Use of the Dietary Approaches to Stop Hypertension (DASH) Eating Plan for Diabetes Management

Use of the Dietary Approaches to Stop Hypertension (DASH) Eating Plan for Diabetes Management Amanda L. Clark, MA, RD, LD, CHES Diabetes self-management education is an integral part of the role of diabetes care practitioners. However, guiding patients with diabetes toward a path of better health is a growing challenge for a variety of reasons. Diabetes ranks as the seventh-leading cause of death, affecting 25.8 million people (8.3%) in the U.S. population. In addition, 35% of adults in the United States 20 years of age have prediabetes. 1 For patients with diabetes or prediabetes, the diagnosis is frequently accompanied by other comorbidities, including hypertension, dyslipidemia, and obesity. This means treatment guidelines must focus not only on blood glucose management, but also on controlling lipids, blood pressure, and body weight. 2 Although glycemic control is an important aspect of health and well-being for patients with diabetes, there are more pieces to the puzzle of effective diabetes management. Adults with diabetes have a risk of death from coronary heart disease that is two to four times higher than that of adults without diabetes. Yet, of people with diabetes 20 years of age, 67% have blood pressure readings of 140/90 mmhg or are taking prescription hypertension agents. 1 These statistics make it clear that diabetes practitioners have an opportunity to support their patients in achieving improvements in areas commonly referred to as the ABCs of diabetes management : A1C, blood pressure, and cholesterol. Lifestyle modification is a cornerstone of management for diabetes and prediabetes. A multitude of guidelines exist regarding proper nutrition, especially with regard to managing chronic conditions such as diabetes, hypertension, and dyslipidemia. Unfortunately, consumers are also bombarded with mixed messages about nutrition from numerous sources. It can be difficult to decipher fact from fiction and to answer one of the simplest questions often asked by patients with diabetes: What can I eat? The Dietary Guidelines for Americans, most recently published in 2010, are a key source of nutrition guidance in the United States. In preparing the most recent version of these guidelines, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services reviewed several different healthy eating patterns, all of which included an abundance of fruits and vegetables, an emphasis on whole grains, and limited amounts of added sugars and solids fats. The Dietary Approaches to Stop Hypertension (DASH) eating pattern was suggested as one such embodiment of these dietary recommendations. 3 This article reviews the DASH eating pattern and how it can be tailored to help patients with diabetes or prediabetes achieve their goals for managing blood pressure, lipid, weight, and glucose levels. What Is the DASH Eating Pattern? The DASH trial, originally published in 1997, reviewed the impact of eating patterns on blood pressure management. Specifically, subjects were fed either a diet rich in fruits and vegetables or a combination diet that was both rich in fruits and vegetables and low-fat dairy foods and low in saturated fat. The study authors concluded that this eating pattern was effective in reducing 244 Diabetes Spectrum Volume 25, Number 4, 2012

blood pressure levels within 2 weeks. Because the study subjects were a heterogeneous representation of the U.S. population and the foods included were widely available, they also concluded that these eating patterns could be easily adopted by most people in the United States. 4 Information about the DASH eating plan and how to implement it is widely available to anyone who might be interested in learning more. The eating pattern, along with overall recommendations, information on its benefits for blood pressure management, and sample meal plans and recipes can be obtained through the National Heart, Lung, and Blood Institute. 5 Table 1 provides an outline of the recommended number of servings from each food group, based on two different levels of caloric intake 1,600 and 2,000 calories per day. Effectiveness of the DASH Eating Pattern A wide array of research exists about the DASH eating plan and its benefits for controlling hypertension and other cardiovascular risk factors. According to a scientific statement from the American Heart Association, the DASH eating plan significantly reduced blood pressure in all major subgroups (regardless of sex, race, or hypertensive status). This outcome is produced by multiple aspects of the diet rather than from one food or nutrient alone, and it is achieved in as little as 2 weeks after implementing the intervention. 6 There is also a growing body of evidence pointing to the benefits of sodium reduction in addition to the DASH eating plan as a way to prevent cardiovascular disease and stroke. 7 This may be particularly important because individuals with hypertension have a higher risk of developing insulin resistance and diabetes, and the combination of diabetes and hypertension greatly increases the risk of heart disease, stroke, kidney disease, and heart failure. 8 Although the benefits of the DASH eating plan for hypertension control and cardiovascular disease risk reduction are well documented, there is less research on the eating plan s specific benefits for diabetes management. Table 1. Recommended Servings in the DASH Eating Pattern, by Calorie Level 5 Recommended Servings/Day in the DASH Eating Pattern Food Groups Serving Size 1,600 calories/day 2,000 calories/day Grains* 1 slice bread 6 6 8 1 oz dry cereal 1/2 cup cooked rice, pasta, or cereal Vegetables 1 cup raw, leafy vegetables 3 4 4 5 1/2 cup cut-up raw or cooked vegetables 1/2 cup vegetable juice Fruits 1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice 4 4 5 Fat-free or low-fat milk and milk products Lean meats, poultry, and fish Nuts, seeds, and legumes Fats and oils Sweets and added sugars 1 cup milk or yogurt 1 1/2 oz cheese 1 oz cooked meat, poultry, or fish 1 egg 1/3 cup or 1 1/2 oz nuts 2 Tbsp peanut butter 2 Tbsp or 1/2 oz seeds 1/2 cup cooked legumes 1 tsp soft margarine 1 tsp vegetable oil 1 Tbsp mayonnaise 2 Tbsp salad dressing 1 Tbsp sugar, jelly, or jam 1/2 cup sorbet or gelatin 1 cup lemonade 2 3 2 3 3 6 6 3 per week 4 5 per week 2 2 3 0 5 per week *Whole grains are preferable for most servings because of their higher fiber and nutrient content. Diabetes Spectrum Volume 25, Number 4, 2012 245

Table 2. Comparison of Studies Reviewing the Impact of the DASH Eating Pattern on Metabolic Factors Study Study design n Subjects have type 2 diabetes? Azadbakht et Randomized, al. 9 crossover clinical trial Ard et al. 10 Randomized trial, ancillary to PREMIER study 33 Yes To assess the impact of a control diet versus the DASH eating pattern on cardiovascular risk in subjects with type 2 diabetes 52 No To assess the impact on insulin sensitivity with lifestyle management of hypertension in three treatment arms: Group A: one-time advice only from National High Blood Pressure Education Program Study goals Key study results (mean values)* Weight (kg) Control group: Baseline: 75.0 ± 1.7 End of study: 72.9 ± 1.8 Change: 2.0 ± 0.3 DASH Group: Baseline: 73.4 ± 1.8 End of study: 68.4 ± 1.7 Change: 5.0 ± 0.9 A1C (%) Control group: Baseline: 7.9 ± 1.9 End of study: 7.4 ± 1.7 Change: 0.5 ± 0.02 DASH Group: Baseline: 7.7 ± 1.9 End of study: 6.1 ± 0.5 Change: 1.7 ± 0.1 HDL cholesterol (mg/dl) Control group: Baseline: 41.2 ± 1.0 End of study: 42.5 ± 1.0 Change: +1.3 ± 0.7 DASH Group: Baseline: 41.2 ± 1.0 End of study: 45.6 ± 1.1 Change: +4.3 ± 0.9 LDL cholesterol (mg/dl) Control group: Baseline: 114.7 ± 3.5 End of study: 111.9 ± 4.1 Change: 2.7 ± 4.8 DASH group: Baseline: 118.7 ± 3.6 End of study: 101.5 ± 3.1 Change: 17.2 ± 3.5 Weight (kg) Group A: Baseline: 94.19 ± 21.55 6 months: 93.02 ± 22.07 Change: 1.18 ± 3.16 Group B: Baseline: 88.61 ± 22.70 Statistically significant change between groups? Yes (P = 0.006) Yes (P = 0.04) Yes (P = 0.0001) Yes (P = 0.02) Group B vs. Group A: Yes (P = 0.0077) Group C vs. Group A: Yes (P = 0.0044) Group C vs. Group B: No (P = 0.672) 246 Diabetes Spectrum Volume 25, Number 4, 2012

Blumenthal et Randomized, al. 11 controlled trial Group B: intensive behavioral intervention and counseling Group C: intensive behavioral intervention and counseling that included DASH guidelines 144 No To assess the impact on lipids and insulin resistance by comparing three groups: Usual diet/control (UC) DASH diet alone (DASH-A) DASH diet with caloric restriction for weight management (DASH-WM) 6 months: 82.20 ± 22.31 Change: 6.4 ± 6.21 Group C: Baseline: 93.18 ± 18.11 6 months: 85.53 ± 14.81 Change: 7.65 ± 7.75 Insulin sensitivity index Group A: Baseline: 2.20 ± 1.13 6 months: 2.20 ± 1.12 Change: + 0 ± 1.06 Group B: Baseline: 2.32 ± 0.65 6 months: 2.97 ± 1.74 Change: +0.66 ± 1.63 Group C: Baseline: 1.96 ± 0.94 6 months: 2.95 ± 1.62 Change: +0.99 ± 1.39 Weight (kg) UC group: Before: 92.6 After: 94.1 Change: +0.9 DASH-A group: Before: 93.0 After: 92.9 Change: 0.3 DASH-WM group: Baseline: 93.9 6 months: 84.5 Change: 8.7 HDL cholesterol (mg/dl)** UC group: Before: 55 After: 54 Change: 1.0 DASH-A group: Before: 53 After: 51 Change: 2.0 DASH-WM group: Before: 55 After: 54 Change: 1.0 Group B vs. Group A: No (P = 0.146) Group C vs. Group A: Yes (P = 0.047) Group C vs. Group B: No (P = 0.616) DASH-WM vs. DASH-A: Yes (P = < 0.001) DASH-WM vs. UC: Yes (P = < 0.001) DASH-WM vs. DASH-A: No (P = 0.115) DASH-WM vs. UC: No (P = 0.911) DASH-A vs. UC: Yes (P = 0.047) continued on p. 248 Diabetes Spectrum Volume 25, Number 4, 2012 247

Table 2. Comparison Table 2. Comparison of Studies Reviewing of Studies the Reviewing Impact of the the Impact DASH of Eating the DASH Pattern Eating on Metabolic Pattern on Factors, Metabolic continued Factors from p. 247 Study Study design n Subjects have type 2 diabetes? Study goals Key study results (mean values)* LDL cholesterol (mg/dl)** UC group: Before: 126 After: 125 Change: 1.0 DASH-A group: Before: 122 After: 122 Change: 0.0 DASH-WM group: Before: 128 After: 112 Change: 16.0 Insulin sensitivity index** UC group: Before: 66.0 After: 68.8 Change: +2.8 DASH-A group: Before: 70.9 After: 68.7 Change: 2.2 DASH-WM group: Before: 74.4 6 months: 75.3 Change: +0.9 Statistically significant change between groups? DASH-WM vs. DASH-A: No (P = 0.054) DASH-WM vs. UC: Yes (P = 0.005) DASH-A vs. UC: No (P = 0.715) DASH-WM vs. DASH-A: Yes (P = 0.031) DASH-WM vs. UC: Yes (P = 0.026) DASH-A vs. UC: No (P = 0.981) *Instances in which the change does not exactly equal the difference between before and after values are the result of rounding. **Because change values with variance were not published for some results in this study, change values for these measures were calculated from before mean values minus after mean values. 248 Diabetes Spectrum Volume 25, Number 4, 2012

Food Item Breakfast Table 3. Sample Menu Using DASH Recommendations Based on ~ 1,600 Calories Number of Servings by DASH Food Group Grains Fruit Vegetables Milk and milk products Meats, fish, and poultry Nuts, seeds, and legumes Fats and oils Sodium* (mg) Carbohydrates* (g) 1 packet instant oatmeal 1 80 19 100 1 cup low-fat milk 1 127 12 105 3/4 cup blueberries 1 0 16 63 1 slice whole-grain toast 1 132 12 69 1 tsp soft (tub) 1 33 0 34 margarine Breakfast subtotals 2 1 0 1 0 0 1 372 59 371 Snack 1/2 cup baby carrots 1 42 5 25 1/2 cup cauliflower 1 30 3 13 2 Tbsp ranch dressing 1 336 6 59 (light) Snack Subtotals 0 0 2 0 0 0 1 408 14 97 Lunch 2 oz skinless chicken 2 44 0 100 breast, grilled 2 slices whole-wheat 2 264 24 138 bread 2 large leaves Romaine 1/2 8 2 10 lettuce 2 slices tomato 1/2 3 2 10 1 tsp Dijon mustard 57 0 3 1 cup cantaloupe chunks 2 26 13 54 1 cup low-fat milk 1 127 12 105 Lunch subtotals 2 2 1 1 2 0 0 529 53 420 Calories* continued on p. 250 Diabetes Spectrum Volume 25, Number 4, 2012 249

Food Item Snack Table 3. Sample Table Menu 3. Sample Using Menu DASH Using Recommendations DASH Recommendations Based on ~ Based 1,600 Calories, on ~ 1,600 continued Calories from p. 249 Number of Servings by DASH Food Group Grains Fruit Vegetables Milk and milk products Meats, fish, and poultry Nuts, seeds, and legumes Fats and oils Sodium* (mg) Carbohydrates* (g) 1 medium apple 1 2 25 95 1 Tbsp peanut butter 1 76 3 94 Snack subtotals 0 1 0 0 0 1 0 78 28 189 Supper 3 oz baked cod 3 66 0 89 1 tsp lemon juice 0 0 1 1/2 cup cooked brown rice Calories* 1 1 23 109 1/2 cup cooked broccoli 1 10 5 26 1 small cornbread muffin (1.5 oz) 1 331 20 134 1 cup low-fat milk 1 127 12 105 Dinner subtotals 2 0 1 1 3 0 0 535 60 464 Totals 6 4 4 3 5 1 2 1,922 214 1,541 *Sodium, carbohydrate, and caloric values for food items obtained from the U.S. Department of Agriculture National Nutrient Database for Standard Reference, available online at http://ndb.nal.usda.gov. Accessed 6 May 2012. 250 Diabetes Spectrum Volume 25, Number 4, 2012

In one small, randomized crossover clinical trial of 33 subjects with type 2 diabetes in Iran, 9 subjects received either a control diet or a diet based on the DASH eating plan. Results revealed that, although all subjects had a similar caloric intake, those on the DASH eating plan consumed foods that were lower in caloric density and saw greater reductions in fasting blood glucose levels, A1C, body weight, and waist circumference. The authors concluded that the DASH eating pattern may reduce cardio-metabolic risk in patients with type 2 diabetes, but longer-term studies are needed. Two other studies have looked at the eating pattern s impact on insulin sensitivity in subjects without type 2 diabetes. A randomized trial ancillary to the PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) blood pressure study 10 of 52 subjects revealed that the DASH eating plan was beneficial for improving a variety of factors in the metabolic syndrome, including blood pressure, lipid levels, and insulin resistance. The authors concluded that the addition of the DASH eating plan led to statistically significant improvements in insulin sensitivity compared to the control group. However, the ENCORE (Exercise and Nutritional Interventions for Cardiovascular Health) trial, 11 a randomized, controlled trial conducted with 144 hypertensive subjects, showed different results. This trial suggested that the DASH eating plan alone may help to reduce blood pressure in hypertensive individuals who are overweight but may not significantly improve insulin sensitivity unless combined with a lifestylemodification program that includes exercise and weight reduction. Table 2 provides an overview of these three studies and their key results. Practical Applications of the DASH Eating Pattern for Diabetes Management When working with patients who have diabetes, it is important to find an eating plan that can be tailored to patients individual needs to help them meet their goals for glycemia, blood pressure, lipids, and weight control. A survey conducted in 2011 by the Academy of Nutrition and Dietetics revealed that, although patients are seeking more information about nutrition, there are several key barriers to healthier eating. The barriers cited include a desire not to give up favorite foods, time required to track food choices, a need for more practical tips, and a lack of understanding about nutrition guidelines. 12 The DASH eating plan may be a beneficial starting point for many patients because it provides guidelines and tools to overcome all of these barriers. Even modest changes can be a step in the right direction; research has shown that few Americans follow eating patterns that even modestly equate with the DASH recommendations. 13 As with implementing any food-choice and eating-pattern changes for diabetes management, it is important to consider how patients are currently managing their diabetes, including pharmacological therapies and previous meal-planning experience. Because the DASH eating plan is widely recommended, it may be an ideal way to assist patients as they work to incorporate a variety of nutritious foods to achieve all of their goals. In addition to blood pressure, lipid, and glucose control, weight management is often a goal for patients with diabetes; indeed, 28% of individuals with type 2 diabetes are overweight (as defined by a BMI of 25 29.99 kg/m 2 ), and 59% are obese (having a BMI 30 kg/m 2 ). 14 Although the DASH eating plan was not specifically designed for weight loss, weight reduction can be achieved by adjusting the recommended number of servings per food group to achieve caloric reduction. Table 3 provides a 1-day sample menu based on the DASH guidelines for servings from each group and a daily sodium limit of < 2,300 mg. It is based on ~ 1,600 calories, a caloric intake that would assist many patients in achieving a healthy weight. This meal plan is written to include ~ 45 60 g carbohydrate per meal and 15 30 g carbohydrate per Diabetes Spectrum Volume 25, Number 4, 2012 snack to assist with glycemic control. By adjusting the number of servings from each food group, this eating plan can be adjusted to meet individual needs for both carbohydrates and calories. For patients in need of additional tips, tools, recipes, and sample meal plans, a printable guide to the DASH eating plan is available online at http://www.nhlbi.nih. gov/health/public/heart/hbp/dash/ new_dash.pdf. 5 Other considerations that may be helpful when implementing the DASH eating plan include making simple replacements such as choosing whole grain foods to increase fiber in place of more refined options and replacing sweets and desserts with fruits or vegetables that offer benefits for blood pressure control, overall nutrient intake, and, often, a lesser impact on blood glucose levels. The DASH eating recommendations may be used as a starting point as a meal-planning tool; however, adjustments and timing of certain foods such as grains, fruits, and lowfat dairy foods may be necessary to ensure consistent carbohydrate intake throughout the day or appropriate timing of meals with insulin or other pharmacological therapies. Because the DASH eating plan may be more effective when combined with exercise and other lifestyle modifications, encouraging patients to adopt an active lifestyle may further improve their outcomes. 8 Conclusion Diabetes management involves controlling of a variety of metabolic factors. The DASH eating plan is one option that has been shown effective in hypertension management and diabetes prevention and that also can be implemented as a tool for managing diabetes. As with any strategy for effective diabetes management, patients must be at the center of the care team, and diabetes practitioners must work with them to implement individualized therapies that they are able to achieve. In general, when it comes to improving the eating habits of people with diabetes, even small changes can have a substantial impact on achieving diabetes management targets and overall health. 251

References 1 U.S. Department of Health and Human Services: National diabetes fact sheet, 2011 [article online]. Available from http://www. cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed 12 February 2012 2 American Diabetes Association: Standards of medical care in diabetes 2012. Diabetes Care 35 (Suppl. 1):S11 S63, 2012 3 U.S. Department of Agriculture and U.S. Department of Health and Human Services: Dietary guidelines for Americans, 2010. Available from http://health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf. Accessed 6 July 2012 4 Appel L, Moore T, Obarzanek E, Vollemer W, Svetkey L, Sacks F, Bray G, Vogt T, Cutler J, Windhauser M, Pao-Hwa L, Karanja N; for the DASH Collaborative Research Group: A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 336:1117 1124, 1997 5 U.S. Department of Health and Human Services, National Institutes of Health, and National Heart, Lung, and Blood Institute: Your guide to lowering your blood pressure with DASH. Available from http://www.nhlbi. nih.gov/health/public/heart/hbp/dash/new_dash. pdf. Accessed 6 July 2012 6 Appel L, Brands M, Daniels S, Karanja N, Elmer P, Sacks F: Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 47:296 308, 2006 7 Appel L, Frohlich E, Hall J, Pearson T, Sacco R, Seals D, Sacks F, Smith SC, Vafiadis DK, Van Horn LV: The importance of populationwide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation 123:1138 1143, 2011 8 Hinderliter AL, Babyak MA, Sherwood A, Blumenthal JA: The DASH diet and insulin sensitivity. Curr Hypertens Rep 13:67 73, 2011 9 Azadbakht L, Rashidi Pour Fard N, Karimi M, Hassan Baghaei M, Surkan PJ, Rahimi M, Esmaillzadeh A, Willett WC: Effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on cardiovascular risks among type 2 diabetic patients. Diabetes Care 34:55 57, 2011 10 Ard JD, Grambow SC, Liu D, Slentz CA, Kraus WE, Svetkey LP: The effect of the PREMIER interventions on insulin sensitivity. Diabetes Care 27:340 347, 2004 11 Blumenthal JA, Babyak MA, Sherwood A, Craighead L, Lin PH, Johnson J, Watkins LL, Wang JT, Kuhn C, Feinglos M, Hinderliter A: Effects of the dietary approaches to stop hypertension diet alone and in combination with exercise and caloric reduction on insulin sensitivity and lipids. Hypertension 55:1199 1205, 2010 12 Academy of Dietetics and Nutrition: Nutrition and you: trends 2011. Available from www.eatright.org/nutritiontrends. Accessed 26 February 2012 13 Mellen PB, Gao SK, Vitolins MZ, Goff DC: Deteriorating dietary habits among adults with hypertension. Arch Intern Med 168:308 314, 2008 14 Apovian CM: Management of diabetes across the course of disease: minimizing obesity-associated complications. Diabetes, Metab Syndr Obes 4:353 369, 2011 Amanda L. Clark, MA, RD, LD, CHES, is a product manager with HealthFitness Corp., based in Bloomington, Minn. 252 Diabetes Spectrum Volume 25, Number 4, 2012