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(Hypertension. 2003;42:8.)
© 2003 American Heart Association, Inc.

Scientific Contributions

Effects of the Dietary Approaches to Stop Hypertension (DASH) Diet on the Pressure-Natriuresis Relationship

Sachie Akita; Frank M. Sacks; Laura P. Svetkey; Paul R. Conlin; Genjiro Kimura for the DASH-Sodium Trial Collaborative Research Group

From the Department of Internal Medicine and Pathophysiology, Nagoya City University Graduate School of Medical Sciences (S.A., G.K.), Nagoya, Japan; Nutrition Department, Harvard School of Public Health and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School (F.M.S.), Boston; Duke Hypertension Center and Sarah W. Stedman Center for Nutritional Studies, Duke University Medical Center (L.P.S.), Durham, NC; and Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School (P.R.C.), Boston, Mass.

Correspondence to Genjiro Kimura, MD, Professor and Chairman, Department of Internal Medicine and Pathophysiology, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. E-mail genki{at}med.nagoya-cu.ac.jp

	Abstract

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Blood pressure-lowering mechanisms of the Dietary Approaches to Stop Hypertension (DASH) diet, rich in fruits, vegetables, and low-fat dairy foods, were analyzed based on the pressure-natriuresis relationship. Participants (n=375) were randomly assigned to control or DASH diet groups by using a parallel-group design. They then ate their assigned diet for 3 consecutive 30-day intervention feeding periods, during which sodium intake varied among 3 levels by a randomly assigned sequence. Urinary sodium excretion rate and mean arterial pressure were measured at the end of each sodium intake level. Mean arterial pressure and urinary sodium excretion were plotted on x and y axes, respectively, for participants eating control and DASH diets and were modeled as linear relationships for simplicity to allow the estimation of the extrapolated x-intercept and slope of the relationships. The DASH diet steepened the slope of the relationship (29.5±3.4 vs 64.9±13.1 [mmol/d]/mm Hg, P=0.0002) without significantly shifting the x-intercept (94.1±0.5 vs 93.2±0.6 mm Hg, NS) of the relationship. These data suggest a natriuretic action of the DASH diet.

Key Words: blood pressure • hypertension, essential • sodium • diet • diuretics

	Introduction

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The Dietary Approaches to Stop Hypertension (DASH) diet, rich in fruits, vegetables, and low-fat dairy foods, has been proved to have substantial blood pressure (BP)-lowering action^1,2 and is now recommended as one of the most important nonpharmacological measures to control BP.^3,4 However, the mechanisms of the action remain unsolved. We have theoretically shown that the mechanisms of BP-lowering action can be analyzed based on the pressure-natriuresis curve,^5–7 which may be drawn using data from the DASH-Sodium Trial.² Effects of different types of antihypertensive agents, including angiotensin-converting enzyme inhibitors, ß-blockers, calcium antagonists, and diuretics, on the pressure-natriuresis curve are also known.^5,6,8 In this article, we studied the effect of the DASH diet on the pressure-natriuresis relationship to clarify the mechanisms of its BP-lowering action.

	Methods

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This was a study ancillary to the DASH-Sodium Trial, a multicenter, randomized feeding trial comparing the effects on BP of 3 levels of sodium intake and 2 dietary patterns,^2,9 and as such, was designed, conducted, and analyzed by the coauthors only.

Study Design
The 412 participants were 22 years of age or older and had systolic BP (SBP) of 120 to 159 mm Hg and diastolic BP (DBP) of 80 to 95 mm Hg without BP-lowering medication. After a 2-week run-in period, by using a parallel-group design, the participants were randomly assigned to one of the 2 dietary patterns: a control diet typical of what many Americans eat and the DASH diet, which emphasizes fruits, vegetables, and low-fat dairy foods,^1,10 with same number of calories as the control diet. Participants ate their assigned diet for 3 consecutive 30-day intervention feeding periods, during which sodium intake varied among the 3 levels by a randomly assigned sequence. The 3 levels of sodium intake (lower, intermediate, and higher) were 50, 100, and 150 mmol/d, respectively, for a 2100-kcal diet.

Measurement Protocol
Trained staff measured BP at each of 3 screening visits on 2 days during the run-in period and on 5 of the last 9 days of each intervention feeding period.^2,9 Baseline BP was defined as the average of the 5 preintervention BPs (screening plus run-in). End-of-feeding BPs were defined as the average of the 5 BPs at the end of each 30-day intervention feeding period. Mean arterial pressure (MAP) was calculated by adding one third of the pulse pressure to DBP. During the last week of each intervention feeding period, a 24-hour urine collection was obtained to measure urinary sodium excretion rate (U_NaV).

Definitions of Subgroups
Participants were self categorized as African American versus other (primarily non-Hispanic white).⁹ They were considered hypertensive if their untreated baseline systolic BP was 140 mm Hg or greater or their diastolic BP was 90 mm Hg or greater. Use of antihypertensive agents was an exclusion criterion.² Obesity was defined as body mass index of 30 kg/m² or greater. Age was dichotomized at the approximate median.

Determination of the Pressure-Natriuresis Curve
By linking data points obtained in a steady state of sodium balance under 3 different amounts of sodium intake, the pressure-natriuresis curves were drawn for both control and DASH diets. MAP (mm Hg) and U_NaV (mmol/d) were plotted on the x and y axes, respectively.^11–13 To compare the major characteristics of the curve, namely, shift of the curve along the arterial pressure axis and steepness of the curve, between control and DASH diets as well as between subgroups, the extrapolated x-intercept (mm Hg) and the slope ([mmol/d]/mm Hg) were calculated from the regression lines.^7,8,14,15

Statistical Analysis
Results are expressed as the mean±SEM, and the significance of the effects of DASH diet (A) and sodium intervention (B) was tested by a 2-way classification analysis of variance and covariance with repeated measures. The presence of interaction (AxB) was considered to indicate that the effect of DASH diet was influenced by sodium intake level. The extrapolated x-intercept and the slope of the pressure-natriuresis curve were obtained as MAP-intercept and the reciprocal of the slope, respectively, by drawing the regression line plotting MAP values as functions of U_NaV. The comparison of the x-intercept and slope of the pressure-natriuresis curve between control and DASH diets, as well as between subgroups, was tested by the Student t test for nonpaired samples.

	Results

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Urinary Sodium Excretion and Blood Pressure
U_NaV and BP measurements were completed in 375 of 412 participants, and these values are presented by sodium level in Table 1. Two-way analysis of variance showed that SBP and MAP were all lowered by DASH diet (A), except in younger participants (P=0.08 for SBP, P=0.12 for MAP). Sodium intervention (B) influenced both SBP and DBP significantly in every subgroup. The presence of interaction (AxB), except in non–African Americans (P=0.054 for SBP, P=0.14 for MAP), indicates that the effect of the DASH diet was significantly altered by the level of sodium intake and that BP reductions by combination of the DASH diet (A) and reduced sodium intake (B) were smaller than their additive, although greater than the effect of either intervention alone.

View this table: [in this window] [in a new window]   TABLE 1. Urinary Sodium Excretion and Blood Pressures in Participants of DASH-Sodium Trial

Pressure-Natriuresis Relationship in Subgroups During Control (Typical American) Diet
Among individuals eating the 3 sodium levels on both control and DASH diets, there were positive relationships between MAP and the corresponding U_NaV in the overall group (Figure 1) and in subgroups (Figure 2). During the control diet, the extrapolated x-intercept was significantly larger in hypertensives than normotensives, indicating that the pressure-natriuresis curve was shifted rightward in hypertensives (Table 2). The slope was shallower in hypertensives than normotensives, in African Americans than in other races, as well as in older (>45 years) than in younger (45 years) participants, indicating that BP was more sodium-sensitive in the former subgroups than in their latter counterparts (Table 2). There were no significant differences in slopes between nonobese (<30 kg/m²) and obese (30 kg/m²) adults and between males and females.

View larger version (12K): [in this window] [in a new window]   Figure 1. Pressure-natriuresis curves in the Dietary Approaches to Stop Hypertension (DASH) Diet-Sodium Trial. Urinary sodium excretion rate (UNaV: mmol/d) and systemic mean arterial pressure (MAP: mm Hg) were plotted on the ordinate and abscissa for control and DASH diets. Open and closed circles represent data for the control and DASH diets, respectively. Error bars indicate ±1 standard errors of the means. Regression lines for 3 different amounts of sodium were UNaV=30x(MAP-94) in control diet, and UNaV=65x(MAP-93) in DASH diet. DASH diet augmented the slope of the pressure-natriuresis curve from 30 to 65 ([mmol/d]/mm Hg, P=0.0002) without affecting the extrapolated intercept of BP axis (94 vs 93 mm Hg, P=0.22), resulting in a decrease in sodium sensitivity of BP from 0.034 to 0.015 mm Hg/(mmol/d). Please note that the discrepancy between data plot and estimated pressure-natriuresis curve (line) is ascribed to the fact that we obtained a regression line from a whole cluster of data instead of averaging the extrapolated x-intercepts and slopes of the line in each participant.

View larger version (24K): [in this window] [in a new window]   Figure 2. Pressure-natriuresis curves in subgroups: A, normotensives versus hypertensives; B, non–African American versus African American; C, age 45 years versus age >45 years; D, nonobese versus obese; and E, male versus female. Open and closed circles represent data for the control and DASH diets, respectively. See legend to Figure 1 for additional explanation.

View this table: [in this window] [in a new window]   TABLE 2. Pressure-Natriuresis Curve in Participants of DASH-Sodium Trial

Effect of DASH Diet on Pressure-Natriuresis Curve
The pressure-natriuresis curve during the DASH diet was similarly obtained and compared with that of the control diet. The extrapolated x-intercept was not significantly altered by the DASH diet (94.1±0.5 vs 93.2±0.6 mm Hg, P=0.22; n=375), whereas the slope was increased from 29.5±3.4 to 64.9±13.1 (mmol/d)/mm Hg (P=0.0002) (Table 2 and Figure 1). The increase in the slope by the DASH diet was observed in all subgroups (Table 2 and Figure 2) although these increases did not reach statistical significance in hypertensives (P=0.055), non–African Americans, (P=0.089) and younger participants (P=0.063). These results indicated that the BP-lowering action of the DASH diet was associated with increased slope of the pressure-natriuresis curve, but not with a leftward shift of the curve along the BP axis.

In the overall study group, the effect of sodium level on BP was found to be greater from low-to-intermediate than from intermediate-to-high sodium intake.² To determine whether the assumption of linearity affected the results in the present study, we analyzed just the low and intermediate sodium levels of the pressure-natriuresis curves. The finding of increased slope and constant x-intercept remained for the overall group (x-intercept: 91.2±0.8 vs 91.8±0.7 mm Hg, P=0.57; slope: 15.6±1.8 vs 33.1±6.7 [mmol/d]/mm Hg, P<0.0001), and for subgroups (data not shown), as can be inferred from visual inspection of the curves (Figures 1 and 2).

Finally, the pressure-natriuresis curves were used to evaluate the subadditive effects on BP of sodium reduction and the DASH diet. The lines for the DASH and control diets drawn between the low and intermediate sodium levels were extrapolated to their point of intersection with the y axis, which was 17 mmol/d. This value represents the sodium level below which, theoretically, no further BP-lowering effect is expected by the DASH diet and sodium intake reduction. However, this level could be somewhat higher if the pressure-natriuresis relationship continues to flatten below 65 mmol/d.

	Discussion

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In this analysis of the results of the DASH-Sodium Trial, pressure-natriuresis curves (arterial pressure–urinary sodium output relationships) were derived by plotting steady state MAP (mm Hg) and U_NaV (mmol/d) on the x and y axes, respectively. Although it is ideal to generate data over a larger continuum to assess this curve more precisely, especially in a range of very low sodium excretion, we simplified the relationship by considering it linear to facilitate calculating the extrapolated x-intercept and slope. We also found that this simplification did not affect the findings, obtained in the usual range of sodium excretion. This approximation has proved useful in previous studies in animals^11,16,17 and humans with normotension^18,19 and hypertension.^5,20

The DASH diet increased the slope of the pressure-natriuresis curve without shifting the curve along the BP axis. We have postulated that the slope of the curve is determined by glomerulo-tubular balance of sodium between glomerular ultrafiltration and tubular reabsorption, whereas the x-intercept is mainly determined by the preglomerular vascular resistance.^7,14 In addition, we previously showed that the reciprocal of the slope represents the sodium sensitivity of BP.^7,15 Increased slope without shifting the curve by the DASH diet suggests a natriuretic action. Guyton had also described theoretically in his textbook¹¹ that diuretics enhanced and multiplied the salt output at each BP level and therefore increased the slope of the pressure-natriuresis curves. In fact, we previously reported the same effects on the pressure-natriuresis relationship by diuretics.⁵ Antihypertensive agents other than diuretics did not enhance the slope of the curve, but shifted the curve leftward to lower the BP level.^5,8 Similar to the findings with the DASH diet, diuretics had greater BP-lowering effects in patients whose slopes were depressed and sodium sensitivity was high,⁵ such as with hypertensives or African Americans. Because the DASH diet is rich in fruits, vegetables, and low-fat dairy foods,^1,10 it contains high amounts of potassium and calcium. Potassium supplements are well known to cause natriuresis and lower BP.^21–23 Calcium has also been shown to blunt the pressure effects of dietary sodium.²⁴ Other unidentified substances contained in the DASH diet may also have exerted the diuretic action. Furthermore, determining the point of intersection of the pressure-natriuresis curves, including the low and intermediate sodium points, suggests that the effect of the DASH diet on BP would vanish at a very low sodium excretion, eg, 20 to 30 mmol per day. Therefore, these findings are consistent with a conclusion that the DASH diet lowers BP through a natriuretic/diuretic action.

Although the greater BP reduction occurred with a combination of DASH diet and reduced sodium, the combined effects were not fully additive, and the effects of sodium reduction were less pronounced under the DASH compared with the control diet, as already reported² and indicated by the presence of the interaction (AxB) between DASH diet and sodium intervention in Table 1. In addition, DASH effects were greater in hypertensives than normotensives, in African Americans than other races, and in older than younger individuals.^2,9,25 The underlying mechanism for these differences in effects can be probed by considering the data in the context of the pressure-natriuresis relationship. First of all, the DASH diet increased the slope of the pressure-natriuresis curve, making BP less sensitive to the amount of sodium intake. Thus, with the DASH diet, the BP-lowering effect of reduced sodium intake became weaker than with the control diet, resulting in their combined effect being smaller rather than fully additive. It is already well known that the pressure-natriuresis curve is shifted to the right and the slope is depressed with increased severity of hypertension,^8,26–28 being consistent with the present results. African Americans and older individuals are known to be sensitive to sodium intake,²⁹ even those who are normotensive,^18,30 and their pressure-natriuresis curves have shallow slopes, perhaps because of reduced glomerular ultrafiltration capability due to fewer nephrons.^7,31 This is also consistent with present findings. Therefore, the DASH diet had greater BP-lowering effects in hypertensives than normotensives, in African Americans than other races, and in older than younger study participants, because the BP-lowering effects of increasing slopes by diuretics is stronger in patients with more depressed slope and higher sodium sensitivity.^5,6 Although obese individuals and females are often considered to be sodium sensitive,³² our data did not confirm this finding. In this way, we think pressure-natriuresis analysis is useful in understanding the overall effects of DASH diet.

In conclusion, evaluating the data from the DASH-Sodium Trial using the pressure-natriuresis curve showed that the DASH diet increased the slope of the relationship as if it were a diuretic. We speculate that the DASH diet effectively lowered BP in groups with high sodium sensitivity mainly by making BP sodium-insensitive through its diuretic action. The pressure-natriuresis curves also suggest that the DASH diet would have no effect on BP at very low sodium intakes, eg, 20 to 30 mmol per day. Further studies are required to elucidate the precise mechanisms of the BP-lowering action of the DASH diet.

Perspectives
The DASH diet is now recommended as one of the most important nonpharmacological measures for controlling BP. Our present study provides a key to understand the mechanism of its BP-lowering action, making it possible to speculate about patients and situations in which it will be most beneficial and on combined effects with various classes of antihypertensive agents.

	Acknowledgments

 
The authors acknowledge and thank the DASH-Sodium Collaborative Research Group.

Received January 24, 2003; first decision February 17, 2003; accepted March 26, 2003.

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This Article Abstract Full Text (PDF) All Versions of this Article: 42/1/8    most recent 01.HYP.0000074668.08704.6Ev1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Akita, S. Articles by Kimura, G. Search for Related Content PubMed PubMed Citation Articles by Akita, S. Articles by Kimura, G. Related Collections Primary prevention Clinical Studies