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intervention study. Obes Metab 16. Koloverou E, Esposito K, Giugliano effects of the Mediterranean : Greek 2010;12:204–209 D, Panagiotakos D. The effect of EPIC prospective cohort study. BMJ on the development of 2009;338:b2337 11. Toobert DJ, Glasgow RE, Strycker LA, mellitus: a meta-analysis of et al. Biologic and quality-of-life outcomes 10 prospective studies and 136,846 partici- 22. Bozzetto L, Alderisio A, Giorgini M, et from the Mediterranean Lifestyle Program. pants. Metabolism 2014;63:903–911 al. Extra-virgin olive oil reduces glycemic Diabetes Care 2003;26:2288–2293 response to a high-glycemic index meal 17. Bantle AE, Chow LS, Steffen LM, et al. in patients with type 1 diabetes: a ran- 12. Itsiopoulos C, Brazionis L, Kaimakamis Association of Mediterranean diet and car- domized controlled trial. Diabetes Care M. Can the Mediterranean diet lower diorespiratory fitness with the development 2016;39:518–524 HbA1c in type 2 diabetes? Results from a of pre-diabetes and diabetes: the Coronary randomized cross-over study. Nutr Metab Artery Risk Development in Young Adults 23. Academy of and Dietetics. Cardiovasc Dise 2011;21:740–747 (CARDIA) study. BMJ Open Diabetes Res Diabetes type 1 and 2 systematic review Care 2016:4:e000229 and guidelines, 2015 [Internet]. Available 13. Toobert DJ, Strycker LA, King 18. Salas-Salvadó J, Bulló M, Babio N, from http://www.andeal.org/topic. DK, et al. Long-term outcomes from cfm?menu=5305. Accessed 11 November a multiple-risk-factor diabetes trial for et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: 2016 Latinas: ¡Viva Bien! Transl Behav Med results of the PREDIMED-Reus nutrition 2011;1:416–426 24. Mayo Clinic. Mediterranean diet intervention randomized trial. Diabetes for health [Internet]. Available from 14. Esposito K, Maiorino MI, Petrizzo M, Care 2011;34:14–19 www.mayoclinic.org/healthy-lifestyle/ Bellastella G, Giugliano D. The effects of 19. Martinez-González MÁ, de la Fuente- nutrition-and-healthy-eating/in-depth/ a Mediterranean diet on need for diabetes Arrillaga C, Nunez-Cordoba JM, et al. mediterranean-diet/art-20047801?pg=2. drugs and remission of newly diagnosed Adherence to Mediterranean diet and risk Accessed 11 November 2016 type 2 diabetes: follow-up of a randomized of developing diabetes: prospective cohort 25. EatingWell. 8 ways to follow the trial. Diabetes Care 2014;37:1824–1830 study. BMJ 2008;336:1348–1351 Mediterranean diet for better health 15. Huo R, Du T, Xu Y, et al. Effects of 20. Esposito K, Chiodini P, Maiorino MI, [Internet]. Available from www. Mediterranean-style diet on glycemic et al. Which diet for prevention of type 2 eatingwell.com/healthy_cooking/ control, weight loss and cardiovascular diabetes? A meta-analysis of prospective healthy_cooking_101_basics_techniques/ risk factors among type 2 diabetes indi- studies. Endocrine 2014;47:107–116 shopping_cooking_guides/8_ways_to_ viduals: a meta-analysis. Eur J Clin Nutr 21. Trichopoulou A, Bamia C, follow_the_Mediterranean_diet. 2015:69:1200–1208 Trhiuchopoulos D. Anatomy of health Accessed 11 November 2016

DASH Eating Plan: An Eating Pattern for Diabetes Management Amy P. Campbell

■ IN BRIEF The DASH (Dietary Approaches to Stop ) eating plan is an acceptable eating pattern for people who have diabetes. In addition to promoting control, this eating pattern has been shown to improve insulin resistance, hyperlipidemia, and even overweight/. This Good Measures, LLC, Boston, MA balanced approach promotes consumption of a variety of foods (whole grains, Corresponding author: Amy P. Campbell, fat-free or low-fat dairy products, fruits, vegetables, poultry, fish, and nuts) and [email protected] is appropriate for the entire family. https://doi.org/10.2337/ds16-0084 he U.S. Department of Agri- Guidelines. Specifically, three food pat- ©2017 by the American Diabetes Association. culture (USDA) has described terns have been developed: the Healthy Readers may use this article as long as the work is properly cited, the use is educational and not Tseveral food patterns designed U.S.-Style Pattern, the Healthy for profit, and the work is not altered. See http:// creativecommons.org/licenses/by-nc-nd/3.0 to help people follow the recom- Vegetarian Pattern, and the Healthy for details. mendations set forth in its Dietary Mediterranean-Style Pattern. The

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American Diabetes Association, in its a diastolic blood pressure of 80–95 calorie needs. Based on the above 2013 position statement “Nutrition mmHg. Subjects in the study ini- recommendations, Table 1 provides Therapy Recommendations for tially followed a control diet low in examples of daily and weekly serv- the Management of Adults With fruits, vegetables, and dairy products, ings that meet DASH targets for a Diabetes,” also promotes the use of a along with a fat intake of 37% of cal- 2,000-calorie eating plan (7,8). variety of eating patterns to help with ories (representative of the typical In terms of macronutrient com- the management of diabetes (1). American diet). After 3 weeks of this position, the nutrient goals of the One of the eating patterns pro- run-in diet, subjects were random- DASH eating pattern are as follows: moted in these recommendations ized to one of the following diets for • Total fat: 27% of calories is the DASH (Dietary Approaches 8 weeks: the control diet, a diet rich • Saturated fat: 6% of calories to Stop Hypertension) plan. This in fruits and vegetables, or a diet that • Protein: 18% of calories eating plan is one of several eating combined fruits, vegetables, and low- • Carbohydrates: 55% of calories patterns that is appropriate for dia- fat dairy foods. Body weight, physical • Cholesterol: 150 mg

betes educators to recommend to activity, and sodium intake were held • Sodium: 2,300 mg (A lower goal FROM RESEARCH TO PRACTICE their patients with diabetes. This constant during the trial. of 1,500 mg sodium was tested dietary approach is a nutritious, bal- The combination diet reduced and found to be even better for anced, and sustainable eating plan systolic blood pressure by 5.5 mmHg lowering blood pressure, partic- that can improve a number of health and diastolic blood pressure by 3.0 ularly for middle-aged and older parameters, including hypertension, mmHg, whereas the fruits and veg- individuals, African Americans, insulin resistance, hyperlipidemia, etables diet reduced systolic blood and those who already had high and overweight/obesity. People with pressure by 2.8 mmHg and dia- blood pressure [9].) diabetes have a higher risk of develop- stolic blood pressure by 1.1 mmHg. • Potassium: 4,700 mg ing hypertension than people without Subgroup analyses showed that • Calcium: 1,250 mg diabetes; in addition, the percentage African Americans and individuals • Magnesium: 500 mg of adults with diabetes ≥18 years of with hypertension showed the great- • Fiber: 30 g age who have hypertension was 57.1% est reductions in blood pressure (3). The DASH eating pattern is in 2009 compared to 46.2% in 1995 DASH Diet: What Is It? (2). Clearly, efforts to help prevent closely aligned with the USDA’s The NHLBI, part of the National and manage hypertension must be dietary recommendations, as outlined Institutes of Health (NIH), promotes increased, especially in the diabetes in the 2015–2020 Dietary Guidelines the DASH diet, or eating pattern, as a population. for Americans. As described in chapter means of preventing and controlling The appeal of the DASH eating 1 of the USDA guidelines, the “Key blood pressure without the use of pattern for patients is that it is also Recommendations” for healthy eat- medication. The DASH eating pat- practical; it does not require spe- ing patterns are as follows: tern is also promoted as a healthful cial foods or supplements, and it is • Consume a healthy eating pattern option for the general population an approach that is appropriate for that accounts for all foods and (4–6). patients’ entire family to follow. This beverages within an appropriate The DASH eating pattern pro- article introduces diabetes educators calorie level. motes blood pressure reduction by to the DASH eating pattern in more • A healthy eating pattern includes: encouraging the consumption of ❍❍ detail, providing the evidence behind A variety of vegetables from foods that are low in saturated fat, the plan and suggesting practical tips all of the subgroups—dark total fat, cholesterol, and sodium and for introducing the DASH eating green, red and orange, legumes high in potassium, calcium, magne- plan to patients. (beans and peas), starchy, and sium, fiber, and protein. In terms of other Overview of the DASH Trial actual food choices, the DASH eating ❍❍ Fruits, especially whole fruits The DASH eating plan was developed pattern encourages whole grains, fat- ❍❍ Grains, at least half of which as an approach to help lower blood free or low-fat dairy products, fruits, are whole grains pressure without the use of medica- vegetables, poultry, fish, and nuts. ❍❍ Fat-free or low-fat dairy, tion. A multicenter trial, funded by Foods that are limited include fatty including milk, yogurt, cheese, the National Heart, Lung, and Blood meats, full-fat dairy products, tropi- and/or fortified soy beverages Institute (NHLBI) and published in cal oils (e.g., coconut, palm, and palm ❍❍ A variety of protein foods, 1997, was conducted to study the kernel oils), and sweets and sugar- including seafood, lean meats effects of dietary patterns on blood sweetened beverages. and poultry, eggs, legumes pressure in 459 adults with a systolic The number of servings of foods (beans and peas), nuts, seeds, blood pressure of <160 mmHg and is based on a person’s estimated and soy products

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TABLE 1. Examples of Daily and Weekly Servings That Meet ❍❍ Oils DASH Targets for a 2,000-Calorie Eating Plan (7,8) • A healthy eating pattern limits: ❍❍ Saturated fats and trans fats, Food Group Daily Servings Serving Sizes (except as noted) added sugars, and sodium Grains and grain 7–8 1 slice bread Key Recommendations that are products 1 cup ready-to-eat quantitative are provided for several cereal* components of the diet that should be 1/2 cup cooked rice, limited. These components are of par- pasta, or cereal ticular public health concern in the Lean meats, poultry, ≤2 3 oz cooked lean meat, United States, and the specified limits and fish skinless poultry, or fish can help individuals achieve healthy eating patterns within calorie limits: Vegetables 4–5 1 cup raw leafy < vegetable • Consume 10% of calories per day from added sugars 1/2 cup cooked • Consume <10% of calories per vegetable day from saturated fats 6 oz vegetable juice • Consume <2,300 mg per day of Fruit 4–5 1 medium piece of fruit sodium 1/4 cup • If alcohol is consumed, it should 1/2 cup fresh, frozen, be consumed in moderation—≤1 or canned fruit drink per day for women and ≤2 6 oz fruit juice drinks per day for men—and only by adults of legal drinking age Low-fat or fat-free dairy 2–3 8 oz milk foods 1 cup yogurt Both the USDA dietary guide- 1 1/2 oz cheese lines and the DASH eating pattern Nuts, seeds, and dry 4–5 per week 1/3 cup or 1 1/2 oz nuts strongly encourage the intake of beans vegetables, fruits, whole grains, and 1 Tbsp. or 1/2 oz seeds lower-fat dairy products, while limit- 1/2 cup cooked dry ing the intake of sugars, saturated fat, beans and sodium (5). Fats and oils† 2–3 1 tsp. soft margarine DASH–Sodium Trial 1 tsp. low-fat mayonnaise Interestingly, although the DASH diet was not low in sodium (provid- 2 Tbsp. light salad dressing ing 2,400 mg of sodium per day), blood pressure was still reduced. To 1 tsp. vegetable oil understand the effect of sodium re- Sweets ≤5 per week 1 Tbsp. sugar striction, the DASH–Sodium trial 1 Tbsp. jelly or jam was conducted. This trial included 1/2 oz jelly beans 412 subjects who were randomized to a control diet or the DASH diet 8 oz lemonade for 90 days. Within each group, sub- Sodium†† <2,300 mg Total from prepared/ jects were then assigned to three diets: packaged foods and added during cooking a high-sodium diet (3.5 g/day), a or at the table moderate-sodium diet (2.3 g/day), or a low-sodium diet (1.2 g/day), each *Serving sizes vary between 1/2 and 1 1/4 cups. Check product nutrition for 30 days. For those on the DASH labels. diet, the greater the reduction in so- †Fat content changes serving counts for fats and oils (e.g., 1 Tbsp. regular dium, the greater was the reduction salad dressing is 1 serving, whereas 1 Tbsp. low-fat salad dressing is 1/2 in blood pressure, although there was serving, and 1 Tbsp. fat-free salad dressing is 0 servings). no significant difference on diastol- ††Limiting sodium to 1,500 mg daily lowers blood pressure even further than ic blood pressure between the high- 2,300 mg sodium daily (8). and moderate-sodium intake levels. Furthermore, lowering sodium intake

78 SPECTRUM.DIABETESJOURNALS.ORG c a m p b e l l to 1.2 g/day would be challenging, Is the DASH eating pattern ben- DASH Eating Pattern in given the amount of sodium used by eficial for people who have diabetes? Gestational Diabetes the food industry in food processing As previously mentioned, the DASH A healthy eating plan is a key factor in (4,10). eating pattern can provide upwards the management of gestational diabe- of 55% of calories from carbohydrate, tes mellitus (GDM); specifically, the OmniHeart Study which may be too high a carbohy- goal is to prevent or reduce adverse The OmniHeart (Optimal Macro- drate intake for some people with maternal and newborn outcomes nutrient Intake Trial for Heart type 2 diabetes. Furthermore, there without instigating any short-term Health) study compared three heart- is little research demonstrating the harmful effects. Various dietary ap- healthy diets that were known to low- glycemic benefits of the DASH eating proaches have been studied, includ- er blood pressure and improve blood plan for people who have diabetes. ing a low–glycemic index (GI) diet, a lipids. These three diets were based Yet, in one study of 31 subjects with low-carbohydrate diet, and a calorie- on the DASH diet but differed in the type 2 diabetes (14), the DASH eat- restricted diet. In a systematic review amount of carbohydrate, protein, and

ing plan did improve blood lipids and and meta-analysis of randomized FROM RESEARCH TO PRACTICE unsaturated fat, while being equiva- blood pressure while also decreasing clinical trials of dietary interventions lent in calories. The higher protein A1C (by 1.7 percentage points) and in GDM, Viana et al. (19) conclud- (25 vs. 15% of calories) and higher fasting blood glucose levels (by 29%). ed that, although the low-GI eating unsaturated fat (10 vs. 8% of calo- Of note, De Paula et al. (15) found plan was associated with less frequent ries) diets showed the most benefit on that fruits and vegetables were the insulin use and lower birth weight blood pressure and blood lipids and two food groups of the DASH eating than the other diets, the DASH diet reduced the estimated 10-year risk of plan that helped to lower blood pres- also holds promise for patients with heart disease compared to the higher- sure in a group of 225 subjects with GDM. In a small trial (20), women carbohydrate diet. Of note, the high- type 2 diabetes. with GDM followed the DASH diet er-protein diet emphasized plant However, the benefits of the for 4 weeks. The DASH diet during sources of protein, which have been DASH eating plan may be applicable pregnancy lowered insulin use, re- associated with reduced blood pres- to people who have type 2 diabetes in duced cesarean rates, and lowered sure (11). Although the OmniHeart other ways. For example, the diets of birth weights. Although the DASH study was not specifically geared to- women in the Nurses’ Health Study approach looks promising for the ward diabetes or glycemic manage- and the Nurses’ Health Study II, and management of GDM, further re- ment, the fact that heart disease is the of men in the Health Professionals search is warranted, as, in this study, leading cause of death among people Follow-Up Study were measured the diet was not followed throughout with diabetes makes its results appli- every 4 years. Adherence scores the pregnancies and deliveries. cable to this population. were computed for the Alternate Mediterranean Diet, the Alternate DASH Eating Pattern for DASH Eating Pattern for Health Eating Index–2010, and Diabetes Prevention Diabetes the DASH diet. Improvement in The DASH eating plan or DASH-like The DASH eating pattern has prov- all three of these scores was associ- eating plans have also led to improve- en to be beneficial for those who are ated with less weight gain, especially ments in insulin sensitivity, further aiming to control or prevent hyper- in younger women or overweight demonstrating that this type of eating tension. Nearly two out of three indi- individuals (16). Weight control is plan may be helpful for individuals viduals with diabetes have hyperten- linked with improved glycemic con- with prediabetes or who are at risk sion (12), so it is reasonable to expect trol in people with type 2 diabetes for type 2 diabetes (21,22). A meta- that the DASH eating plan would be (17). Interestingly, the DASH diet analysis (23) of prospective cohort of benefit for people who have both is ranked by U.S. News & World studies looked at the differences hypertension and diabetes. In a study Report as being “#1 in best diets over- among various diets’ effects in pre- by Paula et al. (13), 40 patients with all” for helping to manage not only venting type 2 diabetes. The au- type 2 diabetes and uncontrolled blood pressure but also weight (18). thors concluded that several diets, blood pressure were randomized to Although the DASH eating pattern is including the DASH diet and the either the DASH diet and increased not specifically aimed at weight loss, Mediterranean diet, were associated physical activity or a control diet and its emphasis on fruits and vegetables, with a 20% decrease in the risk of fu- instructions to maintain their usual lower-fat dairy foods, and reduced ture type 2 diabetes. level of physical activity. Reductions consumption of and sweets The ADA’s nutrition recommen- in blood pressure were greater in the can be beneficial for patients who are dations for adults with diabetes state intervention group compared to the aiming to lose weight or maintain that “there is no ‘ideal’ conclusive control group. their weight at a healthy level. eating pattern that is expected to

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benefit all individuals with diabetes” ❍❍ Consider eating smaller • Discuss tips for dining out because (1). Different types of eating patterns more frequently during the day typical restaurant meals tend to and macronutrient distributions have ❍❍ Limit intake of fatty meats, be high in sodium and saturated been shown to lead to improvements high-fat dairy, and added fats fat, and portions are often large. in glycemic control (24). Given the ❍❍ Drink water or seltzer water Helpful hints include requesting proven health benefits of the DASH instead of sweetened beverages that foods be prepared without eating plan, along with its recom- ❍❍ Aim for at least 150 min/week added salt, asking for sauces and mendation to consume a variety of of physical activity, or about 30 salad dressings on the side, sub- healthful foods, one could infer that min daily on most days of the stituting a vegetable for a refined the DASH eating plan is appropriate week carbohydrate food, limiting bread, for those who have diabetes. • To help meet blood glucose and drinking water or seltzer, and eat- Practical Considerations A1C targets, help patients set ing half of the meal and taking the How can you help your patients get appropriate meal and snack car- rest home for another meal. bohydrate goals. Adjust goals, as started with the DASH eating plan? The DASH eating plan is easily Although this eating plan is healthful needed, based on achievement of pre- and postmeal targets. When adaptable to other styles of eating and for anyone, it is particularly aimed dietary preferences, including vege- at helping those with prehyperten- patients begin this eating plan, suggest that they check their blood tarian, vegan, gluten-free, and kosher. sion or hypertension. A first step is Again, a referral to an RD may be to refer your patients to a registered glucose levels more frequently than usual to learn how this plan warranted for more specific guidance (RD), preferably one who on adapting different styles of eating. has experience working with people affects their glycemic control. who have diabetes. are • Discuss the benefits of planning especially skilled at determining the meals ahead of time to help meet Duality of Interest right “fit” of an eating plan for a spe- DASH plan and weight goals. No potential conflicts of interest relevant to this article were reported. cific patient, taking into account fac- Using a shopping list can help tors such as level of glycemic control, with meal planning and also help References to ensure that healthful foods are other health issues, lifestyle factors, 1. Evert AB, Boucher JL, Cypress M, et al. cultural factors, and personal pref- purchased. Nutrition therapy recommendations for erence. Once it has been determined • If patients are unfamiliar with the management of adults with diabetes. that the DASH eating plan is indeed healthful cooking methods or Diabetes Care 2013;36:3821–3842 cooking in general, suggest that 2. Centers for Disease Control and a good fit for a patient, the following Prevention. Age-adjusted percentage of tips can help ensure success: they watch healthy cooking vid- adults aged 18 years or older with diagnosed • Determine the appropriate cal- eos (available online on YouTube) diabetes who have hypertension, United or even sign up for a cooking class. States, 1995–2009 [Internet]. Available from orie level for the patient, based https://www.cdc.gov/diabetes/statistics/ on overall health and nutrition • Help patients set small goals on comp/fig8.htm. Accessed 16 December 2016 a weekly basis to include a fruit goals. The DASH eating plan 3. Harsha DW, Lin PH, Obarzanek E, can be geared to individuals for and/or vegetable at each meal and Karanja NM, Moore TJ, Caballero B; whom weight loss is a goal. The snack. DASH Collaborative Research Group. • Encourage patients to aim for Dietary Approaches to Stop Hypertension: NIH offers a link on its website a summary study of results. J Am Diet that helps patients and health care eating at least one meatless meal Assoc 1999;99(Suppl. 8):S35–S39 professionals calculate a person’s each week. Meatless meals empha- 4. Sacks FM, Svetkey LP, Vollmer WM, et calorie needs (https://www.super- size plant-based protein sources, al. Effects on blood pressure of reduced including legumes, , tempeh, dietary sodium and the Dietary Approaches tracker.usda.gov/bwp/index.html). to Stop Hypertension (DASH) diet. N Engl In addition, the publication Your and meat substitutes such as soy- J Med 2001;344:3–10 Guide to Lowering Blood Pressure based veggie burgers. Examples 5. U.S. Department of Health and Human with DASH, which can be printed of tasty vegetarian meals are bean Services, U.S. Department of Agriculture. free of charge from http://www. chili, beans and rice, tofu and veg- 2015–2020 Dietary Guidelines for Americans. 8th ed. Available from http://health.gov/ nhlbi.nih.gov/health/resources/ etable stir-fry, and lentil soup. dietaryguidelines/2015/guidelines. Accessed heart/hbp-dash-index, provides • Provide healthful recipes or refer 16 December 2016 serving sizes and food choices for patients to the recipe section of 6. Appel LJ, Sacks FM, Carey VJ, et al. various calorie levels. Your Guide to Lowering Blood Effects of protein, monounsaturated • If weight loss is a goal, encourage Pressure with DASH, the free fat, and carbohydrate intake on blood pressure and serum lipids: results of the patients to: online publication mentioned OmniHeart Randomized Trial. JAMA ❍❍ Reduce portion sizes previously. 2005;294:2455–2464

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7. National Heart, Lung, and Blood 13. Paula TP, Viana LV, Neto AT, Leitao usnews.com/best-diet/dash-diet. Accessed Institute. Description of the DASH eating CB, Gross JL, Azevedo MJ. Effects of the 16 December 2016 plan [Internet]. Available from https://www. DASH diet and walking on blood pres- 19. Viana LC, Gross JL, Azevedo MJ. nhlbi.nih.gov/health/health-topics/topics/ sure in patients with type 2 diabetes and Dietary intervention in patients with dash. Accessed 27 August 2016 uncontrolled hypertension: a random- gestational diabetes: a systematic review ized controlled trial. J Clin Hypertens 8. National Heart, Lung, and Blood and meta-analysis of randomized clinical 2015;17:895–901 Institute. Your guide to lowering your blood trials on maternal and newborn outcomes. pressure with DASH [Internet]. Available 14. Azadbakht L, Fard NR, Karimi M, et Diabetes Care 2014;37:3345–3355 from www.nhlbi.nih.gov/health/resources/ al. Effects of the Dietary Approaches to heart/hbp-dash-index. Accessed 27 August Stop Hypertension (DASH) eating plan on 20. Asemi Z, Samimi M, Tabassi Z, 2016 cardiovascular risks among type 2 diabetic Esmaillzadeh A. The effect of DASH diet on pregnancy outcomes in gestational diabetes: 9. National Heart, Lung, and Blood patients: a randomized crossover clinical Institute. Your guide to lowering your blood trial. Diabetes Care 2011;34:55–57 a randomized controlled clinical trial. Eur J Clin Nutr 2014;68:490–495 pressure with DASH: what is the DASH 15. De Paula TP, Steemburgo T, de Almeida eating plan? [Internet] Available from http:// JC, Dall’Alba V, Gross JL, de Azevedo MJ. 21. Ley, SH, Hamdy O, Mohan V, Hu FB. www.nhlbi.nih.gov/health/resources/heart/ The role of Dietary Approaches to Stop Prevention and management of type 2 dia- hbp-dash-how-plan-html. Accessed 27 Hypertension (DASH) groups in betes: dietary components and nutritional

August 2016 FROM RESEARCH TO PRACTICE blood pressure in type 2 diabetes. Br J Nutr strategies. Lancet 2014;383:1999–2007 10. Whelton PK, He J, Appel LJ, et al. 2012;108:155–162 22. Ard JD, Grambow SC, Liu D, Slentz Primary prevention of hypertension: 16. Fung TT, Pan A, Hou T, et al. Long-term CA, Kraus WE, Svetkey LP. The effect of clinical and public health advisory from the PREMIER interventions on insulin sen- the national High Blood Pressure Program. change in diet quality is associated with sitivity. Diabetes Care 2004;27:340–347 JAMA 2002;288:1882–1888 body weight change in men and women. J Nutr 2015;145:1850–1856 23. Esposito K, Chiodini P, Maiorino MI, 11. Appel LJ, Moore TJ, Obarzanek E, et al.; DASH Collaborative Research Group. 17. Rock CL, Flatt SW, Pakiz B, et al. Bellastella G, Panagiotakos D, Guigliano A clinical trial of the effects of dietary Weight loss, glycemic control and cardio- D. Which diet for prevention of type 2 patterns on blood pressure. N Engl J Med vascular disease risk factors in response to diabetes? A meta-analysis of prospective 1997;336:1117–1124 differential diet composition in a weight studies. Endocrine 2014;47:107–116 loss program in type 2 diabetes: a ran- 12. American Diabetes Association. High 24. Wheeler ML, Dunbar SA, Jaacks LM, et domized controlled trial. Diabetes Care blood pressure [Internet]. Available from al. Macronutrients, food groups, and eating 2014;37:1573–1580 http://www.diabetes.org/are-you-at-risk/ patterns in the management of diabetes: a lower-your-risk/bloodpressure.html. 18. U.S. News & World Report. DASH diet systematic review of the literature, 2010. Accessed 27 August 2016 [Internet]. Available from http://health. Diabetes Care 2010;35:434–445

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