Dietary Approaches to Stop Hypertension (DASH)

Dietary Approaches to Stop Hypertension (DASH)

Clinical Trials URL: http://clinicaltrials.gov/ct2/show/...
Study Type: Clinical Trial
Prepared on December 3, 2010
Study Period: 1993 - 1997
Consent: Unrestricted Consent
Commercial Use Restrictions: No

Objectives

The objective of the Dietary Approaches to Stop Hypertension (DASH) study was to test the effects of dietary patterns characterized by high intakes of certain minerals and fiber associated with low blood pressure compared with each other and with a control dietary pattern relatively low in potassium, magnesium, calcium, and fiber, and has a fat and protein profile mirroring current US consumption.

Background

High blood pressure affects almost 5 million people in the United States and places them at a high risk for cardiovascular disease. High blood pressure is characterized as a systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg, or higher, or the need for antihypertensive medication. The risk of cardiovascular disease increases progressively throughout the entire range of blood pressure levels, thus blood pressure affects the health of many, including those that are not defined as hypertensive. The DASH aims to help prevent this highly prevalent public health problem.

Subjects

The study consisted of 459 healthy free-living adult men and women, 22 years or older, who have a diastolic blood pressure of 80 to 95 mm Hg and a systolic blood pressure less than 160 mm Hg. Since there is a disproportionate burden of hypertensions and its complications in minority populations, and particularly among African Americans, two-thirds of DASH participants are from a minority background.

Design

The Dietary Approaches to Stop Hypertension multicenter, randomized, controlled-feeding trial examined the impact of dietary patterns on blood pressure in 459 adults with blood pressure <160 mm Hg systolic and 80 to 95 mm Hg diastolic. After a 3-week run-in period on a control diet low in fruits, vegetables, and dairy products, and with a fat content typical for Americans, participants were randomized for 8 weeks to either the control diet, a diet rich in fruits and vegetables, or a combination diet that emphasized fruits, vegetables, and low-fat dairy products. Body weight and sodium intake were held constant, and physical activity did not change during the intervention.

Conclusions

This trial demonstrated that certain dietary patterns can favorably affect blood pressure in adults with average systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80 to 95 mm Hg. Specifically, a diet rich in fruits, vegetables, and low-fat dairy products and with reduced saturated and total fat lowered systolic blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.0 mm Hg more than a control diet. A diet rich in fruits and vegetables also reduced blood pressure, but to a lesser extent. The gradient of blood-pressure reduction across diets indicates that some aspects of the fruits-and-vegetables diet reduced blood pressure and that additional aspects of the combination diet reduced it further. In conclusion, a diet rich in fruits, vegetables, and low-fat dairy foods and with reduced saturated and total fat can substantially lower blood pressure. Such a diet offers an additional nutritional approach to the prevention and treatment of hypertension.

Publications

Bray, GA, for the DASH Collaborative Group, "The Effect of Dietary Patterns on Blood Pressure: Results From the Dietary Approaches to Stop Hypertension (DASH) Clinical Trial." Current Concepts in Hypertension, November, 1998, 4-5.
Sacks FM, Obarzanek E, Windhauser M, Svetkey LP, Vollmer WM, McCullough M, Karanja N, P Lin, Steele P, Proschan M, Evans MA, Appel L, Bray GA, Vogt TM, Moore TJ, for the DASH Investigators. Rationale and Design of the Dietary Approaches to Stop Hypertension Trial (DASH). A multicenter controlled-feeding study of dietary patterns. Ann Epidemiol. 1995; 5:108-117.

Dietary Approaches to Stop Hypertension - Sodium Study (DASH-Sodium)

Dietary Approaches to Stop Hypertension - Sodium Study (DASH-Sodium)

Clinical Trials URL: http://www.clinicaltrials.gov/ct2/s...
Study Type: Clinical Trial
Prepared on October 13, 2008
Last Updated on October 17, 2005
Study Period: 1997-2002
Consent: Unrestricted Consent
Commercial Use Restrictions: No
NHLBI Division: DCVS

Objectives

The primary objective of the DASH-Sodium Trial was to test the effects of two dietary patterns and three sodium intake levels on blood pressure in adult men and women with blood pressure higher than optimal or at stage 1 hypertension (systolic 120-159 mm Hg and diastolic 80-95 mm Hg).

Background

Blood pressure is an established risk factor for stroke and heart disease, and research has shown this risk to increase across the full range of blood pressure levels. The DASH study established that a diet emphasizing fruits, vegetables, whole grains, poultry, fish and low-fat dairy products can reduce systolic blood pressure by an average of 5.5 mm Hg and diastolic blood pressure by 3 mm Hg. Coupling the DASH diet with reduced sodium intake may potentially reduce blood pressure levels even further. Approximately 48% of adults have blood pressure above optimum levels, but below stage 2 hypertension (systolic blood pressure 120-159 mm Hg or diastolic pressure 80-95 mm Hg), and the DASH diet along with reduced sodium intake could provide suitable levels of control for a large segment of the population. To examine the effect of the DASH diet along with reduced sodium intake on blood pressure, two dietary patterns (a control diet typical of what many Americans consume and the DASH diet) were compared at three levels of sodium intake: (1) higher level comparable to current US intake, (2) an intermediate level which mirrors the upper limit of current recommendations, and (3) a lower intake which could lower blood pressure even more.

Design

Four clinical centers and a coordinating center participated in the trial. Participants took part in a two week run-in period in which they were fed the higher sodium control diet. After the run-in period, participants were randomly assigned to one of the two diets using a parallel-group design and were fed each of the sodium levels for 30 consecutive days using a randomized crossover design. DASH - sodium was an outpatient feeding study, and study staff prepared all meals and snacks in research kitchens. To be eligible, participants had to be age 22 years or older, with diastolic blood pressure 80-95 mm Hg, systolic blood pressure 120-160 mm Hg, and free of anti-hypertensive medications or medications that would affect blood pressure. A total of 412 participants were randomized, and approximately 60% were African-American and 59% were women. Recruitment began in 1997 and all diets were completed in 1999.

Conclusions

Compared to the higher sodium control diet, the DASH diet reduced systolic blood pressure by an average of 5.9, 7.2, and 8.9 mm Hg for the higher, intermediate and lower sodium intakes respectively. Diastolic blood pressure was reduced by 2.9, 3.5, and 4.5 mm Hg for the higher, intermediate, and lower sodium intake levels. Reducing sodium intake in the control diet from higher to intermediate levels reduced systolic blood pressure by an average of 2.1 mm Hg and by 6.7 mm Hg to the lower sodium intake. Reducing sodium intakes to the lower level resulted in significantly lower systolic blood pressure in all sex, race, and hypertension status subgroups with the exception of non-black participants without hypertension. (N Engl J Med 2001;344:3-10).

DASH DIET NATIONAL INSTITUTES OF HEALTH

EMBARGOED FOR RELEASE Monday, December 17, 2001 5:00 p.m. EST

Contact: NHLBI Communications Office (301) 496-4236

NHLBI Study Finds DASH Diet And Reduced Sodium Lowers Blood Pressure For All

The DASH diet plus reduced dietary sodium lowers blood pressure for all persons, according to the first detailed subgroup analysis of the DASH study results. The Dietary Approaches to Stop Hypertension study was supported by the National Heart, Lung, and Blood Institute (NHLBI). The detailed analysis, published in the December 18, 2001, issue of the Annals of Internal Medicine, showed the blood pressure lowering effects of the DASH diet and reduced dietary sodium in a wide variety of population subgroups: persons with and without hypertension or a family history of hypertension, older and younger adults, men and women, African-American and other races, obese and nonobese, as well as people with higher or lower physical activity levels, larger or smaller waist circumferences, and higher or lower annual family income or education.

While the combination of the DASH diet and reduced dietary sodium produced the biggest reductions, each intervention also lowered blood pressure for all groups when used alone.

The DASH diet is rich in fruits, vegetables, and lowfat dairy foods and reduced in total and saturated fat . It also is reduced in red meat, sweets, and sugar-containing drinks. It is rich in potassium, calcium, magnesium, fiber, and protein. Prior studies found that the DASH diet lowers blood pressure and also lowers blood LDL-cholesterol (the "bad" cholesterol) and the amino acid homocysteine, which appears to increase the risk of heart disease. Prior studies also showed reducing dietary sodium lowers blood pressure, both with and without the DASH diet.

"This new study underscores the blood pressure-lowering effects of a reduced intake of salt and other forms of dietary sodium," said NHLBI Director Dr. Claude Lenfant. "Earlier research on the link between sodium and blood pressure had given conflicting results in various population groups. Now, we can say that cutting back on dietary sodium will benefit Americans generally and not just those with high blood pressure."

"The study's participants have blood pressures in the same range as half of adult Americans, including about 80 percent of those age 50 and older," said Dr. Frank Sacks, Professor of Cardiovascular Disease Prevention, Harvard School of Public Health and chair of the DASH Steering Committee. "Adopting these measures could help millions of Americans avoid the rise in blood pressure that occurs with advancing age."

High blood pressure, also called hypertension, is a major risk for heart disease and the chief risk factor for stroke.

The new data come from the DASH-Sodium study, a multicenter, 14-week randomized "feeding" trial in which all food was provided to participants.

It involved 412 participants, aged 22 and older, and with systolic blood pressures of 120-160 mm Hg and diastolic blood pressures of 80-95 mm Hg.

Fifty-two percent of the participants were women and 48 percent men; 54 percent were African American, 42 percent white, and 10 percent other races. Forty-one percent had hypertension and 59 percent did not.

For 3 months, participants ate either the DASH diet or a typical American diet. Weight was kept stable. During the study period, each group followed three different intakes of dietary sodium for 1 month each in random order. The sodium levels were 3,300 milligrams a day (the average level consumed by Americans), 2,400 milligrams a day (the upper limit currently recommended by the National High Blood Pressure Education Program), and 1,500 milligrams a day.

The largest blood pressure differences occurred for those on the DASH diet with a daily sodium intake of 1,500-milligrams compared with those on the control diet with a sodium intake of 3,300 milligrams.

Detailed analysis showed that the DASH diet and reduced sodium intake reduced blood pressure for all the population subgroups studied. The following list shows the average blood pressure reduction for key subgroups:

• For those with hypertension: 12/6 mm Hg (systolic/diastolic); for those without hypertension, 7/4 mm Hg.
• For those over age 45, 12/6 mm Hg; for those 45 or younger, 6/3 mm Hg.
• For women, 11/5 mm Hg; for men, 7/4 mm Hg.
• For African Americans, 10/5 mm Hg; for non-African Americans, 8/4 mm Hg.

Other results include:

• Compared with the typical American diet, the DASH diet alone (at the higher sodium level) reduced blood pressure by about 6/3 mm Hg for African Americans, and 6/2 mm Hg for other races.
• For those with hypertension, reductions from the DASH diet alone were 7/3 mm Hg; and for those without hypertension, the reductions were 5/3 mm Hg.
• The effects of sodium reduction appeared in all subgroups and were greater for those who ate the typical American diet, compared with those on the DASH diet. The effects from sodium reduction were particularly great for those with hypertension, African Americans, women, and those over age 45. Sodium reduction in those eating the control diet resulted in lower systolic and diastolic pressures by 8.3 mm Hg and 4.4 mm Hg, respectively, in hypertensives, and 5.4 and 2.8 mm Hg, respectively, in non-hypertensives. 

"Following the DASH diet and reducing the intake of dietary sodium are two non-drug approaches that work to control blood pressure," said Dr. Denise Simons-Morton, Leader of the NHLBI Prevention Scientific Research Group and a DASH coauthor. "The blood pressure reductions achieved from this combination came in only 4 weeks and persisted through the duration of the study. Ideally, Americans should use both the DASH diet and reduced sodium approaches but, even if they do only one, they'll still reap significant health benefits.

"If the U.S. food supply were lower in sodium," added Simons-Morton, "it would help lower levels of blood pressure in the general population."

To interview an expert about this study, contact the NHLBI Communications Office at (301) 496-4236.

More information about the DASH diet and related heart-health topics can be found online at www.nhlbi.nih.gov.

Wikipedia on DASH Diet

The DASH diet (Dietary Approaches to Stop Hypertension) is a diet promoted by the National Heart, Lung, and Blood Institute (part of the NIH, a United States government organization) to control hypertension. This eating plan is rich in fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fats. In addition to its effect on blood pressure, it is considered a well-balanced approach to eating for the general public. It is now recommended by the US Department of Agriculture (USDA) as an ideal eating plan for all Americans.
The DASH diet is based on NIH studies that examined three dietary plans and their results. None of the plans were vegetarian, but the DASH plan incorporated more fruits and vegetables, low fat or nonfat dairy, beans, and nuts than the others studied. Not only does the plan emphasize good eating habits, but also suggests healthy alternatives to "junk food" and discourages the consumption of processed foods. The NIH has published a guidebook, "Your Guide to Lowering your Blood Pressure With DASH", which details the nutrition facts of popular mainstream food items and their healthy alternatives. The manual also provides samples of meal plans and proportions along with their associated nutritional information. The last pages of the manual provides a list of resources and how to obtain them.
The diet reduced systolic blood pressure by 6 mm Hg and diastolic blood pressure by 3 mm Hg in patients with normal blood pressure. Those with hypertension dropped by 11 and 6, respectively. There are several eating plans included in the diet, with the daily caloric intake ranging from 1699 to 3100 dietary calories.^[1]

Contents [hide] 1 History and Design 2 Study Results 3 History 4 Conclusions 5 References 6 Further reading 7 External links

[edit] History and Design

Currently, hypertension is thought to affect roughly 50 million people in the U.S. and approximately 1 billion worldwide.^{[2][3][verification needed]} According to the National Heart, Lung and Blood Institute (NHLBI), citing data from 2002 ^{[2][3][verification needed]}, “The relationship between BP and risk of cardiovascular disease (CVD) events is continuous, consistent, and independent of other risk factors. The higher the BP, the greater is the chance of heart attack, heart failure, stroke, and kidney disease. For individuals 40–70 years of age, each increment of 20 mm Hg in systolic BP (SBP) or 10 mm Hg in diastolic BP (DBP) doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mm Hg.”.^{[3][verification needed]}
The prevalence of hypertension led the U.S. [National Institute of Health] (NIH) to propose funding to further research the role of key nutrients in the diet. In 1992 the NHLBI directed five of the most well-respected medical research centers in different cities across the U.S. to conduct the largest and most detailed research study to date. The DASH study involved teams of physicians, nurses, nutritionists, statisticians and research coordinators working in a cooperative venture in which participants were selected and studied in each of the these five research facilities. The chosen facilities and locales for this multi-center study were (1) Johns Hopkins University in Baltimore, Maryland, (2) Duke University Medical Center in Durham, North Carolina, (3) Kaiser Permanente Center for Health Research in Portland, Oregon, (4) Brigham and Women's Hospital in Boston, Massachusetts and (5) Pennington Biomedical Research Center in Baton Rouge, Louisiana.^{[1][verification needed]}
The DASH trials were designed and carried out as a multi-center, randomized, outpatient feeding study with the purpose of testing the effects of dietary patterns on blood pressure. The standardized multi-center protocol was one of the unique features of the DASH diet. Another unique feature of the DASH diet and design was the foods and menu were chosen based on conventionally consumed food items which would be easily adopted by the general public if results were positive.^{[4][verification needed]} . The initial DASH study was begun in August 1993 and ended in July 1997.^[5] Contemporary epidemiological research had concluded that dietary patterns with high intakes of certain minerals and fiber were associated with low blood pressures. The nutritional conceptualization of the DASH meal plans was based in part on this research.^{[4][verification needed]}
Two experimental diets were selected for the DASH study and compared with each other, and with a third: the control diet. The control diet was characteristically low in potassium, calcium, magnesium and fiber. Moreover, the control diet also featured a fat and protein profile consistent with current or contemporary dietary regimens (a “typical American diet”^{[1][verification needed]}). The first experimental diet was an idealized “good” diet consisting of fruits and vegetables but otherwise similar to the control diet (a “fruits and vegetables diet” ^{[5][verification needed]}), with the exception of fewer snacks and sweets. Magnesium and Potassium levels were close to the 75th percentile of U.S. consumption in the fruits-and-vegetables diet, which also featured a high fiber profile. The second experimental diet combined elements of the previous two (control and fruits-and-vegetables)—this diet has been called “the DASH Diet” ^{[2][verification needed]}. The Dash diet (or combination diet) was rich in potassium, magnesium and calcium—a nutrient profile roughly equivalent with the 75th percentile of U.S. consumption. The DASH diet was also high in fruits, vegetables & low fat dairy foods, and also rich in fiber and protein (18%). The combination or “DASH” diet was also high in whole grains, poultry, fish and nuts while being low in fat and red meat content, sweets and sugar-containing beverages.^{[6][verification needed]}
The DASH diet was also focused on providing liberal amounts of key nutrients thought to play a part in lowering blood pressure, based on past medical studies. The DASH diet was designed to be a whole-food diet, low in processed or refined sugars and high in complex carbohydrates.^{[1][verification needed]} One of the unique features of the DASH diet design is that dietary patterns rather than single nutrients were being tested.^{[4][verification needed]} Equally important, the DASH diet features a high quotient of anti-oxidant rich foods thought to retard or prevent chronic health problems including cancer, heart disease and stroke.^{[1][verification needed]}
8,813 people were screened for the study, out of which were ultimately chosen 459 participants whose demographic characteristics most closely resembled the target population and study requirements. The sample population consisted of healthy men and women with an average age of 46, with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures within 80 to 95 mm Hg. African-American and other minority groups were planned to comprise 67% of the study sample, with 49% of the sample being female.^{[4][verification needed]} Indeed, due to the exceptional burden of high blood pressure in minority populations, especially among African-Americans, a major goal of the trial was to recruit enough ethnic minorities to constitute two thirds of the target sample.^{[5][verification needed]}
Participants ate one of the three aforementioned dietary patterns in 3 separate phases of the trial, including (1) Screening, (2), Run-in and (3) Intervention. In the screening phase, participants were screened for eligibility based on the combined results of blood pressure readings and a Stanford 7-Day Physical Activity Recall questionnaire. In the 3 week run-in phase, each subject was given the control diet for 3 weeks, had their blood pressure measurements taken on each of five separate days, gave one 24-hour urine sample and completed a questionnaire on symptoms. At this point the subjects were each randomly assigned to one of the three diets outlined above, to begin at the start of the 4th week. The intervention phase followed next; this was an 8-week period in which the subjects followed the diet they had each been randomly assigned to. Blood pressures and urine samples were collected again during this time together with symptom & physical activity recall questionnaires. The first group of study subjects began the run-in phase of the trial in September 1994 while the fifth and final group began in January 1996.^{[5][verification needed]} Each of the three diets contained the same 3 grams (3,000 mg) of sodium. Participants were also given two packets of salt, each containing 200 mg of sodium, for discretionary use. Alcohol was limited to no more than two beverages per day, and caffeine intake was limited to no more than three caffeinated beverages.^{[6][verification needed]}

[edit] Study Results

The DASH study showed that dietary patterns can and do affect blood pressure in the normal to moderately hypertensive adult population (systolic < 180 mm Hg & diastolic of 80 to 95 mm Hg).^{[5][verification needed]} Respectively, the DASH or “combination” diet lowered blood pressures by an average of 5.5 and 3.0 mm Hg for systolic and diastolic, compared to the control diet. The minority portion of the study sample and the hypertensive portion, from baseline, both showed the largest reductions in blood pressure from the combination diet against the control diet. The hypertensive subjects experienced a drop of 11.4 mm Hg in their systolic and 5.5 mm Hg in their diastolic phases.^{[5][verification needed]} The fruits-and-vegetables diet was also successful, although it produced more modest reductions over the control diet (2.8 mm Hg systolic and 1.1 mm Hg diastolic).^{[6][verification needed]} In the subjects with and without hypertension, the combination diet effectively reduced blood pressure more than the fruits-and-vegetables diet or the control diet did. The data indicated that reductions in blood pressure occurred within two weeks of subjects’ starting their designated diets, which were favorable results,^{[6][verification needed]} and that the results were generalizable to the target sample of the U.S. population.^{[5][verification needed]} Side effects were negligible, but the NEJM study reports that constipation was evidently a problem for some of the subjects. At the end of the intervention phase, 10.1, 5.4 & 4.0 percent of the subjects reported this problem for the control, fruits-and-vegetables and combination diets, respectively. Apart from only one subject (on the control diet) who was suffering from cholecystitis, other gastrointestinal symptoms had a low rate of incidence.

[edit] History

The DASH-Sodium study was conducted following the end of the original DASH study to determine whether the DASH diet could produce even better results if it were low in salt.^{[1][verification needed]} Primarily the researchers were interested in gaining more insight into the effect of sodium reduction when combined with the DASH diet. Design of the trials for the DASH-Sodium study were conducted and the trials took place from September 1997 through November 1999. Like the previous study, it was based on a large sample (412 participants) and was a multi-center, randomized, outpatient feeding study.^{[7][verification needed]} The participants were adults with prehypertension or stage 1 hypertension (average systolic of 120 to 159 mm Hg & average diastolic of 80 to 95 mm Hg) and were randomly assigned to one of two diet groups.^{[6][verification needed]} The two randomized diet groups were the DASH diet and a control diet that mirrored an “average American diet”, and which was somewhat low in key nutrients such as potassium, magnesium and calcium. After being assigned to one of these two diets, and within their assignment the participants ate foods differentiated by 3 distinct levels of sodium content, corresponding to 3,000 mg, 2,400 mg or 1,500 mg/day (hi, intermediate or low), in random order, for 30 consecutive days.^{[6][verification needed]} During the two week run-in phase, all participants ate the high sodium control diet. The 30 day intervention phase followed, in which subjects ate their assigned diets at each of the aforementioned sodium levels (high, intermediate and low) in random order, in a crossover design.^{[7][verification needed]} During the 30 day dietary intervention phase, each participant therefore consumed his or her assigned diet (either DASH or control) at all three sodium levels.

[edit] Conclusions

The primary outcome of the DASH-Sodium study was systolic blood pressure at the end of the 30 day dietary intervention periods. The secondary outcome was diastolic blood pressure. The DASH-Sodium study confirmed that reductions in sodium intake correlated with significantly lower systolic and diastolic blood pressures in both control and DASH diets. Study results indicate that the quantity of dietary sodium in the control diet was twice as powerful in its effect on blood pressure as it was in the DASH diet. Importantly, the control diet sodium reductions from intermediate to low correlated with greater changes in systolic blood pressure than those same changes from high to intermediate (change equal to roughly 40 mmol per day, or 1 gram of sodium). As stated by Sacks, F. et al., reductions in sodium intake by this amount per day correlated with greater decreases in blood pressure when the starting sodium intake level was already at the U.S. recommended dietary allowance, than when the starting level was higher (higher levels are the actual average in the U.S.). These results led researchers to postulate that the adoption of a national lower daily allowance for sodium than the currently held 2,400 mg could be based on the sound scientific results provided by this study.^{[7][verification needed]}
The DASH diet and the control diet at low salt levels were both successful in lowering blood pressure, but the largest reductions in blood pressure were obtained by eating a combination of these two (i.e., a low-salt version of the DASH diet). The effect of this combination at a sodium level of 1,500 mg/day was an average blood pressure reduction of 8.9/4.5 mm Hg (systolic/diastolic). The hypertensive subjects experienced an average reduction of 11.5/5.7 mm Hg.^{[6][verification needed]} The DASH-sodium results indicate that low sodium levels correlated with the largest reductions in blood pressure for participants at both normative and hypertensive levels with the hypertensive participants showing the greatest reductions in blood pressure overall. Moreover, the African-American study participants showed particularly significant reductions in blood pressure.^{[1][verification needed]}

[edit] References

1. ^ ^{a b c d e f g} "Your Guide To Lowering Your Blood Pressure With DASH" (PDF). US Department of Health and Human Services. April 2006. Retrieved 2011-12-28.
2. ^ ^{a b c} Chobanian, Aram; Bakris, George; Black, Henry; Cushman, William; Green, Lee; Izzo Jr, Joseph; Jones, Daniel; Materson, Barry et al. (2003). "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". 42. Bethesda: U.S. Department of Health and Human Services. pp. 1206. doi:10.1161/01.HYP.0000107251.49515.c2. ISSN 0194-911X. PMID 14656957. Retrieved 2011-12-28.
3. ^ ^{a b c} Sacks, Frank M; Obarzanek, Eva; Windhauser, Marlene; Svetkey, Laura; Vollmer, William; McCullough, Marjorie; Karanja, Njeri; Lin, Pao-Hwa et al. (March 1995). "Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH)". Annals of Epidemiology (Elsevier) 5 (2): 108-118. doi:10.1016/1047-2797(94)00055-X. ISSN 10472797. PMID 7795829.
4. ^ ^{a b c d} Appel, Lawrence J; Moore, Thomas J; Obarzanek, Eva; Vollmer, William; Svetkey, Laura; Sacks, Frank; Bray, George; Vogt, Thomas et al. (1997-04-17). "A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure". The New England Journal of Medicine (Massachusetts Medical Society) 335 (16): 1117-1124. doi:10.1056/NEJM199704173361601. ISSN 0028-4793. PMID 9099655. Retrieved 2011-12-28.
5. ^ ^{a b c d e f g} Moore, Thomas; Svetkey, Laura; Appel, Lawrence; Bray, George; Volmer, William (2001). The DASH Diet for Hypertension. New York: Simon & Schuster. ISBN 9780743202954. OCLC 47243951.
6. ^ ^{a b c d e f g} Lewington, S; Clarke, R; Qzilbash, N; Peto, R; Collins, R (2002-12-14). "Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies". Lancet (London: Elsevier) 360 (9349): 1903-13. doi:10.1016/S0140-6736(02)11911-8. PMID 12493255.
7. ^ ^{a b c} Karanja, Njeri; Erlinger, TP; Pao-Hwa, Lin; Miller 3rd, Edgar R; Bray, George (September 2004). "The DASH Diet for High Blood Pressure: From Clinical Trial to Dinner Table". Cleveland Clinic Journal of Medicine (Lyndhurst, Ohio: The Cleveland Clinic Foundation) 71 (9): 745-53. doi:10.3949/ccjm.71.9.745. ISSN 0891-1150. PMID 15478706. Retrieved 2011-12-28.

[edit] Further reading

• Heller, Marla (2007). The DASH Diet Action Plan: Based on the National Institutes of Health Research, Dietary Approaches to Stop Hypertension. Deerfield, IL: Amidon Press. ISBN 9780976340812. OCLC 162507208.
• Nowlan, Sandra (2008). Delicious DASH Flavours: The proven, drug-free, doctor-recommended approach to reducing high blood pressure. Halifax N.S.: Formac. ISBN 9780887807664. OCLC 185022611.
• Sacks, Frank M; Svetkey, Laura; Vollmer, William; Appel, Lawrence; Bray, George; Harsha, David; Obarzanek, Eva; Conlin, Paul et al. (2001-01-04). "Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet". New England Journal of Medicine (Massachusetts Medical Society) 344 (1): 3-10. doi:10.1056/NEJM200101043440101. ISSN 0028-4793. PMID 11136953.

[edit] External links

• What Is the DASH Eating Plan? at The National Heart, Lung, and Blood Institute (NHLBI)
• VIDEO - Which Diet Works: A Nutritional Review, Gail Underbakke, MS, RD, speaks at the University of Wisconsin School of Medicine and Public Health
• DASH A Diet for all diseases at cspinet.org
• DASH for Women at womensheartfoundation.org

Mayo Clinic on DASH Diet

DASH diet: Healthy eating to lower your blood pressure

The DASH diet emphasizes portion size, eating a variety of foods and getting the right amount of nutrients. Discover how DASH can improve your health and lower your blood pressure.

By Mayo Clinic staff
DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is a lifelong approach to healthy eating that's designed to help treat or prevent high blood pressure (hypertension). The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium.
By following the DASH diet, you may be able to reduce your blood pressure by a few points in just two weeks. Over time, your blood pressure could drop by eight to 14 points, which can make a significant difference in your health risks.
Because the DASH diet is a healthy way of eating, it offers health benefits besides just lowering blood pressure. The DASH diet may offer protection against osteoporosis, cancer, heart disease, stroke and diabetes. And while the DASH diet is not a weight-loss program, you may indeed lose unwanted pounds because it can help guide you toward healthier meals and snacks.

DASH diet: Sodium levels

A key goal of the DASH diet is reducing how much sodium you eat, since sodium can dramatically increase blood pressure in people who are sensitive to its effects. In addition to the standard DASH diet, there is also a lower sodium version of the diet. You can choose the version of the diet that meets your health needs:

• Standard DASH diet. You can consume up to 2,300 milligrams (mg) of sodium a day.
• Lower sodium DASH diet. You can consume up to 1,500 mg of sodium a day.

Both versions of the DASH diet aim to reduce the amount of sodium in your diet compared with what you might get in a more traditional diet, which can amount to a whopping 3,500 mg of sodium a day or more. That level is far beyond the recommendation of the 2005 Dietary Guidelines for Americans of a maximum of 2,300 mg of sodium a day.
Studies show that the lower sodium version of the DASH diet is especially helpful in lowering blood pressure for adults who are middle-aged or older, for African-Americans and for those who already have high blood pressure. If you aren't sure which version of the DASH diet is best for you, talk to your doctor.

DASH diet: What to eat

Both sodium versions of the DASH diet include lots of whole grains, fruits, vegetables and low-fat dairy products. The DASH diet also includes some fish, poultry and legumes. You can eat red meat, sweets and fats in small amounts. The DASH diet is low in saturated fat, cholesterol and total fat.
Here's a look at the recommended servings from each food group for the 2,000-calorie-a-day DASH diet.
Grains (6 to 8 servings a day)
Grains include bread, cereal, rice and pasta. Examples of one serving of grains include 1 slice whole-wheat bread, 1 ounce (oz.) dry cereal, or 1/2 cup cooked cereal, rice or pasta.

• Focus on whole grains because they have more fiber and nutrients than do refined grains. For instance, use brown rice instead of white rice, whole-wheat pasta instead of regular pasta and whole-grain bread instead of white bread. Look for products labeled "100 percent whole grain" or "100 percent whole wheat."
• Grains are naturally low in fat, so avoid spreading on butter or adding cream and cheese sauces.

Vegetables (4 to 5 servings a day)
Tomatoes, carrots, broccoli, sweet potatoes, greens and other vegetables are full of fiber, vitamins, and such minerals as potassium and magnesium. Examples of one serving include 1 cup raw leafy green vegetables or 1/2 cup cut-up raw or cooked vegetables.

• Don't think of vegetables only as side dishes — a hearty blend of vegetables served over brown rice or whole-wheat noodles can serve as the main dish for a meal.
• Fresh or frozen vegetables are both good choices. When buying frozen and canned vegetables, choose those labeled as low sodium or without added salt.
• To increase the number of servings you fit in daily, be creative. In a stir-fry, for instance, cut the amount of meat in half and double up on the vegetables.

Fruits (4 to 5 servings a day)
Many fruits need little preparation to become a healthy part of a meal or snack. Like vegetables, they're packed with fiber, potassium and magnesium and are typically low in fat — exceptions include avocados and coconuts. Examples of one serving include 1 medium fruit or 1/2 cup fresh, frozen or canned fruit.

• Have a piece of fruit with meals and one as a snack, then round out your day with a dessert of fresh fruits topped with a splash of low-fat yogurt.
• Leave on edible peels whenever possible. The peels of apples, pears and most fruits with pits add interesting texture to recipes and contain healthy nutrients and fiber.
• Remember that citrus fruits and juice, such as grapefruit, can interact with certain medications, so check with your doctor or pharmacist to see if they're OK for you.

Dairy (2 to 3 servings a day)
Milk, yogurt, cheese and other dairy products are major sources of calcium, vitamin D and protein. But the key is to make sure that you choose dairy products that are low-fat or fat-free because otherwise they can be a major source of fat. Examples of one serving include 1 cup skim or 1% milk, 1 cup yogurt or 1 1/2 oz. cheese.

• Low-fat or fat-free frozen yogurt can help you boost the amount of dairy products you eat while offering a sweet treat. Add fruit for a healthy twist.
• If you have trouble digesting dairy products, choose lactose-free products or consider taking an over-the-counter product that contains the enzyme lactase, which can reduce or prevent the symptoms of lactose intolerance.
• Go easy on regular and even fat-free cheeses because they are typically high in sodium.

Lean meat, poultry and fish (6 or fewer servings a day)
Meat can be a rich source of protein, B vitamins, iron and zinc. But because even lean varieties contain fat and cholesterol, don't make them a mainstay of your diet — cut back typical meat portions by one-third or one-half and pile on the vegetables instead. Examples of one serving include 1 oz. cooked skinless poultry, seafood or lean meat, 1 egg, or 1 oz. water-packed, no-salt-added canned tuna.

• Trim away skin and fat from meat and then broil, grill, roast or poach instead of frying.
• Eat heart-healthy fish, such as salmon, herring and tuna. These types of fish are high in omega-3 fatty acids, which can help lower your total cholesterol.

Nuts, seeds and legumes (4 to 5 servings a week)
Almonds, sunflower seeds, kidney beans, peas, lentils and other foods in this family are good sources of magnesium, potassium and protein. They're also full of fiber and phytochemicals, which are plant compounds that may protect against some cancers and cardiovascular disease. Serving sizes are small and are intended to be consumed weekly because these foods are high in calories. Examples of one serving include 1/3 cup (1 1/2 oz.) nuts, 2 tablespoons seeds or 1/2 cup cooked beans or peas.

• Nuts sometimes get a bad rap because of their fat content, but they contain healthy types of fat — monounsaturated fat and omega-3 fatty acids. They're high in calories, however, so eat them in moderation. Try adding them to stir-fries, salads or cereals.
• Soybean-based products, such as tofu and tempeh, can be a good alternative to meat because they contain all of the amino acids your body needs to make a complete protein, just like meat. They also contain isoflavones, a type of natural plant compound (phytochemical) that has been shown to have some health benefits.

Fats and oils (2 to 3 servings a day)
Fat helps your body absorb essential vitamins and helps your body's immune system. But too much fat increases your risk of heart disease, diabetes and obesity. The DASH diet strives for a healthy balance by providing 30 percent or less of daily calories from fat, with a focus on the healthier unsaturated fats. Examples of one serving include 1 teaspoon soft margarine, 1 tablespoon low-fat mayonnaise or 2 tablespoons light salad dressing.

• Saturated fat and trans fat are the main dietary culprits in raising your blood cholesterol and increasing your risk of coronary artery disease. DASH helps keep your daily saturated fat to less than 10 percent of your total calories by limiting use of meat, butter, cheese, whole milk, cream and eggs in your diet, along with foods made from lard, solid shortenings, and palm and coconut oils.
• Avoid trans fat, commonly found in such processed foods as crackers, baked goods and fried items.
• Read food labels on margarine and salad dressing so that you can choose those that are lowest in saturated fat and free of trans fat.

Sweets (5 or fewer a week)
You don't have to banish sweets entirely while following the DASH diet — just go easy on them. Examples of one serving include 1 tablespoon sugar, jelly or jam, 1/2 cup sorbet or 1 cup (8 oz.) lemonade.

• When you eat sweets, choose those that are fat-free or low-fat, such as sorbets, fruit ices, jelly beans, hard candy, graham crackers or low-fat cookies.
• Artificial sweeteners such as aspartame (NutraSweet, Equal) and sucralose (Splenda) may help satisfy your sweet tooth while sparing the sugar. But remember that you still must use them sensibly. It's OK to swap a diet cola for a regular cola, but not in place of a more nutritious beverage such as low-fat milk or even plain water.
• Cut back on added sugar, which has no nutritional value but can pack on calories.

DASH diet: Alcohol and caffeine

Drinking too much alcohol can increase blood pressure. The DASH diet recommends that men limit alcohol to two or fewer drinks a day and women one or less.
The DASH diet doesn't address caffeine consumption. The influence of caffeine on blood pressure remains unclear. But caffeine can cause your blood pressure to rise at least temporarily. If you already have high blood pressure or if you think caffeine is affecting your blood pressure, talk to your doctor about your caffeine consumption.

DASH diet and weight loss

The DASH diet is not designed to promote weight loss, but it can be used as part of an overall weight-loss strategy. The DASH diet is based on a diet of about 2,000 calories a day. If you're trying to lose weight, though, you may want to eat around 1,600 a day. You may need to adjust your serving goals based on your health or individual circumstances — something your health care team can help you decide.

Tips to cut back on sodium

The foods at the core of the DASH diet are naturally low in sodium. So just by following the DASH diet, you're likely to reduce your sodium intake. You also can cut back on sodium in your diet by:

• Using sodium-free spices or flavorings with your food instead of salt
• Not adding salt when cooking rice, pasta or hot cereal
• Rinsing canned foods to remove some of the sodium
• Buying foods labeled "no salt added," "sodium-free," "low sodium" or "very low sodium"

One teaspoon of table salt has about 2,300 mg of sodium, and 2/3 teaspoon of table salt has about 1,500 mg of sodium. When you read food labels, you may be surprised at just how much sodium some processed foods contain. Even low-fat soups, canned vegetables, ready-to-eat cereals and sliced turkey from the local deli — all foods you may have considered healthy — often have lots of sodium.
You may not notice a difference in taste when you choose low-sodium food and beverages. If things seem too bland, gradually introduce low-sodium foods and cut back on table salt until you reach your sodium goal. That'll give your palate time to adjust. It can take several weeks for your taste buds to get used to less salty foods.

Putting the pieces of the DASH diet together

Try these strategies to get started on the DASH diet:

• Change gradually. To boost your success, avoid dramatic changes in your eating approach. Instead, change one or two things at a time. If you now eat only one or two servings of fruits or vegetables a day, try to add a serving at lunch and one at dinner. Rather than switching to all whole grains, start by making one or two of your grain servings whole grains. Increasing fruits, vegetables and whole grains gradually can also help prevent bloating or diarrhea that may occur if you aren't used to eating a diet with lots of fiber. You can also try over-the-counter products to help reduce gas from beans and vegetables.
• Forgive yourself if you backslide. Everyone slips, especially when learning something new. Remember that changing your lifestyle is a long-term process. Find out what triggered your setback and then just pick up where you left off with the DASH diet.
• Reward successes. Reward yourself with a nonfood treat for your accomplishments.
• Add physical activity. To boost your blood pressure lowering efforts even more, consider increasing your physical activity in addition to following the DASH diet. Combining both the DASH diet and physical activity makes it more likely that you'll reduce your blood pressure.
• Get support if you need it. If you're having trouble sticking to your diet, talk to your doctor or dietitian about it. You might get some tips that will help you stick to the DASH diet.

Remember, healthy eating isn't an all-or-nothing proposition. What's most important is that, on average, you eat healthier foods with plenty of variety — both to keep your diet nutritious and to avoid boredom or extremes. And with the DASH diet, you can have both.

The DASH Diet Eating Plan

US News & World Reports:
Ranked #1, Best and Healthiest Diet Plan

Why did the DASH diet receive the #1 rankings from the expert panel in US New & World Reports? (January 4, 2012, November 1, 2011, and June 7, 2011: "Best diet overall" and "Healthiest diet") Because it is a balanced plan, proven to improve health. It helps to lower blood pressure and cholesterol, and is associated with lower risk of several types of cancer, heart disease, stroke, heart failure, kidney stones, and reduced risk of developing diabetes. And now, there is a new edition of the best-selling book, The DASH Diet Action Plan.
The DASH diet is physician-recommended for people with hypertension (high blood pressure) or prehypertension. The DASH diet eating plan has been proven to lower blood pressure in studies sponsored by the National Institutes of Health (Dietary Approaches to Stop Hypertension). In addition to being a low salt (or low sodium) plan, the DASH diet provides additional benefits to reduce blood pressure. It is based on an eating plan rich in fruits and vegetables, and low-fat or non-fat dairy, with whole grains. It is a high fiber, low to moderate fat diet, rich in potasium, calcium, and magnesium. The full DASH diet plan is shown below. The DASH diet is a healthy plan, designed for the whole family. New research continues to show additional health benefits of the plan. Read about one reader's inspiring journey with the DASH diet and weight loss on Facebook.
In addition to being recommended by your physician, DASH is also endorsed by:

• The National Heart, Lung, and Blood Institute (one of the National Institutes of Health, of the US Department of Health and Human Services)
• The American Heart Association (AHA)
• The 2010 Dietary Guidelines for Americans
• US guidelines for treatment of high blood pressure
• The 2011 AHA Treatment Guidelines for Women
• The Mayo Clinic
• and, the DASH diet formed the basis for the USDA MyPlate.

The DASH eating plan has been proven to lower blood pressure in just 14 days, even without lowering sodium intake. Best response came in people whose blood pressure was only moderately high, including those with prehypertension. For people with more severe hypertension, who may not be able to eliminate medication, the DASH diet can help improve response to medication, and help lower blood pressure. The DASH diet can help lower cholesterol, and with weight loss and exercise, can reduce insulin resistance.
The book, The DASH Diet Action Plan, provides real life solutions to make it easy for people to follow the DASH diet. It has 28 days of meal plans (with adjustments for various calorie levels), recipes, guidance for weight loss, how to eat at restaurants, fast food places, etc. and still stay on track. It shows you how to stock up your kitchen for the DASH diet, and how to read food labels to make good choices. And, of course, the meal plans and recipes are all low sodium/low salt. The book shows you how to add exercise and other lifestyle changes to help lower blood pressure. This book helps you design your own personal "DASH Diet Action Plan."
New research shows that following the DASH diet over time will reduce the risk of stroke and heart disease, as well as kidney stones. The benefits of the DASH diet have also been seen in teens with hypertension. The DASH diet truly is the diet for everyone.

Specifically the DASH diet plan includes:

Type of food	Number of servings for 1600 - 3100 Calorie diets	Servings on a 2000 Calorie diet
Grains and grain products (include at least 3 whole grain foods each day)	6 - 12	7 - 8
Fruits	4 - 6	4 - 5
Vegetables	4 - 6	4 - 5
Low fat or non fat dairy foods	2 - 4	2 - 3
Lean meats, fish, poultry	1.5 - 2.5	2 or less
Nuts, seeds, and legumes	3 - 6 per week	4 - 5 per week
Fats and sweets	2 - 4	limited

Even though most people know that this seems like a very healthy way of eating, they initially may find it hard to implement and sustain. The average American gets 2 - 3 servings of fruits and vegetables combined each day, so following the DASH diet can involve making a concerted effort. The book makes it easier. It helps you with simple lifestyle changes and strategies to make new habits that you will keep for a lifetime. Although weight loss was not a part of the original DASH diet research, the book provides guidance and plans for adapting the DASH diet for successful weight loss. Many women need to follow a lower calorie diet in order to lose weight, so we include a 1200-calorie version of the DASH diet. Although this book was not intended to be an aggressive weight loss program, many of our readers have reported 10 - 35 pound weight loss in a few months. One of our readers recently posted her weight loss journey with the DASH diet on Facebook. The design of the meal plans in the book are based on newer research on how to make satisfying meals, helping to prevent between meal hunger. That is a key feature of high-fiber, low caloric-density, balanced meals with appropriate serving sizes.

Check these links for more information on the book, our reader feedback, DASH diet in the news, DASH diet research, the author Marla Heller, MS, RD, Marla in the media, or to book her for a seminar. We support the American Heart Month (February), the Go Red for Women campaign, and the National Wear Red Day (February 3, 2012), promoting awareness about women's heart health.