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Learn about the DASH diet and dairy's role in it.

Learn about the DASH diet and dairy's role in it.

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  • Greet audience/Thank you for inviting me to talk about dairy products and the DASH eating plan.
  • The DASH eating plan is considered one of the dietary eating patterns that exemplify the 2005 Dietary Guidelines for Americans.
    Research continues to emerge on the DASH eating plan’s benefits to not only hypertensives but those with other conditions such as high cholesterol, metabolic syndrome and poor bone health.
    As you’ll see in the presentation, DASH’s benefits can be seen in children and adolescents that are overweight or obese.
    As we look to the 2010 Dietary Guidelines for Americans, we may see an increased emphasis on the DASH eating plan, with low-fat dairy products as one of its cornerstones, in part due to dairy’s unique nutrient package – especially calcium, potassium and magnesium.
  • Findings by NHLBI show:
    Blood pressure decreases with the DASH eating plan:
    Decrease intake of saturated fat, cholesterol and total fat
    Emphasize fruit, vegetables and low-fat or fat-free milk and milk products
  • 73 million Americans
    1 in 3 adults (age 20 and older) have high blood pressure
    Up from 1 in 4 in 2001
    >40% of African-Americans
    >One-quarter unaware
    Increased risk for heart disease, stroke, cardiac/kidney failure
    $69.4 billion in healthcare costs
    Hypertension – which is defined as a blood pressure reading of 140/90 or greater - is a serious health problem among Americans – and one with serious ramifications if not controlled.
    According to the American Heart Association, an estimated 73 million Americans age 20 and older have high blood pressure. That represents an alarming one-third of the adult population. (http://www.americanheart.org/presenter.jhtml?identifier=212)
    Of those with hypertension, more than a quarter or 28% of people are unaware they have the condition, meaning they’re not receiving necessary treatment. (http://www.americanheart.org/presenter.jhtml?identifier=212)
    If uncontrolled, hypertension can lead to coronary heart disease, stroke, cardiac failure, or kidney failure. Even patients with high-normal blood pressure (systolic pressure of 130 to 139 and diastolic pressure of 85 to 89) bear a high cardiovascular risk. (http://www.americanheart.org/presenter.jhtml?identifier=2129)
    The Framingham Heart Study showed that men and women with high-normal blood pressure had a 1-1/2 to 2-1/2 times greater risk of heart attack, stroke or heart failure than those with optimal blood pressure. (New England Journal of Medicine, Nov. 1, 2001)
    According to American Academy of Pediatrics, about five of every hundred children have higher than normal blood pressure, although fewer than one in a hundred has medically significant hypertension. (AAP, Parenting Corner Q&A, High Blood Pressure, http://www.aap.org/publiced/BK0_HighBloodPressure.htm)
    Health care costs related to hypertension are staggering. For instance, the estimated direct and indirect cost of high blood pressure, such as physician fees and medications, and indirect costs such as lost wages and lowered productivity, in 2008 is $69.4 billion. (AHA “Heart and Stroke Statistics – 2008 Update”)
  • Considering these health and economic consequences, it’s not surprising that preventing hypertension is a public health priority.
    For instance, one of the goals of the US Department of Health and Human Service’s Healthy People 2010 is to reduce the proportion of adults with high blood pressure from 28% to 16% of adults.
    Healthy People 2010 also outlines goals for:
    Increasing awareness and detection
    Improving control
    Reduce the associated CVD risks
  • Research on the effectiveness of DASH in reducing blood pressure is so compelling that it has been acknowledged or incorporated into the dietary recommendations of government and health professional organizations.
    As a few examples:
    For instance, the National Heart, Lung, and Blood Institute’s 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure endorses the DASH diet as a means to obtain adequate intakes of calcium, magnesium, and potassium to prevent and manage hypertension.
    An American Heart Association Scientific Statement, “Dietary Approaches to Prevent and Treat Hypertension,” reviews the substantial body of evidence indicating that multiple dietary factors affect blood pressure. In addition to weight loss and moderating alcohol consumption, the paper supports the consumption by all Americans of “an overall healthy dietary pattern called the DASH diet” to both reduce and treat high blood pressure.
    DASH is one example of a balanced eating plan that exemplifies the 2005 Dietary Guidelines.
    Recommends increasing consumption of low-fat and fat-free milk and milk products, fruits, vegetables and whole grains
    Recommends 3 servings of low-fat and fat-free milk and milk products
    The American Dietetic Association supports DASH with research in JADA and DASH fact sheets.
    National Medical Association supports DASH with new fact sheet.
    American Academy of Pediatrics supports DASH in Dietary Recommendations for Children and Adolescents: Pediatrics, Feb 2006
  • Research supported by the National Heart Lung and Blood Institute has shown that the DASH eating plan (Dietary Approaches to Stop Hypertension) can lower blood pressure and LDL cholesterol which can reduce your risk for heart disease.
    This eating pattern is rich in low-fat dairy products, fruits and vegetables. Specifically, the DASH diet is low in fat and saturated fat and includes three servings of low-fat and fat-free milk and milk products such as milk, yogurt and cheese and eight to 10 servings of fruits and vegetables in a 2,000 calorie plan. It is one example of an eating plan that incorporates the recommendations of the Dietary Guidelines for Americans.
    The DASH eating plan provides nutrients that are often in short supply in the American diet, including calcium, potassium, fiber and magnesium, as well as vitamins A, C and E.
    DASH is unique because it works by adding delicious foods like these to the diet, rather than just restricting or eliminating foods as some dietary approaches often recommend.
  • Here is a summary of the total DASH eating plan pattern
    The goals of this diet design include:
    Create patterns that would have blood-pressure lowering benefit of the vegetarian diet, yet contain enough animal products to make them palatable to nonvegetarians.
    Contain a nutrient profile consistent with studies that had reduced blood pressure.
    Contain commonly available foods that are not supplemented with nutrients beyond what would normally be added as part of common food manufacturing practice.
  • Here is additional information on DASH nutrients found in dairy foods.
    Potassium:
    DASH eating plan recommendation: 4700mg
    Average intake: 2617mg
    Magnesium
    DASH eating plan recommendation: 500mg
    Average intake: 286mg
    What We Eat in America, NHANES 2001-2002, 2005-2006: Usual Nutrient Intakes from Food Compared to Dietary Reference Intakes;http://www.ars.usda.gov/foodsurvey
  • According to the American Heart Association, more than 40 percent of African-Americans have hypertension. Hypertension develops earlier in life in blacks than in whites and is often more severe.
    Men see a higher risk of hypertension in younger years, however, after menopause, women’s chance of getting high blood pressure increases considerably.
    With more than 15 percent of school-aged children diagnosed as overweight or obese, the risk of developing high blood pressure when they grown up increases significantly.
    Statistics according to American Heart Association, Source: NCHS and NHLBI on 3 measures of blood pressure
  • In 2003, the categories of blood pressure changed replacing “high-normal” with prehypertension, indicating the path from elevated blood pressure levels to hypertension. To be considered normal, your systolic and diastolic pressures must fall within the recommended ranges.
    For prehypertension and hypertension, you fall into those categories if your systolic or diastolic pressure is high.
    Also, if your blood pressure is in the pre-hypertensive category, don’t assume it’s low enough to ignore. Only one out of two adults has blood pressure low enough to be considered normal. To prevent blood pressure levels from rising with age (therefore preventing cardiovascular disease, kidney disease and stroke), those with pre-hypertension should initiate primary prevention measures, which we will discuss shortly.
  • In this landmark study, authors conclude: “In the subjects with hypertension, the reduction in blood pressure with the combination diet (-11.4/5.5 mmHg) was similar in magnitude to that observed in trials of drug monotherapy for mild hypertension. Hence, following the DASH combination diet might be an effective alternative to drug therapy in people with stage I hypertension and might prevent or delay the initiation of drug therapy in people with blood pressure levels that straddle the thresholds for drug treatment.” (Appel, et al., NEJM, 1997)]
  • The DASH Trial was unique in that it was the first large-scale trial in the US to examine how blood pressure was affected by specific dietary patterns that included readily-available foods, instead of examining the effects of individual nutrients.
    Investigators planned the DASH diet to be fully compatible with dietary recommendations for reducing risk of CVD, osteoporosis and cancer
    The results of the first DASH trial were published in 1997 in the New England Journal of Medicine.
    This multicenter trial was sponsored by the National Heart, Lung, and Blood Institute.
    The subjects were 459 adults, of which about half (49%) were women and 60% were African Americans.
    Their systolic blood pressure was less than 160 mm Hg and their diastolic blood pressure was 80-95 mm Hg.
  • DASH participants were first fed the control diet during a 3-week run-in period during which individual energy needs to maintain weight were determined.
    After the 3 week run-in, participants were randomized into one of three diets to see if blood pressure levels would differ between the diets. (The next slides will give more detail about the dietary patterns.)
    The calorie intake of participants was adjusted to ensure they maintained a constant weight (not gain or lose weight). People were asked not to change their usual physical activity patterns, which could confound results.
    Sodium was held constant at 3 grams per day across all three diets.
    This level represents a balance between national recommendations and current US consumption.
  • Here is a summary of the results for the Combination diet:
    Blood pressure dropped quickly - within two weeks – and remained lower as long as participants stayed on the diet, in this case 6 weeks of the study.
    In both normotensive and hypertensive subjects, the Combo diet decreased blood pressure more than the other two diets.
    For stage 1 hypertensives on the Combo diet, blood pressure fell as much as with single drug therapy.
    Decreased blood pressure was independent of sodium intake or weight status
    Researchers estimate that if Americans eating a typical Western diet began eating “DASH style,” heart disease could be reduced by 15% and stroke by 27%. In addition, savings in healthcare costs are potentially substantial considering that 70% of hypertensive subjects following the DASH diet may no longer need high blood pressure medication.
    Those with high blood pressure at baseline showed greater blood pressure reductions than those with normal blood pressure at baseline.
    [The DASH diet produced the largest blood pressure reductions among subjects with hypertension. They experienced an average reduction of 11.4 points for systolic blood pressure and 5.5 points for diastolic blood pressure (Appel, et al., NEJM, 1997)
    The DASH diet was particularly effective in reducing blood pressure among African Americans, who are at higher risk for developing hypertension and its complications. The DASH diet lowered systolic blood pressure twice as much in African Americans – an average of 6.8 points, compared to 3.0 points in whites. (Appel, et al., NEJM, 1997))
  • Ok, here are the results.
    The Combination diet reduced systolic blood pressure by 5.5 mmHg more than did the Control diet.
    The Fruit and Vegetable diet reduced systolic blood pressure slightly more than the Control diet (2.8 mmHg), but the difference was not statistically significant.
    The Combination diet reduced systolic blood pressure significantly more than the Fruits and Vegetables diet.
  • Similar to the results for systolic blood pressure, the Combination diet reduced diastolic blood pressure significantly more than the Control diet (3 mmHg) and significantly more than the Fruits and Vegetables diet (1.9 mmHg).
  • Results showed that while the DASH diet significantly reduced blood pressure at all sodium levels when compared to the control diet, the largest reduction was found in the group following the DASH diet at the low sodium level of 1,500 mg/day.
    For the total group, this diet reduced systolic blood pressure by an average of 8.9 points and diastolic blood pressure by 4.5 points, compared to the typical American “control” diet with the high sodium level.
    Similar to results observed in the first DASH trial, the DASH diet at the low sodium level was most effective among subjects with hypertension and among African Americans. Compared to the typical American “control” diet with the high sodium level, the DASH diet at the low sodium level reduced systolic blood pressure by an average of 11.5 points in hypertensives and by 12.6 points in African Americans. This is similar to the results shown in the original DASH study.
  • As you can see from this slide, the greatest blood pressure reduction was achieved by going from a typical American diet (Control) to the DASH Combination diet (far left column). Reducing the sodium level of the DASH Combination diet to 2400 mg, and to 1500 mg reduced blood pressure only by another 1.3 mm Hg and 1.7 mm Hg.
  • A study published in 2007 examined the acceptability of the sodium-reduced research diets used in the DASH-Sodium Trial. Participants consumed in random order either the Control or DASH dietary patterns at all three sodium levels for 30 days each. At the beginning and end of each 30-day period they completed a questionnaire rating the acceptability of the diet on a 9-point scale.
    Overall, diet acceptability scores were about 15% higher for the DASH diet and its components (fruits, vegetables, and dairy foods) than the Control diet at all sodium levels.
    However, African Americans found the Control diet more acceptable than the DASH diet when compared with non-African Americans. African Americans consuming the Control diet rated the lower sodium level (1,500 mg/d) as the least acceptable. Non-African Americans rated the higher sodium level (3,500 mg/d) as the least acceptable.
    Overall, the intermediate sodium level (2,300 mg/d) received somewhat higher ratings of acceptability than the lower or higher sodium levels.
  • The PREMIER trial is a randomized clinical trial among 810 overweight adults with above optimal blood pressure (120-159/80-95 mmHg) which evaluated the effect on blood pressure of two multi-component behavioral interventions. It is the first trial to evaluate simultaneously the effects of weight loss, sodium reduction, increased physical activity, limited alcohol intake, and the DASH diet on blood pressure. PREMIER is the first trial to implement the DASH diet in free-living persons.
    Results showed that in all participants, the Established and Established + DASH interventions significantly reduced systolic and diastolic blood pressure in comparison to the advice group.
    In participants with either normal or high blood pressure, systolic and diastolic blood pressure reductions were the greatest in the Established + DASH group.
    Optimal blood pressure (<120/<80 mmHg) was achieved by 48% of participants in the Established + DASH group, and by 40% of those in the Established group.
  • 2 - Magnesium, calcium, and protein are nutrients that have been associated with improved insulin sensitivity. An ancillary study of PREMIER compared glucose tolerance and insulin sensitivity between the Advice Only, Established, and Established + DASH groups. Compared to the Advice group, insulin sensitivity improved significantly only in the EST + DASH group. [Ard JD, et al., Diabetes Care, 27: 340-347, 2004]
    3- Another PREMIER study assessed the impact of the interventions (Advice Only, Established, and Established + DASH) on blood pressure and other cardiovascular risk factors in those with and without the metabolic syndrome. Although both EST and EST + DASH reduced blood pressure, those in the EST group who had the metabolic syndrome responded more poorly. In contrast, in the EST + DASH group, those with and without metabolic syndrome responded in a similar way. In addition, the EST + DASH group, when compared to the advice only group, reduced diastolic blood pressure, total cholesterol, HOMA (indicator of insulin resistance), and fasting insulin, in those with and without the metabolic syndrome. [Lien LF, et al., Hypertension, 50: 609-616, 2007]
    4- The 2005 Dietary Guidelines for Americans recommends choosing foods low in energy density (kcal/gram) as a strategy for reducing energy intake. This study examined the effect of the dietary interventions used in the PREMIER trial (Advice, Established, Established + DASH) on dietary energy density and investigated whether changes in dietary energy density values over a period of 6 months were related to changes in weight/body composition, dietary, and health-related measures. Of the 3 groups, the EST + DASH group had the greatest reduction in energy density and thegreatest increase in the weight of food consumed (+30 gm/d). Participants with the largest reduction in energy density had the largest decrease in waist circumference and BMI. While decreasing their calorie intake by 500 kcals/day, they increased their intake of fiber, vitamins A, B6, C, and potassium. [Ledikwe JH, et al., Am J Clin Nutr, 85: 1212-1221, 2007]
    5- The PREMIER study documented the extent to which free-living individuals can achieve the DASH nutrient levels and the nutrient goals set by the current Dietary Reference Intakes at 6 and 18 months. Results showed that the EST + DASH “was more effective than EST in meeting DASH-specific targets and DRI recommendations for many nutrients.” At 6 months the EST + DASH participants had intake of total, saturated, monounsaturated, and polyunsaturated fats that were significantly lower and carbohydrate; fiber, riboflavin; vitamins A, B6, and C; beta-carotene; calcium; potassium; and magnesium that were significantly higher compared to the EST and the Advice Only groups. Most of these changes remained significant at 18 months. The Premier trial demonstrated that increasing dairy intake in the population is feasible. Nearly 60% of participants eating DASH diet met the dairy intake goal (2-3 servings), while only a third met the fruit/vegetable intake goal (9-12 servings). [Lin P-H, et al., J Am Diet Assoc, 107: 1541-1551, 2007]
  • DASH diet trumps low-fat diet for Reducing Blood Pressure in Overweight Adults
    In this 12-week clinical trial in 54 free-living overweight or obese men, Australian researchers randomly assigned the men to follow a low-fat diet or the DASH diet. The DASH diet group had significantly higher dairy food intakes than the low-fat diet group, but there was no difference in their fruit and vegetable intakes.
    Over the 3-month period, participants in both groups had comparable weight loss of about 11 pounds.
    The DASH diet group had a significantly greater decrease in both systolic and diastolic blood pressure than did the low-fat diet group. The percentage decrease in SBP was 5.5% in the DASH group compared with a 1.4% decrease in the low-fat group. The percentage decrease in DBP was 6.4% in the DASH group compared with 1.0% decrease in the low-fat group.
    The authors attribute the greater blood pressure reductions in the DASH group to a higher dairy intake, and particularly to their higher intakes of potassium and calcium.
  • Greater adherence to the DASH dietary pattern was associated with a lower risk of both CHD and stroke. 
    Women with the highest vs. lowest DASH score had a significant 24% lower risk for both fatal and non-fatal CHD.  The association was similar among women with and without a history of hypertension and among active and sedentary women.
    Women with the highest vs. the lowest DASH score had a significant 18% lower risk of stroke.  This association was stronger among women who smoked and those with hypertension. 
    In a subsample of the group, the DASH score was significantly associated with lower plasma levels of C-reactive protein and interleukin 6, which are markers for inflammation – now established as a pathway to atherosclerosis and cardiovascular disease. 
    This study, say the authors, “is the first to our knowledge to examine the association between a DASH-style diet and clinical CVD outcomes.”  They conclude, “A diet that resembles the DASH eating plan, with high intake of fruits, vegetables, and whole grains, moderate intake of legumes, nuts, and low-fat dairy products, and low intake of red and processed meats and sodium, was significantly associated with lower risk of CHD and stroke in women.”
  • A study published in 2000 in the journal Circulation suggests that following the DASH diet may reduce risk for heart disease by lowering abnormally high blood levels of the amino acid homocysteine. High homocysteine levels are associated with increased risk for heart disease and stroke.
    In this randomized, controlled feeding trial of 118 adults, following the DASH diet significantly reduced blood levels of homocysteine compared to a typical Western diet.
    Because high homocysteine levels are linked to inadequate intakes of the B-vitamins folate, vitamin B12 and vitamin B6, researchers speculate that the DASH diet reduces homocysteine because low fat dairy products, fruits and vegetables, such as milk, oranges, spinach and dry beans, are rich in these vitamins.
    Researchers estimate that reductions in homocysteine from following the DASH diet reduce heart disease by an additional 7% to 9% on top of the 15% to 27% reduction in heart disease and stroke resulting from DASH-induced decreases in blood pressure.
  • There’s more good news about DASH and heart health.
    A study published in 2001 in the American Journal of Clinical Nutrition showed that subjects following the DASH diet reduced their levels of total cholesterol an average of 13.7 points or 7.3% compared to control subjects eating a typical American diet.
    Subjects on DASH also lowered their LDL cholesterol by 10.7 points or 9% compared to controls.
    Regarding HDL cholesterol, DASH was associated with an average decrease of 3.7 points or 7.5%. A significant decrease in the LDL: HDL ratio was seen only in men. The researchers concluded that although this undesirable response needs further study, overall, the DASH diet affects coronary heart disease risk favorably, decreasing the 10-year risk of heart disease by 12.1%.
    (Obarzanek, et al., Am J Clin Nutr, 2001 Jul;74(1):80-9)
  • The DEW-IT was the first study to evaluate the effect of a comprehensive lifestyle intervention -- incorporating the DASH diet, reduced sodium (2300 mg/d), and weight loss and regular exercise – on blood pressure and other cardiovascular risk factors in 44 hypertensive and overweight adults who were taking a single blood pressure medication.
    Participants were randomly assigned to the intervention group (reduced calorie DASH diet with 1800 mg of sodium, and exercise for 9 weeks), or the control group (no intervention).
    At the end of the 9 week study, participants in the lifestyle group weighed on average ~11 pounds less than those in the control group. They also had net reductions in 24-hour ambulatory systolic and diastolic blood pressure of 9.5 mmHg and 5.3 mmHg, respectively. They also had significantly lower total, LDL, and HDL cholesterol (-25 mg/dL, -18 mg/dL, and -5 mg/dL, respectively).
  • The metabolic syndrome is characterized by a group of metabolic risk factors in one person. They include:
    Abdominal obesity (excessive fat tissue in and around the abdomen)
    Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)
    Elevated blood pressure
    Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar)
    Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood)
    Proinflammatory state (e.g., elevated C-reactive protein in the blood)
    People with the metabolic syndrome are at increased risk of coronary heart disease and other diseases related to plaque buildups in artery walls (e.g., stroke and peripheral vascular disease) and type 2 diabetes. The metabolic syndrome has become increasingly common in the United States. It’s estimated that over 50 million Americans have it.
    The dominant underlying risk factors for this syndrome appear to be abdominal obesity and insulin resistance. Insulin resistance is a generalized metabolic disorder, in which the body can’t use insulin efficiently. This is why the metabolic syndrome is also called the insulin resistance syndrome.
    Other conditions associated with the syndrome include physical inactivity, aging, hormonal imbalance and genetic predisposition.
  • A population based crossectional study by the same researchers among 827 adults in Tehran found that the highest vs. lowest intake of dairy foods was associated with significantly lower odds of having an enlarged waist circumference, hypertension, and the metabolic syndrome.  [Azadbakht L, et al., Dairy consumption is inversely associated with the prevalence of the metabolic syndrome in Tehranian adults, Am J Clin Nutr, 82: 523-530, 2005]
    Another study examined the effects of the DASH diet in subjects with metabolic syndrome. Compared with the control diet, the DASH diet led to increased HDL, lower triglycerides, lower blood pressure, weight loss, and reduced fasting blood glucose in both men and women. (Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F. Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome. Diabetes Care. 2005. 28:2823-2831)
  • In addition to having a beneficial effect on the regulation of blood pressure and circulating levels of homocysteine and cholesterol levels, the DASH diet could have a beneficial effect on calcium and bone metabolism. Many of the nutrients that are plentiful in the DASH diet, such as calcium, magnesium, potassium, and vitamin C, have important independent roles in bone health.
    A study published in the Journal of Nutrition evaluated the effects of the DASH diet compared with a control diet at three different sodium levels (high 3450 mg/d; intermediate 2300 mg/d; low 1150 mg/d) on markers of bone formation and resorption (breakdown) that make up bone turnover.
    After 30 days, the DASH diet significantly reduced bone turnover, which if sustained, say the authors, “may improve bone mineral status and ultimately reduce the risk of osteoporosis.”
    Though sodium intake was consistently associated with urinary calcium excretion, it did not consistently affect bone turnover.
    The positive effect of the DASH diet on bone turnover likely resulted from a number of factors, including higher calcium, potassium and magnesium intake, its lower acidity and possible fruit and vegetable derived antioxidants and phytochemicals.
  • The DASH eating plan was designed to stop hypertension, however, research supports DASH benefits beyond blood pressure.
  • Among non-Hispanic blacks age 20 and older, the following have HBP (defined as systolic pressure of 140 mm Hg or higher or diastolic pressure of 90 mm Hg or higher, or taking antihypertensive medicine or being told twice by a physician or other professional that you
    African Americans and Cardiovascular Diseases — Statistics 5
    have hypertension):
    ⎯ 42.6 percent of men.
    ⎯ 46.6 percent of women.
    (NHANES [1999-2004], NCHS, and NHLBI)
    .Among black adults age 20 and older, the following are overweight or obese (BMI of 25.0 kg/m2 and higher):
    ⎯ 67.0 percent of men.
    ⎯ 79.6 percent of women.
    Of these, the following are obese (BMI of 30.0 kg/m2 and higher):
    ⎯ 30.8 percent of men.
    ⎯ 51.1 percent of women.
    (NHANES 2001-04; National Center for Health Statistics. Health, United States, 2006. Unpublished data. NCHS data in adults are for age 20 and older..)
    Data from the NHLBI’s ARIC study found that hypertension was a particularly powerful risk factor for CHD in black persons, especially in black women.
  • Increased Incidences of Hypertension
    42.6 percent for African-American men vs 32.5 percent for non-Hispanic white men
    46.6 percent for African-American women vs 31.9 percent for Non-Hispanic white women
    Increased Incidences of Obesity
    67.0 percent of men vs 71 percent of Non-Hispanic white men
    79.6 percent of women vs 57.6 percent of Non-Hispanic white women
    Diabetes
    Diabetes: After adjusting for population age differences, 2004–2006 national survey data for people aged 20 years or older indicate that 6.6% of non-Hispanic whites, 7.5% of Asian Americans, 10.4% of Hispanics, and 11.8% of non-Hispanic blacks had diagnosed diabetes.
    Lower Calcium/Dairy Intake
    Calcium intake – 788mg African-Americans age 20+
    Calcium intake – 1006mg White age 20+
  • This slide illustrates that the magnitude of systolic blood pressure reduction with the Combination diet was twice as great in African Americans as in Whites and was greater for those with hypertension than for those with normal blood pressure at baseline.
    Svetkey, L.P., D. Simons-Morton, W.M. Vollmer, et al. Arch. Intern. Med. 159: 285, 1999
  • A similar pattern is seen for diastolic blood pressure.
  • Two studies demonstrate the importance of a diet rich in dairy foods, fruits, and vegetables for achieving a healthy blood pressure in children and adolescents.
    Research has shown that children who consistently eat more servings of dairy foods, fruits and vegetables had the lowest blood pressure levels over time. Conversely, those who ate the least amount of dairy foods, fruits and vegetables had the highest blood pressure levels over time.
    The DASH (Dietary Approaches to Stop Hypertension) Eating Plan is encouraged as one of the lifestyle modifications to help prevent and control high blood pressure in children. A DASH-type diet, rich in fruits, vegetables and low-fat dairy foods, was more effective than routine outpatient care at improving systolic blood pressure and diet quality in adolescents with elevated blood pressure.
    Moore study:
    This study used 8 years of data from 95 children initially 3 to 6 years old at enrollment in the prospective Framingham Children’s Study to estimate the independent and combined effects of fruits and vegetables and dairy products on childhood blood pressure from preschool to early adolescence.
    Results showed:
    Children who consumed either 4 or more servings per day of fruits and vegetables or 2 or more servings per day of dairy products during the preschool years had smaller increases in blood pressure per year. 
    By early adolescence, the combination of these food groups (fruits/vegetables and dairy products) had a greater beneficial impact on blood pressure than the food groups individually.
    These results indicate that a diet rich in fruits, vegetables, and dairy products as the DASH diet, has beneficial effects on blood pressure throughout childhood.
    [Moore, et al., Epidemiology, 16(1): 4-11, 2005]
  • This study examined the effectiveness of a 3 month clinic-based behavioral nutrition intervention emphasizing a diet high in fruits, vegetables, and low-fat dairy (DASH intervention) versus routine outpatient hospital-based nutrition care on diet and blood pressure in 57 adolescents 11-18 years with prehypertension or hypertension.  Participants were randomly assigned to follow a DASH-type diet or routine care (RC).  Both groups received a 60-minute counseling session with a dietitian.  The DASH diet was a slightly modified adult version to conform to the nutritional needs of adolescents with food serving recommendations at 3 calorie levels based on age and gender.  The dietary recommendations for the RC  group were consistent with the National High Blood Pressure Education Program’s pediatric dietary recommendations (reducing dietary sodium, limiting high fat foods, reducing portion sizes, eating nutrient-dense forms of foods), but did not specify calorie or serving recommendations.
     
    Results:  
    The DASH group had a greater decrease in systolic blood pressure from baseline to 3 months (post-treatment) when compared to the RC group (-7.9% vs. 1.5%, respectively)
    By post-treatment (6 months), 50% of the DASH group achieved blood pressure normalization versus 36% in the RC group.
    “Compared with RC participants, DASH adolescents had greater increases in potassium  (42%) and magnesium (36%) intake and lowered their intake of saturated fat.”
    [Couch SC, et al., J Pediatr, 152: 494-501, 2008] 
  • The National Heart, Lung and Blood Institute of the National Institutes of Health encourages all individuals to adopt lifestyle changes to prevent or manage high blood pressure.
    Of course, medications are sometimes required to control hypertension, but they are expensive and have potential side effects.
    They include losing weight; increasing physical activity; limiting alcohol consumption; reducing dietary sodium, total fat, saturated fat and cholesterol, and consuming enough calcium, potassium and magnesium.
  • The DASH diet as a whole was designed to be higher in potassium, magnesium, calcium, fiber, and protein and lower in saturated and total fats and cholesterol than typical U.S. consumption. A paper published in the Journal of the American Dietetic Association determined how various food groups contributed to the intakes of several essential nutrients in the DASH dietary pattern.
    Dairy foods were among the top sources of calcium, potassium, magnesium, zinc, and vitamin A in the DASH diet.
    Dairy foods contributed the most calcium to the DASH diet – about 60% of the total intake.
    Whole grains, vegetables and low-fat dairy foods contributed half of the potassium intake in the DASH diet.
    Most of the magnesium came from whole grains, fruits, vegetables, low-fat dairy foods, and nuts/seeds/legumes.
    Low-fat dairy foods were second only to whole grains as a source of zinc in the DASH diet.
    Vegetables, fruits, and low-fat dairy foods contributed nearly all of the vitamin A intake in the DASH diet.
    Dairy foods were among the top sources of the nutrients considered most important in blood pressure lowering – calcium, potassium, and magnesium.
  • National Dairy Council has created three advertorials that were placed in key HP publications last Spring. This one, geared toward adults, was placed in AAFP’s American Family Physician
    journal and the Journal of the American Dietetic Association in June.
  • This advertorial highlights the benefit of the DASH eating plan for African-Americans and appeared in the Journal of the American Medical Association ‘s July issue, distributed at their national conference in Atlanta.
  • Geared toward pediatricians treating children and adolescents at risk for hypertension, this advertorial appeared in AAP’s journal Pediatrics in June.
  • NDC worked with the American Dietetic Association on this fact sheet, which appeared in the June issue of JADA. A similar fact sheet on DASH is in the works with the National Medical Association
    and both of these fact sheets are being distributed at annual HP conferences.

Transcript

  • 1. The DASH Eating Plan The Role of Dairy and Dairy Nutrients in Promoting the Benefits of DASH 1
  • 2. The DASH Eating Plan 2
  • 3. Why DASH? 3
  • 4. Dietary Approaches to Stop Hypertension • Research has shown that the DASH Eating Plan can lower blood pressure. 4
  • 5. Why DASH? “If uncontrolled, hypertension can lead to coronary heart disease, stroke, cardiac failure, or kidney failure” 5
  • 6. Goal: Hypertension from 28% to 16% of adults. 6 U.S. Department of Health and Human Services. Healthy People 2010. January 2005.
  • 7. DASH: Recommended by 7
  • 8. DASH Eating Plan Basics 8
  • 9. DASH Eating Plan • Emphasizes nutrient-rich low-fat dairy products, fruits and vegetables • Consistent with the 2005 Dietary Guidelines • Provides nutrients of concern: calcium, potassium, fiber and magnesium, as well as vitamins A, C and E. • Positive approach - focused on what to include, not what to avoid 9 U.S. Department of Health and Human Services. Your Guide to Lowering Your Blood Pressure with DASH. 2nd Edition, April 2006
  • 10. DASH Eating Plan based on a 2,000 calorie diet Food Group Daily Servings Grains 6-8 Vegetables 4-5 Fruits 4-5 Low-fat or fat-free dairy products 2-3 Meats, poultry, fish 6 or less Nuts, seeds, dry beans and peas 4-5/week Fats and oils 2-3 Sweets 5 or less/week 10 U.S. Department of Health and Human Services. Your Guide to Lowering Your Blood Pressure with DASH. 2nd Edition, April 2006
  • 11. How Are Americans Doing? Fruits/Vegetables: DASH recommendation American average Milk Group Foods DASH recommendation American average 8-10 daily servings 3.04 daily servings 3.00 daily servings 1.7 daily servings Calcium Intake DASH trial American average 11 What We Eat in America, NHANES 2001-2002, 2005-2006: Usual Nutrient Intakes from Food Compared to Dietary Reference Intakes;http://www.ars.usda.gov/foodsurvey 1250mg daily 970mg daily
  • 12. DASH Eating Plan Benefits 12
  • 13. Hypertension/blood pressure Metabolic Syndrome 13 Heart Health & Stroke Bone Health
  • 14. coronary heart disease Hypertension stroke cardiac failure kidney failure A blood pressure reading of 140/90 mm/Hg or greater A serious health problem among Americans with ramifications if not controlled 14
  • 15. Who’s at Risk? African Americans Postmenopausal Women 15 American Heart Association; High Blood Pressure Statistics; www.americanheart.org, (7/08) Men Overweight children & adolescents
  • 16. Prevention is Key Systolic (mm Hg) Normal Prehypertension <120 and 120-139 <80 80-89 Hypertension Stage 1 Stage 2 16 Diastolic (mm Hg) 140-159 or >160 90-99 >100 JNC VII, Hypertension. 2003; 42:1206-1252
  • 17. What the Research Says 17
  • 18. DASH: Central to Prevention • Landmark study shows the DASH eating plan can help reduce blood pressure • In mild hypertension, DASH can be as effective as a single antihypertensive medication 18 Appel, et al., N Engl J Med, 1997
  • 19. DASH Trial DASH Trial • N = 459 adults • 49% women • 60% African Americans • Systolic < 160 mm Hg • Diastolic 80 – 95 mm Hg 19
  • 20. DASH Study Design • 3-week run-in on control diet • 8-week randomization to one of three diets: – Control – Fruits and vegetables – Combination: fruits, vegetables and low fat dairy products • Energy intake adjusted to ensure constant weight • Sodium content of all three diets was approximately 3000 mg/daily 20
  • 21. Results: Combination Diet with Low-fat Dairy = Greatest Blood Pressure Reduction • Quick and lasting results with BP reduction within 2 weeks and sustained for 6 more weeks • Decreased blood pressure more than other diets 21
  • 22. Results: Combination Diet with Low-fat Dairy = Greatest Blood Pressure Reduction • Results rival medications – Stage 1 hypertensives, blood pressure fell as much as with single drug therapy • Effect independent of sodium intake / weight status • Hypertensives more than normotensives – African-Americans with hypertension benefit the most 22
  • 23. Systolic BP (mm Hg) DASH: Mean Systolic BP 132 130 128 Control F&V Combo 126 124 122 B as el 23 Intervention Week 8 7 6 5 4 3 2 1 in e 120
  • 24. DASH: Mean Diastolic BP 86 Diastolic BP (mm Hg) 85 84 83 Control 82 F&V 81 Combo 80 79 78 B as el 24 Intervention Week 8 7 6 5 4 3 2 1 in e 77
  • 25. DASH Sodium Trial • N = 412 adults – 57% women – 57% African Americans • Control Diet vs. DASH Combination Diet • Sodium level (30 days each) – High (3,300 mg) – Medium (2,400 mg) – Low (1,500 mg) 25 Sacks, et al., N Engl J Med, 2001
  • 26. Results: Reduced Blood Pressure at All Sodium Levels • Largest reduction at low sodium level • Total group: • Hypertensives: Systolic 11.5 mm Hg • African American hypertensives: Systolic 26 Systolic/Diastolic 8.9/4.5 mm Hg 12.6 mm Hg
  • 27. DASH Sodium Trial 136 134 Systolic Blood Pressure (mmHg) 132 130 128 Control DASH 126 124 122 120 High 3300 Intermediate 2400 Low 1500 Sodium Levels (mgNa) 27
  • 28. Acceptability of the DASH-Sodium Eating Plan • Acceptability of DASH eating plan (with fruits, vegetables, low-fat dairy products) 15% higher than control diet at all sodium levels • Intermediate sodium level (2,300 mg/d) received highest acceptability ratings overall • African-Americans found control diet more acceptable; lowest sodium level least acceptable 28 Karanja, et al. JADA, 2007
  • 29. Low Sodium: Tough to Achieve • Average American sodium intake = 3,436 mg daily • Current Dietary Guideline = 2,400 mg daily – Average American would need to decrease sodium intake more than 30% to meet recommendation • Lowest DASH sodium level = 1,500 mg daily – To achieve the average American would need to reduce sodium intake more than 50% 29 What We Eat in America, NHANES 2001-2002, 2005-2006: Usual Nutrient Intakes from Food Compared to Dietary Reference Intakes;http://www.ars.usda.gov/foodsurvey
  • 30. PREMIER Trial • First trial to implement DASH in free-living persons • 810 adults with above optimal blood pressure randomized to: – Advice only – Established blood pressure interventions (weight loss, sodium reduction, increased physical activity, limited alcohol) – Established + DASH 30 PREMIER Collaborative Research Group, JAMA, 2003
  • 31. Results: EST + DASH Most Effective • EST + DASH had greatest reduction in blood pressure¹ • Additional Benefits of EST + DASH: – Enhanced insulin sensitivity² – Reduced risk factors in those with metabolic syndrome³ – Decreased waist circumference and BMI4 – Enhanced nutrient intakes5 31 1 PREMIER, JAMA, 2003 2 Ard, et al., Diab Care, 2004 3 Lien, et al., Hypertension, 2007 4 Ledikwe, et al., Am J Clin Nutr, 2007 5 Lin, et al., JADA, 2007
  • 32. DASH Significantly Reduces Blood Pressure Over Low-Fat Diet • 12-week clinical trial in 54 free-living overweight/obese men • Randomly assigned low-fat diet or DASH • Both groups had comparable weight loss • DASH group had significantly greater reductions in systolic and diastolic blood pressure – attributed to higher dairy intake, and higher intakes of calcium and potassium 32 Nowson, et al., Am J Clin Nutr, 2005
  • 33. Heart Health and Stroke Coronary Heart Disease (CHD) 16 million Americans in 2005 Stroke: 5.8 million Americans in 2005 Heart Disease and Stroke Statistics, 2008 Update-at-a-Glance, American Heart Association, 2008. 33
  • 34. DASH Associated with Lower CHD and Stroke Risk 88,000 female nurses in Nurses Health Study Subjects with greatest adherence to DASH: ↓ 24% risk for both fatal and non-fatal CHD ↓ 18% risk for stroke 34 Fung TT, et al., Arch Intern Med, 2008
  • 35. DASH Lowers Homocysteine Levels • DASH eating plan may reduce risk for heart disease by lowering abnormally high blood levels of the amino acid homocysteine. • High homocysteine levels are associated with increased risk for heart disease and stroke. Effect may be caused by vitamin B-rich dairy, fruits, vegetables. • 35 Lowering homocysteine with DASH may reduce heart disease by an additional 7% – 9% on top of the 15-27% reduction in heart disease and stroke (due to decreases in blood pressure). Appel, et al Circulation, 2000
  • 36. DASH Promotes Heart Health Subjects following DASH diet: Total cholesterol 13.7 mg/dL LDL cholesterol 10.7 mg/dL HDL cholesterol 3.7 mg/dL 36 Obarzanek, et al Am J Clin Nutr, 2001
  • 37. DASH Reduces CHD Risk Factors The DEW-IT Trial • 44 randomized subjects • Half received lifestyle modifications – Reduced calorie DASH diet – Exercise – Reduced sodium intake 37 Miller, et al., Hypertension, 2002 Blood pressure Weight an average of 11 lbs. Cholesterol
  • 38. Metabolic Syndrome Metabolic syndrome is characterized by a group of metabolic risk factors, including: • • • • • • High LDL cholesterol High triglycerides Low HDL cholesterol Elevated blood pressure Abdominal obesity Insulin resistance or glucose intolerance Effects an estimated 50 million Americans 38 American Heart Association, What is the Metabolic Syndrome?, www.americanheart.org (8/08)
  • 39. DASH Reduces Risk Factors in Subjects with Metabolic Syndrome In subjects with metabolic syndrome: • Increased HDL • Lower triglycerides • Lower BP • Weight loss • Reduced fasting blood glucose 39 Azadbakht et al., Diabetes Care, 2005
  • 40. Bone Health According to the National Osteoporosis Foundation: • • • 40 Osteoporosis is a major public health threat for an estimated 44 million Americans (age 55 and older). In the U.S. today, 10 million individuals are estimated to already have the disease, 34 million more may have low bone mass, placing them at increased risk for osteoporosis. While osteoporosis is often thought of as an older person's disease, it can strike at any age. National Osteoporosis Foundation Prevalence Statistics, 8/08
  • 41. DASH Promotes Bone Health • DASH diet significantly reduced bone turnover • Positive effect of DASH on bone turnover likely resulted from many factors, including higher calcium, potassium and magnesium intake • Long term clinical trials needed to confirm the benefits of DASH on bone health 41 Lin et al., J Nutr, 133: 3130, 2003
  • 42. Summary: Reduce Risk with DASH • Research suggests DASH eating plan may: – – – – – – Reduce risk of CHD and stroke Reduce blood pressure Reduce cholesterol levels Reduce homocysteine levels Support weight loss Cut risk factors in metabolic syndrome • Improves bone metabolism 42
  • 43. Focus African Americans and the DASH Eating Plan 43
  • 44. African-Americans: Increased Risk Factors Compared to Caucasians • Higher Incidences of Hypertension¹ • Higher Incidences of Overweight or Obesity in Women¹ • Higher Rates of Diabetes¹ • Lower Calcium/Dairy Intake² ¹American Heart Association, African Americans and Cardiovascular Disease Statistics Fact Sheet, 2008 Update 44 ²What We Eat in America, NHANES 2005-2006: Usual Nutrient Intakes from Food Compared to Dietary Reference Intakes;http://www.ars.usda.gov/foodsurvey
  • 45. African Americans See Greater Benefit from DASH Eating Plan DASH eating plan is twice as effective at lowering systolic blood pressure among African-Americans as in Caucasians Systolic Blood Pressure Net BP Reduction, mm Hg 14 12 Hypertensive 10 Normotensive 8 6 4 2 0 45 Svetkey, et al. Arch Intern Med , 1999 Black Non-Hispanic White
  • 46. Similar Pattern in Diastolic Diastolic Blood Pressure Net BP Reduction, mm Hg 14 Hypertensive 12 Normotensive 10 8 6 4 2 0 46 Black Svetkey, et al. Arch Intern Med , 1999 Non-Hispanic White
  • 47. Focus Children, Adolescents and the DASH Eating Plan 47
  • 48. Children May Benefit from DASH Eating Plan • Children who consistently eat more low-fat dairy, fruits and vegetables have lower systolic blood pressure in early adolescence. 48 Moore, et al. Epidemiology, 2005.
  • 49. DASH Helps Manage Hypertension in Adolescents • DASH-type diet more effective than routine out-patient care at improving systolic blood pressure and diet quality in adolescents with elevated blood pressure. 49 Couch, et al, J Pediatr, 2008
  • 50. Encourages the DASH eating plan as one of the lifestyle modifications to help prevent and control high blood pressure in children. 50 National High Blood Pressure Education Program Working Group, 4th report. Pediatrics, 2004
  • 51. “Although there are no comparable clinical trial data in children, there is no reason to suspect that the DASH diet would not be safe to implement in older children and adolescents as long as protein and calorie needs are met.” 51 Dietary Recommendations for Children and Adolescents: Pediatrics, Feb 2006
  • 52. Dairy’s Role in DASH Eating Plan 52
  • 53. DASH: Core to Prevention Lose weight Increase physical activity Limit alcohol Dietary changes consistent with DASH eating plan 53 U.S. Department of Health and Human Services. Your Guide to Lowering Your Blood Pressure with DASH. 2nd Edition, April 2006
  • 54. Dairy and the DASH Eating Plan • Consume a diet rich in fruits, vegetables and low-fat milk and milk products – Low-fat and fat-free milk and yogurt, and reduced-fat cheese • Reduce sodium, saturated fat, cholesterol • Consume adequate calcium, potassium, magnesium 54 U.S. Department of Health and Human Services. Your Guide to Lowering Your Blood Pressure with DASH. 2nd Edition, April 2006
  • 55. Dairy: A Top Source of Nutrients in DASH Eating Plan 55 Lin, et al., JADA, 2003
  • 56. Important for Parents and Kids Dairy foods supply four of the seven “nutrients of concern” for which American adults have low intakes: vitamin A, calcium, magnesium and potassium Dairy foods supply three of the five nutrients of concern for which children have low intakes: calcium, potassium, and magnesium1 56 ¹ Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office, January 2005
  • 57. Doing DASH Find the following educational resources, tips and recipes on www.nationaldairycouncil.org/dash 57
  • 58. Patient Education Resources 58
  • 59. Advertorials 59
  • 60. Advertorials 60
  • 61. Advertorials 61
  • 62. More Dairy DASH Facts 62
  • 63. Top Ten Tips 1.Start with Breakfast Get ahead of the game and start your day with a whole grain cereal, fruit and low-fat milk or yogurt. 63
  • 64. Top Ten Tips 2. Rethink your drink Make low-fat and fat-free milk your beverage of choice. Serve low-fat plain or flavored milk at meals. Choose a skinny latte or milk steamer. 64
  • 65. Top Ten Tips 3. Get Veggies Try new vegetables by serving them raw with low-fat yogurt dip, topping them with cheese or adding them to recipes. 65
  • 66. Top Ten Tips 4. Mix it up Make pizza with reduced-fat cheese and vegetables. Create a baked potato bar with vegetables for topping, beans, salsa, and cheese. Sprinkle cheese on top of soups and casseroles 66
  • 67. Top Ten Tips 5. Add fruit Create a fruit smoothie or liquado with low-fat milk, yogurt and fresh fruit chunks. Serve a platter of roasted nuts, pretzels, fruits and vegetables served with low-fat yogurt dip. Create fruit and cheese kabobs. 67
  • 68. Top Ten Tips 6. Nourish your sweet tooth Try low-fat chocolate milk for a nutrient-rich beverage break. Feed your cravings with fresh or dried fruits or fruit filled gelatin. Layer low-fat yogurt with granola and/or fruit for a sweet treat. 68
  • 69. Top Ten Tips 7. Make substitutions Use low-fat milk in place of water when cooking, especially with oatmeal, brown rice and whole-grain pasta dishes. 69
  • 70. Top Ten Tips 8. Super soups Prepare soups with low-fat milk instead of water. Add extra fresh, canned or frozen vegetables to prepared soups. 77
  • 71. Top Ten Tips 9. DASH on the go Enjoy portable dairy products such as string cheese, yogurt smoothies or milk in chug-style single serve resealable containers, when you need to “dash” around on the go. They can be easily consumed in the car, at the office or on the road. 71
  • 72. Top Ten Tips 10. Eat at school Encourage kids to make nutrientrich choices at school, such as low-fat plain or flavored milk, apples or carrots instead of chips, and yogurt for dessert. 72
  • 73. Recipes • www.nationaldairycouncil.org • www.nhlbi.nih.gov/health/public /heart/hbp/dash/recipes.html 73
  • 74. Additional DASH Resources National Heart, Lung and Blood Institute: www.nhlbi.nih.gov American Heart Association: www.americanheart.org American Dietetic Association: www.eatright.org 74
  • 75. Insert Local Dairy Council Contact Info Your Connection to Dairy Nutrition Expertise, Information and Resources 75