A significant decrease in blood pressure through a family-based nutrition health education programme among community residents in Taiwan. Comprehensive nutrition plan improves cardiovascular risk factors in essential hypertension. A food-based dietary strategy lowers blood pressure in a low socio-economic setting: a randomised study in South Africa. The influence of a physician and patient intervention program on dietary intake. The PREMIER intervention helps participants follow the Dietary Approaches to Stop Hypertension dietary pattern and the current Dietary Reference Intakes recommendations. Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. The effect of dietary patterns on blood pressure control in hypertensive patients: results from the Dietary Approaches to Stop Hypertension (DASH) trial. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. Relationship to blood pressure of combinations of dietary macronutrients. Findings of the Multiple Risk Factor Intervention Trial (MRFIT). Randomized Controlled Trial on Lifestyle Modification in Hypertensive Patients The effect of a dietary portfolio compared to a DASH-type diet on blood pressure. Blood pressure and diet in normotensive volunteers: absence of an effect of dietary fiber, protein, or fat. CONTROLLED, RANDOMISED TRIAL OF THE EFFECT OF DIETARY FAT ON BLOOD PRESSURE Effects of Comprehensive Lifestyle Modification on Diet, Weight, Physical Fitness, and Blood Pressure Control: 18-Month Results of a Randomized Trial Diet and exercise intervention have favourable effects on blood pressure in mild hypertensives: the Oslo Diet and Exercise Study (ODES). Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure. The dietary approaches to stop hypertension (DASH) clinical trial: implications for lifestyle modifications in the treatment of hypertensive patients.
OBJECTIVE To evaluate the effect on decrease in blood pressure of modifying risk factors for stroke , such as blood lipid profiles , diet habits and indices of body weight , through a family-based nutrition health education programme among hypertensive patients and pre-hypertensive subjects without taking any antihypertensive drugs . DESIGN AND SETTING This was a community-based prospect i ve study . The study population was r and omly selected from communities in Taipei ; potential subjects were invited by telephone to participate . SUBJECTS After excluding subjects whose blood pressure was normal and those using antihypertensive drugs , there were 390 participants included in the study . Subjects in the intervention group ( n 293 ) received nutrition health education on blood pressure control and stroke-related risk factor modification at each visit . Non-intervention subjects ( n 97 ) only acquired a general education sheet available in clinics . The blood pressure of study subjects was measured at baseline and 6-month follow-up to evaluate the intervention 's effect on decrease in blood pressure . RESULTS Significant decreases of 2.0 mmHg and 5.9 mmHg in systolic blood pressure were observed both in pre-hypertensive and hypertensive subjects in the intervention group . Additionally , intervention subjects with improvement of total cholesterol and LDL cholesterol , decrease in indices of body weight and increase in consumption of fruit and vegetables also had significant lowering of blood pressure . CONCLUSIONS The present study provided evidence that the blood pressure of pre-hypertensive and hypertensive subjects could decrease significantly , without taking antihypertensive drugs , after modifying blood lipid profiles and waist by dietary habits changed through a family-based nutrition heath education programme , result ing in a significant effect on stroke risk reduction Increased arterial pressure is known to be influenced by a variety of nutrients . Compliance with dietary recommendations for risk reduction is often limited by the complexity of their implementation . In addition , how improvements in total diet , rather than single nutrients , influence concomitant cardiovascular risk factors has not been thoroughly explored . We assessed the effects of a nutritionally complete prepared meal program , the Campbell 's Center for Nutrition and Wellness plan ( CCNW ) , compared with dietary therapy in which participants received a structured nutritional assessment and prescription and selected their own foods , in 101 women and men with mild-to-moderate hypertension . Outcome measures included blood pressure ( BP ) , lipids and lipoproteins , glucose , glycosylated hemoglobin ( HbA1c ) , insulin , homocysteine , nutrient intake , compliance , and quality of life . Both dietary interventions significantly lowered BP ( P < .0001 ) , while simultaneously improving the overall cardiovascular risk profile . Significantly greater benefits were observed with the CCNW plan as compared with the participant selected diet in cholesterol and LDL levels ( both P < .0001 ) , LDL : HDL ( P < .001 ) , HbA1c ( P < .05 ) , homocysteine ( P < .001 ) , total nutrient intake ( P < .0001 ) , compliance ( P < .0001 ) , and quality of life ( P < .001 ) . This study demonstrates that improving the total diet to include the full array of recommended dietary guidelines , rather than focusing on single nutrients , has significant benefits for the cardiovascular risk profile of hypertensive persons beyond BP control . Compared with typical dietary therapy , the comprehensive CCNW meal plan has significantly greater effects on multiple cardiovascular risk factors while yielding greater compliance and improved quality of life OBJECTIVE To assess the impact of a food-based intervention on blood pressure ( BP ) in free-living South African men and women aged 50 - 75 years , with drug-treated mild-to-moderate hypertension . METHODS A double-blind controlled trial was undertaken in eighty drug-treated mild-to-moderate hypertensive subjects r and omised to an intervention ( n 40 ) or control ( n 40 ) arm . The intervention was 8-week provision of six food items with a modified cation content ( salt replacement ( SOLO ) , bread , margarine , stock cubes , soup mix and a flavour enhancer ) and 500 ml of maas ( fermented milk)/d . The control diet provided the same quantities of the targeted foods but of st and ard commercial composition and 500 ml/d of artificially sweetened cooldrink . FINDINGS The intervention effect estimated as the contrast of the within-diet group changes in BP from baseline to post-intervention was a significant reduction of 6.2 mmHg ( 95 % CI 0.9 , 11.4 ) for systolic BP . The largest intervention effect in 24 h BP was for wake systolic BP with a reduction of 5.1 mmHg ( 95 % CI 0.4 , 9.9 ) . For wake diastolic BP the reduction was 2.7 mmHg ( 95 % CI -0.2 , 5.6 ) . CONCLUSIONS Modification of the cation content of a limited number of commonly consumed foods lowers BP by a clinical ly significant magnitude in treated South African hypertensive patients of low socio-economic status . The magnitude of BP reduction provides motivation for a public health strategy that could be adopted through lobbying of the food industry by consumer and health agencies BACKGROUND Efficient dietary interventions for patients with hypertension in clinical setting s are needed . OBJECTIVE To assess the separate and combined influence of a physician intervention ( MD-I ) and a patient intervention ( PT-I ) on dietary intakes of patients with hypertension . DESIGN A nested 2 × 2 design , r and omized controlled trial conducted over 18 months . PARTICIPANTS A total of 32 physicians and 574 out patients with hypertension . INTERVENTION MD-I included training modules addressing the Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure hypertension management guidelines and lifestyle modification . PT-I included lifestyle coaching to adopt the Dietary Approaches to Stop Hypertension ( DASH ) eating pattern , reduce sodium intake , manage weight , increase exercise , and moderate alcohol intake . MAIN OUTCOME MEASURES Dietary intakes were measured by the Block Food Frequency Question naire . Concordance with the DASH dietary pattern was estimated by a DASH score . STATISTICAL ANALYSES The main effects of MD-I and PT-I , and their interaction , were evaluated using analysis of covariance . RESULTS After 6 months of intervention , MD-I participants significantly increased intakes of potassium , fruits , juices , and carbohydrate ; decreased intake of fat ; and improved overall dietary quality as measured by the Healthy Eating Index . PT-I intervention result ed in increased intakes of carbohydrate , protein , fiber , calcium , potassium , fruits and fruit juices , vegetables , dairy and Healthy Eating Index score , and decreased intakes in fat , saturated fat , cholesterol , sodium , sweets , and added fats/oils/sweets . In addition , PT-I improved overall DASH concordance score . The change in DASH score was significantly associated with the changes in blood pressure and weight at 6 months . At 18 months , most changes reversed back toward baseline levels , including the DASH score . CONCLUSIONS Both MD-I and PT-I  improved eating patterns at 6 months with some sustained effects at 18 months . Even though all dietary changes observed were consistent with the DASH nutrient targets or food group guidelines , only the PT-I intervention was effective in improving the overall DASH concordance score . This finding affirms the role of medical nutrition therapy in long-term intensive interventions for hypertension risk reduction and weight management and underlines the need for development of maintenance strategies . Furthermore , this study emphasizes the importance of collaborations among physicians , registered dietitians and other dietetics practitioners , and lay health advisors while assisting patients to make healthy behavior changes OBJECTIVE To examine the influence of the PREMIER study lifestyle interventions on dietary intakes and adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern and the Dietary Reference Intakes ( DRI ) . DESIGN An 18-month multicenter , r and omized controlled trial comparing two multicomponent lifestyle intervention programs to an advice only control group . SUBJECTS/ SETTING A total of 810 participants were recruited from local communities and r and omized into the study . Individuals were eligible if they were aged 25 years or older , had body mass index between 18.5 and 45.0 , not taking antihypertensive medication , and had prehypertension or stage 1 hypertension ( systolic blood pressure 120 to 159 mm Hg and diastolic blood pressure 80 to 95 mm Hg ) . INTERVENTION The two active intervention programs were a behavioral lifestyle intervention that implements established recommendations , and an established intervention plus the DASH dietary pattern . Both interventions consisted of intensive group and individual counseling sessions . The control group received a brief advice session after r and omization and again after 6 months of data collection . Dietary intakes were collected by two r and om 24-hour recalls at baseline , 6 months , and 18 months . MAIN OUTCOME MEASURES The primary outcome of the PREMIER study was change in systolic blood pressure at 6 months . The main outcomes examined here include dietary variables collected by 24-hour recall at each time point . STATISTICAL ANALYSES Nutrient intakes were calculated and compared among the time points and the three intervention groups using mixed models with repeated measures at 6 and 18 months . Proportion of participants who met or achieved the original DASH nutrient intake levels and the DRIs were calculated and compared among the three intervention groups . P<0.01 was considered statistically significant . RESULTS Participants in both the established intervention and established intervention plus DASH dietary pattern groups substantially reduced energy , total fat , saturated fat , and sodium intake and these reductions persisted throughout the study . Established intervention plus DASH dietary pattern group participants increased intakes of fruits , vegetables , dairy , and many vitamins and minerals ; these increases were significantly greater than that of the control and established intervention groups . A majority of established intervention plus DASH dietary pattern group participants achieved at least two thirds of the DRI recommendations for most nutrients at 6 months , despite their reduction in total energy intake . Some but relatively small recidivism occurred at 18 months . CONCLUSIONS Both the established intervention and established intervention plus DASH dietary pattern group intervention were effective in helping participants follow established recommendations to control blood pressure . The advice-only control group also made some behavior changes , mainly decreasing energy and sodium intake . Only the established intervention plus DASH dietary pattern group significantly increased intakes of DASH-specific food groups , including fruits , vegetables , and dairy products , and nutrients , including protein , fiber , calcium , potassium , and magnesium . Most of the increases did not reach the levels consumed in the original DASH feeding studies . Whereas the established intervention plus DASH dietary pattern group intervention provides a useful platform to achieve the DASH dietary pattern and current DRI recommendations , intervention enhancements , including a greater emphasis on nutrient-dense foods , would likely improve this intervention OBJECTIVE To determine the effects of dietary patterns on blood pressure in subgroups . METHODS Dietary Approaches to Stop Hypertension ( DASH ) was a r and omized controlled feeding study conducted at 4 academic medical centers . Participants were 459 adults with untreated systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg . For 3 weeks , participants were fed a " control " diet . They were then r and omized to 8 weeks of ( 1 ) control diet ; ( 2 ) a diet rich in fruits and vegetables ; or ( 3 ) a combination diet rich in fruits , vegetables , and low-fat dairy foods , and reduced in saturated fat , total fat , and cholesterol ( the DASH combination diet ) . Weight and salt intake were held constant . Change in diastolic blood pressure was the primary outcome variable , and systolic blood pressure a secondary outcome . Subgroups analyzed included race , sex , age , body mass index , years of education , income , physical activity , alcohol intake , and hypertension status . RESULTS The combination diet significantly lowered systolic blood pressure in all subgroups ( P<.008 ) , and significantly lowered diastolic blood pressure ( P<.01 ) in all but 2 subgroups . The fruits- and -vegetables diet also reduced blood pressure in the same subgroups , but to a lesser extent . The combination diet lowered systolic blood pressure significantly more in African Americans ( 6.8 mm Hg ) than in whites ( 3.0 mm Hg ) , and in hypertensive subjects ( 11.4 mm Hg ) than in nonhypertensive subjects ( 3.4 mm Hg ) ( P<.05 for both interactions ) . CONCLUSIONS The DASH combination diet , without sodium reduction or weight loss , significantly lowered blood pressure in virtually all subgroups examined , and was particularly effective in African Americans and those with hypertension . The DASH combination diet may be an effective strategy for preventing and treating hypertension in a broad cross section of the population , including segments of the population at highest risk for blood pressure-related cardiovascular disease To determine the impact of dietary patterns on the control of hypertension we studied the subgroup of 133 participants with systolic blood pressure ( BP ) of 140 to 159 mm Hg and /or diastolic BP of 90 to 95 mm Hg enrolled in the Dietary Approaches to Stop Hypertension ( DASH ) study . Participants were fed a control diet for a 3-week period and were then r and omized to receive for 8 weeks either the control diet ; a diet rich in fruits and vegetables , but otherwise similar to control ; or a combination diet rich in fruits , vegetables , and low-fat dairy products , including whole grains , fish , poultry , and nuts , and reduced in fats , red meats , sweets , and sugar-containing beverages .  Sodium intake and body weight were held constant throughout the study . The combination diet significantly reduced systolic BP ( -11.4 mm Hg , P < .001 ) and diastolic BP ( -5.5 mm Hg , P < .001 ) . The fruits- and -vegetables diet also significantly reduced systolic BP ( -7.2 mm Hg , P < .001 ) and diastolic BP ( -2.8 mm Hg , P = .013 ) . The combination diet produced significantly greater BP effects ( P < .05 ) than the fruits- and -vegetables diet .  Blood pressure changes were evident within 2 weeks of starting the intervention feeding . After the 8-week intervention period , 70 % of participants eating the combination diet had a normal BP ( systolic BP < 140 and diastolic BP < 90 mm Hg ) compared with 45 % on the fruits- and -vegetables diet and 23 % on the control diet . In patients with hypertension , the DASH combination diet effectively lowers BP and may be useful in achieving control of Stage 1 hypertension CONTEXT Weight loss , sodium reduction , increased physical activity , and limited alcohol intake are established recommendations that reduce blood pressure ( BP ) . The Dietary Approaches to Stop Hypertension ( DASH ) diet also lowers BP . To date , no trial has evaluated the effects of simultaneously implementing these lifestyle recommendations . OBJECTIVE To determine the effect on BP of 2 multicomponent , behavioral interventions . DESIGN , SETTING , AND PARTICIPANTS R and omized trial with enrollment at 4 clinical centers ( January 2000-June 2001 ) among 810 adults ( mean [ SD ] age , 50 [ 8.9 ] years ; 62 % women ; 34 % African American ) with above-optimal BP , including stage 1 hypertension ( 120 - 159 mm Hg systolic and 80 - 95 mm Hg diastolic ) , and who were not taking antihypertensive medications . INTERVENTION Participants were r and omized to one of 3 intervention groups : ( 1 ) " established , " a behavioral intervention that implemented established recommendations ( n = 268 ) ; ( 2 ) " established plus DASH,"which also implemented the DASH diet ( n = 269 ) ; and ( 3 ) an " advice only " comparison group ( n = 273 ) . MAIN OUTCOME MEASURES Blood pressure measurement and hypertension status at 6 months . RESULTS Both behavioral interventions significantly reduced weight , improved fitness , and lowered sodium intake . The established plus DASH intervention also increased fruit , vegetable , and dairy intake . Across the groups , gradients in BP and hypertensive status were evident . After subtracting change in advice only , the mean net reduction in systolic BP was 3.7 mm Hg ( P<.001 ) in the established group and 4.3 mm Hg ( P<.001 ) in the established plus DASH group ; the systolic BP difference between the established and established plus DASH groups was 0.6 mm Hg ( P = .43 ) . Compared with the baseline hypertension prevalence of 38 % , the prevalence at 6 months was 26 % in the advice only group , 17 % in the established group ( P = .01 compared with the advice only group ) , and 12 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .12 compared with the established group ) . The prevalence of optimal BP ( < 120 mm Hg systolic and < 80 mm Hg diastolic ) was 19 % in the advice only group , 30 % in the established group ( P = .005 compared with the advice only group ) , and 35 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .24 compared with the established group ) . CONCLUSION Individuals with above-optimal BP , including stage 1 hypertension , can make multiple lifestyle changes that lower BP and reduce their cardiovascular disease risk BACKGROUND Elevated blood pressure remains a widespread major impediment to health . Obesity and specific dietary factors such as high salt and alcohol intake and low potassium intake adversely affect blood pressure . It is a reasonable hypothesis that additional dietary constituents , particularly macronutrients , may also influence blood pressure . METHODS AND RESULTS Participants were 11,342 middle-aged men from the Multiple Risk Factor Intervention Trial ( MRFIT ) . Data from repeat 24-hour dietary recalls ( four to five per person ) and blood pressure measurements at six annual visits were used to assess relationships , singly and in combination , of dietary macronutrients to blood pressure , adjusted for multiple possible confounders ( demographic , dietary , and biomedical ) . Multiple linear regression was used to assess diet-blood pressure relations in two MRFIT treatment groups ( special intervention and usual care ) , with adjustment for confounders , pooling of coefficients from the two groups ( weighted by inverse of variance ) , and correction of coefficients for regression-dilution bias . In multivariate regression models , dietary cholesterol ( milligrams per 1000 kilocalories ) , saturated fatty acids ( percent of kilocalories ) , and starch ( percent of kilocalories ) were positively related to blood pressure ; protein and the ratio of dietary polyunsaturated to saturated fatty acids were inversely related to blood pressure . These macronutrient-blood pressure findings were obtained in analyses that controlled for body mass , dietary sodium and ratio of sodium to potassium , and alcohol intake , each positively related to blood pressure , and intake of potassium and caffeine , both inversely related to blood pressure . CONCLUSIONS These data support the concept that multiple dietary factors influence blood pressure ; hence , broad improvements in nutrition can be important in preventing and controlling high-normal and high blood pressure The authors examined the effects of a comprehensive lifestyle modification intervention on blood pressure ( BP ) and other  cardiovascular risk factors in hypertensive patients . A total of 70 participants were r and omly placed into either a lifestyle intervention or a control group . Four education classes and individual counseling sessions were held for the intervention group . Participants in the control group were provided with routine outpatient services and were asked to maintain their usual lifestyle . Data were gathered at baseline and at the end of 6 months . At the end of 6 months , BP , body weight , body mass index , waist circumference , and fasting lipids , apart from high-density lipoprotein cholesterol , significantly declined in the intervention group . Healthpromoting lifestyle scores of the intervention group had increased significantly compared to those of the control group . In conclusion , the results demonstrate the feasibility of comprehensive lifestyle modification and show its beneficial effects BACKGROUND AND AIM Compared to a DASH-type diet , an intensively applied dietary portfolio  reduced diastolic blood pressure at 24 weeks as a secondary outcome in a previous study . Due to the importance of strategies to reduce blood pressure , we performed an exploratory analysis pooling data from intensively and routinely applied portfolio treatments from the same study to assess the effect over time on systolic , diastolic and mean arterial pressure ( MAP ) , and the relation to sodium ( Na(+ ) ) , potassium ( K(+ ) ) , and portfolio components . METHODS AND RESULTS 241 participants with hyperlipidemia , from four academic centers across Canada were r and omized and completed either a DASH-type diet ( control n = 82 ) or a dietary portfolio that included , soy protein , viscous fibers and nuts ( n = 159 ) for 24 weeks . Fasting measures and 7-day food records were obtained at weeks 0 , 12 and 24 , with 24-h urines at weeks 0 and 24 . The dietary portfolio reduced systolic , diastolic and mean arterial blood pressure compared to the control by 2.1 mm Hg ( 95 % CI , 4.2 to -0.1 mm Hg ) ( p = 0.056 ) , 1.8 mm Hg ( CI , 3.2 to 0.4 mm Hg ) ( p = 0.013 ) and 1.9 mm Hg ( CI , 3.4 to 0.4 mm Hg ) ( p = 0.015 ) , respectively . Blood pressure reductions were small at 12 weeks and only reached significance at 24 weeks . Nuts , soy and viscous fiber all related negatively to change in mean arterial pressure ( ρ = -0.15 to -0.17 , p ≤ 0.016 ) as did urinary potassium ( ρ = -0.25 , p = 0.001 ) , while the Na(+)/K(+ ) ratio was positively associated ( ρ = 0.20 , p = 0.010 ) . CONCLUSIONS Consumption of a cholesterol-lowering dietary portfolio also decreased blood pressure by comparison with a healthy DASH-type diet . CLINICAL TRIAL REG . NO . : NCT00438425 , clinical trials.gov In the course of four controlled experiments on the effect of specific dietary components on cardiovascular risk factors , the effects on blood pressure of various sources of dietary fiber , of type and amount of dietary fat , and of animal versus plant were measured in young normotensive volunteers . In each of the four experiments a group of 50 to 75 healthy student volunteers received a control diet for 11/2 to 21/2 wk . They were then r and omized into subgroups which received various test diets for periods ranging from 4 to 12 wk . In each experimental one group received the control diet throughout the whole experimental period . Diets differed between groups in one dietary component only . All foodstuffs were weighed out individually according to each person 's energy needs . Body weights and Na intake were controlled . Initial blood pressures were about 120 mm Hg systolic and 70 mm Hg diastolic . Both systolic and diastolic blood pressure decreased during the test period in all four experiments on almost every diet , including the control diets , by about 0 to 5 mm Hg . However , changes in blood pressure over the test period were never significantly different between the test groups and the control groups . Thus , none of the investigated dietary factors had a demonstrable effect on blood pressure in young normotensive persons 57 couples living in two communities of North Karelia , aged 30 - 50 years , were r and omly allocated to three groups . After a 2-week baseline period group I followed a diet low in fat ( 23 % of energy ) with a high polyunsaturated/saturated ( P/S ) ratio ( 1 . 0 ) , group II reduced daily salt intake from 192 mmol to 77 mmol , and group III ( control group ) continued the usual diet . After the 6-week intervention period groups I and II reverted to their usual diets . In group I systolic blood pressure declined from 138 . 4 to 129 . 5 mm Hg and diastolic blood pressure from 88 . 9 to 81 . 3 mm Hg during the intervention period ; the values rose during switch-back . The fall was greater among hypertensive than among normotensive subjects . In groups II and III the mean blood pressure changed very little during the study Context Can adults make sustained changes in unhealthy lifestyle behaviors ? Content In this multicenter trial , 810 adult volunteers with prehypertension or stage 1 hypertension were r and omly assigned to a multicomponent behavioral intervention group , a group combining the behavioral intervention plus the Dietary Approaches to Stop Hypertension ( DASH ) diet , or an advice only group . At 18 months , participants in both behavioral intervention groups had less hypertension , more weight loss , and better reduction in sodium and fat intake than those receiving advice only . The participants in the DASH diet group also increased their intake of fruits , vegetables , and fiber . Implication s Motivated adults can sustain several lifestyle changes over 18 months , which might reduce their risk for cardiovascular disease . The Editors The public health burden of chronic diseases related to suboptimal diet and physical inactivity is enormous . It has been estimated that these lifestyle factors contribute to approximately 20 % of deaths in the United States ( 1 ) . Incidence of atherosclerotic cardiovascular disease , overweight and obesity , elevated blood pressure and lipid levels , diabetes , osteoporosis , and cancer is increased by unhealthy lifestyles ( 2 - 8 ) . Multiple lifestyle factors , such as physical inactivity ; excessive intake of calories , sodium , saturated fat , and cholesterol ; and inadequate intake of fruits , vegetables , and low-fat dairy products , are etiologically related to the development of these diseases ( 4 , 5 , 8 - 10 ) . To reduce the burden of chronic disease , increased physical activity and changes in diet are needed , yet few intervention studies have attempted to achieve many lifestyle changes simultaneously . The PREMIER r and omized trial tested the effects of 2 multicomponent behavioral interventions on blood pressure ( 11 ) . Both interventions promoted increased physical activity , weight loss , and reduced sodium intake , each of which is recommended by the 2005 Dietary Guidelines Scientific Advisory Committee ( 12 ) . One intervention also added the Dietary Approaches to Stop Hypertension ( DASH ) diet ( 13 ) . This diet , which is high in fruits , vegetables , and low-fat dairy products and low in saturated fat , total fat , and cholesterol , meets each of the major nutrient recommendations that were established by the Institute of Medicine ( 14 - 18 ) . We report the effects of the PREMIER interventions on lifestyle changes and blood pressure status at 18 months . The main results of PREMIER , namely change in blood pressure at 6 months , were reported previously ( 11 ) . Methods The PREMIER study design and rationale ( 19 ) and intervention methods ( 11 ) have been described previously . The institutional review boards at each clinical center ; an external protocol review committee appointed by the National Heart , Lung , and Blood Institute ( NHLBI ) ; and the NHLBI review ed and approved the protocol ( available at www.kpchr.org/public/premier/intervention/default.asp ) . The NHLBI also appointed a data and safety monitoring board to monitor the trial . Each participant provided written informed consent . The trial was conducted from January 2000 through November 2002 . Study Participants Participants were generally healthy adults , age 25 years or older , who had prehypertension or stage 1 hypertension and met the Joint National Committee VI ( JNC VI ) criteria for a 6-month trial of nonpharmacologic therapy ( 2 ) . Targeted recruitment methods were used to ensure adequate representation of clinical ly important subgroups , in particular , African-American persons . Specific methods varied from site to site but included direct mailings , radio and newspaper advertisements , and networking within the local African-American communities . Eligibility criteria included not taking antihypertensive medication and having a systolic blood pressure of 120 to 159 mm Hg and a diastolic blood pressure of 80 to 95 mm Hg , based on the average of 3 screening visits . Persons with prehypertension ( systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg ) were included because of the excess risk for cardiovascular disease in those with blood pressure within this range ( 20 ) . Major exclusion criteria were a body mass index less than 18.5 kg/mg2 or greater than 45.0 kg/m2 , use of antihypertensive drugs or other drugs that affect blood pressure , JNC VI risk category C ( target organ damage or diabetes ) , use of prescription weight loss medications , previous cardiovascular event , congestive heart failure , angina , cancer , and consumption of more than 21 alcoholic drinks per week . Trial Conduct Eligible participants were r and omly assigned , with equal probability , to 1 of 3 groups : an advice only comparison group ( advice only ) ; an intervention group that targeted established , guideline -recommended lifestyle recommendations ( established ) ( 2 ) ; or an intervention group targeting the established recommendations and adding the DASH dietary pattern ( established plus DASH ) ( 13 ) . Computer-generated treatment assignments were stratified by clinic and hypertension status and were assigned in blocks of varying sizes to provide balance over time . The actual assignments were administered by using a password-protected , Web-based application developed by the coordinating center and accessible only by authorized individuals . All clinic measurement staff were blinded to treatment assignment , and all intervention staff were blinded to clinic measurements . Hypertension was defined by using the JNC VI criteria for hypertension treatment : an average systolic blood pressure of 140 mm Hg , a diastolic blood pressure greater than 90 mm Hg , or use of antihypertensive medication . Normal blood pressure was defined as systolic blood pressure less than 120 mm Hg , diastolic blood pressure less than 80 mm Hg , and no use of antihypertensive medication ( 21 ) ( Figure ) . Intervention was provided by master 's degreelevel counselors ( dietitians and health educators trained in behavioral methods ) . The counselors were central ly trained before the start of the study , attended annual 3-day training sessions , and participated in monthly conference calls . Figure . Flow diagram of enrollment , measurements , and visit completion . Advice Only  Group Participants in the advice group  received advice to follow the National High Blood Pressure Education Program lifestyle recommendations for blood pressure control ( 2 ) . Lifestyle recommendations included reducing weight ( if overweight ) , following a reduced-sodium diet , engaging in regular moderate-intensity physical activity , and eating a heart-healthy diet , including the DASH diet . This advice was provided in two 30-minute individual sessions , 1 immediately after r and om assignment and 1 after the 6-month data collection visit . A PREMIER counselor review ed the guidelines with the participant and provided printed educational material s and information about community re sources . This intervention did not include advice to keep a food or exercise diary . Behavioral Interventions in the Established and Established plus DASH Groups Participant goals for the established and established plus DASH groups included weight loss of at least 6.8 kg ( 15 lb ) for those with a body mass index of 25 kg/m2 or greater , at least 180 minutes per week of moderate-intensity physical activity , no more than 100 mmol per day of dietary sodium , and alcohol consumption of no more than 30 mL ( 1 oz ) per day ( 2 drinks ) for men and 15 mL ( 0.5 ) oz per day ( 1 drink ) for women . Participants assigned to the established plus DASH group ( but not those in the established group ) also received counseling on the DASH diet , with goals for increased consumption of fruits and vegetables ( 9 to 12 servings/d ) and low-fat dairy products ( 2 to 3 servings/d ) and reduced consumption of saturated fat ( 7 % of energy ) and total fat ( 25 % of energy ) . The intervention format , contact pattern , and behavior change strategies for the established and established plus DASH groups were identical . During the first 6 months , participants in both behavioral intervention groups attended 14 group sessions and 4 individual sessions ; during months 7 to 18 , they attended monthly group sessions supplemented with 3 individual counseling sessions . Throughout the trial , participants in the established and established plus DASH groups ( but not those in the advice group ) kept food diaries , monitored dietary calorie and sodium intakes , and recorded minutes of physical activity . Self-monitoring was used to provide individualized feedback , reinforcement , problem solving , and support . Social support for initial behavior changes and maintenance of change was provided during the group sessions . More detailed descriptions of the behavorial intervention methods are available ( 22 ) . Measurements Blood pressure was assessed twice at each measurement , and systolic and diastolic blood pressures were calculated by using the mean of all available measurements ( 4 sets before r and om assignment , 3 sets at 6 and 18 months , and 1 set at 3 and 12 months ) . For 4 participants who were started on antihypertensive drug therapy between the 12- and 18-month visits , we obtained an official set of blood pressure measurements before initiation of therapy and used these as our 18-month blood pressure values for analysis . A similar procedure was used to obtain the 6-month blood pressure value for the 1 participant who began taking antihypertensive drugs between the 3- and 6-month visits . Two 24-hour dietary recalls , 1 obtained on a weekday and the other obtained on a weekend , were collected at baseline and at 6 and 18 months by telephone interview ( 23 ) . Intakes of nutrients and food groups were calculated by using the Nutrition Data System for Research , version NDS-R 1998 ( University of Minnesota , Minneapolis , Minnesota ) . Urinary excretion of sodium ( reflecting salt intake ) and potassium ( reflecting fruit and vegetable intake ) was obtained from 24-hour urinary collection s at baseline The purpose of this study was to investigate the effect of 1-year diet intervention , exercise intervention and both combined on blood pressure ( BP ) in normotensives and mild hypertensives . Two hundred and nineteen sedentary middle aged men and women with slightly deranged coronary heart disease ( CHD ) risk factors were r and omised to a control , a diet , an exercise and a diet + exercise group . Based on baseline diastolic BP , participants were divided into tertiles , giving baseline average BP of 141.4/96.7 in tertile 1 , 130.7/87.6 in tertile 2 and 121.9/79.0 in tertile 3 . The 1-year net-difference in BP between the intervention groups and the control group decreased across the tertiles ; in tertile 1 being -11.2/-6.7 ( p < 0.05 ) , -11.3/-6.7 ( p < 0.05 for systolic BP only ) and -7.0/-5.1 ( NS ) in the combined , diet and exercise group respectively . Triglycerides , HDL cholesterol , and insulin variables were significantly and favourably changed , the changes being most marked in the combined group . The results show that diet and diet + exercise are about equally effective in reducing BP , and the effects may be dependent on the baseline level . Within the upper tertile of baseline BP , the decline in BP in the combined intervention and the diet group are almost comparable to those obtained with drug treatment . In addition , other important CHD risk factors were all changed in a beneficial direction Epidemiologic studies have found that dietary patterns characterized by high intakes of certain minerals and fiber are associated with low blood pressure .  Dietary Approaches to Stop Hypertension ( DASH ) is a multicenter , r and omized , controlled-feeding trial design ed to test the effects on blood pressure of two such dietary patterns consumed for 8 weeks . The two experimental diets will be compared with each other and with a control dietary pattern that is relatively low in potassium , magnesium , calcium , and fiber , and has a fat and protein profile mirroring current consumption . The first experimental diet , arguably termed " ideal , " is high in fruits , vegetables , whole cereal products , low-fat dairy products , fish , chicken , and lean meats design ed to be low in saturated fat and cholesterol ; moderately high in protein ; and high in minerals and fiber . The second experimental diet tests the effect of fruits and vegetables alone . Its potassium , magnesium , and dietary fiber content will be at the same high levels as the ideal dietary pattern , while its fat , protein , and calcium content will resemble that of the control dietary pattern . The study population will consist of 456 healthy men and women , aged 22 years or older , with systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg . African-American and other minority groups will comprise 67 % of the population . Participants will eat one of the three dietary patterns . The DASH trial has unique features . First , dietary patterns rather than single nutrients are being tested . Second , all food for the experimental diets is provided to the participants using a st and ardized multicenter protocol . Because the dietary patterns are constructed with commonly consumed food items , the results , if positive , may be conveniently implemented in dietary recommendations to the general public Lifestyle modifications , such as weight loss , sodium restriction , and limiting alcohol consumption , are important components of the initial treatment of hypertensive patients . The Dietary Approaches to Stop Hypertension ( DASH ) study investigated the effects of dietary patterns on blood pressure in individuals with diastolic blood pressure between 80 - 95 mmHg . Two different dietary patterns were tested in this feeding study . A diet enriched in fruits and vegetables and a diet enriched in fruits , vegetables , and low-fat dairy products and low in total and saturated fat ( combination diet ) were compared with a control diet . Dietary intake was adjusted so that participants did not lose weight , and all study diets had comparable sodium intake ( approximately 3 grams/day ) . All meals were provided for 459 participants for an 11-week period . Those r and omized to the combination diet ( n = 151 ) had a significant change in systolic ( -5.5 mmHg ; p < 0.001 ) and diastolic blood pressure ( -3.0 mmHg ; p < 0.001 ) after subtracting the response to the control diet ( n = 154 ) . The fruits- and -vegetables diet ( n = 154 ) produced a significant but lesser decrease in blood pressure ( systolic , -2.8 mmHg ; p < 0.001 and diastolic , -1.1 mmHg ; p = 0.07 ) . Hypertensive individuals and African Americans had particularly favorable responses with blood pressure reductions , which were significantly greater than other subgroups . The combination diet was well-accepted and adherence to the diet was high ( > 90 % ) for all participants . The DASH combination diet is an effective lifestyle modification for lowering blood pressure in patients with high-normal or Stage 1 hypertension
For most comparisons , the credibility of evidence was rated very low to moderate , with the exception for the DASH vs. the low-fat dietary approach for which the quality of evidence was rated high .
Conclusion : The present network meta- analysis suggests that the DASH dietary approach might be the most effective dietary measure to reduce blood pressure among hypertensive and pre-hypertensive patients based on high quality evidence
ABSTRACT Background : Pairwise meta-analyses have shown beneficial effects of individual dietary approaches on blood pressure but their comparative effects have not been established .
Objective : Therefore we performed a systematic review of different dietary intervention trials and estimated the aggregate blood pressure effects through network meta- analysis including hypertensive and pre-hypertensive patients .