Dietary Approaches to Stop Hypertension This show is by Nancy Kennedy, MS, RD and Food and Health Communications, Inc. We are going to teach you about the DASH diet – a simple diet that uses inexpensive every-day foods for better health. The DASH program that has been documented in clinical research to reduce blood pressure as effectively as one drug therapy...especially effective in people with high blood pressure, but also reduces blood pressure in those with normal pressures! Speaker: We suggest you read http://www.foodandhealth.com/cpecourses/salt_new.php and http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf prior to giving this show. Both are free and available on the internet.

Dietary Approaches to Stop Hypertension Acronym DASH- stands for Dietary Approach to Stop Hypertension References from both studies are: -Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24. -Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. N Engl J Med 2001;344:3-10

Start the DASH Recommended Servings From the Various Food Groups for DASH Lower Your Sodium Increase Your Potassium Increase Your Magnesium Increase Your Calcium Here are the topics for this section. We will show you how to follow the DASH diet.

Start the DASH (cont.) Increase Fruit and Vegetable Consumption Consume More Legumes Increase Your Fiber Intake Reduce Your Fat Intake Continued – what is covered in the Start the DASH section. You will see that you have to concentrate on eating MORE of the right foods.

Recommended Servings From the Various Food Groups for DASH* Food Group: Daily Servings: Whole grains, (ounce) 6 Vegetables, (half cup) 3-4 Fruits, (half cup) 4 Lowfat/nonfat milk, (cup) 2-3 Lean meats, fish, poultry, (ounce) 3-6 Nuts, seeds, dry beans 3 per week Oils (tsp) 2 Sweets, added sugars 0 These serving recommendations are consistent with a caloric intake of about 1600 calories. That is a close estimate for the amount of calories necessary for an adult male who wants to lose weight or an adult female who is active and does not need to lose weight. If you have a different caloric requirement you will need to adjust your servings. There is a chart in your handouts which will help you do that. Also, refer to the chart in your handout for appropriate serving sizes in each category. THIS IS VERY IMPORTANT. 7-8 grains a day may seem like a lot but most people eat double the serving size of cereal; 1 bagel for example would count for 2 grain servings Speaker: USE FOOD MODELS HERE TO SHOW APPROPRIATE PORTION SIZES or refer to the handout for serving sizes. *For 1,600 calories

Recommended Servings From the Various Food Groups for DASH* Food Group Daily Servings Grains 6-8 Vegetables 4-5 Fruits 4-5 Lowfat/nonfat dairy 2-3 Meats, fish, poultry 6 oz or less Nuts, seeds, dry beans 4-5 per week Fats and oils 2-3 Sweets 5 or less per week These serving recommendations are consistent with a caloric intake of about 2000 calories. That is a close estimate for the amount of calories necessary for an adult male who wants to lose weight or an adult female who is active and does not need to lose weight. If you have a different caloric requirement you will need to adjust your servings. There is a chart in your handouts which will help you do that. Also, refer to the chart in your handout for appropriate serving sizes in each category. THIS IS VERY IMPORTANT. 6-8 grains a day may seem like a lot but most people eat double the serving size of cereal; 1 bagel for example would count for 2 grain servings Speaker: USE FOOD MODELS HERE TO SHOW APPROPRIATE PORTION SIZES or refer to the handout for serving sizes. *For 2000 calories

Servings for a 2000 Calorie Diet: 7-8 servings Grains and Grain Products per day 4-5 servings Vegetables per day 4-5 servings Fruits per day 2-3 servings Low fat or Nonfat Dairy Foods per day 2 or fewer servings of Meats, Poultry and Fish per day (you should try to have 2 servings of fish per week) 4-5 servings Nuts, Seeds and Legumes per week 2-3 servings of added fat Less than 1 sweet per day (5 per week) The amount for sodium is the average between the 2400 mg sodium diet and the 1600 mg sodium diet. If someone has high blood pressure then they should keep the sodium to 1600 mg a day or less.

Lower Sodium The DASH-Sodium trial found that reducing sodium from 3,300 to 1,500 mg on the American diet lowered blood pressure more than adopting the DASH diet without sodium reduction http://www.foodandhealth.com/cpecourses/salt_new.php#_Toc10070709 (6.7 mmHg) – BP lowered on American diet with 1500 mg sodium (5.9 mmHg) – BP lowered on DASH without sodium reduction

Lower Sodium Limit processed foods: canned, boxed, frozen meals; canned soups; boxed cereals; bread; deli meat; cheese Limit “fast food” meals Limit salt in cooking and at the table use more herbs and spices in cooking limit use of condiments Check labels for sodium content Do you think you don’t consume that much salt because you rarely use the salt shaker? Think again!! Only 10% of the salt consumed in the American diet comes from the salt shaker. Most of the sodium in the food you eat comes from processed foods and meals eaten away from home.

Lower Your Sodium Intake Tomato juice 820 Cheese 600 Ham 1020 Bread 175 Potato chips 155 Cereal 300 Pizza 1200 Fresh vegetables 50 Skim milk 120 Roasted chicken 30 Brown rice 10 Baked potato 15 Oatmeal 10 Spaghetti* 390 *with low-sodium sauce Fresh and whole is always a better choice than processed foods. Look at the foods on the left and compare them to the foods on the right. Using fresh, whole foods that are minimally processed will always yield a lower sodium intake.

Compare Labels! It pays to compare labels when you are shopping. Look at these two examples. On the left is a label from a can of ordinary tomato sauce. The sodium is 370 mg. But on the right is a label from a can of tomato sauce that does not contain added salt. The sodium is only 15mg. If the sodium from a product has a daily value of 5% or less, that product is considered to be low in sodium. Another good way to see if a product is low in sodium is to compare the amount of sodium per calorie.

Increase Your Potassium High intakes of potassium have been shown to lower blood pressure The DASH diet contains about 4,700 mg potassium The average American diet contains about 3,000 mg The average American diet contains more sodium than potassium. As you can see by these figures, the average American needs to consume one and a half times the amount of potassium that he or she is currently consuming. The following slide will show you were to get it!

Food Sources of Potassium Fruits, especially bananas, oranges and prunes Vegetables, especially potatoes, broccoli, peas and spinach Dried beans Nuts Whole grains These were all key foods on the DASH diet.

Increase Your Magnesium High intakes of magnesium have been shown to lower blood pressure The DASH diet contains about 500 mg magnesium The average American diet contains about 180-230 mg The average American is also low on magnesium consumption – it looks like we have to double or even triple our consumption of this important mineral!

Food Sources of Magnesium Nuts Seeds Seafood Legumes (beans and peas) Dark green leafy vegetables Whole grain breads and cereals Chocolate You can see that many of the foods that are good sources of magnesium were also good sources of potassium. These foods were all key foods on the DASH study. Everyone will love the last choice here on this slide!

Calcium and Blood Pressure Diets low in calcium have been associated with high blood pressure The DASH diet contains about 1,240 mg calcium The average American eats about 700-800 mg of calcium per day As you can see, we need to increase calcium by about 50%.

Calcium and Blood Pressure Read food labels to determine how much calcium you are getting The label pictured here shows 40% daily value or 400 mg of calcium You will usually get 300 mg of calcium from foods that you eat. The rest must come from sources that are high in calcium such as skim milk, yogurt, cheese, dark leafy greens, calcium-fortified grains, fortified orange juice and fortified soy products.

Increase Your Calcium Make it a goal to eat a lowfat, high-calcium dairy food two to three times a day If dairy does not agree with you try lactase tablets, or buy lactose-free products There are several calcium-fortified soyfoods including: soymilk, tofu and soy cheese Dairy- use lowfat or nonfat products at meals or snacks; drink skim milk, lowfat cheese and crackers for a snack; lowfat yogurt as a dessert or snack (frozen yogurt does not really have a lot of calcium in it). You have a list of good food sources of calcium in your handouts. The label shown in the picture is for Skim Plus milk. This is skim milk with added calcium – it contains 40% of the daily value which is equal to 400 mg of calcium. For comparison purposes, skim milk contains 30% of the daily value or 300 mg.

Food Sources of Calcium Skim milk Nonfat yogurt Fat-free ricotta Salmon and sardines with bones Broccoli Kale Bok choy Dried beans Lowfat pudding Turnip greens Calcium fortified foods such as orange juice, cereal, soymilk Almonds Tofu with calcium On DASH need 2 servings per day – we have listed non-fat dairy since these contain the least amount of saturated fat. Cheese is also a good source of calcium but it is high in sodium and saturated fat.

Increase Fruit and Vegetable Consumption Plan a minimum of three meals per day At each meal have 1 fruit serving Have 2 vegetables at lunch and 2-3 at dinner Plan 1-2 fruit servings for snacks Try dried fruits mixed with nuts and seeds In order to DASH you have to EAT! Buy little cans of fruit for packed lunches Use fruit with a meal as a salad or dessert Use fresh and frozen vegetables or unsalted canned Use raw vegetables and dip with a meal or a snack Keep vegetables cut up in the refrigerator Stock up on produce in the grocery store and buy less meat

Consume More Legumes Try bean, pea or lentil soup for lunch Replace meat in casseroles, pasta dishes and stir-fry dishes with beans Add beans to your salad; eat baked beans Use nuts for snacks; add them to salads and casseroles Sprinkle seeds on bread, cereal and salad Some examples of vegetarian meals. You have the recipes in your packet. There are many excellent vegetarian cookbooks available. Vegetarian cookbooks are great because they usually use

Fiber and Blood Pressure High fiber diets have been shown to lower blood pressure A high-fiber diet will help you control your weight The DASH diet contains on average, 30-40 grams of fiber per day The average American eats 10-15 grams of fiber per day The DASH diet contains plenty of fiber. Current recommendations are 25-35 g of fiber per day. Most Americans need to DOUBLE or TRIPLE their fiber consumption. The key DASH foods will help you do this.

DASH Daily Fiber Report Food group Servings Fiber(g) Grains 7-8 14-24 Vegetables 4-5 8-15 Fruits 4-5 8-12 Nuts, beans, seeds 4-5 per week 3-8 Total 23-59 These are all foods on the DASH diet! You can see that the DASH diet is adequate in fiber.

Increase Your Fiber Use whole grains rather than foods made with white flour Look for the word whole in the ingredient list Compare the fiber content on grains and cereals Enriched wheat flour is the same as white flour Try whole wheat pastas Try brown rice instead of white Many times whole grains will have more fat than white flour counterparts. That’s OK, it is the fat from the grain- a healthy type of fat Wheat bread and crackers do not mean whole wheat. You have to look for products that state made from whole grains or 100% whole wheat. Read the ingredients – a whole grain should be listed first. FDA law currently states that if a product claims made from whole grains it has to contain at least 51% whole grain products. Rye bread is not necessarily a whole grain because rye bread is made mostly from white flour. Also experiment with other grains such as amaranth, bulgur, graham See the handout on whole grains.

Bran Germ This is a rough diagram of a whole kernel of wheat. The white signifies the endosperm which is used to make white flour. The germ and the bran are left off. These both contain important minerals and fiber – this is why you should always choose 100% whole grain products. Endosperm

Reduce Your Fat Intake The DASH diet contained 27% of calories as fat in foods (meats, dairy and grains and mixed dish recipes) added to foods (approximately 2.5 servings per day of added fats, oils, and salad dressing) To maintain fat intake at roughly the same level as the DASH diet, we recommend not exceeding 2-3 servings daily of added fat such as margarine or mayonnaise The DASH diet contained 27% of calories as fat. The fat in this diet was present both in foods (meats, dairy and grains and mixed dish recipes) and added to foods (approximately 2.5 servings per day of added fats, oils, and salad dressing). To maintain fat intake at roughly the same level as the DASH diet, we recommend not exceeding 2-3 servings daily of added fat such as margarine or mayonnaise. Amounts in parentheses are considered one serving. soft margarine or butter (1 teaspoon) regular mayonnaise (1 teaspoon) or low fat mayonnaise (1 tablespoon) salad dressing (1 tablespoon) or light salad dressing (2 tablespoons) 1 teaspoon oil (olive, corn, canola, safflower or other vegetable oils)

Reduce Your Fat Intake Reduce the amount of butter, margarine and salad dressing you use Try lowfat or fat-free versions of high fat items such as margarine, dairy or meat products Limit “fast food” eating and snacking Check food labels for fat content Bake, broil, poach, grill or roast rather than fry Be careful not to get carried away with fat free foods- they still have calories!

Eat Less Saturated Fat Buy less meat and choose leaner cuts or white poultry without the skin Choose fish a couple times a week Limit any animal protein to the size of a deck of cards (3-4 ounces) Include two or more vegetarian meals each week You have a handout with the lower fat cuts of meat Gradually cut down the portion of meat you eat Try some new fish recipes and experiment with different types of fish

Eat Less Saturated Fat Use lowfat or nonfat dairy products When adding fat choose olive or canola oils; liquid or soft margarines Limit rich desserts and chocolate Read labels While meat is a significant source of saturated fat, it is also found in other places. Here are tips to help you avoid hidden saturated fats.

Eat Less Trans Fat Read labels – limit or avoid foods that are made with partially hydrogenated oils: Crackers Cookies Shortening Candy Fried foods Avoid full fat dairy products and fatty meats Trans fatty acids, also known as trans fat, are made during partial hydrogenation of vegetable oils. Usually the hydrogen atoms at a double bond are positioned on the same side of the carbon chain. However, partial hydrogenation reconfigures some double bonds and the hydrogens end up on different sides of the chain. This type of configuration is called "trans" (means "across" in Latin). Trans fatty acids are also found in the milk and meat of ruminant animals: cattle, goats, sheep. The new trans fat label is shown – this may be put into effect soon by the FDA. The trans fat will have to be listed with saturated fat instead of total fat as it is now.

Limit Consumption of Sweets The DASH diet contained, on average, less than one serving per day of sweets or about 5 servings per week Most of the sweets were low in fat: Maple syrup, sugar Jello® Jam, jelly, marmalade Jelly beans, hard candies Sorbet, sherbet, popsicle, frozen yogurt Amounts in parentheses are considered one serving. maple syrup (1 tablespoon) sugar (1 tablespoon) jelly or jam (1 tablespoon) Jello (1/2 cup) jelly beans (1/2 oz.) sugared lemonade or fruit punch (8 fl. oz.) hard candies (3 pieces) sherbet (1/2 cup) popsicle (1) low fat or nonfat frozen yogurt (1/2 cup)

Appendix Other Risk Factors for Hypertension The Role of Caffeine The Role of Stress The Effects of Stress on the Body Drugs That Can Raise Blood Pressure We will discuss other factors of blood pressure here

Other Risk Factors for Hypertension Smoking Drinking Sedentary lifestyle Being overweight especially if you carry your weight around the middle DRINKING: According to the researchers, in 72 percent of hypertensive subjects, alcohol abstention resulted in blood pressure falling to normal levels. On average, the men's systolic blood pressure (the first number in a blood pressure reading) dropped an average of 7.2 mm Hg, while their diastolic pressure (the second number) declined by 6.6 mm Hg, after they gave up alcohol. Heart rate also dropped significantly during the 1-month program, by an average of 7.9 beats per minute. Men who were considered hypertensive at the start of the study appeared to derive greater benefit from alcohol abstention than did men with normal blood pressure readings. Among hypertensives, systolic and diastolic blood pressure dropped an average of 12.2 and 10.6 mm Hg, respectively, according to the authors. "These results show that heavy alcohol consumption has an important effect on blood pressure," the Spanish researchers conclude. They add that the findings "strengthen the recommendation of alcohol- intake reduction as a priority for those patients with essential hypertension who are usual alcohol drinkers.” Source: Hypertension 1999;33:647-652, 653-657. NOT EXERCISING: Blood flow is also affected by exercise through the production of nitrous oxide in the blood stream. When muscle tissue requires additional nutrients, it produces nitrous oxide to signal the blood vessels to dilate, which then allows more blood (and nutrients) to flow to the muscles. This reaction takes place during exercise, but has a lasting effect on the body. Even after exercise is completed, blood vessels may remain dilated, with greater blood flow, throughout the day. This naturally increased dilation will cause a reduction in blood pressure level, and can also provide relief for patients with weaker hearts, as less strain is put on the heart muscle. Thickened hearts have been associated with an increased risk of arrythmia and sudden death, and have traditionally been treated with dilating medications; an exercise routine seems to provide that benefit, naturally.

The Role of Caffeine Heavy coffee consumption may trigger a rise in blood pressure The effect is more pronounced in younger people Each cup of coffee consumed per day increased systolic and diastolic blood pressure by 0.8 and 0.4 mm Hg, respectively In the second study, an international team of researchers led by Dr. Michael J. Klag of Johns Hopkins University in Baltimore, Maryland, report that chronic, heavy coffee consumption may also trigger a rise in blood pressure. Klag and colleagues conducted a detailed review of 11 studies of coffee consumption. In total, these studies involved more than 500 participants consuming an average of five cups of coffee per day over almost 2 months. The investigators found that, "on average, coffee drinking was associated with a 2.4 mm Hg higher systolic blood pressure and 1.2 mm Hg higher diastolic blood pressure." They calculate that each cup of coffee consumed per day increased systolic and diastolic blood pressure by 0.8 and 0.4 mm Hg, respectively. The team also note that the effect of coffee on blood pressure was more pronounced in younger people. These "findings provide support for a relationship between coffee intake and higher blood pressure," the study authors conclude. They call for more research on the coffee-blood pressure connection, especially in people who already have high blood pressure, in smokers, and in people who experience stress. Source: Hypertension 1999;33:647-652, 653-657. Hypertension 1999; 33:647-652, 653-657

The Role of Stress There is no definitive proof that ongoing stress is a cause of hypertension Feeling tense or angry causes a transient rise in blood pressure Feeling tense or angry causes a transient rise in BP Suppressed or buried feelings may be more tied to hypertension alpha and beta blockers affect the sympathetic nervous system and would be good for someone under a lot of emotional stress J. Psychosom Res 1998; 45:139-148

The Effects of Stress on the Body Increased oxygen demand equals increased heart rate and blood pressure Increased stickiness of platelets Increased mobilization of triglycerides and LDL Lowered threshold for disturbances in cardiac rhythm Activation of macrophage cells from the immune system Stress can have a profound effect on your cardiovascular system – especially over a long period of time.

Drugs That Can Raise Blood Pressure Oral contraceptives Steroids NSAIDS Nasal decongestants Appetite suppressants Cyclosporine Some antidepressants Oral contraceptives- hypertension 2-3 xs more common in women taking; risk increases with age; problem is aggravated by smoking; may also be true for menopausal women on HRT NSAIDS- nasal decongestants: contain ephedrine or phenylpropolamine, which increase BP appetite suppressants- also contain ephedrine or pseudoephedrine Cyclosporine: used for transplantpatients, causes vasoconstriction and salt-retention

Putting It In Action Take Small Steps Breakfast Lunch Dinner Dessert/Snacks Achieving and Maintaining Behavior Change This section will offer tips on making DASH work for you.

Take Small Steps This diet is higher in fruits and vegetables than the typical American diet It is much higher in fiber Add high-fiber foods gradually Drink lots of water Small changes are more likely to become permanent This diet is higher in fruits and vegetables than the typical American diet so it is also higher in fiber. This can cause gas and bloating, so add foods gradually and drink lots of water Research shows that small changes are nore likely to result in PERMANENT behavior changes than trying to do it all at once

Breakfast Choose oatmeal or whole grain cereal Read labels to find low-sodium cereal – many packaged cereals are high in sodium Include fruit Include high-calcium dairy product like yogurt or skim milk Breakfast is an excellent opportunity to add whole grains, dairy and fruit to your diet. Missing breakfast is a big nutritional mistake – if you are in a hurry you can experiment with

Lunch Large salad Soup or stir fry dish with veggies Use oil & vinegar to reduce sodium Lots of veggies Nuts and seeds, too Soup or stir fry dish with veggies Limit deli sandwiches – bread, cheese, condiments and deli meats are high in sodium Consider low-sodium tuna, fresh roasted/baked chicken, lean meat or baked/grilled fish Lunch should include 2 servings of grains and 2 servings of vegetables. It may include protein such as meat, fish or chicken, nuts, seeds, beans, lowfat dairy ors fruit too.

Dinner Include vegetables Large salad Use oil and vinegar to reduce sodium Lots of veggies Nuts and seeds too Vegetarian entrée: pasta, stir fry, soup, chili Consider low-sodium tuna, fresh roasted/baked chicken, lean meat or fish Dinner should include 2-3 servings of grains and at least 2 servings of vegetables. It may also include a lean protein, beans, nuts, seeds, lowfat dairy or fruit.

Snack or Dessert Fruit or vegetables 100% whole grain bread Nut butter Nonfat yogurt Use skim milk for smoothie Light use of nuts Snacks and desserts should include lowfat dairy, whole grains, fruit, vegetables and or nuts. Concentrate on putting enough of the DASH foods into your diet – make snacks and desserts count. Remember, on the DASH diet, sweets were limited to 5 or less per week. When you fill up on sweets and other refined foods, you limit the room you have for the DASH foods.

Achieving and Maintaining Behavior Change Break the process into small steps Write things down If you slip, ask yourself why you got off track See if you tried to do too much too fast Don’t worry about a slip Making a major change in your diet is not easy. Work on getting each meal more healthful. For example, work on breakfast for a week, then shift to lunches and finally dinner. Another way to approach this change is to work on each section of the DASH pyramid. For example, work one week on getting enough fruits and vegetables then shift to leaner protein and finally get used to having lowfat dairy products. Wean yourself off sweets and processed snack foods slowly.

“Flaming enthusiasm, backed by horse sense and persistence, is the quality that most frequently makes for success.” – Dale Carnegie Dale Carnegie has a great saying that will help you with your success. You need enthusiasm, common sense and persistence.

Dietary Approaches to Stop Hypertension Make the DASH to better health!! Thank you for watching our show. In the next slide you will see a summary of what we just covered and I will answer questions.

Questions and Answers Start the DASH Appendix Putting It In Action Speaker – here is an overview of what you just covered. Now is the time to accept questions on your presentation. Introduction to hypertension – we will give you the basic information about hypertension and high blood pressure DASH Details – here we will examine the details of the 2 DASH studies Start the DASH – you will learn how to eat the DASH diet Appendix – here is more information on diet and lifestyle with regards to hypertension and blood pressure Putting it in action – you will gain valuable success tips for changing your diet and lifestyle