DASH Diet

The DASH Diet (and sample meal plans)

People always ask me for recommendations on diets. A diet  isn’t just used for weight loss, or a short-term benefit, but provides the basis for a long-lasting lifestyle change. With the new recommendations from The American College of Cardiology to treat hypertension, they recommend this as the first line of treatment for stage one hypertension (130/80 or more). In fact, most would argue that the first line of treatment for hypertension should be the use of diet and sodium restriction.

The power of the DASH diet was shown in multiple studies, such as that people who follow a DASH diet with 1500 mg of sodium have a decrease in their blood pressure equal to what you get when you take most blood pressure medicines. Yup- eat your way to health – case proven.

The new guidelines for blood pressure control advocate that the first line of therapy be diet and lifestyle change and this is the diet that is recommended.

Think of the DASH like a Mediterranean diet PLUS.  It was modeled after the Mediterranean Diet, but added some new features based on new information.

In the case of the DASH diet, I highly recommend it as a basis for a healthy life.  The DASH diet was meant to decrease salt intake while maintaining flavor. It turns out that DASH does more than reduce salt intake: people who DASH have a decreased  risk of heart disease, diabetes, and as people age the DASH diet provides some protection of cognitive function.

The DASH diet is the best diet that most people have NEVER heard of.

DASH diet – made by science, not by notions

Far too many diets (or lifestyles) are made with notions, and not with science. An idea that if you eat this way it will lead to health and freedom from disease. People who follow such plans, or attempt to, become cult-like in their devotion to those notions. DASH, however, is unlikely to get such converts because it was developed by science, not by notions – hence, you will find no DASH cultists telling you why you are eating wrong.

Most may have heard about the DASH diet when it was named #1 by US News and World Report. There was a reason this was the top diet- and one that I recommend to my patients looking for an outline to adopt a healthy lifestyle.

The DASH Diet was initially developed to  decrease sodium (DASH stands for Dietary Approaches to Stop Hypertension). Too often low-sodium diets were bland, and salt substitutes were deadly, so a group of scientists, nutritionists, doctors, and assorted cooks went about to develop a tasty diet that would follow the best evidence about guidelines for nutrition. Developed by physicians and nutritionists from the National Institutes of Health, DASH is currently the 5^th most common diet searched for in search engines. Like most diet plans, there are books filled with recipes and explaining how the diet will help a person lose weight, feel younger, and allow men to see their shoes again.

The Dash diet is rich in fruits, vegetables, low fat or nonfat dairy, whole grains, lean meats, fish, poultry, nuts, and beans. High fiber and low fat – what is not to love? The emphasis on home preparation means less salt. Since there are 5-7 servings of fruits and vegetables and grains, all of which have low amounts of salt, there is lots of bulk, but not lots of sodium. While this diet is healthy, and available freely on the government’s NIH website, it is really an “open source diet.” As we learn more about foods, and change our opinion, the diet can change. As a result there are many books out there that have DASH on the cover, but one has to be careful because some of those books are little more than versions of a Paleo/High Protein diet. I have reprinted the pages from the NIH with their recommendations below.

DASH Eating Plan—Number of Food Servings by Calorie Level

Food Group	1,200 Cal.	1,400 Cal.	1,600 Cal.	1,800 Cal.	2,000 Cal.	2,600 Cal.	3,100 Cal.
Grainsa	4–5	5–6	6	6	6–8	10–11	12–13
Vegetables	3–4	3–4	3–4	4–5	4–5	5–6	6
Fruits	3–4	4	4	4–5	4–5	5–6	6
Fat-free or low-fat dairy productsb	2–3	2–3	2–3	2–3	2–3	3	3–4
Lean meats, poultry, and fish	3 or less	3–4 or less	3–4 or less	6 or less	6 or less	6 or less	6–9
Nuts, seeds, and legumes	3 per week	3 per week	3–4 per week	4 per week	4–5 per week	1	1
Fats and oilsc	1	1	2	2–3	2–3	3	4
Sweets and added sugars	3 or less per week	3 or less per week	3 or less per week	5 or less per week	5 or less per week	≤2	≤2
Maximum sodium limitd	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day

 

DASH Eating Plan—Serving Sizes, Examples, and Significance

Food Group	Serving Sizes	Examples and Notes	Significance of Each Food Group to the DASH Eating Plan
Grainsa	1 slice bread1 oz dry cerealb½ cup cooked rice, pasta, or cerealb	Whole-wheat bread and rolls, whole-wheat pasta, English muffin, pita bread, bagel, cereals, grits, oatmeal, brown rice, unsalted pretzels and popcorn	Major sources of energy and fiber
Vegetables	1 cup raw leafy vegetable½ cup cut-up raw or cooked vegetable½ cup vegetable juice	Broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes	Rich sources of potassium, magnesium, and fiber
Fruits	1 medium fruit¼ cup dried fruit½ cup fresh, frozen, or canned fruit½ cup fruit juice	Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines	Important sources of potassium, magnesium, and fiber
Fat-free or low-fat dairy productsc	1 cup milk or yogurt1½ oz cheese	Fat-free milk or buttermilk; fat-free, low-fat, or reduced-fat cheese; fat-free/low-fat regular or frozen yogurt	Major sources of calcium and protein
Lean meats, poultry, and fish	1 oz cooked meats, poultry, or fish1 egg	Select only lean; trim away visible fats; broil, roast, or poach; remove skin from poultry	Rich sources of protein and magnesium
Nuts, seeds, and legumes	⅓ cup or 1½ oz nuts2 Tbsp peanut butter2 Tbsp or ½ oz seeds½ cup cooked legumes (dried beans, peas)	Almonds, filberts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, split peas	Rich sources of energy, magnesium, protein, and fiber
Fats and oilsd	1 tsp soft margarine1 tsp vegetable oil1 Tbsp mayonnaise2 Tbsp salad dressing	Soft margarine, vegetable oil (canola, corn, olive, safflower), low-fat mayonnaise, light salad dressing	The DASH study had 27% of calories as fat, including fat in or added to foods

a Whole grains are recommended for most grain servings as a good source of fiber and nutrients.
b Serving sizes vary between ½ cup and 1¼ cups, depending on cereal type. Check the product’s Nutrition Facts label.
c For lactose intolerance, try either lactase enzyme pills with dairy products or lactose-free or lactose-reduced milk.
d Fat content changes the serving amount for fats and oils. For example, 1 Tbsp regular salad dressing = one serving; 1 Tbsp low-fat dressing = one-half serving; 1 Tbsp fat-free dressing = zero servings.

The doctors and nutritionists, who developed this food plan, did so based on their best evidence in the literature at that time. The diet is not meant to be cast in stone, because our knowledge of nutrition changes. They didn’t use the logical fallacy of a “biotruth” to sell it. They used science. Might this diet change- it might. Consider the DASH diet to be “open-sourced,” so that as we learn more about what are “good” and “healthy” foods and eating habits, the diet can change.

From a science and medicine perspective the DASH diet makes the most sense of all the major diet plans. Little wonder that most professionals find this diet to be the favorite of all diet plans.

Should people restrict their salt intake? The answer depends: clearly those individuals who have impairment of their heart, liver, or kidneys will need to restrict salt or sodium intake. With salt restriction combined with the DASH diet reduced hypertension in almost all comers. It also reduced cardiac deaths. Whether you need to restrict salt or not, the DASH diet is a healthy diet for all people to follow.

Is this a good weight loss diet plan? By lowering the number of calories burned it can be good for weight loss as well as weight maintenance. Instead of looking at any diet as a weight loss plan, it is better to look at the diet as a lifestyle change. Sustaining weight loss is much better with the DASH diet than most.

Sticking With DASH

In follow up studies, patients who were provided food for the DASH diet did fairly well, but other people on the diet. Participants in one study showed a significant decrease in total fat, saturated fat and cholesterol intake, while increase in intake of dietary fiber and many vitamins and minerals after intervention. Following the diet is fairly easy, because there is nothing restricted on this diet (as in don’t eat carbohydrates, or don’t eat meat) it is simple once a person develops the menu plans. It is a healthy lifestyle change that provides for little sense of deprivation. Two factors help provide adherence to DASH: menu planning, so that people know what they are eating on a daily basis with the food provided, or providing the food for them directly.

It may be that the latest trend in companies supplying food (such as Blue Apron) will increase to provide full menus with ingredients.  Sadly, Blue Apron doesn’t always incorporate a lot of good vegetables and is more grain based. Although, providing menu plans and shopping lists should also work to improve compliance.  It is sad that few people make their own menu plans, and thus fall to random victims of their own fate with diet.

Heart Healthy

Most cardiologists rank the diet highly with regard to cardiac health. Besides being low in salt, it decreases the “bad” cholesterol (LDL) as well as triglycerides (which some cardiologists feel have the most important role with heart disease). The DASH diet showed a 13% risk reduction in the Framingham scores – significant.

Diabetes

People who are on the DASH have a 20% risk reduction in developing diabetes. For those who have diabetes the DASH diet also conforms to the dietary recommendations and is generally considered to be safe for patients who have diabetes.

Aging Well

Cognitive decline in the elderly is multifactorial, but one of the factors is diet. In studies, the DASH diet provided slower rates of cognitive decline.

Pregnant women with gestational diabetes had better outcomes when they adhered to the DASH diet.

Fat. The DASH diet follows recommendation of 20 to 35 percent of daily calories come from total fat, and less than 10 per cent of calories coming from saturated fat. There are a number of scientists who would state that this percent of fat may be too low, based on other studies. Just as those who follow the teachings of Dr. Ornish would think this level is too high. One can adapt this diet to increase or decrease fat – but rather than taking the “talking head” version – it might be best to follow this and check your own chemistry (blood draws) to see how you do on this diet or a variation of it.

Protein. While most of America is in love with protein, the amount of protein that is sold (in protein drinks or in some dietary recommendations) is more protein than the body requires. The DASH guidelines are not going to leave a person deprived of protein, nor is it built along the notions that we need excess protein.

Carbohydrates. Carbohydrates come from a wide variety of fruits and vegetables as well as grains. Processed food is not the source, and most notions of modern diets are critical of processed carbohydrates. There are those who “believe” that all grains are evil, and while their hypothesis does not stand the test of science, they seem to be sprouting books faster than all the hops in Bavaria. Unless a person has a specific gluten or grain-type allergy; this is a refreshing change away from the anti-grain world. Not surprising, since DASH was developed to follow recommendations that the government developed, DASH falls easily in the amounts of carbohydrates that people are recommended to have.

Salt. DASH was developed as an alternative diet to follow the recommendations of sodium. But the recommendation of 2,300 mg., is probably too restrictive, salt intake is even more restrictive for those who are 51 or older, African-American or have hypertension, diabetes, liver, or chronic kidney disease. For those individuals there are meal plans to follow the limit of 1,500 mg (a little over half a teaspoon a day). For those individuals, salt intake should be low. 1500 is pretty low, but the science backs that this may be the right number. Further, a reduction in salt happens easily when people get rid of highly processed foods. That Subway sandwich may seem healthy but can have 600 mg of sodium in it.

Other nutrients. Everyone seems to be low in Vitamin D, fiber, potassium, and B12 these days. And these were labeled as concerning, so most diets are checked against how they stack up with these micronutrients:

• Fiber is missing in the standard American diet, and the amounts recommended are 22 to 34 grams for adults. Fiber is beneficial for having healthy gut bacteria, keeps a person “regular,” and provides one of the senses of satiety. There is plenty of fiber in the DASH plan. As one of my patients was adopting this diet, having not previously eaten much fiber, she thought that DASH stood for dashing off to the bathroom. But once the bacteria that love fiber become well established in your colon, bloating will cease, and you will be just fine.
• The recommended amount of potassium is 4700 grams per day (about 10 large bananas a day). Most Americans get too little potassium and evidence is that potassium counters salt’s ability to raise blood pressure, decreases bone loss and reduces the risk of developing some kidney stones. It’s not that easy to get the recommended daily 4,700 mg. from food. DASH, however, provides sufficient potassium.
• The mineral of bones, used to build and maintain bones, and essential in the blood stream for a variety of cellular functions. While most Americans get little (hence the advertisements for milk) the DASH diet provides lots of mechanisms to consume the recommended levels of calcium. This is especially true for those over 50. DASH has abundant calcium.
• Vitamin D. Almost every American seems to be deficient in vitamin D these days. Sunlight is the mixed blessing, providing the ability to convert fat to vitamin D, but for those who live in cloudy areas, or who are vampires, most miss the government’s recommendation of 15 microgram a day. DASH is also less than this amount, however, fortified foods can provide more. Alaskans get little sunlight but they do eat salmon, and 3 ounces of sockeye salmon provides almost 20 micrograms of vitamin D.
• Vitamin B- A requirement to make red blood cells, this vitamin has been called the “energy” vitamin. Most Americans do not get enough of this, and certainly this is a long-term issue with vegetarian and vegan diets. However, DASH provides more than enough.

Given that DASH provides not only the macro but most micronutrients, there is no need to have external supplementation with this diet. Spending your money on fruits and vegetables instead of vitamins always seems to work out well.

REFERENCES:

Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC. Br J Nutr. 2014 Nov 28:1-15. PMID: 25430608

Relationship between Dietary Approaches to Stop Hypertension score and Alternative Healthy Eating Index score with plasma asymmetrical dimethylarginine levels in patients referring for coronary angiography.
Mokhtari Z, Hosseini S, Miri R, Baghestani AR, Zahedirad M, Rismanchi M, Nasrollahzadeh J.J Hum Nutr Diet. 2015 Mar 18. PMID: 25786774

Which diet for prevention of type 2 diabetes? A meta-analysis of prospective studies. Esposito K, Chiodini P, Maiorino MI, Bellastella G, Panagiotakos D, Giugliano D.Endocrine. 2014 Sep;47(1):107-16. PMID: 24744219

The effect of DASH diet on pregnancy outcomes in gestational diabetes: a randomized controlled clinical trial.
Asemi Z, Samimi M, Tabassi Z, Esmaillzadeh A.Eur J Clin Nutr. 2014 Apr;68(4):490-5. PMID: 24424076

Effects of Dietary Approaches to Stop Hypertension (DASH) diet on some risk for developing type 2 diabetes: a systematic review and meta-analysis on controlled clinical trials. Shirani F, Salehi-Abargouei A, Azadbakht L.Nutrition. 2013 Jul-Aug;29(7-8):939-47. PMID: 23473733

Relation of DASH- and Mediterranean-like dietary patterns to cognitive decline in older persons.
Tangney CC, Li H, Wang Y, Barnes L, Schneider JA, Bennett DA, Morris MC.Neurology. 2014 Oct 14;83(16):1410-6.PMID: 25230996

Compliance with the Dietary Approaches to Stop Hypertension (DASH) diet: a systematic review.
Kwan MW, Wong MC, Wang HH, Liu KQ, Lee CL, Yan BP, Yu CM, Griffiths SM.PLoS One. 2013 Oct 30;8(10):e78412.PMID: 24205227

The effect of home-delivered Dietary Approach to Stop Hypertension (DASH) meals on the diets of older adults with cardiovascular disease. Troyer JL, Racine EF, Ngugi GW, McAuley WJ.Am J Clin Nutr. 2010 May;91(5):1204-12 PMID: 20200258

Weight loss maintenance: A review on dietary related strategies. Soeliman FA, Azadbakht L.J Res Med Sci. 2014 Mar;19(3):268-75.PMID: 24949037

Sample Menu Plan

Two things to note about this sample menu – first, look at the number of calories that are in this plan – over 2,000.  That is what the average male should burn in a day. This plan is from the Mayo Clinic. Below this is a 1500 calorie, which is what the average female should burn in a day. That means, if you eat this, you will neither lose weight nor gain weight if you are a male. If you are a female, you may gain weight on this plan.

Breakfast

• 1 store-bought (commercial) whole-wheat bagel with 2 tablespoons peanut butter (no salt added)
• 1 medium orange
• 1 cup fat-free milk
• Decaffeinated coffee

Lunch

Spinach salad made with:

• 4 cups of fresh spinach leaves
• 1 sliced pear
• 1/2 cup canned mandarin orange sections
• 1/3 cup slivered almonds
• 2 tablespoons red wine vinaigrette

12 reduced-sodium wheat crackers

1 cup fat-free milk

Dinner

• Herb-crusted baked cod, 3 ounces cooked (about 4 ounces raw)
• 1/2 cup brown rice pilaf with vegetables
• 1/2 cup fresh green beans, steamed
• 1 small sourdough roll
• 2 teaspoons olive oil
• 1 cup fresh berries with chopped mint
• Herbal iced tea

Snack (anytime)

• 1 cup fat-free, low-calorie yogurt
• 4 vanilla wafers

Day 1 nutritional analysis
Calories:	2,015	Cholesterol:	70 mg
Total fat:	70 g	Sodium:	1,607 mg
Saturated fat:	10 g	Total carbohydrate:	267 g
Trans fat:	0 g	Dietary fiber:	39 g
Monounsaturated fat:	25 g	Sugars:	109 g
Potassium:	3,274 mg	Protein:	90 g
Calcium:	1,298 mg	Magnesium:	394 mg

Day 1 DASH servings
Grains and grain products:	7
Vegetables:	5
Fruits:	4
Dairy foods (low-fat or fat-free):	3
Meats, poultry and fish:	3
Nuts, seeds and dry beans:	2
Fats and oils:	3
Sweets:	1

Below is a 1500 Calorie A Day DASH plan. This one is from The University of Illinois. An average male would lose about one pound a week on this plan.

1500 Calories/Day DASH Diet – Sample Menu