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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.

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Desk top training the role of the dash diet l.jpg

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


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Hypertension Prevalence

  • 50 million hypertensive US adults

  • One-third unaware

  • Less than half of American adults have optimal blood pressure

  • Increases in prevalence and severity in African Americans


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Blood Pressure Categories - Adults

JNC VI Risk Stratification and Treatment Recommendations


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Untreated Hypertension

Target Organ Damage Includes:

  • Hypertensive heart disease

  • Cerebrovascular disease

  • Renal disease

  • Large vessel disease


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Public Health Challenge of Hypertension

  • Prevent BP rise with age

  • Decrease existing prevalence

    • Healthy People 2010 goal – 16%

  • Increase awareness and detection

    • Has no symptoms, called the “silent killer”

  • Improve control

  • Reduce cardiovascular risks

  • Increase recognition of importance of controlling systolic hypertension


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National High Blood Pressure Education Program

Updated Recommendations to Prevent Hypertension

  • Maintain normal body weight for adults

    • BMI 18.5-24.9 kg/m2

  • Reduce sodium intake to no more than 100 mmol/day

  • Regular physical activity – at least 30 minutes most days of the week

  • Limit alcohol consumption

  • Maintain adequate potassium intake

  • Consume a diet rich in fruits, vegetables and low-fat dairy products

  • Reduce saturated fat and total fat in diet

    JAMA, Oct 16, 2002


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Mineral Intake and Hypertension

Calcium

  • 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. 1998:98:613-617


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Calcium in the blood:Regulated to maintain

constant blood levels to control critical body functions.

Calcium inside cells: Maintained at

very low levels

Ca entering cells serves as a signal

  • Implications

  • High blood pressure

  • Obesity

  • Cancer


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How Calcium Affects Blood Pressure

Low dietary calcium

1,25-(OH)2D

Calcium

Calcium

Blood vessel contraction

Blood Pressure

Vascular Smooth Muscle Cell


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Calcium Intake % of AI

Source: USDA Continuing Survey of Food Intakes by Individuals, 1994-1996.


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Mineral Intake and Hypertension

Potassium

  • Clinical trials and meta-analyses indicate potassium supplementation lowers BP

  • Adequate K intake, preferably from food sources, should be maintained

  • Evidence is strong enough to support a health claim on high potassium foods

JAMA, Oct. 16, 2002 and JNC VI, Arch Intern Med. 1997;157:2413-45


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Mineral Intake and Hypertension

Magnesium

  • Evidence suggests an association between lower dietary magnesium intake and high blood pressure

  • Not enough evidence exists to justify a recommendation of increased Mg intake

JNC VI, Arch Intern Med. 1997;157:2413-45


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The DASH Study

Dietary Approaches to Stop Hypertension

L.J. Appel et al, N Engl J Med; 366:1117-1124, 1997


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DASH is Unique

  • Tested dietary patterns rather than single nutrients

  • Experimental diets used common foods that can be incorporated into recommendations for the public

  • Investigators planned the DASH diet to be fully compatible with dietary recommendations for reducing risk of CVD, osteoporosis and cancer


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DASH Study Design

  • 3-week run-in on control diet

  • 8-week randomization to one of three diets:

    • Control

    •  Fruits and vegetables

    • Combination:  fruits, vegetables and low fat dairy products

  • Energy intake adjusted to ensure constant weight

  • Sodium content of all three diets was approximately 3000 mg/daily


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DASH Subject Characteristics

  • Systolic bp < 160 mm Hg

    • Average was 132 mm Hg

  • Diastolic bp 80-95 mm Hg

    • Average was 85 mm Hg

  • 459 randomized

    • 133 hypertensive

    • 326 normotensive

  • 22 years and older

  • 50% women

  • 29% untreated hypertensive

  • Not currently taking hypertensive meds


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DASH Study Test Diets

Designed to achieve distinct differences in the intakes of:

  • Fiber

  • Minerals Ca, K, and Mg

  • Protein

  • Total fat, saturated, poly and monounsaturated fat.

  • Cholesterol intake targeted to be lower in the combination diet.


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DASH Study Test Diets

Control diet

  • Modeled after the typical American diet

  • 37% fat, 15% protein

  • Calcium deficient – 443 mg/day

  • Potassium – 1700 mg/day

  • Magnesium – 165 mg/day


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DASH Study Test Diets

Fruit and vegetable diet

  • Similar to control diet in fat and protein content

  • Included 8-10 servings fruits and vegetables

  • Calcium – 534 mg/day

  • Potassium – 4101 mg/day

  • Magnesium – 423 mg/day


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DASH Study Test Diets

Combination diet

  • Similar to fruit and vegetable diet

  • Low fat and cholesterol

  • At least 3 servings of dairy foods

  • Calcium – 1265 mg/day

  • Potassium – 4415 mg/day

  • Magnesium – 480 mg/day


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Controlled Feeding Trial

  • 7-day menu cycle (21 meals)

  • 4 calorie levels: 1600, 2100, 2600, 3100

  • Lunch/dinner consumed on-site weekdays

  • Weekend meals consumed off-site

  • Adherence recorded objectively and subjectively




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DASH Author’s Conclusions

  • Blood pressure reduction is rapid

  • Blood pressure is comparable to drugs

  • BP effect can be generalized to all Americans

  • Dietary Ca/F&V effect independent of

    • Sodium intake

    • Weight change

  • DASH has public health implications

    • Preventive measure against hypertension

    • Reduce stroke by 27% and CHD by 15%


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DASH-Sodium

Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet

Sacks, F.M., et al. New England Journal of Medicine. Jan 4, 2001


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DASH-Sodium: Subjects

  • 412 randomized

  • 57% women

  • 57% ethnic minority

  • Systolic BP of 120-159 mmHg

  • Diastolic BP of 80-95 mmHg

  • 41% hypertensive


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DASH-Sodium Trial: Study Design

Sodium levels:Lower: 1500 mg/day; Intermediate: 2400 mg/day; Higher: 3,300mg/day

Lower

Sodium

Intermediate

Sodium

Higher

Sodium

Randomization

Control Diet, N = 204

Control Diet

DASH Diet, N = 208

Lower

Sodium

Intermediate

Sodium

Higher

Sodium

Run-in:

11-14 days

Intervention

(Three 30-day periods, random order)




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DASH-Sodium: Results

  • 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.

  • Reducing dietary sodium, lowered blood pressure for both the control and DASH diets in all participants.

  • Largest reductions in blood pressure were found with the DASH diet at the lowest sodium intake.


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DASH Reduces Homocysteine Levels

  • Effect a result of diet high in vitamin B-rich milk and milk products, fruits and vegetables

  • Lowering homocysteine with DASH may reduce CVD risk an additional 7%-9%

    -Appel, et al. Circulation, 102:852, 2000


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DASH Reduces Cholesterol

  • Total cholesterol 13.7 mg/dl

  • LDL cholesterol 10.7 mg/dl

  • HDL cholesterol 3.7 mg/dl

    -Obarzanek, et al, Am J Clin Nutr, 74:80, 2001


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Unresolved Issues

  • What are the principal nutrients in foods responsible for the BP-lowering effect of the DASH diet?

  • What is the effect of DASH in free-living individuals selecting their own food?

  • What is the combined effect of simultaneously implementing all known lifestyle interventions that influence BP?


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DASH Diet Patternbased on a 2,000 calorie diet

Food GroupServings*

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


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Killing many birds with one stone

DASH meets multiple dietary recommendations

  • NIH-NHLBI-ATP III

  • AHA

  • USDA/DHHS Dietary Guidelines

  • NCI and AICR

  • Surgeon General


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Dietary recommendations includesTherapeutic Lifestyle Changes (TLC)

  • Saturated fat: 7% of total calories

  • Cholesterol: < 200 mg/day

  • Weight reduction

  • Increased physical activity

  • Viscous (soluble) fiber: 10-25 g/day

  • Plant stanols/sterols: 2 g/day


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Take Time for Some TLC

  • Choose foods low in saturated fat

    • Whole grains

    • Fruits

    • Vegetables

    • Fat free or 1% dairy products

    • Lean meats, fish, skinless poultry

    • Dried peas/beans


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Take Time for Some TLC (cont)

  • Choose foods low in cholesterol

    • Plant-based foods

      • Grains

      • Fruits

      • Vegetables

      • Dried beans


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Our Challenge

The challenge for extension educators is how do we translate these recommendations into daily food and lifestyle choices for our clients.


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Summary

  • If time is limited, focus on one behavior you would like for people to change such as:

    • Add one more vegetable today

    • Snack on a piece of fruit instead of a cookie

    • Buy low fat milk and/or yogurt

    • Use garbanzo beans on salads

    • Have a 1/3 cup nuts as a snack


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Resources

  • Cholesterol and Fats Fact Sheet

    • www.ext.colostate.edu/pubs/foodnut/09319.html

  • Third Report of the Expert Panel on. Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults (Adult Treatment Panel III)

    • www.nhlbi.nih.gov/guidelines/cholesterol

      • Executive Summary


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Resources (cont)

  • High Blood Cholesterol - What You Need to Know

    • www.nhlbi.nih.gov/health/public/heart/chol/hbc_what.htm

  • National Dairy Council resources

    • www.nationaldairycouncil.com

  • Western Dairy Council educational materials

    • 800-274-6455


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