10/22/2009

DASH eating plan recommended by:

DASH: an Eating Plan for

Lifelong Health

Lynn L. Moore, DSc, MPH

Preventive Medicine & Epidemiology
Boston University School of Medicine

Primary Goals of Today’s Talk DASH Eating Plan (Adults)

Re-assess the evidence for DASH based on a 2,000 calorie diet

Examine effects of DASH on health outcomes Food Group Daily Servings
in adults (in addition to BP) Vegetables 4-5

Look at new data on DASH and health Fruits 4-5

outcomes in children and adolescents Low-fat or fat-free dairy products 2-3

Grains (esp. whole grains) 6-8
Secondary Goals Meats (lean), poultry, fish 6 or less
Nuts, seeds, dry beans, peas 4-5/week

Raise question of what constitutes a “DASH
Fats and oils 2-3
eating plan”. Sweets 5 or less/week

Identify some unanswered questions
U.S. Department of Health and Human Services. Your Guide to Lowering Your Blood
3 4
Pressure with DASH. 2nd Edition, April 2006

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Major DASH Food Groups Original DASH Clinical Trial

Three diets
Dairy: milk, yogurt, cheese  Control (typical American)
(Ca, Potassium, Mg, vit D, phos, protein)  Fruits and vegetables (K, mg, fiber)
 Combination: fruits, vegetables, low-fat
dairy (K, mg, fiber, ca, pro)

Fruit: melons, bananas, papaya, prunes,
Isocaloric (no wt loss)

oranges (Mg, potassium, vit C, fiber),

459 adults
fortified juices (Ca)  50% women
 60% African-American
Vegetables: broccoli (vit A), soy (Ca,
Elevated BP:
potassium), beets, mushrooms, potatoes  SBP < 160 mm Hg
 DBP 80 – 95 mm Hg
(B6), green leafy/spinach (vit A, Mg, Ca),
tomatoes, (potassium, Mg) (fiber)
Intervention Period – 8 wks
Appel LJ N Engl JMed 1997;336:1117-1124
5 6

DASH and Mean SBP Change Other Findings Related to DASH & BP

In DASH-sodium trial, DASH lowered BP at all
134
Control levels of sodium intake but DASH + low
Fruit & Veg
132 DASH
sodium led to greatest reductions in BP
130
 (Sacks F, N Engl J Med 2001)
African-Americans particularly vulnerable to
SBP (mmHg)

128

126 adverse BP effects of low potassium diet
124  (Morris RC, Hypertension 1999)
122

In IWHS, concordance with DASH (using
120
0 1 2 3 4 5 6 7 8
score) was not associated with lower risk of Htn
Follow-up Time (wks)  (Folsom AR, AJH 2007)

WHI emphasizing fruits, veg & whole grains led
• Effects in African-Americans were nearly double those of Caucasians to modest reductions in SBP & DBP
 (Howard BV, JAMA 2006)
7 Appel L. N Engl J Med 1997;336:1117-1124 8

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SBP Change in Setting of Metabolic Why the Inconsistent Results?

Syndrome: (PREMIER Study)
Original RCT, well-controlled feeding study-
demonstrated efficacy of DASH approach in
6-month follow up subjects with low intakes of key nutrients.
0.0

• In setting of MetS,
Baseline intakes key nutrients higher in some
Mean Change in SBP (mmHg)

-2.0

DASH diet enhanced
-4.0 beneficial effect of EST subsequent studies so effects may be weaker.
-6.0 intervention
-8.0 -6.8
-6.2
WHI did not emphasize dairy intake. Review
• In those without MetS,
-10.0
-8.4
the EST intervention &
(Kris-Etherton) concludes: there is growing
-12.0
-9.8
-11.2
EST + DASH were evidence that dairy is involved in BP regulation.
-12 equally effective
Advice only
-14.0
Met. Syndrome No Met. Syndrome EST
DASH scoring systems equally weight all dietary
EST+DASH
components and may wash out important
No added benefit of DASH compared with EST alone for lipids, insulin resistance or glucose
dietary effects.
9 Lien LF et al. Hypertension 2007;50:609-616 10

Long-term Health Effects of Elevated DASH vs. Routine Care

Blood Pressure Begin Early Change in BP & BMI in Adolescents with HBP
2
1
0
-1
-2
-3
-4
Change

-5 Change in BMI
-6
-7
-8 Change in DBP
-9 DASH
-10
-11 Change in SBP Routine Care
-12
End of Rx 3-mo. f/u End of Rx 3-mo. f/u End of Rx 3-mo. f/u
Post-treatment completers 3-Month follow-up completers
DASH = 24; RC = 22 DASH = 18; RC = 18

12 Couch et al, J Pediatr 2008;152:494-501

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DASH Eating Pattern in Young Children DASH Eating Pattern in Young Children
and Early Adolescent SBP and Early Adolescent DBP
60
116
114
FV / Dairy Intake
58 FV / Dairy Intake

DBP (mm Hg)

Low / Low
112
Low / High
SBP (mm Hg)

Low / Low
110 High / Low
56 High / Low
High / High
108 Low / High
High / High
106 54

104
52
102
100
Preschool Diet Elementary Age 50
Preschool Diet Elementary Age

Low Dairy: <2 servings/day

Low Fruit/Veg: <4 servings/day
Adjusted for age, sex, baseline BP, activity level, and intake of mg & sodium Adjusted for age, sex, baseline BP, activity level, and intake of mg & sodium
13 Moore LL et al Epidemiology 2005:16:4-11 14 Moore LL et al Epidemiology 2005:16:4-11
Moore et al. Epidemiology 2005;16:4-11 (FCS)
Moore et al. Epidemiology 2005;16:4-11

DASH Eating Pattern and Blood

Pressure in Adolescent Girls Effect of DASH Diet on Body Fat
110
SPB in Adolescent Girls • DASH eating pattern group had
lower DBP levels throughout
Outcomes in Children and Adolescents
DA<2.5, FV<3 svgs adolescence
109 DA<2.5, FV>=3 svgs
DA>=2.5, FV<3 svgs
108
SBP (mmHg)

DA>=2.5, FV>=3 svgs

DPB in Adolescent Girls
67
107
66
106 65
DBP (mmHg)

64
105 63
62
104
61
9-10 11-12 13-14 15-16 17-18 19-20 60
59
9-10 11-12 13-14 15-16 17-18 19-20
• Both higher dairy groups had lower
SBPs than those with lower dairy intake

Models are adjusted for ages, SES, race, activity, TV & height.
15
Data from National Growth & Health Study

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DASH Eating Pattern and BMI in BMI Level According to DASH

Adolescent Girls Adherence Score
27

28 25
26
23

BMI (kg/m )
BMI (kg/m2 )

2
24

22 DA<2.5 & FV<3 svgs/day 21

DA<2.5 & FV>=3 svgs/day <2.75
20 DA>=2.5 & FV<3 svgs/day
19 2.75-<3.25
DA>=2.5 & FV>=3 svgs/day
3.25+
18
9-10 11-12 13-14 15-16 17-18 19-20 17
Age (years) 9 10 11 12 13 14 15 16 17 18 19
Age (yrs)
Both higher dairy intake groups had lower BMI levels than those with lower dairy intakes DASH adherence score modified from Leviton (2009) NGHS

Adjusted for age, height, SES, race, activity, & TV watching Adjusted for age, height, race, socioeconomic status, activity level & tv/video hrs/day.
17 18 (NGHS)
NGHS Data

DASH Eating Pattern and Waist

Circumference Effect of DASH Diet on
Blood Lipid Levels
80

Adolescent Girls
78
W aist Circum ference (cm)

76

74

72

DA<2.5 & FV<3 svgs/day

70
DA<2.5 & FV>=3 svgs/day
68 DA>=2.5 & FV<3 svgs/day

DA>=2.5 & FV>=3 svgs/day

66
9-10 11-12 13-14 15-16 17-18 19-20
Age (years)

19 Adjusted for age, height, SES, race, activity, & TV watching

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Comparing DASH vs. Fruits/Veg. Diet Does the Effect of DASH on Lipids
Alone on Changes in Lipid Levels Differ by Presence of Inflammation?
10 Total Cholesterol 10
LDL Cholesterol

Treatment Effect (%)

Treatment Effect (%)

0.2 5 5
0 0
DASH FV
0.1 -5 -5
-10 -10
Mean change (mmol/L)

-15 Low CRP -15

0 Low CRP
Subjects were -20 High CRP -20
High CRP
-25 -25
-0.1 participants in Week 0 Week 4 Week 8 Week 12 Week 0 Week 4 Week 8 Week 12
original DASH
-0.2 trial

T reatm en t Effect (%)

10
-0.3 HDL Cholesterol Triglycerides

Treatment Effect (%)

5
40
30
0
20
-0.4 -5
10
-10
Low CRP 0
-15
-0.5 High CRP
-10 Low CRP
-20 -20
TC LDL HDL Trig TC LDL HDL Trig High CRP
-25 -30
Week 0 Week 4 Week 8 Week 12 Week 0 Week 4 Week 8 Week 12
DASH: 7% of calories from saturated fat vs. 14% in controls & 13% on FV diet
Data from original DASH-sodium trial
21 Obarzanek E, Am J Clin Nutr 2001;74:80-9 22 Erlinger et al. Circulation 2003;108:150-154

DASH Eating Pattern and LDL in DASH Eating Pattern and HDL in
Adolescent Girls Adolescent Girls
DA<2.5, FV<3 svgs/day 58
106
104 DA<2.5, FV>=3 svgs/day 57
DA>=2.5, FV<3 svgs/day
102 56
LDL (mg/dL)

DA>=2.5, FV>=3 svgs/day

HDL (mg/dL)

100 55
98 54
96 53
94 DA<2.5, FV<3 svgs/day
52 DA<2.5, FV >=svgs/day
92
51 DA>=2.5+, FV<3 svgs/day
90
DA>=2.5, FV>=3 svgs/day
50
9-10 11-12 13-14 15-16 17-21
Age (years)
9-10 11-12 13-14 15-16 17-20
Age (years)
NGHS

Adjusted for age, height, SES, race, activity, & TV watching Adjusted for age, height, SES, race, activity, & TV watching
23 24
NGHS

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Changes in Insulin Sensitivity: DASH

DASH and Diabetes-related Outcomes
vs. Established Diet (PREMIER Study)
Advice only
3.30 EST w/o DASH
EST + DASH
3.10

Insulin Sensitivity Index

2.90

2.70

2.50

2.30

2.10

1.90

1.70

1.50
Baseline 6 Months
Time

After adjusting for baseline differences, DASH group had 35% greater increase in
insulin sensitivity.
Ard et al. Diabetes Care 2004;27:340-347
26

Relative Risk of Type 2 Diabetes by

DASH Dietary Score DASH Diet and Bone Health
Adherence to DASH Plan
1.40
Mod High
1.20

1.00

0.80

0.60

0.40

0.20

0.00
All Whites Blacks/Hispanics

Adjusted for age, sex, education level, race/ethnicity, glucose tolerance, family hx diabetes,
smoking, energy intake, energy expenditure, BMI, insulin sensitivity, and insulin secretion

Limitations: (a) use of single FFQ, (b) scoring system for DASH DASH: high in calcium, potassium, mg, vitamin C, protein

27 Liese et al. Diabetes Care 2009;32:1434-1436

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Effect of DASH on Markers of Bone Summary – DASH in Adults

Formation & Resorption
40
In controlled trials, DASH reduces BP, LDL-cholesterol, and
CTX, DASH
30 OC, DASH markers of bone turnover while improving insulin sensitivity.
OC, Control

20
CTX, Control
DASH scoring systems show varying results in epi. studies
(which may reflect limitations of scoring system). Not know
% Change

10
whether some components should be weighted more heavily.
0

DASH eating pattern, especially when combined with other
-10 lifestyle changes, has beneficial effects on body composition
-20
Race-specific effects need further study.
-30

DASH plan likely to reduce risk of developing Htn, CVD,
Baseline Period 1 Period 2 Period 3
CTX = C-terminal telopeptide of type 1 collagen Each sodium period = 30 days
osteoporosis and perhaps diabetes and CHF.
OC = osteocalcin 3 sodium intake levels: 50, 100, 150 mmol/d

29 * Lin,P.H., J Nutr 2003; 133:3130-36 30

Summary – DASH for Children Possible Mechanisms of Effect

Prospective studies show higher combined intakes of dairy &
FV led to lower gains in SBP & DBP throughout childhood
& adolescence

DASH intervention in adolescents with elevated BP lowered
SBP without lowering BMI

Higher intakes FV & dairy led to lower gains in BMI, % body
fat (BIA) & waist circumference, independent of activity

Higher intakes of FV & dairy led to substantially lower LDL
and TC levels, without lowering HDL. No beneficial effects
on triglyceride levels.

Adherence to DASH is very low in African-American teens.
Thus data are inadequate to draw conclusions at this time.
31

DASH eating pattern may displace other food components
that could have adverse effects

DASH, especially when combined with other lifestyle
changes, may lead to weight loss, thereby benefiting BP,
lipids, insulin sensitivity, and other CVD risk

DASH may lead to greater adherence
 Simplify the message (fruits, vegetables, dairy)
 Palatability
32

8

Mechanisms of Effect (2)

Potassium, calcium, magnesium – each of these nutrients has
been found to have anti-hypertensive effects through several
possible mechanisms
 Alterations in sodium balance and renal clearance of sodium
 Adverse effects of sodium imbalance on sympathetic nervous
system & renin-angiotensin system (e.g., vasoconstriction)
 Stimulation of calcium regulatory hormones (e.g., PTH), thereby
affecting vascular resistance
 Effects of calcium on “agouti” gene (expressed in adipose
tissue) which stimulates calcium influx into cells

Fiber and/or glycemic index of DASH foods
33
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Mechanisms of Effect (3)

Bioactive peptides derived from milk proteins (casein and whey)
inhibit the function of ACE (an enzyme that plays a crucial role in
the renin-angiotensin system. Inhibition of the ACE pathway
reduces sodium retention, thereby lowering BP

Higher intake of proteins may promote muscle anabolism or
reduce catabolism, thus preserving lean mass under weight loss
conditions (reducing BP, insulin resistance)

Glutamate – primary (vegetable) dietary amino acid may counteract
oxidative stress & enhance nitric oxide’s hypotensive effects

Plant polyphenols (e.g., flavonoids) have anti-oxidant properties
that lead to reduced inflammation and oxidative stress (associated
with hyperlipidemia). This beneficial effects of FV polyphenols on
inflammation & oxidative stress shown even in adolescents. (Holt,
JADA, 2009)
34
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Percent of Adults with Hypertension whose

Diet Resembles DASH Eating Pattern
15
15

Before DASH recommendations

NHANES:
NHANES: 1999-2004
1988-1994
Percent Concordance

10
10

5
5

16% 13%

0
0 0 1 2 3 4 5 6 7 8 9
0 1 2 3 4 5 6 7 8 9
DASH Score
DASH Score

Mellen PB, Arch. Intern. Med 2008;168(3):308-314

10