The DASH Diet and Blood Pressure
Shirley R. Craddick, MHA, RD, Patricia J. Elmer, PhD,
Eva Obarzanek, PhD, MPH, RD, William M. Vollmer, PhD,
Laura P. Svetkey, MD, MHS, and Martha C. Swain, BA
Address
Kaiser Permanente Center for Health Research,
3800 North Interstate, Portland, OR 97227, USA.
E-mail: shirley_craddick@att.net
Current Atherosclerosis Reports 2003, 5:484–491
Current Science Inc. ISSN 1523–3804
Copyright © 2003 by Current Science Inc.
High blood pressure (also called hypertension) is one of the
most important and common risk factors for atherosclerotic
cardiovascular disease (CVD) and other chronic diseases.
National guidelines recommend that all individuals with blood
pressure readings of 120/80 mm Hg or higher adopt healthy
lifestyle habits, including the Dietary Approaches to Stop
Hypertension (DASH) diet, to manage their blood pressure.
The DASH diet, which is high in fruits, vegetables, and low-fat
dairy products and reduced in fat, has been shown in large,
randomized, controlled trials to reduce blood pressure
significantly. The DASH diet also has been shown to reduce
blood cholesterol and homocysteine levels and to enhance
the benefits of antihypertensive drug therapy. The DASH diet
should be promoted, along with maintaining healthy weight,
reducing sodium intake, increasing regular physical activity,
and limiting alcohol intake, for lowering blood pressure and
reducing the risk of CVD.
Introduction
High blood pressure (hypertension) is one of the most
important and common risk factors for atherosclerotic
cardiovascular disease (CVD) and other chronic diseases
[1]. Although almost 50 million Americans meet criteria
for hypertension (blood pressure of 140/90 mmHg or
higher) [2], many more individuals are at increased risk for
CVD because their blood pressure levels are above optimal
(>120/80 mm Hg). Extensive data show that increased
blood pressure is related to increased risk of CVD through
a broad range of blood pressures, beginning at levels previ-
ously designated above optimal, but not yet hypertensive
[3,4•]. The Seventh Report of the Joint National Commit-
tee (JNC) on Prevention, Detection, Evaluation, and Treat-
ment of High Blood Pressure (JNC 7) [5] recommends that
all individuals with blood pressure readings of 120/80 mm
Hg or higher adopt lifestyle modifications to help prevent
or manage hypertension.
Several lifestyle factors are known to decrease blood
pressure. These include a diet high in fruits, vegetables, and
low-fat dairy products and reduced in fat (ie, the Dietary
Approaches to Stop Hypertension [DASH] diet); weight
loss; reduced sodium intake; regular physical activity; and
limited alcohol consumption [5]. Although all of these
lifestyle changes may be difficult for the average person to
achieve, incremental changes in one or more of these
factors can add up to clinically relevant reductions in
blood pressure. For example, compared with a typical diet
in the United States, the combination of the DASH dietary
pattern plus a reduced sodium level of 1500 mg reduces
blood pressure in stage 1 hypertension about the same
amount as single-drug therapy [6••]. The JNC 7 report
estimated that for patients with stage 1 hypertension and
additional cardiovascular risk factors, achieving a sustained
12-point reduction in systolic blood pressure over 10 years
will prevent one death for every 11 patients treated [5]. The
DASH diet and sodium reduction may also help millions
of Americans with what the JNC 7 report calls “prehyper-
tension” (a range from 120/80 mm Hg to 139/89 mm Hg)
to prevent or delay hypertension [5].
The Original DASH Studies
When the DASH trial began in 1993, obesity, sodium
intake, and alcohol consumption were known to influence
blood pressure. The influence of other dietary factors that
were observed in vegetarian diet trials and observational
studies [7,8] was less clear. The purpose of both the DASH
and DASH-Sodium studies was to assess the influences of
dietary patterns on blood pressure. The initial trial, DASH,
tested the effects on blood pressure of a diet high in fruits,
vegetables, and low-fat dairy foods, and low in fat. DASH-
Sodium compared the effects on blood pressure of differ-
ent levels of dietary sodium in conjunction with the DASH
eating pattern. The DASH and the DASH-Sodium trials
were randomized, controlled, out-patient feeding studies
conducted at four clinical centers to compare the effects of
dietary patterns on blood pressure.
The DASH Trial
The DASH trial studied a sample of 459 adults with above-
optimal diastolic blood pressure or stage 1 hypertension. All
 The DASH Diet and Blood Pressure • Craddick et al.
study foods were provided to the participants. The primary
outcome measure was change in blood pressure between the
end of run-in and the end of an 8-week controlled feeding
period [9]. A detailed explanation of the trial’s rationale and
design, including the dietary patterns summarized in the
following text, are presented elsewhere [10,11].
The DASH trial compared the effects on blood pressure
of three dietary patterns: a control diet similar to what
many Americans consume; a diet high in fruits and vegeta-
bles, but otherwise similar to the control diet; and the
DASH dietary pattern. The control dietary pattern approxi-
mated the typical American diet; it contained refined
grains, dairy fat, meats, and sugar, and few fruits, nuts,
legumes, and vegetables. Its micronutrient profile for
potassium, magnesium, and calcium was designed to be
about the 25th percentile of intake of the US population,
and its macronutrient profile and fiber content reflected
current consumption in the United States [12].
The DASH dietary pattern is high in fruits, vegetables,
and low-fat dairy products, and reduced in fats, red meat,
sweets, and sugar-containing beverages. Compared with
the control diet, the DASH diet has lower levels of total fat,
saturated fat, and cholesterol, and higher levels of potas-
sium, calcium, magnesium, fiber, and protein [11]. The
potassium, magnesium, and calcium contents of the DASH
diet were designed to approximate the 75th percentile of
intake of the US population [12].
The trial’s intermediate (fruits and vegetables) dietary
pattern was designed to test the blood pressure-lowering
effect of fruits and vegetables. The fruits and vegetables diet
had potassium, magnesium, and dietary fiber content
similar to the DASH diet, and fat, protein, and calcium
contents similar to those of the control diet.
Sodium was held relatively constant across the dietary
patterns, alcohol was limited to two drinks per day, and
caffeine-containing beverages were limited to three drinks
per day. Daily sodium intake ranged from 2.5 to 4.0 g,
depending on the energy level, with up to 0.4 g/d provided
for discretionary use and monitored so that total sodium
intake could be estimated. Caloric intake was adjusted as
needed to maintain stable weight over time, and partici-
pants were asked not to make other habit changes, such as
changing their physical activity.
The trial was conducted in three phases: screening, run-in,
and intervention. The run-in phase was a 3-week period
during which all participants were given the control diet. The
intervention phase lasted 8 weeks, during which participants
followed their assigned diets; they were not told their diet
assignment. A 7-day menu cycle included 21 meals at four
calorie levels for each dietary pattern to accommodate a range
of energy requirements. Food was prepared in research kitch-
ens using a common protocol. Each weekday, the study
participants ate lunch or dinner on site and received food to
consume off site for all other meals during the week. Partici-
pants kept a daily food diary of any additional food they
consumed beyond the prescribed diet. Eating food outside
485
Figure 1. Mean systolic blood pressure at baseline and during each
intervention week, according to the Dietary Approaches to Stop
Hypertension (DASH) diet, for 379 subjects with complete set of
weekly blood pressure measurements. (Adapted from Appel et al. [9];
with permission.)
the study-provided foods was discouraged [9,10]. More than
95% of the 459 randomized participants completed the inter-
vention phase and attended on-site meals [9].
The DASH diet quickly and significantly lowered blood
pressure compared with the control diet, whereas the fruit
and vegetable diet reduced blood pressure by about half as
much (Fig. 1). Blood pressure measurements were also
taken for 24 hours with ambulatory blood pressure moni-
tors, and the DASH diet was found to lower blood pressure
throughout the day [13]. The effects of the DASH diet on
blood pressure held for a variety of subgroups. The effects
of the DASH diet were especially pronounced in individu-
als with stage 1 hypertension, in whom blood pressure was
reduced on average by 11.4/5.5 mm Hg [9,14]. These
effects on blood pressure occurred under conditions of
constant weight and a sodium intake only slightly below
average US consumption.
The DASH-Sodium Trial
The DASH-Sodium trial studied the joint effects of the
DASH diet and reduced sodium on blood pressure in
adults with above-optimal blood pressure or stage 1 hyper-
tension. Participants were randomly assigned to eat either
the DASH diet or a control diet typical of what many Amer-
icans eat, and within their assigned diet consumed three
sodium levels for 30 days each in a randomly assigned
order. The sodium levels tested included a “higher” daily
intake, consistent with current average US consumption;
an “intermediate” daily intake, corresponding to the upper
limit of current US recommendations; and a “lower” daily
intake, corresponding to a level hypothesized to be more
486 Nutrition

Table 1. Calculated nutrient profiles of the DASH- sure was significantly lower for participants eating the DASH
Sodium and control diets at the lower sodium level* diet compared with those eating the control diet. The
DASH-Sodium findings held in all subgroups [6••,16•,17].
DASH- Although the effects on blood pressure of the DASH diet
Sodium Control
and sodium reduction were not fully additive, the lowest
Protein, g 94.3 74.5 blood pressures were consistently observed when individu-
Protein, % kcal 18 14.3 als ate the DASH diet at the lowest sodium level.
Carbohydrate, g 306 256
Carbohydrate, % kcal 58.5 49
Total fat, g 63.1 87.1
Total fat, % kcal 27.2 37.6 Other Studies Using the DASH Eating Pattern
Saturated fat, g 14.4 35.7 The Diet, Exercise, and Weight Loss Intervention Trial
Saturated fat, % kcal 6.2 15.4 (DEW-IT) [18•] was a 9-week, randomized, controlled,
Monounsaturated fat, g 25.9 28.5 feeding trial that incorporated weight loss, sodium reduc-
Monounsaturated fat, % kcal 11.2 12.3 tion, increased physical activity, and a hypocaloric version
Polyunsaturated fat, g 18.1 16.4 of the DASH diet. Participants were overweight or obese
Polyunsaturated fat, % kcal 7.8 7.1
and taking a stable dose of an antihypertensive medica-
Cholesterol, mg 128 272
Total dietary fiber, g 29.9 10.8 tion. The DEW-IT physical activity, diet, and gradual
Potassium, mg 4538 1741 weight-loss goals were well accepted by the participants.
Magnesium, mg 498 173 The intervention resulted in blood pressure reductions
Calcium, mg 1260 453 similar to those from pharmacotherapy (9.5/5.3 mm Hg
Zinc, mg 12.1 7.7 compared with the control group) and similar to the blood
Thiamin, mg 1.7 1.4 pressure effects found in the nonmedicated hypertensive
Riboflavin, mg 2.1 1.4
participants in the DASH-Sodium trial. It also resulted in
Niacin (nicotinic acid), mg 24.1 22.6
Vitamin B6, mg 2.8 1.4 favorable effects on fitness and serum total and low-
Vitamin B12, µg 3.8 3.1 density lipoprotein (LDL) cholesterol levels [18•]. Despite
Vitamin C, mg 300 143 the limited number of participants (n=23 in the control
Vitamin E, mg/d tocopherol units 14 7.9 group and n=22 in the intervention group), the blood
Sodium, mg (lower level) 1226 1162 pressure effects were statistically significant.
*Mean of 7-day menus at the 2100-kcal level from the DASH-Sodium
The multicenter PREMIER trial [19] tested the effects on
trial. Percentages of calories from unsaturated fatty acids do not add up blood pressure of two intensive behavioral interventions
to percentage of calories from total fat because the glycerol content of compared with an advice-only intervention. Participants were
the fatty acids was not included. In addition, the percentages of calories
from macronutrients may exceed 100% because they were calculated
810 community-dwelling adults with above-optimal blood
using the Atwater factors, which do not fully account for nonavailable pressure or stage 1 hypertension who were not taking anti-
carbohydrates. This particularly occurs with high-carbohydrate, hypertensive medication. Those randomized into the “estab-
high-fiber diets such as DASH.
DASH—Dietary Approaches to Stop Hypertension.
lished plus DASH” intervention received counseling on
established guidelines for blood pressure control, including
weight loss, sodium reduction, increased physical activity, and
beneficial for blood pressure reduction [15]. As with the limited alcohol intake. In addition, they were counseled to
DASH trial, participants were provided with all of their follow the DASH diet. Goals included nine to 12 servings per
food during the study. The nutrient contents of the DASH day of fruits and vegetables, two to three servings per day of
and control diets at the lower sodium level for the 2100 low-fat dairy products, 7% or less of energy from saturated fat,
kcal menu are shown in Table 1. The nutrient contents and 25% or less of energy from total fat. As a strategy for
were calculated from Moore’s Extended Nutrient (MENu) weight loss, this intervention recommended substituting
database (Version 3.1, Pennington Biomedical Research fruits and vegetables for high-fat, high-calorie foods.
Foundation, Baton Rouge, LA). Detailed explanations of The PREMIER trial “established” intervention also
the DASH-Sodium trial’s rationale and design [15] and the offered counseling on established guidelines for blood pres-
main findings [6••,16•] appear elsewhere. sure control, but it did not include counseling on the DASH
Of the 412 study participants, 94% completed the study diet, and thus did not have goals for fruit and vegetable or
and provided blood pressure measurements during each dairy intake. It did recommend weight loss, reduced sodium
intervention period. For participants in each diet arm, the intake, increased physical activity, and limited alcohol intake.
study found significant, stepwise reductions in blood pres- It also recommended 10% or less of energy intake from satu-
sure in going from the “higher” to “intermediate” to “lower” rated fats and 30% or less of energy intake from total fat, and
sodium levels (Fig. 2). Blood pressure reductions from substituting fruits and vegetables for high-fat and high-
reduced sodium intakes were significantly greater for partici- calorie foods. An “advice-only” group, which served as the
pants eating the control diet than those eating the DASH control intervention, received advice about lifestyle modifi-
diet. The study found that for each sodium level, blood pres- cations for blood pressure control.
 The DASH Diet and Blood Pressure • Craddick et al. 487

Figure 2. Effect on systolic blood pressure of reduced sodium intake and the Dietary
Approaches to Stop Hypertension (DASH) diet. The mean systolic blood pressures are shown
for the high-sodium control diet. The mean changes in blood pressure are shown for various
sodium levels (solid lines), and the mean differences in blood pressure between the DASH and
control diets at each level of sodium intake are shown (dotted lines). Unidirectional arrows are
used for simplicity, although the order in which participants were given the sodium levels was
random, with a crossover design. The numbers next to the dotted lines connecting the data
points are the mean changes in systolic blood pressure. The 95% CIs are given in parentheses.
There was a significant difference in systolic blood pressure between the high-sodium and low-
sodium phases of the control diet (mean, -6.7 mm Hg; 95% CI, -5.4 to -8.0; P<0.001) and the
DASH diet (mean, -3.0 mm Hg; 95% CI, -1.7 to -4.3; P<0.001) and between the high-sodium
phase of the control diet and the low-sodium phase of the DASH diet (mean, -8.9 mm Hg; 95%
CI, -6.7 to -11.1; P<0.001). Asterisks (P<0.05), daggers (P<0.01), and double daggers
(P<0.001) indicate significant differences in systolic blood pressure between groups or
between sodium categories. (Data from Sacks et al. [6••].)

Participants in both PREMIER behavioral interventions
accomplished substantial weight loss, reduced sodium
intake, and increased physical fitness [20••]. In addition,
persons assigned to the “established plus DASH” interven-
tion significantly increased their intake of fruits and vegeta-
bles and dairy products relative to the other two groups
(Table 2). After 6 months, both intervention groups signifi-
cantly lowered blood pressure relative to the advice-only
group (3.7/1.7 mm Hg for “established” and 4.3/2.6 mm
Hg for “established plus DASH”). Blood pressure reductions
were greatest for participants in the “established plus DASH”
group, although the difference between the two interven-
tions did not achieve statistical significance [20••]. The
prevalence of hypertension, which was approximately 38%
at baseline in all three groups, decreased to 12% in the
“established plus DASH” group, 17% in the “established”
group, and 26% in the “advice-only” group at 6 months.
Hypertension prevalence thus was significantly less for the
two active interventions compared with the “advice-only”
group. The difference in hypertension prevalence between
the “established plus DASH” and “established” groups did
not achieve statistical significance [20••].
The lack of a significant incremental benefit in the “estab-
lished plus DASH” group compared with the “established”
group presumably reflects a combination of factors. First, as
was demonstrated in DASH-Sodium and other trials
[6••,21], it is likely that the effects of multiple lifestyle
changes on blood pressure are not fully additive. Second, the
dietary contrast between the “established” and the “estab-
lished plus DASH” groups was less than that in the original
DASH studies. Because the PREMIER study was not a feeding
study like DASH and DASH-Sodium, the community-
dwelling participants in the “established plus DASH” group
did not fully adopt the DASH diet. In addition, participants
in the “established” group ate a healthier diet than the
control diet used in the DASH and DASH-Sodium studies.
Another randomized, controlled trial tested the hypo-
thesis that the DASH diet enhances the blood pressure
response to antihypertensive medication in patients with
stages 1 and 2 hypertension, using the angiotensin receptor
blocker losartan [22•]. The study found that the DASH diet
at sodium levels slightly below US consumption in combi-
nation with losartan significantly reduced blood pressure
compared with losartan and a control diet. These findings
suggest that the DASH diet may be a useful adjuvant therapy
for patients currently taking angiotensin receptor blockers.
The mean incremental blood pressure response to the
DASH diet in this study was intermediate to those found in
the DASH and DASH-Sodium studies, possibly due to the
smaller number of participants [22•]. Patients with higher
Table 2. Changes in lifestyle factors from baseline to 6 months among participants in the PREMIER trial
488

Mean (SD) P value

Established plus
Established plus Established vs Established plus DASH vs
Intervention outcome Advice only Established DASH advice only DASH vs advice only established
Nutrition

Weight, kg n=242 n=238 n=233

Baseline 95.8 (17.0) 96.2 (17.8) 98.8 (19.3)
6 Months 94.7 (17.2) 91.3 (18.2) 93.0 (19.0)
Change -1.1 (3.2) -4.9 (5.5) -5.8 (5.8) <0.001 <0.001 0.07
Fitness (heart rate at stage n=235 n=226 n=232
2 of exercise test), beats/min
Baseline 130.32 (14.7) 130.6 (14.2) 130.1 (14.6)
6 Months 125.0 (15.6) 122.6 (15.7) 121.1 (15.8)
Change -5.3 (9.7) -8.0 (11.1) -9.0 (10.7) 0.005 <0.001 0.28
Dietary recalls n=232 n=227 n=230
Fruits and vegetables, servings/d
Baseline 4.4 (2.3) 4.6 (2.4) 4.8 (2.5)
6 Months 4.9 (2.7) 5.1 (2.5) 7.8 (3.2)
Change 0.5 (2.8) 0.5 (2.6) 3.0 (3.6) 0.79 <0.001 <0.001
Dairy, servings/d
Baseline 1.6 (1.2) 1.7 (1.3) 1.8 (1.3)
6 Months 1.7 (1.4) 1.5 (1.1) 2.3 (1.2)
Change 0.1 (1.6) -0.2 (1.5) 0.5 (1.6) 0.02 <0.001 <0.001

DASH—Dietary Approaches to Stop Hypertension.

Adapted from Writing Group of the PREMIER Collaborative Research Group [20••]; with permission.
 The DASH Diet and Blood Pressure • Craddick et al.
baseline plasma renin activity had greater blood pressure
responses to the DASH diet and losartan, implying an
interaction with the renin-angiotensin system. The renin-
angiotensin system is further implicated in the blood
pressure-lowering effect of the DASH dietary pattern by
evidence of genetic modulation of this effect. Specifically,
the systolic blood pressure response to the DASH diet is
greatest in individuals with the AA polymorphism of the
angiotensinogen gene (-6.9 mm Hg) and least in those with
the GG polymorphism (-2.8 mm Hg) (P for trend=0.08 for
systolic blood pressure) [23].
The DASH Dietary Pattern and other
Cardiovascular Disease Risk Factors
The DASH diet is consistent with national dietary recommen-
dations for reducing CVD risk [24–26]. In addition to its
blood pressure-lowering effects, evidence suggests that the
DASH diet also has beneficial effects on other CVD risk factors.
For example, results from the DASH study showed that
compared with the control diet, the DASH diet signifi-
cantly reduced cholesterol without significantly increasing
triglycerides [27••]. Total cholesterol was reduced by 13.7
mg/dL (7.3%) and LDL cholesterol by 10.7 mg/dL (9.0%).
High-density lipoprotein (HDL) cholesterol also was
reduced, by 3.7 mg/dL (7.5%), and the total/HDL choles-
terol and LDL/HDL cholesterol ratios also decreased, but
not significantly. The commonly observed rise in triglycer-
ides from a carbohydrate-rich diet did not occur.
These effects on blood lipids generally persisted in
subgroups defined by ethnicity, sex, and baseline levels of
lipids. The effect of the DASH diet on total cholesterol and
LDL cholesterol was more pronounced in men than
women, however. In addition, HDL cholesterol decreased
more in participants with higher, rather than lower, HDL
cholesterol levels at baseline. The Framingham risk assess-
ment score calculated for the DASH cohort for 10-year risk
of coronary heart disease, which takes into account both
blood pressure and blood lipid changes, predicts that fol-
lowing the DASH diet would decrease risk by 12% [27••].
The lipid results from the DASH-Sodium trial were
similar to those of the DASH trial. The DASH diet signifi-
cantly decreased total cholesterol and LDL cholesterol at
every level of sodium intake. It also decreased HDL choles-
terol, but did not significantly increase triglycerides [28].
In addition, the DASH-Sodium trial showed that sodium
reduction did not adversely affect blood lipids.
The DEW-IT study also examined the effect on blood
lipids of weight loss, sodium reduction, increased physical
activity, and the DASH diet. DEW-IT found that, similar to
the DASH and DASH-Sodium trials, the intervention
significantly reduced total cholesterol and LDL cholesterol.
It also reduced HDL cholesterol but did not significantly
increase triglycerides [18•].
The effect of the DASH diet on homocysteine, a poten-
tial risk factor for CVD, has also been studied. More than
489
30 observational studies have reported a direct association
between blood levels of homocysteine and CVD [29].
Nutrients known to affect homocysteine levels include
folate and possibly vitamins B6 and B12 [30,31]. Because
the DASH diet is rich in fruits, vegetables, whole grains,
and dairy, and contains these nutrients, the DASH diet
could be expected to have a beneficial effect on homo-
cysteine. Appel et al. [32•] studied 118 participants from
one DASH clinical center and found that, compared with
the control diet, the DASH diet reduced serum levels of
homocysteine by 0.8 µmol/L (P=0.03).
Conclusions
The DASH study determined that a diet rich in fruits, vegeta-
bles, and low-fat dairy foods and low in fat quickly and signi-
ficantly reduces blood pressure in adults. These results were
obtained without requiring participants to lose weight or
reduce their sodium intake. The DASH-Sodium trial con-
firmed the DASH study findings and also determined that the
DASH diet lowers blood pressure at higher, intermediate, and
lower dietary-sodium levels. The combined effects on blood
pressure of a low-sodium diet and the DASH diet were found
to be greater than the effects of either intervention alone.
In addition, the DASH eating pattern improves cardio-
vascular disease risk factors other than blood pressure. It
lowers total and LDL cholesterol without increasing triglyc-
erides, possibly because of the DASH diet’s high fiber
content and the focus on whole grains [33]. Although the
DASH diet, like other low-fat, high-carbohydrate dietary
patterns, reduces HDL cholesterol, its high fruit and vegeta-
ble content also lowers homocysteine blood levels. Thus,
overall, the DASH diet is likely to reduce CVD risk.
Several innovative features of the DASH trials are impor-
tant to note. First, the DASH trials were the first in the area of
nutrition and blood pressure research to shift the focus from
individual nutrients to dietary patterns. This shift permitted
experimental tests of whole diets found in observational stud-
ies to be associated with lower blood pressure. Second, the
DASH trials used the experimental design of an out-patient
feeding study. Efficacy studies can determine dietary effects on
blood pressure with high precision under well-controlled
conditions and with high adherence to the dietary regimen.
Such a design can help resolve inconsistencies in the literature
on diet and blood pressure, as long as the third important
innovative feature of the DASH trials is also present, which is
that each of the DASH trials featured a large sample size of
more than 400 participants. This achievement was made pos-
sible because several centers collaborated on the trials, allow-
ing each trial’s intervention phase to be completed within
about 2 years. The large sample size was critical because it
ensured that small changes in blood pressure could be
detected, and small changes population-wide have significant
implications for reducing disease risk for conditions that are
widely prevalent, such as high blood pressure [34]. In addi-
tion, the large sample size provided adequate power to exam-
490 Nutrition
ine blood pressure effects in important subgroups defined by
hypertension status, ethnicity, sex, and age.
The DASH-Sodium eating pattern has also been used to
evaluate the influence of the diet with added interventions,
including antihypertensive drug therapy [22•] and weight
loss plus increased physical activity [18•]. The results of both
studies were consistent with the findings of the DASH trials.
Results of the PREMIER trial indicated that community-
living persons may find it difficult to completely adopt the
DASH eating pattern. Although the “established plus DASH”
group consumed more fruits and vegetables than the “estab-
lished” group, the group did not achieve the DASH goal of
nine to 12 servings per day. Adopting the DASH diet admit-
tedly is difficult for free-living persons. American society’s
fast pace and multiple demands, both at work and home,
make it hard for free-living persons to shop and prepare low-
fat, low-sodium meals that include nine to 12 servings of
fruits and vegetables each day. Time that could be used to
prepare food at home is crowded out with other demands;
therefore, many American meals are purchased from restau-
rants, take-out facilities such as delicatessens, and supermar-
kets with ready-made food or frozen food. Ready-made food
tends to be higher in fat and sodium and have few or small
servings of fruits and vegetables.
Public health and healthcare organizations need to
continue to help Americans adopt healthy food prepara-
tion and eating habits. Continuous emphasis needs to be
made to show Americans how to find and choose produce,
prepare and serve a variety of fruits and vegetables quickly,
buy low-sodium foods, reduce meat consumption,
increase low-fat dairy, and enjoy whole grains. Food manu-
facturers, grocery stores, and food service industries should
prepare and make more widely available low-sodium
foods with more vegetable content.
The DASH dietary pattern has proven to have beneficial
effects. It may be easier than many other dietary patterns to
follow because it is a wholistic diet and focuses on major
food groups (fruits and vegetables, low-fat dairy, whole
grains, legumes and nuts) rather than individual nutrients.
It does not require purchase of unusual foods or advanced
cooking knowledge or training. In addition, study partici-
pants have found it satisfying and generally acceptable [9].
Following a healthy lifestyle that includes the DASH
dietary pattern, healthy weight, lower sodium intake,
increased regular physical activity, and limited alcohol intake
can lower blood pressure significantly. Many persons find
these changes difficult to maintain in daily life. Still, having
several options available should mean that one or more will
be attractive enough to be adopted by individuals who care
about their health. Encouragement from public health orga-
nizations, healthcare systems, and societal institutions can
help. These lifestyle changes can substantially lower the risk
of CVD as well as the risk of other chronic diseases, including
diabetes, osteoporosis, and perhaps cancer. The DASH
dietary pattern is one big step along the path to managing
blood pressure and maintaining good health.
Acknowledgments
Supported by cooperative agreements and grants from the
National Heart, Lung, and Blood Institute Office of Research
on Minority Health, and National Center for Research
Resources of the National Institutes of Health (HL50981,
HL50968, HL50972, HL50977, HL50982) (U01-HL57173,
to Brigham and Women’s Hospital; U01-HL57114, to Duke
University; U01-HL57190, to Pennington Biomedical
Research Center; U01-HL57139 and K08 HL03857-01, to
Johns Hopkins University; and U01-HL57156, to Kaiser
Permanente Center for Health Research) and by the General
Clinical Research Center Program of the National Center for
Research Resources (M01-RR02635, to Brigham and
Women’s Hospital, and M01-RR00722, to Johns Hopkins
University). (HL60570, HL60571, HL60573, HL60574,
HL62828, RR00052.)
References and Recommended Reading
Papers of particular interest, published recently,
have been highlighted as:
• Of importance
•• Of major importance
1. Lenfant C, Chobanian AV, Jones DW, Roccella EJ: Seventh
Report of the Joint National Committee on the Prevention,
Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7): resetting the hypertension sails. Circulation
2003, 107:2993–2994.
2. Wolz M, Cutler J, Roccella EJ, et al.: Statement from the
National High Blood Pressure Education Program:
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and diastolic, and cardiovascular risks. US population data.
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4.• Vasan RS, Larson MG, Leip EP, et al.: Impact of high-normal
blood pressure on the risk of cardiovascular disease.
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Investigated the association between blood pressure and the
incidence of cardiovascular disease at 10-year follow-up among
6859 participants in the Framingham Heart Study. A step-wise
increase in cardiovascular event rates was noted in persons with
higher baseline blood pressure.
5. Chobanian AV, Bakris GL, Black HR, et al.: The Seventh Report
of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure: the
JNC 7 report. JAMA 2003, 289:2560–2572.
6.•• Sacks FM, Svetkey LP, Vollmer WM, et al.: Effects on blood
pressure of reduced dietary sodium and the Dietary
Approaches to Stop Hypertension (DASH) diet. DASH-
Sodium Collaborative Research Group. N Engl J Med
2001, 344:3–10.
An out-patient feeding study investigated the effect of different levels
of dietary sodium, in conjunction with the DASH diet, in 412 partici-
pants, some with hypertension and some without. The DASH diet was
associated with a significantly lower systolic blood pressure at each
sodium level. Both reducing sodium intake below the current recom-
mendation of 100 mmol/d and eating the DASH diet lowered blood
pressure substantially, with greater effects in combination than singly.
7. Sacks FM, Rosner B, Kass EH: Blood pressure in vegetarians.
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 The DASH Diet and Blood Pressure • Craddick et al.
9. Appel LJ, Moore TJ, Obarzanek E, et al.: A clinical trial of
the effects of dietary patterns on blood pressure. DASH
Collaborative Research Group. N Engl J Med 1997,
336:1117–1124.
10. Sacks FM, Obarzanek E, Windhauser MM, et al.: Rationale and
design of the Dietary Approaches to Stop Hypertension trial
(DASH). A multicenter controlled-feeding study of dietary pat-
terns to lower blood pressure. Ann. Epidemiol 1995, 5:108–118.
11. Karanja NM, Obarzanek E, Lin PH, et al.: Descriptive character-
istics of the dietary patterns used in the Dietary Approaches
to Stop Hypertension Trial. DASH Collaborative Research
Group. J Am Diet Assoc 1999, 99:S19–S27.
12. Lin PH, Windhauser MM, Plaisted CS, et al.: The Linear
Index Model for establishing nutrient goals in the Dietary
Approaches to Stop Hypertension trial. DASH Collaborative
Research Group. J Am Diet Assoc 1999, 99:S40–S44.
13. Moore TJ, Vollmer WM, Appel LJ, et al.: Effect of dietary
patterns on ambulatory blood pressure : results from the
Dietary Approaches to Stop Hypertension (DASH) Trial.
DASH Collaborative Research Group. Hypertension 1999,
34:472–477.
14. Svetkey LP, Simons-Morton D, et al.: Effects of dietary
patterns on blood pressure: subgroup analysis of the Dietary
Approaches to Stop Hypertension (DASH) randomized
clinical trial. Arch Intern Med 1999, 159:285–293.
15. Svetkey LP, Sacks FM, Obarzanek E, et al.: The DASH Diet,
Sodium Intake and Blood Pressure Trial (DASH-sodium):
rationale and design. DASH-Sodium Collaborative Research
Group. J Am Diet Assoc 1999, 99:S96–S104.
16.• Vollmer WM, Sacks FM, Ard J, et al.: Effects of diet and sodium
intake on blood pressure: subgroup analysis of the DASH-
sodium trial. Ann Intern Med 2001, 135:1019–1028.
Evaluated effects on blood pressure of reduced sodium intake and
the DASH diet in the DASH-Sodium trial subgroups. Generally, in
all subgroups, the DASH diet and reduced sodium intake were each
associated with significant decreases in blood pressure; these two
factors combined produced the greatest reductions.
17. Vollmer WM, Sacks FM, Svetkey LP: New insights into the
effects on blood pressure of diets low in salt and high
in fruits and vegetables and low-fat dairy products.
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18.• Miller ER III, Erlinger TP, Young DR, et al.: Results of the Diet,
Exercise, and Weight Loss Intervention Trial (DEW-IT).
Hypertension 2002, 40:612–618.
The DEW-IT trial studied the association of the DASH diet and exer-
cise with ambulatory blood pressure, serum lipids, weight, and fitness
in 44 hypertensive, overweight adults on a single blood pressure med-
ication. The comprehensive lifestyle intervention was found to sub-
stantially lower blood pressure and improve blood pressure control.
19. Svetkey LP, Harsha DW, Vollmer WM, et al.: Premier: a clinical
trial of comprehensive lifestyle modification for blood pres-
sure control: rationale, design and baseline characteristics.
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20.•• Writing Group of the PREMIER Collaborative Research Group:
Effects of comprehensive lifestyle modification on blood
pressure control: main results of the PREMIER clinical trial.
JAMA 2003, 289:2083–2093.
Studied the effect on blood pressure of two multicomponent behav-
ioral interventions over 6 months in 810 community-dwelling adults.
Both significantly reduced weight, improved fitness, and lowered
sodium intake, and the intervention that included the DASH diet
also increased fruit, vegetable, and dairy intake.
21. The Trials of Hypertension Prevention Collaborative Research
Group: Effects of weight loss and sodium reduction interven-
tion on blood pressure and hypertension incidence in over-
weight people with high-normal blood pressure. The Trials
of Hypertension Prevention, phase II. Arch Intern Med 1997,
157:657–667.
491
22.• Conlin PR, Erlinger TP, Bohannon A, et al.: The DASH diet
enhances the blood pressure response to losartan in
hypertensive patients. Am J Hypertens 2003, 16:337–342.
Clinical trial to assess the blood pressure response to the DASH diet
and an antihypertensive medication, losartan, in 55 hypertensive
participants. The DASH diet was found to enhance the blood
pressure reduction from losartan.
23. Svetkey LP, Moore TJ, Simons-Morton DG, et al.: Angiotensino-
gen genotype and blood pressure response in the Dietary
Approaches to Stop Hypertension (DASH) study. J Hypertens
2001, 19:1949–1956.
24. US Department of Agriculture (USDA), US Department of
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Healthy Base. Aim for Fitness Build a Healthy Base
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Evaluation, and Treatment of High Blood Cholesterol in
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lines: revision 2000: A statement for healthcare professionals
from the Nutrition Committee of the American Heart
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27.•• Obarzanek E, Sacks FM, Vollmer WM, et al.: Effects on blood
lipids of a blood pressure-lowering diet: the Dietary
Approaches to Stop Hypertension (DASH) Trial. Am J Clin
Nutr 2001, 74:80–89.
Studied the effects of diet on plasma lipids, focusing on subgroups by
sex, race, and baseline lipid concentrations in 436 participants from
the DASH trial. Compared with the control diet, the DASH diet
resulted in lower total, LDL, and HDL cholesterol, without significant
effects on triacylglycerol, and thus is likely to reduce coronary heart
disease risk.
28. Appel LJ, Sacks FM, Harsha D, et al.: The effects of sodium
reduction on blood lipids; results from the DASH-Sodium
feeding study [abstract]. Hypertension 2003, in press.
29. Boushey CJ, Beresford SA, Omenn GS, Motulsky AG: A quanti-
tative assessment of plasma homocysteine as a risk factor
for vascular disease. Probable benefits of increasing folic
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30. Clarke R, Armitage J: Vitamin supplements and cardiovascular
risk: review of the randomized trials of homocysteine-
lowering vitamin supplements. Semin Thromb Hemost 2000,
26:341–348.
31. Verhaar MC, Stroes E, Rabelink TJ: Folates and cardiovascular
disease. Arterioscler Thromb Vasc Biol 2002, 22:6–13.
32.• Appel LJ, Miller ER III, Jee SH, et al.: Effect of dietary patterns
on serum homocysteine: results of a randomized, controlled
feeding study. Circulation 2000, 102:852–857.
This study found that the DASH diet significantly reduced fasting
levels of total serum homocysteine. Because elevated blood levels of
homocysteine are associated with an increased risk of atherosclerotic
cardiovascular disease, these results provide additional insights into
the mechanisms by which diet might influence the occurrence of
atherosclerotic cardiovascular disease.
33. Parks EJ, Hellerstein MK: Carbohydrate-induced hypertriacylg-
lycerolemia: historical perspective and review of biological
mechanisms. Am J Clin Nutr 2000, 71:412–433.
34. Cook NR, Cohen J, Hebert PR, et al.: Implications of small
reductions in diastolic blood pressure for primary preven-
tion. Arch Intern Med 1995, 155:701–709.