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Recommendations Summary

HTN: DASH Dietary Pattern 2015

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    HTN: DASH Diet

    The registered dietitian nutritionist (RDN) should counsel on a Dietary Approaches to Stop Hypertension (DASH) dietary pattern plus reduced sodium intake for blood pressure (BP) reduction in adults with hypertension (HTN). Research indicates that in adults with pre-hypertension and HTN, the DASH dietary pattern, compared with the typical American diet lowered systolic blood pressure (SBP) by 5mm Hg to 6mm Hg and diastolic blood pressure (DBP) by 3mm Hg. Reducing sodium intake in those consuming the typical American diet or DASH diet also lowered BP. DASH in combination with a reduced sodium diet lowered BP more than reduced sodium intake alone. The effect was greater in those with HTN.

    Rating: Strong
    Imperative

    HTN: DASH Diet and Weight Reduction

    For overweight or obese adults with HTN, the RDN should counsel on a calorie-controlled DASH dietary pattern for weight management and BP reduction. Research indicates that the DASH diet with a sodium range of 1, 500mg to 2, 400mg reduced systolic blood pressure (SBP) by 2mm Hg to 11mm Hg and diastolic blood pressure (DBP) by 0mm Hg to 9mm Hg in overweight or obese hypertensive adults, regardless of anti-hypertensive medications. DASH plus weight reduction resulted in greater reductions in SBP of 11mm Hg to 16mm Hg and DBP of 6mm Hg to 10mm Hg than weight reduction alone.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no potential risks or harms associated with the application of this recommendation.

    • Conditions of Application

      The recommendation HTN: DASH Diet and Weight Reduction applies only to overweight or obese adults with hypertension.

    • Potential Costs Associated with Application

      There are no costs associated with the application of this recommendation.

    • Recommendation Narrative

      DASH 

      The following evidence to support the DASH recommendation is based on the 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Eckel et al, 2014):

      Blood Pressure

      • ES3. When all food was supplied to adults with BP 120mm Hg to 159/80mm Hg to 95mm Hg and both body weight and sodium intake were kept stable, the DASH dietary pattern, compared with a typical American diet of the 1990s, lowered BP by 5mm Hg to 6mm Hg (SBP) /3mm Hg (DBP) – Strength of Evidence: High
      • ES5. Reducing sodium intake lowers BP in adults with either pre-hypertension or hypertension who are eating either the typical American diet or the DASH dietary pattern. The effect is greater in those with hypertension. Strength of Evidence: High
      • ES6. In adults 22 years to 80 years of age with BP 120mm Hg to 159mm Hg (SBP)/80mm Hg to 95mm Hg (DBP), the combination of reduced sodium intake plus eating the DASH dietary pattern lowers BP more than reduced sodium intake alone. Strength of Evidence: Moderate.
      DASH Diet and Weight Reduction

      A total of nine studies were included in the evidence analysis supporting the HTN: DASH Diet and Weight Reduction recommendation:
      • Seven positive quality randomized controlled trials (RCTs) (Azadbakht et al, 2005; Blumenthal et al, 2010; Elmer et al, 2006; Epstein et al, 2012; Kirpizidis et al, 2005; Nowson et al, 2005; Nowson et al, 2009)
      • One positive quality randomized crossover trial (Al-Solaiman et al, 2010)
      • One neutral quality randomized crossover trial (Huggins et al, 2011).
      There were no studies that met the search inclusion criteria for normal weight adults with HTN. All studies were of overweight and obese adults.
      • Nine studies provide evidence that the DASH diet with a sodium range of 1, 500mg to 2, 400mg reduced SBP by 2mm Hg to 11mm Hg and DBP by 0mm Hg to 9mm Hg in overweight or obese adults with hypertension regardless of anti-hypertensive medications. DASH plus weight loss resulted in reductions in SBP of 11mm Hg to 16mm Hg and DBP of 6mm Hg to 10mm Hg. 
        • In two studies, DASH was compared to interventions that increased potassium and magnesium intake through supplementation (Al-Solaiman et al, 2010) or by diet (Huggins et al, 2011)
        • Three studies included sodium reduction to 1, 500mg (Huggins et al, 2011; Kirzipidis et al, 2005; Nowson et al, 2009), two kept intake at 3, 000mg to 3, 600mg per day (Al-Solaiman et al, 2010; Nowson et al, 2005) and the remaining trials limited intake to 2, 300mg to 2, 800mg per day
        • Two studies evaluated DASH compared to controls who received no dietary advice (Kirzipidis et al, 2005) or advice on a healthy diet including sodium reduction (Nowson et al, 2009). SBP and DBP reductions were observed. No significant (NS) differences were observed between those receiving or not receiving anti-hypertensive therapy.
        • Two studies found that the DASH diet resulted in significant reductions in SBP and DBP. Relative to potassium, magnesium and fiber supplementation, the DASH diet resulted in a greater reduction in SBP and DBP (Al-Solaiman et al, 2010). In contrast, dietary advice to increase intake of foods high in potassium and magnesium and decrease sodium intake to approximately 1, 500mg (Huggins et al, 2011) vs. the DASH diet with approximately 2, 600mg sodium resulted in similar significant reductions of SBP, and non-significant (NS) changes in DBP. Urinary potassium and magnesium excretion were similar during each diet intervention period and were significantly different from the control period. 
      • Four studies evaluated the effect on BP of a DASH diet in combination with weight reduction diet (Azadbakht et al, 2005; Blumenthal et al, 2010; Elmer et al, 2006; Nowson et al, 2005):
        • DASH plus weight reduction resulted in significantly greater differences in BP reductions compared to controls than weight reduction alone in two studies (Azadhbakht et al, 2005; Nowson et al, 2005). Nowson et al, 2009 found that weight loss explained 7% and 6%, respectively, of the variance in SBP and DBP reduction with a DASH diet compared to a reference healthy diet, although weight loss was not a component of the intervention.
        • Elmer et al, 2006 found NS differences in BP changes between those following DASH plus established recommendations (weight reduction, sodium reduction) and established recommendations only 
        • Blumenthal et al,  2010 found that DASH plus weight reduction resulted in significantly greater reductions in SBP and DBP compared with DASH alone.   

    • Recommendation Strength Rationale

      • Conclusion statements from the AHA/ACC Prevention Guideline supporting HTN: DASH Diet – Strength of Evidence: High, High, Moderate
      • Conclusion statement for DASH Diet and Weight Reduction is Grade I.


       

    • Minority Opinions

      None.