Complete Health Improvement Program (CHIP)

Cancer and cardiovascular disease (CVD) are the leading causes of mortality in the United States, with heart disease ranking as the number one cause of death in 2009, cancer ranking second, and stroke ranking fourth. One in three deaths reported yearly in the United States is attributed to CVD, leading to estimated direct and indirect annual costs of $273 billion and $444 billion, respectively. Strategies that address hypertension, high cholesterol, and smoking can greatly reduce the human and economic burden not only of CVD, but also cancer and other diseases that share preventable, common risk factors with CVD. Since almost half of U.S. adults have one or more of these preventable risk factors, communitywide changes and policies targeting CVD have the potential to significantly improve the health of the American public. 

The Complete Health Improvement Program (CHIP) is a lifestyle modification course for groups of adults (aged 18 or older) in any community or workplace setting. The CHIP curriculum is designed to improve nutrition and reduce CVD risk factors by educating participants about the medical benefits of adopting healthy eating and physical activity behaviors. Participants are highly encouraged to participate in the program with a spouse or significant other.

The CHIP curriculum includes a series of eighteen 45-minute educational lectures on downloadable video files. The lectures are delivered by several health experts in a group setting in 90-minute sessions that incorporate facilitated discussions and a series of three health risk assessments. The sessions are held at regular intervals over 12 weeks. Lecture topics include modern medicine and health myths, atherosclerosis, coronary risk factors, obesity, dietary fiber, dietary fat, diabetes, hypertension, cholesterol, exercise, osteoporosis, cancer, lifestyle and health, the Optimal Diet, behavioral change, and self-worth. Participants are given a textbook and workbook containing assignments with learning objectives to accompany each lecture. During the group discussions, participants review the information presented in the lecture, focusing on what information was new to them, what they liked or disliked, and what they will do differently going forward. All sessions are led by a trained and certified presenter, whose task is to manage the process rather than provide content, encourage regular exercise, provide a small number of food samples and, in some cases, cooking demonstrations. Presenters do not need to be health professionals except for facilitation in medical settings; where the presenters should be a physician or an allied health professional.   

Participants are encouraged to follow preset dietary and exercise goals. The dietary goals consist of adopting a more plant-based diet emphasizing as-grown, unrefined food such as whole grains, legumes, vegetables, and fresh fruits and maintaining a diet that is low in fat (less than 20% of energy), animal protein, sugar, and salt; very low in cholesterol; and high in fiber. The exercise goal comes from the Surgeon General's Report on Physical Activity and Health and consists of working toward walking or exercising for at least 30 minutes daily. Participants are given pedometers to wear and are encouraged to keep an exercise log to record the number of miles and/or steps (goal: 10,000 steps) walked per day.

After completing the course, participants are encouraged to join a CHIP alumni support organization to help them maintain their new eating and exercising behaviors. Members receive a monthly newsletter with news of health-promoting community events such as health dinners, walking groups, and support-group meetings.

In the original clinical trials of CHIP, participants met in a group four times weekly for 2-hour sessions across 4 weeks of program curriculum delivery. The program included a series of sixteen 1-hour educational lectures by the developer, Dr. Hans Diehl, on the importance of healthy lifestyles, nutrition, and physical activity in reducing risk factors associated with hypertension and cardiovascular disease, supplemented by four 1-hour question-and-answer sessions by a dietician and medical professionals on prevention, arrest, and reversibility of chronic diseases. All sessions in the original clinical trials were led by one or more members of a team of trained presenters (typically a registered dietitian, physical therapist, and medical doctor), who provided live, hands-on education, answering participants' questions about lecture topics and workbook assignments and giving cooking and exercise demonstrations. The course also included access to scheduled shopping tours in a local supermarket by a dietitian. 

-13 hours of educational lectures (via video files)
-13 hours of facilitated group discussions, food sampling, and cooking demonstrations
-15 hours of intensive CHIP training and certification for presenters, provided by the Lifestyle Medicine Institute

The intervention targets adults aged 18 years or older.

The intervention is delivered in community and workplace settings.

Materials required for implementation include:

-CHIP Participant kit

For the costs associated with the program, please contact: The Lifestyle Medicine Institute.

A randomized clinical study evaluated the effects of a 40-hour, 4-week educational course for adults (aged 24 to 81 years) on the importance of making better lifestyle choices to improve nutrition and lower cardiovascular disease risk factors at 6-month follow-up. A total of 348 volunteers, aged 18 years or older, were recruited from a metropolitan area by targeted advertising and marketing through a local health care system, CHIP alumni groups, and corporate client sites. Volunteers were randomized either as paired (with a spouse or significant other) or individual unit to CHIP or a waitlist (delayed intervention for 7 months) control group using a random number generator by the study coordinator. Those assigned to the waitlist control group were entered into CHIP at 7 months post-baseline.

CHIP participants were encouraged to adopt a more plant-based diet emphasizing as-grown, unrefined food; walk or exercise at least 30 minutes daily; and record their level of physical activity each day using a provided pedometer and exercise log. The study outcomes were nutrition, chronic disease risk factors, and physical activity.

For the nutrition outcome, 14 measures were assessed using the Block 98.2 full-length dietary questionnaire. This 98-item, self-report dietary intake instrument includes per-day measures of:

-Total energy (kilocalories) and percentages of energy from fat, protein, and carbohydrates
-Servings of vegetables, fruit, whole grain, and meat
-Grams or milligrams of fruit and vegetable fiber, dietary cholesterol, dietary fat, polyunsaturated fat, monounsaturated fat, and saturated fat 

Chronic disease risk factors were assessed by measuring weight, calculating body mass index from standard medical weight and height scales recently calibrated, and estimating body fat percentage with a Tanita TBF -300A Body Composition Analyzer/Scale using bioelectrical impedance analysis. Physical activity (defined as total steps per week) was measured by a Walk4Life Model 2000 Life Stepper pedometer worn for 7 days and self-recorded in a daily log.

A total of 348 volunteer participants were randomized and analyzed from 403 volunteers assessed for eligibility, yielding a recruitment rate of 86%. Seventy-two percent of participants were female, 94% were White, 76% were married, and 50% had an annual family income of more than $60,000. There were no statistically significant differences between the intervention and control groups in baseline demographic characteristics; the mean age of 50.1 years for intervention participants was very close to the mean age of 50.8 years for control participants. Of the 348 randomized participants, 146 (42%) participated as pairs. However, since outcome measures did not differ between pairs and individual study participants at either baseline or the 6-month follow-up, pairs and individual study participants were not separated in any of the outcome analyses. A total of 318 (91%) participants completed both baseline and 6-month follow-up assessments. Thirty (9%) participants (21 in the intervention group, 9 in the control group) completed the baseline assessment but not the 6-month follow-up. 

• From baseline to 6-month follow-up, intervention group participants reported larger decreases in daily kilocalories of fat (p<.0001), protein (p<.0001), and total energy (p<.0001) but a larger increase in daily kilocalories from carbohydrates (p<.0001) compared with control group participants. 
  
  
  
  
• From baseline to 6-month follow-up, intervention group participants increased their servings per day of vegetable (p<.0001), fruit (p<.0001), and whole grain (p<.0001) and decreased their meat servings per day (p<.0001) more than control group participants. 
  
  
  
  
• From baseline to 6-month follow-up, intervention group participants increased their daily grams of fruit and vegetable fiber (p<.0001) and decreased their daily milligrams of dietary cholesterol (p<.0001) and daily grams of fat (p<.0001) more than control group participants.
  
  
  
  
  
• From baseline to 6-month follow-up, intervention group participants reported larger decreases in daily grams of polyunsaturated fat (p<.0001), monounsaturated fat (p<.0001), and saturated fat (p<.0001) than control group participants.
  
  
  
  
  
• Compared with participants in the control group, participants in the intervention group had larger decreases in body mass index (p<.0001), weight (p<.0001), and percentage of body fat (p<.0001) from baseline to the 6-month follow-up. 

Additional Findings

• Although physical activity (measured as total steps per week) increased by 30% for participants in the intervention group from baseline to 6-month follow-up, physical activity also increased 13% for participants in the control group over the same period. There was no statistically significant difference between the study groups for this outcome.