Abstract
The Dietary Approaches to Stop Hypertension (DASH) trial showed that a diet rich in fruits, vegetables, low-fat dairy products with reduced total and saturated fat, cholesterol, and sugar-sweetened products effectively lowers blood pressure in individuals with prehypertension and stage I hypertension. Limited evidence is available on the safety and efficacy of the DASH eating pattern in special patient populations that were excluded from the trial. Caution should be exercised before initiating the DASH diet in patients with chronic kidney disease, chronic liver disease, and those who are prescribed renin-angiotensin-aldosterone system antagonist, but these conditions are not strict contraindications to DASH. Modifications to the DASH diet may be necessary to facilitate its use in patients with chronic heart failure, uncontrolled diabetes mellitus type II, lactose intolerance, and celiac disease. In general, the DASH diet can be adopted by most patient populations and initiated simultaneously with medication therapy and other lifestyle interventions.
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Yoon SS, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and its treatment and control, 1999–2008. NCHS Data Brief. 2010;48:1–8.
Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch Intern Med. 1993;153(5):598–615.
Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration. Lancet. 2000;356(9246):1955–64.
Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997;336(16):1117–24.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289(19):2560–72.
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens. 2004;18(3):139–85.
Program CHE. 2010 Canadian hypertension education program recommendations. An annual update. Can Fam Physician. 2010;56(7):649–53.
Sacks FM, Rosner B, Kass EH. Blood pressure in vegetarians. Am J Epidemiol. 1974;100(5):390–8.
Wright A, Burstyn PG, Gibney MJ. Dietary fibre and blood pressure. Br Med J. 1979;2(6204):1541–3.
Obarzanek E, Velletri PA, Cutler JA. Dietary protein and blood pressure. JAMA. 1996;275(20):1598–603.
Kesteloot H, Joossens JV. Relationship of dietary sodium, potassium, calcium, and magnesium with blood pressure. Belgian Interuniversity Research on Nutrition and Health. Hypertension. 1988;12(6):594–9.
Joffres MR, Reed DM, Yano K. Relationship of magnesium intake and other dietary factors to blood pressure: the Honolulu heart study. Am J Clin Nutr. 1987;45(2):469–75.
Margetts BM, Beilin LJ, Vandongen R, Armstrong BK. A randomized controlled trial of the effect of dietary fibre on blood pressure. Clin Sci (Lond). 1987;72(3):343–50.
Swain JF, Rouse IL, Curley CB, Sacks FM. Comparison of the effects of oat bran and low-fiber wheat on serum lipoprotein levels and blood pressure. N Engl J Med. 1990;322(3):147–52.
Whelton PK, Appel L, Charleston J, Dalcin AT, Ewart C, Fried L, et al. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. Results of the Trials of Hypertension Prevention, Phase I. JAMA. 1992;267(9):1213–20.
Wang Y, Wang QJ. The prevalence of prehypertension and hypertension among US adults according to the new joint national committee guidelines: new challenges of the old problem. Arch Intern Med. 2004;164(19):2126–34.
Vasan RS, Larson MG, Leip EP, Evans JC, O'Donnell CJ, Kannel WB, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18):1291–7.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. 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. 2002;360(9349):1903–13.
Cooper R, Rotimi C. Hypertension in blacks. Am J Hypertens. 1997;10(7 Pt 1):804–12.
• Moranne O, Froissart M, Rossert J, Gauci C, Boffa JJ, Haymann JP, et al. Timing of onset of CKD-related metabolic complications. J Am Soc Nephrol. 2009;20(1):164–71. This study shows the onset of various CKD-related metabolic complications at different levels of GFR.
Kidney Disease Outcomes Quality Initiative. K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(5 Suppl 1):S1–290.
Kidney Disease Outcomes Quality Initiative. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis. 2000;35(6 Suppl 2):S1–140.
Levey AS, Greene T, Beck GJ, Caggiula AW, Kusek JW, Hunsicker LG, et al. Dietary protein restriction and the progression of chronic renal disease: what have all of the results of the MDRD study shown? Modification of Diet in Renal Disease Study group. J Am Soc Nephrol. 1999;10(11):2426–39.
Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330(13):877–84.
Locatelli F, Alberti D, Graziani G, Buccianti G, Redaelli B, Giangrande A. Prospective, randomised, multicentre trial of effect of protein restriction on progression of chronic renal insufficiency. Northern Italian Cooperative Study Group. Lancet. 1991;337(8753):1299–304.
Ganesh SK, Stack AG, Levin NW, Hulbert-Shearon T, Port FK. Association of elevated serum PO(4), Ca x PO(4) product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients. J Am Soc Nephrol. 2001;12(10):2131–8.
• Levitan EB, Wolk A, Mittleman MA. Consistency with the DASH diet and incidence of heart failure. Arch Intern Med. 2009;169(9):851–7. This large prospective, observational study shows that diets consistent with the DASH diet are associated with lower rates of heart failure in at risk adults.
Levitan EB, Wolk A, Mittleman MA. Relation of consistency with the dietary approaches to stop hypertension diet and incidence of heart failure in men aged 45 to 79 years. Am J Cardiol. 2009;104(10):1416–20.
Lopes HF, Martin KL, Nashar K, Morrow JD, Goodfriend TL, Egan BM. DASH diet lowers blood pressure and lipid-induced oxidative stress in obesity. Hypertension. 2003;41(3):422–30.
Lin PH, Allen JD, Li YJ, Yu M, Lien LF, Svetkey LP. Blood pressure-lowering mechanisms of the DASH dietary pattern. J Nutr Metab. 2012;2012:472396.
Haider AW, Larson MG, Franklin SS, Levy D. Systolic blood pressure, diastolic blood pressure, and pulse pressure as predictors of risk for congestive heart failure in the Framingham Heart Study. Ann Intern Med. 2003;138(1):10–6.
Akita S, Sacks FM, Svetkey LP, Conlin PR, Kimura G. Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the pressure-natriuresis relationship. Hypertension. 2003;42(1):8–13.
Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114(1):82–96.
Liu LC, Voors AA, van Veldhuisen DJ, van der Veer E, Belonje AM, Szymanski MK, et al. Vitamin D status and outcomes in heart failure patients. Eur J Heart Fail. 2011;13(6):619–25.
Gotsman I, Shauer A, Zwas DR, Hellman Y, Keren A, Lotan C, Admon D. Vitamin D deficiency is a predictor of reduced survival in patients with heart failure; vitamin D supplementation improves outcome. Eur J Hear Fail. 2012;14(4):357–66.
Dobnig H, Pilz S, Scharnagl H, Renner W, Seelhorst U, Wellnitz B, et al. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality. Arch Intern Med. 2008;168(12):1340–9.
Schleithoff SS, Zittermann A, Tenderich G, Berthold HK, Stehle P, Koerfer R. Vitamin D supplementation improves cytokine profiles in patients with congestive heart failure: a double-blind, randomized, placebo-controlled trial. Am J Clin Nutr. 2006;83(4):754–9.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16(6):e1–194.
Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1–90.
Dunn SP, Bleske B, Dorsch M, Macaulay T, Van Tassell B, Vardeny O. Nutrition and heart failure: impact of drug therapies and management strategies. Nutr Clin Pract. 2009;24(1):60–75.
• Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344(1):3–10. This is a multi-center, randomized, controlled feeding study shows that the DASH diet plus sodium reduction reduces blood pressure greater than either intervention alone. This is the only study to make this comparison.
American Diabetes Association. Standards of medical care in diabetes--2012. Diabetes Care. 2012;35 (Suppl 1):S11–63.
Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31 Suppl 1:S61–78.
• Appel LJ, Sacks FM, Carey VJ, Obarzanek E, Swain JF, Miller ER, 3rd, et al. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005;294(19):2455–64. This randomized, crossover feeding study shows that a diet consistent with the DASH diet that partially substitutes carbohydrates with monounsaturated fat reduces blood pressure in adults with prehypertension and stage I hypertension. This is the only study to make this comparison.
Franz M, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, et al. American Diabetes Association position statement: evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. J Am Diet Assoc. 2002;102(1):109–18.
The Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes. Recommendations for the nutritional management of patients with diabetes mellitus. Eur J Clin Nutr. 2000;54(4):353–5.
Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care. 2003;26(8):2261–7.
Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev. 2009;1:CD006296.
O'Shea RS, Dasarathy S, McCullough AJ. Alcoholic liver disease. Hepatology. 2010;51(1):307–28.
O'Brien A, Williams R. Nutrition in end-stage liver disease: principles and practice. Gastroenterology. 2008;134(6):1729–40.
Plauth M, Merli M, Kondrup J, Weimann A, Ferenci P, Muller MJ. ESPEN guidelines for nutrition in liver disease and transplantation. Clin Nutr. 1997;16(2):43–55.
Runyon BA. Management of adult patients with ascites due to cirrhosis: An update. Hepatology. 2009;49(6):2087–107.
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53(3):397–417.
Stollman NH, Raskin JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 1999;94(11):3110–21.
Scrimshaw NS, Murray EB. The acceptability of milk and milk products in populations with a high prevalence of lactose intolerance. Am J Clin Nutr. 1988;48(4 Suppl):1079–159.
Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamliyan TA, Kane RL, et al. Systematic review: effective management strategies for lactose intolerance. Ann Intern Med. 2010;152(12):797–803.
Benjamin RM. Dietary guidelines for Americans, 2010: the cornerstone of nutrition policy. Public Health Rep. 2011;126(3):310–1.
Barton SH, Kelly DG, Murray JA. Nutritional deficiencies in celiac disease. Gastroenterol Clin North Am. 2007;36(1):93–108. vi.
Thompson T. Gluten contamination of commercial oat products in the United States. N Engl J Med. 2004;351(19):2021–2.
Miller 3rd ER, Erlinger TP, Young DR, Jehn M, Charleston J, Rhodes D, et al. Results of the diet, exercise, and weight loss intervention trial (DEW-IT). Hypertension. 2002;40(5):612–8.
• Blumenthal JA, Babyak MA, Hinderliter A, Watkins LL, Craighead L, Lin PH, et al. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch Intern Med. 2010;170(2):126–35. This randomized, controlled study of overweight and obese adults shows that the DASH diet plus weight loss causes greater reduction in blood pressure than the DASH diet alone.
Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA. 2003;289(16):2083–93.
Svetkey LP, Pollak KI, Yancy Jr WS, Dolor RJ, Batch BC, Samsa G, et al. Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients. Hypertension. 2009;54(6):1226–33.
Ahuja TS, Freeman Jr D, Mahnken JD, Agraharkar M, Siddiqui M, Memon A. Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors. Am J Nephrol. 2000;20(4):268–72.
• Jain N, Kotla S, Little BB, Weideman RA, Brilakis ES, Reilly RF, et al. Predictors of hyperkalemia and death in patients with cardiac and renal disease. Am J Cardiol. 2012;109(10):1510–3. This retrospective analysis of 15,803 patients with cardiovascular disease (defined as hypertension and heart failure) shows that chronic kidney disease, diabetes mellitus, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists are significant predictors of hyperkalemia.
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Tyson, C.C., Nwankwo, C., Lin, PH. et al. The Dietary Approaches to Stop Hypertension (DASH) Eating Pattern in Special Populations. Curr Hypertens Rep 14, 388–396 (2012). https://doi.org/10.1007/s11906-012-0296-1
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DOI: https://doi.org/10.1007/s11906-012-0296-1