Dietary Approaches to Stop Hypertension (DASH) Diet and Blood Pressure Reduction in Adults with and without Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

The Dietary Approaches to Stop Hypertension (DASH) diet is recognized as an effective dietary intervention to reduce blood pressure (BP). However, among randomized controlled trials (RCTs) investigating the DASH diet–mediated BP reduction, there are significant methodological and clinical differences. The purpose of this study was to comprehensively assess the DASH diet effect on BP in adults with and without hypertension, accounting for underlying methodological and clinical confounders. We systematically searched Medline and the Cochrane Collaboration Library databases and identified 30 RCTs (n = 5545 participants) that investigated the BP effects of the DASH diet compared with a control diet in hypertensive and nonhypertensive adults. Both random-effects and fixed-effect models were used to calculate the mean attained systolic BP (SBP) and diastolic BP (DBP) differences during follow-up. Subgroup and meta-regression analyses were also conducted. Compared with a control diet, the DASH diet reduced both SBP and DBP (difference in means: −3.2 mm Hg; 95% CI: −4.2, −2.3 mm Hg; P < 0.001, and −2.5 mm Hg; 95% CI: −3.5, −1.5 mm Hg; P < 0.001, respectively). Hypertension status did not modify the effect on BP reduction. The DASH diet compared with a control diet reduced SBP levels to a higher extent in trials with sodium intake >2400 mg/d than in trials with sodium intake ≤2400 mg/d, whereas both SBP and DBP were reduced more in trials with mean age <50 y than in trials of older participants. The quality of evidence was rated as moderate for both outcomes according to the Grading of Recommendations, Assessment, Development, and Evaluation approach. The adoption of the DASH diet was accompanied by significant BP reduction in adults with and without hypertension, although higher daily sodium intake and younger age enhanced the BP-lowering effect of the intervention. This meta-analysis was registered at www.crd.york.ac.uk/prospero as CRD42019128120.

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“…In 1997, the Dietary Approaches to Stop Hypertension (DASH) diet became a promising strategy for the treatment of high BP [ 74 ], and subsequent randomized clinical trials (RCTs) have supported this evidence [ 32 ]. This eating pattern promotes vegetables, fruits, whole grains, low- or free-fat dairy products, legumes and nuts intake, while restricting the intake of red and processed meat and sugar-sweetened beverages [ 74 , 75 ].…”

“…The DASH diet is characterized by a low-fat content (27% of daily calorie intake from fat), especially saturated fats (6% of energy) and dietary cholesterol (150 mg/d approximately), and reduced sodium content (from 1500 to 2300 mg/day), but it is rich in fiber (>30 g/day), potassium, magnesium and calcium compared to other dietary patterns [ 55 , 76 ]. The DASH diet has proven to be a useful strategy for the treatment of hypertension [ 32 , 33 , 55 , 77 ], and several epidemiological studies have associated higher adherence to the DASH diet with a better cardiometabolic profile [ 34 , 36 , 37 , 38 , 39 , 78 , 79 , 80 ]. In a meta-analysis of several cohort studies, Schwingshackl et al reported that higher adherence to the DASH diet was associated with a significant reduction in the risk of all-cause mortality (RR: 0.78 (95% CI 0.77 to 0.80), the incidence of or mortality by CVD and cancer (RR: 0.78 (95% CI 0.76 to 0.80); RR: 0.84 (95% CI 0.82 to 0.87), respectively) and the incidence of T2DM (RR: 0.82 (95% CI 0.78 to 0.85)) [ 40 ].…”

“…Regarding the use of DASH diet as an approach for the treatment of hypertension, a recent meta-analysis of 30 RCT with 5545 hypertensive and non-hypertensive participants concluded that the DASH diet together with lifestyle interventions significantly decreased systolic and diastolic BP measurements compared with a control diet (mean differences: −3.2 mm Hg (95% CI −4.2 to −2.3) and −2.5 mm Hg (95% CI −3.5 to −1.5), respectively) [ 32 ]. This effect was more pronounced when sodium intake was lower than 2400 mg/d, in subjects under the age of 50, and in participants with hypertension but without antihypertensive medication [ 32 ]. Moreover, on comparing the antihypertensive effects of the DASH diet with 13 other eating patterns (including low-fat diet, Nordic diet, MedDiet, Paleolithic diet and low-sodium diet), the DASH diet was the most effective, especially in comparison with low-fat diets [ 33 ].…”

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