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Desk Top Training: The Role of the DASH Diet Jennifer Anderson, PhD, RD Department of Food Science and Human Nutrition Cooperative Extension Colorado State University Special Thanks to Stephanie Smith for use of slides from Western Dairy Council Hypertension Prevalence l 50 million hypertensive US adults l One-third unaware l Less than half of American adults have optimal blood pressure l Increases in prevalence and severity in African Americans Blood Pressure Categories - Adults Systolic (mm Hg) Diastolic (mm Hg) Optimal 180 or 90-99 100-109 110 JNC VI Risk Stratification and Treatment Recommendations3 Untreated Hypertension Target Organ Damage Includes: l Hypertensive heart disease l Cerebrovascular disease l Renal disease l Large vessel disease Public Health Challenge of Hypertension l Prevent BP rise with age l Decrease existing prevalence Healthy People 2010 goal 16% l Increase awareness and detection Has no symptoms, called the “silent killer” l Improve control l Reduce cardiovascular risks l Increase recognition of importance of controlling systolic hypertension National High Blood Pressure Education Program Updated Recommendations to Prevent Hypertension l Maintain normal body weight for adults BMI 18.5-24.9 kg/m2 l Reduce sodium intake to no more than 100 mmol/day l Regular physical activity at least 30 minutes most days of the week l Limit alcohol consumption l Maintain adequate potassium intake l Consume a diet rich in fruits, vegetables and low-fat dairy products l Reduce saturated fat and total fat in diet JAMA, Oct 16, 2002 Mineral Intake and Hypertension Calcium l American Heart Association Statement Increasing calcium intake may preferentially lower blood pressure in salt-sensitive people Benefits more evident with low initial calcium intakes (300-600 mg/day) Circulation. 1998:98:613-6177 Calcium inside cells: Maintained at very low levels Ca entering cells serves as a signal Calcium in the blood: Regulated to maintain constant blood levels to control critical body functions. Implications High blood pressure Obesity Cancer Vascular Smooth Muscle Cell Blood vessel contractionCalcium Calcium 1,25-(OH)2D How Calcium Affects Blood Pressure Low dietary calcium Blood Pressure Calcium Intake % of AI Source: USDA Continuing Survey of Food Intakes by Individuals, 1994-1996. Mineral Intake and Hypertension Potassium l Clinical trials and meta-analyses indicate potassium supplementation lowers BP l Adequate K intake, preferably from food sources, should be maintained l Evidence is strong enough to support a health claim on high potassium foods JAMA, Oct. 16, 2002 and JNC VI, Arch Intern Med. 1997;157:2413-4511 Mineral Intake and Hypertension Magnesium l Evidence suggests an association between lower dietary magnesium intake and high blood pressure l Not enough evidence exists to justify a recommendation of increased Mg intake JNC VI, Arch Intern Med. 1997;157:2413-4512 The DASH Study Dietary Approaches to Stop Hypertension L.J. Appel et al, N Engl J Med; 366:1117-1124, 1997 DASH is Unique l Tested dietary patterns rather than single nutrients l Experimental diets used common foods that can be incorporated into recommendations for the public l Investigators planned the DASH diet to be fully compatible with dietary recommendations for reducing risk of CVD, osteoporosis and cancer DASH Study Design l 3-week run-in on control diet l 8-week randomization to one of three diets: Control Fruits and vegetables Combination: fruits, vegetables and low fat dairy products l Energy intake adjusted to ensure constant weight l Sodium content of all three diets was approximately 3000 mg/daily DASH Subject Characteristics l Systolic bp 160 mm Hg Average was 132 mm Hg l Diastolic bp 80-95 mm Hg Average was 85 mm Hg l 459 randomized 133 hypertensive 326 normotensive l 22 years and older l 50% women l 29% untreated hypertensive l Not currently taking hypertensive meds DASH Study Test Diets Designed to achieve distinct differences in the intakes of: l Fiber l Minerals Ca, K, and Mg l Protein l Total fat, saturated, poly and monounsaturated fat. l Cholesterol intake targeted to be lower in the combination diet. DASH Study Test Diets Control diet l Modeled after the typical American diet l 37% fat, 15% protein l Calcium deficient 443 mg/day l Potassium 1700 mg/day l Magnesium 165 mg/day DASH Study Test Diets Fruit and vegetable diet l Similar to control diet in fat and protein content l Included 8-10 servings fruits and vegetables l Calcium 534 mg/day l Potassium 4101 mg/day l Magnesium 423 mg/day DASH Study Test Diets Combination diet l Similar to fruit and vegetable diet l Low fat and cholesterol l At least 3 servings of dairy foods l Calcium 1265 mg/day l Potassium 4415 mg/day l Magnesium 480 mg/day Controlled Feeding Trial l 7-day menu cycle (21 meals) l 4 calorie levels: 1600, 2100, 2600, 3100 l Lunch/dinner consumed on- site weekdays l Weekend meals consumed off -site l Adherence recorded objectively and subjectively DASH: Mean Systolic BP New Eng J Med, 336:1117-24 (April 17),199722 DASH: Mean Diastolic BP New Eng J Med, 336:1117-24 (April 17), 199723 DASH Authors Conclusions l Blood pressure reduction is rapid l Blood pressure is comparable to drugs l BP effect can be generalized to all Americans l Dietary Ca/F Intermediate: 2400 mg/day; Higher: 3,300 mg/day DASH II Sodium DASH II Sodium DASH-Sodium: Results l At each of the three levels of sodium intake, blood pressure was lower for those on the DASH diet than for those on the control diet. l Reducing dietary sodium, lowered blood pressure for both the control and DASH diets in all participants. l Largest reductions in blood pressure were found with the DASH diet at the lowest sodium intake. DASH Reduces Homocysteine Levels l Effect a result of diet high in vitamin B-rich milk and milk products, fruits and vegetables l Lowering homocysteine with DASH may reduce CVD risk an additional 7%-9% -Appel, et al. Circulation, 102:852, 2000 DASH Reduces Cholesterol l Total cholesterol 13.7 mg/dl l LDL cholesterol 10.7 mg/dl l HDL cholesterol 3.7 mg/dl -Obarzanek, et al, Am J Clin Nutr, 74:80, 2001 Unresolved Issues l What are the principal nutrients in foods responsible for the BP-lowering effect of the DASH diet? l What is the effect of DASH in free-living individuals selecting their own food? l What is the combined effect of simultaneously implementing all known lifestyle interventions that influence BP? DASH Diet Pattern based on a 2,000 calorie diet Food Group Servings* Grains 7-8 Vegetables 4-5 Fruits 4-5 Low-fat or fat free dairy 2-3 Meats, poultry, fish less than 2 Nuts, seeds, dry beans and peas 4-5/week Fats and oils 2-3 Sweets 5/ week *servings varied from day to day, average intake over a week close to recommended Killing many birds with one stone DASH meets multiple dietary recommendations l NIH-NHLBI-ATP III l AHA l USDA/DHHS Dietary Guidelines l NCI and AICR l Surgeon General Dietary recommendations includes Therapeutic Lifestyle Changes (TLC) l Saturated fat: 7% of total calories l Cholesterol: 200 mg/day l Weight reduction l Increased physical activity l Viscous (soluble) fiber: 10-25 g/day l Plant stanols/sterols: 2 g/day Take Time for Some TLC lChoose foods low in saturated fat Whole grains Fruits Vegetables Fat free or 1% dairy products Lean meats, fish, skinless poultry Dried peas/beans Take Time for Some TLC (cont) lChoose foods low in cholesterol Plant-based foods lGrains lFruits lVegetables lDried beans Our Challenge The challenge for extension educators is how do we translate these recommendations into dail