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The DASH Diet David M CHAPTER 89 THE DASH DIET David M. Lessens, MD, MPH • David Rakel, MD WHAT IS THE DASH DIET? BESIDES LOWERING SODIUM, BY WHAT DASH stands for Dietary Approaches to Stop Hyper- OTHER MEANS MIGHT THE DASH DIET tension. This eating plan was initially developed to BENEFIT HEALTH? lower blood pressure,1 but it has since been found to modify several disease risk factors and outcomes, Oxidative stress refers to one’s ability to detoxify the including improvements in cholesterol levels and insu- products of cellular damage. Much of this damage is lin sensitivity. This diet favors meals that are low in caused by inflammation, which plays a foundational role animal and dairy fat and rich in fruits, vegetables, and in many chronic diseases, including obesity. In a small whole grains. It is a well-balanced diet that can be fol- study, investigators found that the DASH diet decreased lowed by everyone, including those in low socioeco- blood pressure and enhanced antioxidant capacity, espe- nomic strata,2 to help lead a healthy lifestyle (Table cially in obese individuals.4 In another study, researchers 89.1). It is similar to the antiinflammatory diet discussed found lower levels of proinflammatory markers, includ- in Chapter 88. ing C-reactive protein and interleukin-6, among those consuming this diet.5 Researchers have postulated the importance of potas- HOW MUCH CAN I EXPECT MY BLOOD sium, magnesium, and fiber in the DASH diet’s role in PRESSURE TO COME DOWN? lowering blood pressure. One crossover study, for exam- ple, had obese and lean individuals consume a usual diet, Two sentinel studies have investigated how adher- the DASH diet, and a usual diet supplemented with spe- ence to the DASH diet can reduce blood pressure. The cific amounts of potassium, magnesium, and fiber match- original study,1 which took place among four academic ing those of the DASH diet. Each eating plan was also health care centers, divided subjects into three groups: matched for calcium and sodium. After 3 weeks, only one ate a normal American diet, one ate an American obese individuals adhering to the DASH diet showed an diet but with more fruits and vegetables, and one ate the improvement in blood pressure and endothelial func- DASH diet. In those eating the DASH diet and with no tion. The study’s investigators concluded that nutritional high blood pressure, the average systolic value dropped factors other than these five must be contributing to the by 5.5 mm Hg and the diastolic value by 3 mm Hg. For observed health benefits, and these remain a topic of fur- those who already had high blood pressure, the systolic ther investigation.6 value dropped by 11.6 mm Hg and the diastolic value The DASH diet also contains nitrate-rich root veg- by 5.3. Blood pressure also dropped in the group eat- etable like beets, carrots, and turnips. Consuming nitrates – ing more fruits and vegetables, but not as much. Fur- (NO3 ) from such sources may increase the body’s avail- thermore, these changes occurred after just 2 weeks on able nitric oxide (NO), which may lead to vasodilation – the diet. and decreased blood pressure. Ingested nitrates (NO3 ) 3 – The second DASH trial examined the effect of a are reduced to nitrites (NO2 ) by enteral bacteria and reduced dietary sodium intake (at three separate levels: then are reabsorbed by the intestines and excreted in the 3300, 2300, or 1500 mg daily) as participants consumed stool (the reason manure is such a good fertilizer, which is a normal American diet or followed the DASH eating rich in nitrites). Nitrites are further reduced in the endo- plan. Results showed that reducing dietary sodium low- thelium to NO (Fig. 89.1). ered blood pressure for both eating plans, but at each In a study of 72 hypertensive patients, 36 were given level, blood pressure was lower for those on the DASH 250 mL of beetroot juice once daily (6.4 mmol nitrate) eating plan. These studies emphasize and highlight that and 36 were given a nitrate-free beetroot juice pla- nutritional features of the DASH diet may play a role in cebo. The 24-hour blood pressure monitoring showed reducing blood pressure, apart from reducing sodium sustained reductions of 7.7 mm Hg in systolic pres- consumption. sure and 5.2 mm Hg in diastolic pressure in the treat- ment group. This is just slightly less than the average blood pressure drop with single antihypertensive drug In those with high blood pressure, the DASH diet on an therapy (9.1 mm Hg/5.5 mm Hg). The nitrate-rich average lowered systolic blood pressure by 11.6 mm Hg and beetroot juice also improved endothelial function by diastolic blood pressure by 5.3 mm Hg. ∼20%.7 878 Downloaded for Aman Shah ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on December 21, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. 89 THE DASH DIET 879 TABLE 89.1 The DASH Diet Significance of Each Daily Food Group in the Food Group Servings Serving Sizes Examples and Notes Dash Eating Plan Grains and grain 7–8 1 slice bread Whole wheat bread, English muffin, Major sources of products 1 oz dry cereal* pita bread, bagel, cereals, grits, energy and fiber ½ cup cooked rice, pasta, or oatmeal, crackers, unsalted cereal pretzels, and popcorn Vegetables 4–5 1 cup raw leafy vegetables Tomatoes, potatoes, carrots, green Rich sources of ½ cup cooked vegetables peas, squash, broccoli, turnip potassium, 6 oz vegetable juice greens, collards, kale, spinach, magnesium, and artichokes, green beans, lima fiber beans, sweet potatoes Fruits 4–5 6 oz fruit juice Apricots, bananas, dates, grapes, Important sources 1 medium fruit oranges, orange juice, grapefruit, of potassium, ¼ cup dried fruit grapefruit juice, mangoes, melons, magnesium, and ½ cup fresh, frozen, or peaches, pineapples, prunes, fiber canned fruit raisins, strawberries, tangerines Low-fat or fat-free 2–3 8 oz milk Fat-free (skim) or low-fat (1%) milk, Major sources of dairy foods 1 cup yogurt fat-free or low-fat buttermilk, fat- calcium and protein 1.5 oz cheese free or low-fat regular or frozen yogurt, low-fat and fat-free cheese Meats, poultry, 2 or less 3 oz cooked meats, poultry, Select only lean; trim away visible Rich sources of protein and fish or fish fat; broil, roast, or boil instead of and magnesium frying; remove skin from poultry 1 Nuts, seeds, and 4–5 per 1.5 oz or ⁄3 cup nuts Almonds, filberts, mixed nuts, Rich sources of dry beans week ½ oz or 2 tbsp seeds peanuts, walnuts, sunflower seeds, energy, magnesium, ½ cup cooked dry beans kidney beans, lentils potassium, protein, and peas and fiber Fats and oils† 2–3 1 tsp soft margarine Soft margarine, low-fat mayonnaise, DASH has 27% of its 1 tbsp low-fat mayonnaise light salad dressing, vegetable calories from fat, 2 tbsp light salad dressing oil (such as olive, corn, canola, or including that in or 1 tsp vegetable oil safflower) added to foods Sweets 5 per week 1 tbsp sugar Maple syrup, sugar, jelly, jam, fruit- Sweets should be low 1 tbsp jelly or jam flavored gelatin, jelly beans, hard in fat ½ oz jelly beans candy, fruit punch, sorbet, ices 8 oz lemonade *Equals ½–1¼ cup, depending on cereal type. Check the product’s nutrition label.†Fat content changes serving counts for fats and oils. For example, 1 tbsp of regular salad dressing equals one serving; 1 tbsp of a low-fat dressing equals ½ serving; 1 tbsp of a fat-free dressing equals zero servings. From the Dietary Approaches to Stop Hypertension study, as published by the Joint National Committee on Prevention, Detection, Evalu- ation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordination Committee. The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med. 1997;157:2413–2446. total cholesterol, low-density lipoprotein, weight, tri- Proton pump inhibitors reduce enzymes (DDAH, ADMA) that are needed to make nitric oxide. Taking this class of glycerides, and fasting blood glucose concentration, medicines may negate the beneficial influence vegetables while raising high-density lipoprotein. Although the have on blood pressure and may help explain the increased magnitude of the effects varied by sex, they were positive risk for myocardial infarction seen with long-term use of in both groups.8 An investigation of 31 type 2 diabetic this class of medicine. H2 blockers do not inhibit these individuals also found favorable changes in these param- enzymes. eters, including hemoglobin A1c (decrease of 1.7),9 and adherence to this diet may actually have the potential to prevent type 2 diabetes.10 Interestingly, the lipid- and glucose-lowering effects of the DASH diet seem to be BESIDES LOWERING BLOOD PRESSURE, independent of sodium intake, which again supports the notion that this eating plan works through several nutri- HOW ELSE DOES THIS DIET AFFECT tional mechanisms.9 CARDIOVASCULAR HEALTH? In a retrospective analysis using data from the Nurses’ Health Study, a DASH score was composed A study of 116 men and women with metabolic syndrome on the basis of foods that individuals had consumed. In showed that consuming a DASH diet versus a control comparing the top and bottom 20% on the basis of this diet can reduce most of the metabolic risks, including score, the investigators found a nearly 50% decrease in Downloaded for Aman Shah ([email protected]) at Elsevier - Demonstration Account from ClinicalKey.com by Elsevier on December 21, 2017.
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