REVIEW

CURRENT
OPINION The role of diet for prevention and management
of hypertension
Cemal Ozemek a, Deepika R. Laddu a, Ross Arena a, and Carl J. Lavie b

Purpose of review
Regular consumption of a diet high in sodium, energy dense foods, fat content, refined carbohydrates,
added sugar and low in fruits and vegetables contributes to an increased risk of developing hypertension
(HTN) and cardiovascular disease. This review aims to provide a synopsis of evidence-based dietary
approaches that have been effective in lowering blood pressure (BP) in pre-HTN and individuals with HTN.

Recent findings
Recent dietary recommendations have emphasized overall dietary patterns and its relation between food
and BP. The Dietary Approaches to Stop Hypertension (DASH) diet and modifications to the DASH diet,
coupled with reductions in sodium intake, show dose-dependent decreases in BP. Implementation of digital
lifestyle interventions based on the DASH diet have been effective and show potential for clinical
application.

Summary
Adopting a diet rich in plant-based foods, whole grains, low-fat dairy products, and sodium intake within
normal limits can be effective in the prevention and management of HTN. These diets have been found to
be more effective in older adults and hypertensive persons, particularly in studies that provided meals or
frequent dietary counseling.

Keywords
blood pressure, Dietary Approaches to Stop Hypertension diet, diet, sodium intake

INTRODUCTION The current profile of the Western diet is char-

Elevated resting blood pressure (BP) holds an inde-
pendent and strong dose-dependent association
with risk of developing cardiovascular disease
(CVD), heart failure, stroke, and kidney disease
and has been shown to hold true across all ages,
races, ethnicities, and sex [1]. Although the cause of
elevated BP is complex and multifaceted among
individuals, consistent evidence highlights physical
inactivity, smoking, excess alcohol consumption,
and an imbalance in dietary habits (i.e. favoring
high sodium, low potassium, and limited fruit
and vegetable intake) as major contributors to the
development of CVD across populations [2–6].
Although the cessation of smoking, becoming regu-
larly physically active, and lowering alcohol con-
sumption reduces SBP and DBP, this review will
highlight the contributions of altering dietary prac-
tices and dietary patterns for the prevention and
management of hypertension (HTN). Therefore, the
authors direct the reader to previous reviews on the
impact of other healthy lifestyle practices on lower-
&&
ing BP [7 ].
acterized by an excess intake of sodium, saturated
fats, sugar, and inadequate intake of fruits, vegeta-
bles, whole grains, and omega-3 fatty acids and has
come with sobering consequences on cardiovascular
health of developed countries [8]. Further, key life-
style practices that include increased consumption
of foods and drinks out of home (i.e. sit-down and
fast-food restaurants), ready-to-eat meals and con-
venience snacks consumed ‘at home,’ and foods
with large portion sizes have contributed, globally,
a
Department of Physical Therapy and the Integrative Physiology Labora-
tory, College of Applied Health Sciences, University of Illinois at Chicago,
Chicago, Illinois and bDepartment of Cardiovascular Diseases, John
Ochsner Heart and Vascular Institute, Ochsner Clinical School-University
of Queensland School of Medicine, New Orleans, Los Angeles, USA
Correspondence to Cemal Ozemek, PhD, Clinical Assistant Professor,
Department of Physical Therapy, College of Applied Health Sciences,
University of Illinois, Chicago, 1640 W Roosevelt Rd (MC 887), Chicago,
IL 60608, USA. Tel: +1 312 355 3996; fax: +1 312 413 8333;
e-mail: ozemek@uic.edu
Curr Opin Cardiol 2018, 33:388–393
DOI:10.1097/HCO.0000000000000532

www.co-cardiology.com Volume 33  Number 4  July 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 The risk of cardiovascular disease (CVD) exponentially
increases as resting SBP and DBP increase.
 Resting blood pressure (BP) greater than the current
normal levels (SBP <120 mmHg and DBP <80 mmHg)
nearly doubles an individual’s risk for CVD.
 Excess intake of sodium, saturated fats, sugar, coupled
with an inadequate intake of fruits, vegetables are
positively associated with BP and risk of developing
CVDs.
 Dietary interventions, such as the DASH diet, may lower
resting SBP and DBP by 11 and 5 mmHg, respectively.
 Future studies are required to investigate whether long-
term (>12 months) compliance to dietary interventions
similar to the DASH diet are as effective as
pharmacologic approaches to lowering BP.
to the greater intakes in sodium and high-energy
dense foods (kcal/g) with (i.e. higher fat content,
refined carbohydrates and excessive amounts of
added sugar and sugary sweetened beverage con-
sumption, low-fruit and vegetable intakes). With
the burgeoning trends in obesogenic food environ-
ment, it is becoming more and more apparent that
as individual eating behaviors adapt to the afore-
mentioned low ‘nutrient-dense’ dietary pattern, the
prevalence of CVD risk factors quickly follow [9].
Despite our understanding of lifestyle behaviors
that lead to chronic elevations in BP and the pre-
ventable or manageable nature of HTN for most
individuals, little has been accomplished to dramat-
ically attenuate the incidence of HTN across pop-
ulations. Accordingly, major health organizations
have placed special emphasis on early prevention of
HTN through detection and promotion of healthy
lifestyle behavior change.
CLINICAL MANAGEMENT OF ELEVATED
BLOOD PRESSURE
In the most recent iteration of the American Heart
Association (AHA) and American College of Cardiol-
ogy (ACC) guidelines for the Prevention, Detection,
Evaluation, and Management of Hypertension, cate-
gories of resting BP levels were reclassified. (‘‘Nor-
mal’’, <120 mm Hg SBP and <80 mm Hg DBP;
‘‘Elevated:, 120–129 mm Hg SBP and <80 mm Hg
DBP; ‘‘Hypertension Stage 1’’, 130–139 mm Hg SBP
or 80–89 mm Hg DBP; ‘‘Hypertension Stage 2’’,
140 mm Hg SBP or 90 mm Hg DBP). An impetus
for this update was stimulated by an in-depth review
of the literature that identified nearly double the risk
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Role of diet in management of hypertension Ozemek et al.
of developing coronary heart disease (CHD) and
stroke in those with a SBP/DBP of 130–139/85–
89 mmHg compared with normotensive (<120/
&&
80 mmHg) individuals [10 ]. Nevertheless, clinicians
are still encouraged to place heavy emphasis on
lifestyle modification, particularly diet, for preven-
tion and management of elevated BP regardless of the
course of pharmacologic therapy taken.
A common barrier to physician endorsement of
dietary modification and patient adoption of rec-
ommended diets is the frequent over inundation of
‘fad diets’ promoting rapid weight loss and health
improvements with little or no scientific evidence of
efficacy or feasibility for long-term behavior change.
Accordingly, health organizations, such as the
National Health, Lung, and Blood Institute, AHA,
and ACC, have endorsed evidence-based diets that
should be recommended to patients. In this review,
we will focus on presenting expected BP-lowering
effects of dietary interventions that have been rig-
orously tested, rather than focus on dispelling pop-
ular ‘fad diets.’
BLOOD PRESSURE-LOWERING EFFECTS
OF THE DIETARY APPROACHES TO STOP
HYPERTENSION DIET
With respect to HTN prevention and maintenance,
recent dietary recommendations have focused on
empirical evidence examining foods consumed
in combinations, or the overall dietary pattern, and
its relation between food and BP. As such, larger
emphasis on dietary patterns have been endorsed
by the Dietary Guidelines for Americans [11], and
the AHA/ACC/The Obesity Society [12], as they offer
the opportunity to characterize the overall nutri-
tional density, and thus, dietary quality of more
‘realistic’ eating behaviors in a population [13].
Among dietary patterns studied, the Dietary
Approaches to Stop Hypertension (DASH) diet has
been consistently endorsed by health organizations
(i.e. National Heart, Lung, and Blood Institute, AHA,
Dietary Guidelines for Americans, United States (US)
guidelines for treatment of high BP) as an effective
diet for controlling BP. Its development was influ-
enced by early observational studies highlighting
the relation between low prevalence rates of HTN
and CVD in those with eating behaviors that avoid
eating animal products, are low in saturated fat,
high in polyunsaturated fat, and low in cholesterol
[14]. Additionally, the adoption of a diet rich in
vegetables and devoid or limited consumption of
red meat by normotensive or hypertensive individ-
uals previously incorporating red meat frequently
into their diet, has been shown to lower BP [15,16].
Subsequently, the DASH diet was developed to
www.co-cardiology.com 389
Hypertension
emphasize a dietary profile mainly consisting of
plant-based foods, whole grains, and low-fat dairy
products. Compliance with the diet has been shown
to reduce SBP in HTN by 11 and 3 mmHg in normo-
tensive individuals [17,18], similar to early pharma-
cologic interventions for those with HTN [2].
The initial landmark study enrolled adults with
SBP <160 mmHg and DBP between 80 and 95 mmHg
and randomized participants to either an 8-week
control diet (low in fruits, vegetables, and dairy prod-
ucts, with an average fat content similar to the Amer-
ican diet), or a diet rich in fruits and vegetables, or a
combination diet rich in fruits, vegetables, and low-
fat dairy products, with reduced saturated and total
fat [17]. Compared with the control diet, the combi-
nation diet lowered SBP and DBP by 5.5 and
3.0 mmHg, respectively, whereas the fruits and vege-
table diet lowered SBP and DBP by 2.8 and 1.1 mmHg,
respectively. Notably, participants classified with
HTN (140, 90 mmHg, or both) at baseline, experi-
enced a decrease in SBP and DBP by 11.4 and
5.5 mmHg, respectively, in response to the combina-
tion diet compared with the control diet. Individuals
classified as without HTN (<140 and 90 mmHg) were
found to experience a decrease in SBP and DBP by 3.5
and 2.1 mmHg in the combination diet compared
with the control diet. Numerous subsequent studies
presented similar findings and a meta-analysis of the
DASH diet (or modified DASH-style dietary patterns)
on CVD risk factors demonstrated significant
decreases in SBP and DBP by 5.2 and 2.6 mmHg,
respectively, while contributing to a 13% reduction
in the 10-year Framingham risk score for CVD [19].
It must be noted, however, that in many of the
trials, successful lowering of BP via the DASH diet
were observed under investigator-controlled condi-
tions, such as providing participants with meals, and/
or employing regular dietary counselling. Thus, prag-
matic efficacy of these studies and ‘real-world’ com-
pliance of achieving and maintaining BP reductions
based on dietary recommendations alone, remains to
be in question [20]. Long-term adherence to diets
with stringent fat intake may present challenges for
individuals previously consuming a Western diet
[21]. Efforts to assuage these concerns have been
proposed and carried out to alter the original DASH
diet to permit variation in macronutrient composi-
tion. A recent study by Chiu et al. [22] performed a
three period, 3-week, randomized crossover study in
participants with an SBP <160 mmHg and a DBP
between 80 and 95 mmHg, free of known CHD,
diabetes, or other chronic diseases. Participants were
randomized to the order to consume either the DASH
diet, control diet (typical US diet), and a higher-fat,
lower carbohydrate modification of the DASH diet.
The modified DASH diet substituted full-fat dairy
390 www.co-cardiology.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
products for nonfat and low-fat dairy foods while
reducing 12% of energy from carbohydrates. Both
forms of the DASH diet showed similar decreases in
SBP (4 mmHg) and DBP (3 mmHg) compared with
the control diet, without any significant differences
when compared with each other. Despite these favor-
able responses, definitive recommendations on the
modified DASH diet cannot be made, because of the
small sample size and short-term intervention
period. Likewise, adoptions to DASH-style diet that
offer flexibility in food choices have been proposed
for sociocultural feasibility [23], underscoring their
generalizability to various populations. Thus, evolv-
ing an individual’s diet to a DASH-like diet pattern
provides one potential strategy to increase long-term
adherence and redeem similar health benefits associ-
ated with the traditional DASH diet in non-HTN and
individuals with HTN.
REDUCED SODIUM INTAKE
The average American’s diet consists of roughly
3400 mg of sodium per day, far exceeding the upper,
safe limit of the clinical dietary recommendations of
2400 mg/day [2,4,6]. Evidence of a strong positive
association between an individual’s daily sodium
intake and resting BP is especially concerning, with
those exceeding recommended daily levels having
an increased risk of stroke (risk ratio 1.24, 95% CI
1.08–1.43), and higher mortality risk from stroke
(1.63, 95% CI 1.27–2.10), and CHD (1.32, 95% CI
1.13–1.53). Although the mechanistic contribu-
tions of high sodium intake on cardiovascular
health are not completely understood, potential
mediating effects may be associated with alterations
in renal function, fluid volume, fluid regulatory
hormones, vascular function, cardiac function,
and the autonomic nervous system [24–28].
Interventions aimed at reducing daily sodium
intake have been effective in both primary and sec-
ondary prevention of HTN in populations that are
older, African American, or those with a greater
&&
sodium sensitivity [29 ]. Favorable, initial outcomes
from the landmark DASH diet intervention on BP
prompted subsequent modifications to include goals
of reducing sodium intake [30]. In the seminal study
by Sacks et al. the effects of three levels of sodium
intake, high 3600 mg/day, intermediate 2300 mg/day,
and low 1200 mg/day, coupled with either a control
diet (typical US diet) or standard DASH diet on BP were
examined in HTN and normotensive individuals.
Over a 30-day period, dose-dependent reductions in
BP were observed between the control diet and DASH
diet as well as within diets across the respective levels
of sodium intake. Moreover, participants non-HTN
(<140 and 90 mmHg) participants had a 7.1 mmHg
Volume 33  Number 4  July 2018

lower SBP on the low-sodium diet compared with the
control diet, and 11.5 mmHg lower SBP in participants
who had HTN (per old BP guidelines). In a more recent
&&
analysis of this data, Juraschek et al. [31 ] categorized
participants in the respective interventions by prein-
tervention resting SBP (<130, 130–139, 140–149, and
150 mmHg). In the control diet, lowering sodium
intake from high (3600 mg/day) to low (1200 mg/day)
contributed to significant average SBP differences of
3.2, 8.56, 8.99, and 7.04 mmHg across the SBP
categories. The trend for mean SBP differences (4.5,
4.2, 4.7, and 10.6 mmHg) were not significant
(P ¼ 0.66) across sodium intake from high to low while
following the DASH diet. However, a significant trend
across categories existed in the mean differences
between the low sodium-DASH diet compared with
the high sodium-control diet (5.3, 7.5, 9.7, and
20.8 mmHg). These compelling outcomes empha-
size the BP-lowering effects of both sodium reduction
and the DASH diet for HTN prevention as well as
management. It is worth noting, however, that further
sodium reductions to 1500 mg/day or less are not
advised among high-risk groups (i.e. individuals with
heart failure, diabetes, kidney disease, and CVD), as
such low intakes have been associated with adverse
CVD outcomes [6]. Additionally, long-term compli-
ance to reducing sodium intake has been challenging
in the general population [32,33]. Yet, maintaining
reductions in sodium consumption by at least
1000 mg/day is effective in lowering BP [4].
POTASSIUM SUPPLEMENTATION
Maintenance of an electrolyte balance is physiologi-
cally critical for normal cardiovascular function and
health. Potassium is a key regulator of BP through its
vasodilatory effects on the peripheral vasculature as
well as its contributions to increasing urinary sodium
excretion to help maintain appropriate circulating
sodium levels [34]. Both high sodium and low potas-
sium are independently associated with elevated BP,
and modification of either component alone lowers
BP [34]. A Western diet low in vegetables and fruits
and high in sodium intake promotes an imbalance
between sodium and potassium, favoring a high
ratio, which has been highlighted as associated with
elevated BP levels [35–37]. Interventions aimed at
increasing the dietary consumption for fruits and
vegetables have demonstrated increases in urinary
potassium (a marker of adequate potassium levels in
apparently healthy individuals), along with decreases
in resting SBP/DBP by roughly 4.4/2.5 mmHg in HTN
and 1.8/1.0 mmHg in individuals without HTN [38].
In addition to sodium and potassium holding inde-
pendent effects on BP, their complex, inverse inter-
actions influence biological regulation of BP.
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Role of diet in management of hypertension Ozemek et al.
Increases in potassium intake in those consuming
high dietary sodium have experienced greater BP-
lowering effects compared with those with low-
sodium intake [39], with the largest benefit observed,
when sodium intake is at least 4 g/day[36]. The
inverse holds true where the BP-lowering effects of
a low-sodium intake occur whenever potassium lev-
els are low. Yet, little to no evidence exists to suggest
that a combination of a low-sodium and high-potas-
sium diet result in an additive effect on lowering BP
&&
[29 ]. Lastly, although some evidence supports the
potential BP-lowering effects of increasing potassium
intake, there remains insufficient evidence to include
specific recommendations on increasing potassium
to lower BP [4].
MEDITERRANEAN DIET
Dietary practices in countries along or near the Med-
iterranean are frequently recognized as being heart-
healthy, that prolong life free from CVD. Addition-
ally, it is relatively easier for individuals to identify
foods associated with this diet, which generally con-
sists of a dietary profile with regular consumption of
fruits, vegetables, breads, potatoes, beans, nuts,
cheese, yogurt, fish and lean poultry. Olive oil is
the predominant source of fat, with red meat con-
sumed in low quantities along with an overarching
philosophy on consuming foods and red wine in
moderation. Many of these characteristics are similar
to the DASH diet, with interventions reporting
decreases in BP comparable with the conventional
DASH diet [2,22]. Alternatively, a meta-analysis of six
studies, with an average follow-up period of roughly
2 years revealed modest reductions in both SBP and
DBP (<2 mmHg) [40]. Despite, these less impressive
outcomes, the direction of changes in BP observed in
these studies, along with other common risk factors
for CVD favored the Mediterranean diet over low-fat
diets they were tested against. Additionally, analyses
were not stratified based on BP categories, which may
have revealed more impressive decreases in BP in
those with a higher resting BP.
WEIGHT LOSS
The prevalence of obesity has reached epidemic
proportions in Westernized countries and has been
independently associated with elevated BP. Gener-
ally, a dose–response relation exists between weight
lost and BP, such that a kilogram reduction in body
weight results in a 1 mmHg reduction in SBP. The
effects of weight loss on BP has been explored by
many randomized controlled trials, achieved by
either caloric restriction, increased physical activity,
or both. Regardless, of the means in which one
www.co-cardiology.com 391
Hypertension
achieves weight loss, a large meta-analysis of the
available data suggests that a 4.44 mmHg decrease in
SBP and 3.57 mmHg in DBP can be achieved by
losing 5 kg. Further reductions in SBP and DBP are
possible when more than 5 kg (SBP 6.63 mmHg
and DBP, 5.12 mmHg) of weight is lost compared
with those loosing less than 5 kg (SBP 2.70 mmHg
and DBP 2.01 mmHg) [41]. Provided the common
difficulties associated with achieving and maintain-
ing weight loss, emphasis should be placed on
improving the quality of foods consumed, particu-
larly whenever considering the dramatic BP lower
effects that can be achieved in the absence of weight
loss [14,17].
PRACTICAL CONSIDERATIONS
Due to the daunting nature of initiating and
maintaining lifestyle changes by patients, it is
not feasible to expect physicians to convey the
importance of dietary modifications for health and
describe strategies to follow specific dietary plans
under limited time constraints. As we have empha-
sized before, building a multidisciplinary team con-
sisting of experts across disciplines that implement
healthy lifestyle interventions, is highly recom-
&&
mended for successful lifestyle interventions [7 ].
Several trends in the Western diet have been
identified as being particularly harmful to cardio-
vascular health. In response, a number of diets
have been created and advertised at a rate that
seems to inundate the general population with
claims of efficacy with little scientific support.
Therefore, it is critical for experts to provide
clarity and specific dietary modifications relative
to the desired outcomes using evidence-based
approaches. Integrating registered dieticians into
the clinical setting to provide dietary recommen-
dations and monitor progress with BP-lowering
dietary interventions has been particularly effec-
tive [42,43]. Leveraging the support of dietitians
can be especially impactful whenever providing
care in areas or to individuals from lower income
neighborhoods and/or are of low socioeconomic
status. These characteristics have been identified
to be related to limited geographic accessibility to
supermarkets, being in closer proximity to fast-
food restaurants, as well as facing financial barriers
that limit affordability of foods that fall in line
with the DASH diet. Consequently, individuals
may be less likely to follow the DASH diet com-
pared with those with the greatest geographic and
economic accessibility [44].
Lastly, in addition to forging multidisciplinary
relationships within an organization to promote
implementation and adoption of healthy lifestyle
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changes, the use of technology in behavior change
has become more widely promoted. Digital lifestyle
interventions, available through smart phone plat-
forms, can circumvent common barriers to dissemi-
nating and implementing BP-lowering dietary
interventions, such as the DASH diet, that previ-
ously would rely on paper forms and frequent in-
person consultations [45]. Implementation of digi-
tal programs that provide coaching and/or extensive
resources on following a dietary intervention can
lead to significant improvements in health. A recent
study recruited 50 participants to test the efficacy of
a 24-week mobile HTN prevention program, based
on the DASH diet, that provided in-app human
coaching with biweekly phone calls, meal logging,
&
BP trading and access to educational material [46 ].
Those that completed the program (40 of 50) expe-
rienced a significant decrease in SBP (8 mmHg) and
DBP (4 mmHg). Although this area of research is in
its infancy and longer intervention are required,
digital approaches to dietary behavior change are
becoming more feasible, given the exponential
increase in adoption of smart phone technology
across demographics [47].
CONCLUSION
Dietary strategies including the DASH diet and
sodium reduction are effective in the prevention
and management of HTN. These diets have been
found to be more effective in older adults and
persons with HTN, particularly in studies that pro-
vided meals or frequent dietary counseling. Consid-
ering that there are many challenges associated with
dietary behavior change, clinicians are encouraged
to adopt multidisciplinary approaches to facilitate
the adoption of balanced dietary patterns.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statis-
tics—2015 update: a report from the American Heart Association Circulation
2015; 131:e535.
Volume 33  Number 4  July 2018

2. Gay HC, Rao SG, Vaccarino V, Ali MK. Effects of different dietary interven-
tions on blood pressure: systematic review and meta-analysis of randomized
controlled trials. Hypertension 2016; 67:733–739.
3. Mozaffarian D, Fahimi S, Singh GM, et al., Global Burden of Diseases Nutrition
and Chronic Diseases Expert Group. Global sodium consumption and death
from cardiovascular causes. N Engl J Med 2014; 371:624–634.
4. Van Horn L. Dietary sodium and blood pressure: how low should we go? Prog
Cardiovasc Dis 2015; 58:61–68.
5. McLaren L, Sumar N, Barberio AM, et al. s Population-level interventions in
government jurisdictions for dietary sodium reduction. Cochrane Database
Syst Rev 2016; 9:CD010166.
6. Davy BM, Halliday TM, Davy KP. Sodium intake and blood pressure: new
controversies, new labels. .. new guidelines? J Acad Nutr Diet 2015;
115:200–204.
7. Ozemek C, Phillips SA, Popovic D, et al. Nonpharmacologic management of
&& hypertension: a multidisciplinary approach. Curr Opin Cardiol 2017;
32:381–388.
Reviews the effects of healthy lifestyle modification interventions on managing
hypertension in multidisciplinary settings.
8. Zhang D, Cogswell ME, Wang G, Bowman BA. Evidence of dietary improve-
ment and preventable costs of cardiovascular disease. Am J Cardiol 2017;
120:1681–1688.
9. Danaei G, Singh GM, Paciorek CJ, et al. The global cardiovascular risk
transition: associations of four metabolic risk factors with national income,
urbanization, and Western diet in 1980 and 2008. Circulation 2013;
127:1493–502; 502e1-8.
10. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/
&& ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention,
detection, evaluation, and management of high blood pressure in adults: a
report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017. pii:
S0735-1097(17)41519-1.
Outlines the latest guidelines for the prevention, detection, evaluation, and
management of high blood pressure in adults.
11. US Department of Health and Human Services and US Department of
Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. 2015.
12. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for
the management of overweight and obesity in adults: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines and The Obesity Society. J Am Coll Cardiol 2014; 63(25 Pt
B):2985–3023.
13. Eckel RH, Jakicic JM, Ard JD, et al., American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guide-
line on lifestyle management to reduce cardiovascular risk: a report of the
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol 2014; 63(25 Pt B):2960–2984.
14. Sacks FM, Rosner B, Kass EH. Blood pressure in vegetarians. Am J Epidemiol
1974; 100:390–398.
15. Rouse IL, Beilin LJ, Armstrong BK, Vandongen R. Blood-pressure-lowering
effect of a vegetarian diet: controlled trial in normotensive subjects. Lancet
1983; 1:5–10.
16. Margetts BM, Beilin LJ, Vandongen R, Armstrong BK. Vegetarian diet in mild
hypertension: a randomised controlled trial. Br Med J (Clin Res Ed) 1986;
293:1468–1471.
17. 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.
18. Appel LJ, Champagne CM, Harsha DW, et al. Effects of comprehensive
lifestyle modification on blood pressure control: main results of the PREMIER
clinical trial. JAMA 2003; 289:2083–2093.
19. Siervo M, Lara J, Chowdhury S, et al. Effects of the Dietary Approach to Stop
Hypertension (DASH) diet on cardiovascular risk factors: a systematic review
and meta-analysis. Br J Nutr 2015; 113:1–15.
20. Kwan MW, Wong MC, Wang HH, et al. Compliance with the Dietary
Approaches to Stop Hypertension (DASH) diet: a systematic review. PLoS
One 2013; 8:e78412.
21. Henkin Y, Garber DW, Osterlund LC, Darnell BE. Saturated fats, cholesterol,
and dietary compliance. Arch Intern Med 1992; 152:1167–1174.
22. Chiu S, Bergeron N, Williams PT, et al. Comparison of the DASH (Dietary
Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood
pressure and lipids and lipoproteins: a randomized controlled trial. Am J Clin
Nutr 2016; 103:341–347.
23. Mozaffarian D. Dietary and policy priorities for cardiovascular disease, diabetes,
and obesity: a comprehensive review. Circulation 2016; 133:187–225.
24. Jacob F, Clark LA, Guzman PA, Osborn JW. Role of renal nerves in devel-
opment of hypertension in DOCA-salt model in rats: a telemetric approach.
Am J Physiol Heart Circ Physiol 2005; 289:H1519–H1529.
0268-4705 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Role of diet in management of hypertension Ozemek et al.
25. He FJ, Markandu ND, Sagnella GA, MacGregor GA. Importance of the renin
system in determining blood pressure fall with salt restriction in black and
white hypertensives. Hypertension 1998; 32:820–824.
26. Schmidlin O, Sebastian AF, Morris RC Jr. What initiates the pressor effect of
salt in salt-sensitive humans? Observations in normotensive blacks. Hyper-
tension 2007; 49:1032–1039.
27. Brooks VL, Haywood JR, Johnson AK. Translation of salt retention to central
activation of the sympathetic nervous system in hypertension. Clin Exp
Pharmacol Physiol 2005; 32:426–432.
28. Farquhar WB, Edwards DG, Jurkovitz CT, Weintraub WS. Dietary sodium
and health: more than just blood pressure. J Am Coll Cardiol 2015; 65:
1042–1050.
29. Appel LJ. The effects of dietary factors on blood pressure. Cardiol Clin 2017;
&& 35:197–212.
Provides a comprehensive summary of the dietary effects on blood pressure.
30. 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.
31. Juraschek SP, Miller ER 3rd, Weaver CM, Appel LJ. Effects of sodium
&& reduction and the DASH diet in relation to baseline blood pressure. J Am
Coll Cardiol 2017; 70:2841–2848.
Highlights the separate and combined effects of a low sodium and DASH diet
across baseline resting blood pressure stratifications.
32. Jiang J, Liu M, Troy LM, et al. Concordance with DASH diet and blood
pressure change: results from the Framingham Offspring Study. J Hypertens
2015; 33:2223–2230.
33. Kim H, Andrade FC. Diagnostic status of hypertension on the adherence to
the Dietary Approaches to Stop Hypertension (DASH) diet. Prev Med Rep
2016; 4:525–531.
34. Park J, Kwock CK, Yang YJ. The effect of the sodium to potassium ratio on
hypertension prevalence: a propensity score matching approach. Nutrients
2016; 8:pii: E482.
35. Jackson SL, Cogswell ME, Zhao L, et al. Association between urinary sodium
and potassium excretion and blood pressure among adults in the United
States: National Health and Nutrition Examination Survey, 2014. Circulation
2018; 137:237–246.
36. Aburto NJ, Hanson S, Gutierrez H, et al. Effect of increased potassium intake
on cardiovascular risk factors and disease: systematic review and meta-
analyses. BMJ 2013; 346:f1378.
37. Perez V, Chang ET. Sodium-to-potassium ratio and blood pressure, hyperten-
sion, and related factors. Adv Nutr 2014; 5:712–741.
38. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in
sodium and potassium intake: a metaregression analysis of randomised trials.
J Hum Hypertens 2003; 17:471–480.
39. van Bommel E, Cleophas T. Potassium treatment for hypertension in patients
with high salt intake: a meta-analysis. Int J Clin Pharmacol Ther 2012;
50:478–482.
40. Nordmann AJ, Suter-Zimmermann K, Bucher HC, et al. Meta-analysis com-
paring Mediterranean to low-fat diets for modification of cardiovascular risk
factors. Am J Med 2011; 124:841.e2–851.e2.
41. Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction on blood
pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;
42:878–884.
42. Nakano M, Eguchi K, Sato T, et al. Effect of intensive salt-restriction education
on clinic, home, and ambulatory blood pressure levels in treated hypertensive
patients during a 3-month education period. J Clin Hypertens (Greenwich)
2016; 18:385–392.
43. Lenders CM, Deen DD, Bistrian B, et al. Residency and specialties training
in nutrition: a call for action. Am J Clin Nutr 2014; 99(5 Suppl):
1174S–S1183.
44. Mackenbach JD, Burgoine T, Lakerveld J, et al. Accessibility and affordability
of supermarkets: associations with the DASH diet. Am J Prev Med 2017;
53:55–62.
45. Hageman PA, Pullen CH, Hertzog M, Boeckner LS. Effectiveness of tailored
lifestyle interventions, using web-based and print-mail, for reducing blood
pressure among rural women with prehypertension: main results of the
Wellness for Women: DASHing towards Health clinical trial. Int J Behav
Nutr Phys Act 2014; 11:148.
46. Toro-Ramos T, Kim Y, Wood M, et al. Efficacy of a mobile hypertension
& prevention delivery platform with human coaching. J Hum Hypertens 2017;
31:795–800.
A digital dietary intervention demonstrating long-term efficacy of lowering blood
pressure.
47. Price-Haywood EG, Harden-Barrios J, Ulep R, Luo Q. eHealth literacy: patient
engagement in identifying strategies to encourage use of patient portals
among older adults. Popul Health Manag 2017; 20:486–494.
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