u003eLessons Learned Through \u0026lsquo;The Store to Door\u0026rsquo; Framework\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline grocery stores with home delivery are becoming increasingly accessible, offering a growing geographic range that now includes areas of Boston where physical grocery stores may be limited or far from residents\u0026apos; homes. These virtual stores provide an extensive variety of products that may not be available in the person\u0026rsquo;s neighborhood. This accessibility supports personalized meal planning and allows adults to maintain dietary preferences aligned with their ethnic traditions.\u003c/p\u003e\n\u003cp\u003eThe goal of the home deliveries was to remove barriers related to accessing DASH-patterned groceries like lack of transportation, cost, and local grocery store availability. The groceries were sent directly to the participant\u0026rsquo;s home or another convenient location with either Amazon Fresh, Whole Foods, or Instacart. The platform was switched based on participant preference, timing needs of delivery, and the store\u0026rsquo;s food availability. Delivery times were able to accommodate any work schedule with options in the early morning (before 8AM) and late night (after 10PM) depending on the courier. Multiple store options allowed for greater diversity in food selections.\u003c/p\u003e\n\u003cp\u003eOnline grocery shopping has significantly emerged in the last several years\u003csup\u003e14\u003c/sup\u003e and GoFresh is one of the first to use these services on a large-scale, nutrition intervention\u003csup\u003e13\u003c/sup\u003e. With this novelty, some roadblocks emerged such as limited food selection, store availability, and skill/knowledge of the third-party shopper. One common complaint of online grocery stores from GoFresh participants thus far was the unreliability of their shoppers.\u0026nbsp;Poor quality and incorrect items were sometimes selected or substituted, which are amplified in a nutrition study because of the strict dietary guidelines. In addition, online vendors were not consistent with providing complete, accurate nutrition information. This limitation is also reported elsewhere.\u003csup\u003e15,16\u003c/sup\u003e Many times, the dietitians needed to refer to the product company\u0026rsquo;s website for a complete evaluation of the nutrition label. Culture-specific produce and items were not widely available, such as plantains, yuca, chayote, papaya, fresh collard greens, lima beans, ackee, certain legumes like pigeon peas and lima beans, and barley. The locally owned grocery or corner stores that do sell these products are not regularly available for online shopping.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe delivery of the food itself also exposed barriers related to poor packaging, delivery outside the time window, and failure to follow delivery instructions. This presented challenges for families living in multi-family homes or apartment buildings, especially when groceries were not delivered to the correct door. If 25% or more of a food group\u0026rsquo;s items were missing, a supplemental order was sent with priority placed on high potassium foods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAddressing Barriers Through \u0026lsquo;The Gate to Plate\u0026rsquo; Framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGeneral Principles\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDietitian counseling was designed to facilitate the \u0026lsquo;gate to plate\u0026rsquo; framework by promoting preparation, consumption, and acceptability of groceries. We used motivational interviewing in a person-centered fashion, emphasizing open-ended questions, rolling-with-resistance, reflective listening, and affirmations. Participants had autonomy over weekly grocery selection and meal preparation, enabling adaptation to a wide range of diverse cultural heritages. During the introduction call, dietitians listened to participants\u0026rsquo; descriptions of their eating and food preparation customs and worked to mold the DASH plan to their personal pattern.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThrough Education\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the grocery order and counseling, a 12-week curriculum was developed to aid in adherence and understanding of the DASH plan (\u003cstrong\u003eSupplemental Table ST1\u003c/strong\u003e). The curriculum was designed to progress from a more informative, teaching style in the first six weeks, to hands on application and strategy building in the latter six weeks. Topics in the first six weeks included principles of the DASH plan, high potassium foods, potassium and sodium\u0026rsquo;s effect on the body, understanding the nutrition label, and alternatives to salt. It was designed to deliver novel nutrition information to the participants and build their knowledge of healthy eating. The second six weeks focused on practical goal building to foster long-lasting behavior change. For example, topics in the second six weeks included: how to adhere to DASH at social events, make DASH work for the entire family, develop a personalized DASH shopping list, adapt favorite recipes to DASH guidelines, and set goals to help maintain DASH. During week 12, dietitians reviewed a list of resources in the local community where participants can find DASH groceries, including food banks, farmer\u0026rsquo;s markets, corner stores, grocery stores, and community health centers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThrough Domains II-IV: The Gate-to-Plate Framework\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDomain II: Meal Preparation\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePreparing DASH-compliant and flavorful meals can be challenging for some. Low sodium diets can be bland for those who rely on salt to flavor their food. Therefore, GoFresh Dietitians encouraged seasoning without salt and instead highlighted herbs and spices to bring out the natural flavors of food. Low sodium was encouraged not only through education, but also by including salt-free seasonings in grocery orders. Limited time for food preparation can be another major barrier.\u003csup\u003e18\u003c/sup\u003e The dietitians addressed this by providing simple recipes and easy-prep tips or semi-prepped grocery items to facilitate uptake (see cases 3, 4, and 5 in \u003cstrong\u003eSupplement Material ST1\u003c/strong\u003e for examples).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDomain III: Social and Family Influences\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eCaregiving responsibilities (e.g., children or parents) can reduce time for self-care, including meal preparation, which can be a significant barrier to adopting a healthy diet or maintaining a healthy lifestyle.\u003csup\u003e19\u003c/sup\u003e There can also be peer pressure or social influences when adopting a new diet.\u003csup\u003e20\u003c/sup\u003e To address this barrier, dietitians tailored their recommendations to involve the needs of the family members at home. For example, dietitians included family members in the food preparation and grocery selection and provided flexible scheduling (see practice case 3 in \u003cstrong\u003eSupplement Material SM1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDomain IV: Individual Beliefs and Knowledge\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIndividual beliefs and knowledge can act as barriers to adopting the DASH plan due to misinformation, health perceptions, fear of change, and knowledge gaps (see case 4 in \u003cstrong\u003eSupplement Material SM1\u003c/strong\u003e). A limited understanding of food\u0026rsquo;s impact on health can provide limited motivation to adjust eating patterns.\u003c/p\u003e\n\u003cp\u003eIndividual beliefs and knowledge were addressed with motivational interviewing (MI) techniques, specifically prioritizing patient autonomy and decision making. Dietitians used the \u003cem\u003e\u0026lsquo;elicit-provide-elicit\u0026rsquo;\u003c/em\u003e MI strategy to give the participant control over what suggestions were offered to them.\u003csup\u003e21\u003c/sup\u003e This strategy ensured their beliefs were incorporated into the counseling but also gave the dietitian the opportunity to provide other perspectives or information. The didactic modules were used to explain \u0026lsquo;why\u0026rsquo; and more important, \u0026lsquo;how\u0026rsquo; the DASH plan impacts their health.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDomain V: Culture Adaptation of DASH\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe erasure of culture when discussing diet can alienate participants and in turn decrease the likelihood of diet adoption. As reported elsewhere, culture is a social determinant of health thus dietary guidelines and recommendations need to consider cultural personalization.\u003csup\u003e22\u003c/sup\u003e Adapting the DASH plan to the participant\u0026rsquo;s style of eating was a major part of \u0026lsquo;the gate to plate\u0026rsquo; model. During the first call, the dietitian gathered information on the participant\u0026apos;s eating habits and lifestyle, including cooking patterns and food preferences. The dietitian used this information when making food choice suggestions or referenced the cookbook when appropriate. The grocery order sheet was customized to each participant to include frequently ordered DASH-appropriate foods in order to promote autonomy in ordering and respect individual food preferences. By sending groceries instead of meals, participants could order the grocery components that matched their preferences within each DASH category. Lastly, through education modules, recipe adaption strategies were discussed like ingredient swaps for more DASH aligned cuisine components and DASH additions vs. removal of an ingredient were facilitated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003ehighlights the DASH principles applied to four cuisines: soul food, Afro-Latin, African Heritage, and Afro-Caribbean. It also highlights high potassium (\u0026gt;250 mg/serving) foods in each of these cuisines with an asterisk. It is important to note that there is extensive diversity even within regional cuisine, so it is best to let the individual steer the decision making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Reported Adherence and Promoting Engagement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring weekly calls, participants reported the number of meals and snacks consumed from non-study sources the prior week. These two metrics were used to determine each participant\u0026rsquo;s intervention adherence score via the following formula:\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1751601623.png\" width=\"671\" height=\"140\"\u003e\u003c/p\u003e\n\u003cp\u003eThe same formula was used for the percentage of snacks. Notably, this formula only focused on grocery adherence, which may not reflect DASH adherence. While outside foods were discouraged during the study, they could be DASH-compliant using the modules and knowledge gained for informed food decision making.\u003c/p\u003e\n\u003cp\u003eLeftover food from previous orders was also used to assess adherence. If there were many fruits and vegetables left over, then the dietitian dedicated additional counseling time on strategies to increase fruit and vegetable consumption. Adherence data will be published in future papers after the study has completed.\u0026nbsp;Other objective measures of adherence are outlined in \u003cstrong\u003eSupplement Table ST3\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrior trials demonstrated the ability of a low sodium DASH dietary pattern to improve CVD risk factors, with greater effects among Black adults.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, there is still a need to address barriers that limit adoption of this healthy dietary pattern in real-world settings. The GoFresh, dietitian-assisted, DASH-patterned grocery intervention allowed for the implementation of DASH in a personalized manner that aimed to address barriers related to accessing DASH groceries and potential gaps in knowledge and skills related to preparing DASH meals. Future work should continue to delineate and address the barriers related to choosing, obtaining, preparing, consuming, and maintaining the DASH plan through grocery selection across the globe.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDASH, Dietary Approaches to Stop Hypertension; GO, weekly grocery ordering call; GO#, week number of 12-week intervention; RZ, randomization visit; FV1, follow up visit 1 (3-month mark); FV2, follow up visit 2 (6-month mark); FV3, follow up visit 3 (12-month mark); MI, motivational interviewing\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants completed in-person, written informed consents prior to enrollment. These trials were approved by the Institutional Review Board at Beth Israel Deaconess Medical Center.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGoFresh and GoFreshRx studies are funded by the American Heart Association grant American Heart Association (AHA) Health Equity Research Network (HERN) on the Prevention of Hypertension (award number 878488) and the National Institute of Minority Health and Health Disparities, R01MD016068, respectively. Dr Turkson-Ocran is supported by the National Heart, Lung, Blood Institute of the National Institutes of Health under award number 3R01HL158622-01S1\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eKF was the primary writer of this manuscript. All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe investigators thank the participants who participated in these trials.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMartin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. \u003cem\u003eCirculation\u003c/em\u003e. 2024;149(8). doi:10.1161/CIR.0000000000001209\u003c/li\u003e\n\u003cli\u003eHoward G, Cushman M, Moy CS, et al. Association of Clinical and Social Factors With Excess Hypertension Risk in Black Compared With White US Adults. \u003cem\u003eJAMA\u003c/em\u003e. 2018;320(13):1338. doi:10.1001/jama.2018.13467\u003c/li\u003e\n\u003cli\u003eAppel LJ, Moore TJ, Obarzanek E, et al. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. \u003cem\u003eN Engl J Med\u003c/em\u003e. 1997;336(16):1117-1124. doi:10.1056/NEJM199704173361601\u003c/li\u003e\n\u003cli\u003eSacks FM, Svetkey LP, Vollmer WM, et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2001;344(1):3-10. doi:10.1056/NEJM200101043440101\u003c/li\u003e\n\u003cli\u003eZhang FF, Liu J, Rehm CD, Wilde P, Mande JR, Mozaffarian D. Trends and Disparities in Diet Quality Among US Adults by Supplemental Nutrition Assistance Program Participation Status. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2018;1(2):e180237. doi:10.1001/jamanetworkopen.2018.0237\u003c/li\u003e\n\u003cli\u003eBarnes LL, Dhana K, Liu X, et al. Trial of the MIND Diet for Prevention of Cognitive Decline in Older Persons. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2023;389(7):602-611. doi:10.1056/NEJMoa2302368\u003c/li\u003e\n\u003cli\u003eEstruch R, Ros E, Salas-Salvad\u0026oacute; J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2018;378(25). doi:10.1056/NEJMoa1800389\u003c/li\u003e\n\u003cli\u003eNeal B, Wu Y, Feng X, et al. Effect of Salt Substitution on Cardiovascular Events and Death. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2021;385(12):1067-1077. doi:10.1056/NEJMoa2105675\u003c/li\u003e\n\u003cli\u003eLeBlanc KE, Baer-Sinnott S, Lancaster KJ, et al. Perspective: Beyond the Mediterranean Diet\u0026mdash;Exploring Latin American, Asian, and African Heritage Diets as Cultural Models of Healthy Eating. \u003cem\u003eAdv Nutr\u003c/em\u003e. 2024;15(5):100221. doi:10.1016/j.advnut.2024.100221\u003c/li\u003e\n\u003cli\u003eCouch SC, Helsley RN, Siegel FU, et al. Design and rationale for the supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial. \u003cem\u003eAm Heart J\u003c/em\u003e. 2022;248:21-34. doi:10.1016/j.ahj.2022.02.011\u003c/li\u003e\n\u003cli\u003eMiller ER, Cooper LA, Carson KA, et al. A Dietary Intervention in Urban African Americans. \u003cem\u003eAm J Prev Med\u003c/em\u003e. 2016;50(1):87-95. doi:10.1016/j.amepre.2015.06.010\u003c/li\u003e\n\u003cli\u003eJuraschek SP, Gelber AC, Choi HK, Appel LJ, Miller ER. Effects of the Dietary Approaches to Stop Hypertension (DASH) Diet and Sodium Intake on Serum Uric Acid. \u003cem\u003eArthritis Rheumatol\u003c/em\u003e. 2016;68(12):3002-3009. doi:10.1002/art.39813\u003c/li\u003e\n\u003cli\u003eTurkson-Ocran RAN, Cluett JL, Fitzpatrick SL, et al. Rationale and Design of the Groceries for Black Residents of Boston to Stop Hypertension Among Adults Without Treated Hypertension (GoFresh) Trial. \u003cem\u003eAm J Hypertens\u003c/em\u003e. 2023;36(5):256-263. doi:10.1093/ajh/hpad008\u003c/li\u003e\n\u003cli\u003eTyrv\u0026auml;inen O, Karjaluoto H. Online grocery shopping before and during the COVID-19 pandemic: A meta-analytical review. \u003cem\u003eTelemat Inform\u003c/em\u003e. 2022;71:101839. doi:10.1016/j.tele.2022.101839\u003c/li\u003e\n\u003cli\u003eSharib JR, Pomeranz JL, Mozaffarian D, Cash SB. Disclosure of mandatory and voluntary nutrition labelling information across major online food retailers in the USA. \u003cem\u003ePublic Health Nutr\u003c/em\u003e. 2024;27(1):e203. doi:10.1017/S1368980024001289\u003c/li\u003e\n\u003cli\u003ePomeranz JL, Cash SB, Springer M, Del Giudice IM, Mozaffarian D. Opportunities to address the failure of online food retailers to ensure access to required food labelling information in the USA. \u003cem\u003ePublic Health Nutr\u003c/em\u003e. 2022;25(5):1375-1383. doi:10.1017/S1368980021004638\u003c/li\u003e\n\u003cli\u003eMifflin M, St Jeor S, Hill L, Scott B, Daugherty S, Koh Y. A new predictive equation for resting energy expenditure in healthy individuals. \u003cem\u003eAm J Clin Nutr\u003c/em\u003e. 1990;51(2):241-247. doi:10.1093/ajcn/51.2.241\u003c/li\u003e\n\u003cli\u003eHollis-Hansen K, Haskins C, Turcios J, et al. A pilot randomized controlled trial comparing nutritious meal kits and no-prep meals to improve food security and diet quality among food pantry clients. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2023;23(1):2389. doi:10.1186/s12889-023-17355-3\u003c/li\u003e\n\u003cli\u003eCavallo M, Morgana G, Dozzani I, et al. Unraveling Barriers to a Healthy Lifestyle: Understanding Barriers to Diet and Physical Activity in Patients with Chronic Non-Communicable Diseases. \u003cem\u003eNutrients\u003c/em\u003e. 2023;15(15):3473. doi:10.3390/nu15153473\u003c/li\u003e\n\u003cli\u003eStok FM, de Vet E, de Ridder DTD, de Wit JBF. The potential of peer social norms to shape food intake in adolescents and young adults: a systematic review of effects and moderators. \u003cem\u003eHealth Psychol Rev\u003c/em\u003e. 2016;10(3):326-340. doi:10.1080/17437199.2016.1155161\u003c/li\u003e\n\u003cli\u003eUnderstanding Motivational Interviewing | Motivational Interviewing Network of Trainers (MINT). Accessed November 22, 2024. https://motivationalinterviewing.org/understanding-motivational-interviewing\u003c/li\u003e\n\u003cli\u003eDisparities R on the P of HE and the E of H, Practice B on PH and PH, Medicine I of. Culture as a Social Determinant of Health. In: \u003cem\u003eLeveraging Culture to Address Health Inequalities: Examples from Native Communities: Workshop Summary\u003c/em\u003e. National Academies Press (US); 2013. Accessed December 11, 2024. https://www.ncbi.nlm.nih.gov/books/NBK201298/\u003c/li\u003e\n\u003cli\u003eAbout Us. ESHA Research. Accessed November 15, 2024. https://esha.com/about-us/\u003c/li\u003e\n\u003cli\u003eKeith JN, Nicholls J, Reed A, Kafer K, Gregory D. M. The Prevalence of Self-reported Lactose Intolerance and the Consumption of Dairy Foods Among African American Adults Are Less Than Expected. \u003cem\u003eJ Natl Med Assoc\u003c/em\u003e. 2011;103(1):36-45. doi:10.1016/S0027-9684(15)30241-8\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: DASH Eating Plan\u0026mdash;Number of Food Servings by Weekly Calorie Level\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"758\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eFood Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e8400\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e9800\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e11200\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e12600\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e16000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e18200\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21700\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eGrains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e35-42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42-56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e56-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e70-77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e84-91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eVegetables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e30-37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e35-42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eFruits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e30-37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e35-42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eFat-free or low-fat dairy products\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eLean meats, poultry, and fish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21-28 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e42-63 or less\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eNuts, seeds, legumes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e3 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e3 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e3-4 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e4 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e4-5 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e6 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e7 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e7 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2589%;\"\u003e\n \u003cp\u003eFats and oils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e14-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.59264%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: DASH Foods Categorized by Cuisine\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"857\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eDASH Food Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eSoul Food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eLatin Heritage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eAfrican Heritage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eAfro-Caribbean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eFruits\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003ePeaches, apples, bananas*, rhubarb*, strawberries, oranges, watermelon, cantaloupe*, honeydew, persimmons\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003ePapaya, mango, oranges, avocado*, breadfruit*, star fruit, passion fruit*, melons*, guanabana*, guava*, pineapple, sapote*, bananas*, custard apple*, prickly pear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eBananas*, dates*, dried figs*, figs, grapefruit, honeydew, cantaloupe*, lemons, limes, mangos, oranges, papaya, pomegranates, pumpkin puree, tamarind, watermelon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eAkee, avocados*, bananas*, dates*, dried figs*, figs, grapefruit, guava*, lemons, limes, mangos, honeydew, cantaloupe*, oranges, papaya, pomegranate, pumpkin puree, tamarind pulp*, watermelon\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eVegetables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eCollard greens, bell peppers, onions, acorn squash*, yellow squash, zucchini, turnips, turnip greens, beets, beet greens*, okra*, potatoes*, sweet potatoes*, corn, cucumber, tomatoes, mustard greens*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eTomatoes, onions, peppers (both sweet and hot), yuca*, batata*, plantains* (both green and ripe), potatoes*, summer squash, pumpkin, chayote, heart of palm, spinach*, collard greens, cabbage*, carrots*, \u0026ntilde;ame*, tomatillos, corn, yams*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eAsparagus, beets*, Brussels sprouts*, broccoli*, butternut squash*, red cabbage*, green cabbage, carrots*, eggplant, okra*, onions, bell peppers, radish*, scallions*, acorn squash*, yellow squash, zucchini, jicama, callaloo*, chard*, collard greens, kale*, mustard greens*, plantains*, spinach*, turnip, tomatoes and canned tomato varieties (no salt added), potatoes*, sweet potatoes*, yams*, yuca*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eBroccoli*, butternut squash*, red cabbage*, green cabbage, carrots*, eggplant, okra*, onions, bell peppers, scallions*, acorn squash*, yellow squash, zucchini, callaloo*, chard*, collard greens, kale*, mustard greens*, plantains*, spinach*, turnip, tomatoes and canned tomato varieties (no salt added)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eGrains\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eGrits, cornbread, rice, cornmeal, sorghum, millet, wheat breads, pasta\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eMaize (corn), rice, tortillas (flour and corn), pasta, bread, barley, cracked wheat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eAmaranth, barley, couscous, maize/ corn, rice varieties, sorghum, teff, wild rice, oats\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eBarley, couscous, maize/ corn, oats, rice varieties, wild rice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eLean proteins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eChicken*, pork*, catfish, shrimp, oysters, crawfish*, turkey, beef*, crab*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eChicken*, beef*, pork*, goat*, cod*, salmon*, tuna*, clams*, mussels*, octopus*, sea bass*, shrimp, scallops, squid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eChicken*, turkey, eggs, lean beef*, lean pork*, goat*, cod*, haddock*, salmon*, halibut*, shrimp, scallops, canned tuna, canned salmon*, red snapper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eChicken*, turkey, eggs, lean beef*, lean pork*, goat*, cod*, haddock*, salmon*, halibut*, shrimp, scallops, canned tuna, canned salmon*, red snapper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eDairy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eMilk*, cheeses\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eFresh cheese (queso blanco), milk*, crema, yogurt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eCoconut milk (light), Yogurt, Almond milk, Soy Milk\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eCoconut milk, light\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eNuts, seeds, and legumes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eBlack eyed peas, red beans*, lima beans*, peanuts*, sesame seeds, cowpeas, pecans*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eBlack beans*, red beans*, lentils*, peanuts*, pigeon peas (gandules)*, coconut*, almonds*, cashews*, pumpkin seeds*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eBlack-eyed peas, butter beans, chickpeas, kidney beans*, lentils*, lima beans*, pigeon peas*, Brazil nuts*, cashews*, coconut*, peanuts*, pecans*, pumpkin seeds*, sunflower seeds*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eBlack-eyed peas, butter beans, chickpeas, kidney beans*, lentils*, lima beans*, pigeon peas*, peas, cashews*, coconut*, peanuts*, pumpkin seeds*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.902%;\"\u003e\n \u003cp\u003eSpices and seasonings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5869%;\"\u003e\n \u003cp\u003eHot chiles, vinegar, garlic, molasses, fil\u0026eacute; powder, paprika, onion powder, garlic powder, oregano, thyme, chicken broth, cinnamon, nutmeg, allspice, ginger\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3034%;\"\u003e\n \u003cp\u003eHot chiles, achiote, cilantro, epazote, cumin, oregano, chili powder, cilantro, thyme, ginger, garlic, bitter orange, lime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eHot peppers and chilies, no salt added and low-sodium broths, vinegars, bay leaf, cinnamon, cilantro, cloves, coriander, cumin, curry, dill, garlic powder, ginger, mustard, nutmeg, onion powder, oregano, paprika, parsley, peppers, sage, sesame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1039%;\"\u003e\n \u003cp\u003eHot peppers and chilies, no salt added and low-sodium broths, vinegars, bay leaf, cinnamon, cilantro, cloves, coriander, cumin, curry, dill, garlic powder, ginger, mustard, nutmeg, onion powder, oregano, paprika, parsley, peppers, sage, sesame, turmeric\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*High potassium foods (\u0026gt;250 mg per 100 g)\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"hypertension, medically tailored groceries, nutrition, DASH diet, dietitian","lastPublishedDoi":"10.21203/rs.3.rs-6222158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6222158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Dietary Approaches to Stop Hypertension (DASH) Eating Plan is proven to lower blood pressure; however, the original DASH diet involved a set menu of meals prepared in a metabolic kitchen. There is little evidence mapping this dietary pattern to real-world groceries, tailored to a range of cultural preferences and dietary practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe GoFresh Trial, a parallel-arm randomized, controlled trial, is studying the impact of DASH-patterned, home-delivered groceries on the blood pressure of Black adults living in communities with reduced access to grocery stores. Participants were able to choose DASH-patterned groceries according to their preferences for themselves and up to five family members from local supermarkets. A dietitian assisted participants with grocery selection to ensure that groceries followed a DASH pattern and met potassium/sodium ratio of \u0026gt;2.2 with kilocalories from saturated fat ≤7%. In addition, dietitians provided weekly educational modules on sustainably adopting DASH. Two conceptual frameworks were designed to address five domains related to diet adoption: accessibility and cost, food preparation, social influences, individual beliefs, and cultural adaptations. To support meal preparation, a recipe book and 24 demonstration videos were created in collaboration with Boston chefs to highlight heritage diets like African and Afro-Caribbean.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompliance assessments include 24-hour urine paired with 24-hour nutrition recalls, seated blood pressure, and surveys collecting information on food preparation and shopping habits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings from this study will inform policy related to healthy food access and provide real-world examples of how DASH might be adapted in a real-world context now and in years to come.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e NCT05121337. 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