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(Hypertension. 2001;37:268.)
© 2001 American Heart Association, Inc.

Scientific Contributions

Editorial Commentary: BBs and Bullets

The Impact of Dietary Factors on Blood Pressure

Lawrence J. Appel; Edgar R. Miller

From the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Md.

Correspondence to Lawrence J. Appel, Johns Hopkins Medical Institutions, 2024 E Monument St, Suite 2-645, Baltimore, MD 21205-2223. E-mail lappel@welch.jhu.edu

Key Words: blood pressure • nutrition • diet • ascorbic acid • antioxidants

	Introduction

 
An impressive body of evidence supports the concept that multiple dietary factors affect blood pressure.¹ Typically, the blood pressure response to manipulation of a single nutrient is modest and heterogeneous; that is, the response can vary by baseline nutrient intake, baseline blood pressure, demographic factors, genetic polymorphisms, and other host factors. In this setting, the search for new dietary factors is fraught with hazards. The risk of false-negative results is high, especially in underpowered clinical trials, as is the risk of false-positive results, especially in observational studies that must deal with the treacherous issue of confounding.

In addition to sodium intake, potassium intake, weight, and alcohol consumption, other diet-related factors likely affect blood pressure. For instance, preliminary evidence suggests that an increased intake of protein² and of monounsaturated fats³ might also reduce blood pressure. Will the likely impact of new factors be substantial (a "bullet") or modest (a "BB")? Results from the Dietary Approaches to Stop Hypertension (DASH) trial have raised the hope that bullets are plausible.⁴ However, the impressive effects of the DASH diet most certainly resulted from the combined impact of several nutrients with modest effects on blood pressure rather than from a single nutrient with large effects. Still, because even a modest population-wide reduction in blood pressure (eg, 3 mm Hg in systolic blood pressure in nonhypertensives) can lead to substantial reductions in cardiovascular disease,⁵ the search for additional dietary factors is clearly worthwhile. A major impediment, of course, is that the detection of such modest effects . . . [Full Text of this Article]