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DASH diet

The DASH diet is a flexible eating plan that helps create a heart-healthy eating style for life. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Heart failure (HF) occurs when the heart’s pumping is not able to keep up with the body’s demands for blood and oxygen and may decompensate. Unlike a heart attack, it develops slowly over years and may take a long time to become symptomatic. According to the latest statistics, 6.7 million Americans over the age of 19 are affected (1).  These numbers are projected to increase to 8.7 million by 2030, with the greatest growth among those aged 35 to 64 (2).

There are two types of heart failure, systolic and diastolic. Put simply, the difference is that the output of blood with each contraction of the heart’s left ventricle is generally preserved in diastolic HF, while it can be significantly reduced in systolic HF.

Fortunately, both types can be diagnosed with an echocardiogram, an ultrasound of the heart. The signs and symptoms of both include shortness of breath during daily activities or when lying down; edema or swelling in the feet, legs, ankles or stomach, reduced exercise tolerance; and feeling tired or weak. These can have a significant impact on your quality of life.

Major lifestyle risk factors for heart failure include obesity, smoking, poor diet, being sedentary, excessive alcohol intake (3). Medical conditions that increase your risk include diabetes, coronary artery disease, high blood pressure, and valvular heart disease.

Heart failure can be treated with medication, including blood pressure medications, such as beta blockers, ACE inhibitors and angiotensin receptor blockers. All of these have side effects. We are going to look at recent studies that examine the role of diet in reducing your risk. 

The role of antioxidants in your diet

If we look beyond the risk factors mentioned above, some studies have explored the role oxidative stress may play an important role in contributing to HF.

In an analysis of the Swedish Mammography Cohort, researchers showed that a diet rich in antioxidants reduces the risk of developing HF (4). In the group that consumed the most nutrient-dense foods, there was a significant 42 percent reduction in the development of HF, compared to the group that consumed the least. The antioxidants were mainly from fruits, vegetables, whole grains, coffee and chocolate. Fruits and vegetables were responsible for most of the effect.

This study was the first to investigate the impact of dietary antioxidants on heart failure prevention.

This was a large study: it involved 33,713 women with 11.3 years of follow-up. Still, there are limitations, because it was an observational study, and the population involved only women. However, the results are very exciting, and there is little downside to applying this approach.

Applying the DASH diet

A 2022 study examined the effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the risk of developing HF (5). This study included over 76,000 men and women, ages 45-83 and without previous HF, ischemic heart disease or cancer from the Cohort of Swedish Men and the Swedish Mammography Cohort.

The DASH diet emphasizes consuming fruit, vegetables, whole grains, nuts and legumes, and low-fat dairy and de-emphasizes red and processed meat, sugar-sweetened beverages, and sodium.

The researchers found that long-term adherence to the DASH diet was associated with a lower risk of HF. The greater the participants’ adherence, the greater the positive effect.

Interestingly, even replacing one serving per day of red and processed meat with one serving per day of other DASH diet foods was associated with an approximate 10 percent lower risk of HF.

Comparing a variety of diets

The REGARDS (REasons for Geographic and Racial Differences in Stroke) Trial examined the impact of five dietary patterns on later development of HF in over 16,000 patients followed for a median of 8.7 years. The dietary patterns included convenience, plant-based, sweets, Southern, and alcohol/salads (6). 

Researchers found that a plant-based dietary pattern was associated with a significantly lower risk of HF. Compared with the lowest quartile, the highest quartile of adherence to the plant-based dietary pattern was associated with a 41 percent lower risk of HF. 

The highest adherence to the Southern dietary pattern was associated with a 72 percent higher risk of HF after adjusting for age, sex, and race and for other potential confounding factors. Researchers found less effect after further adjusting for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease.

They did not observe any associations with the other 3 dietary patterns.

These studies suggest that we should seek to prevent heart failure with dietary changes, including consuming higher amounts of antioxidant-rich foods, such as fruits and vegetables, and lower amounts of red and processed meats.

References:

(1) Circulation. 2024;149:e347–913. (2) hfsa.org. (3) cdc.gov. (4) Am J Med. 2013 Jun:126(6):494-500. (5) Eur J of Prev Cardiology 2022 May: 29(7): 1114–1123. (6) J Am Coll Cardiol. 2019 Apr 30; 73(16): 2036–2045.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Sticking to a plant-rich diet that can reduce high blood pressure. Stock photo
Call to arms to reverse high blood pressure, once and for all

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension (high blood pressure) and COVID-19 are intertwined. Those who have hypertension are more susceptible to COVID-19 and are more likely to get a severe form and experience complications from the virus. A study done in China captured the statistics: of 1099 patients infected, 15 percent had hypertension, and of those with severe cases, 23.7 percent had hypertension (1). Ultimately, those with hypertension are at higher risk, but we don’t at this point understand the specifics of why.

Even before the COVID-19 pandemic, a recent study showed that the number of deaths from hypertension had increased a whopping 26 percent overall from 2007 to 2017 (2). 

What about medications to blunt the association? There is a THEORY, not a study, that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may be harmful by increasing ACE2 in the lungs, which is a receptor that COVID-19 binds to; however, there is also a case for these medications having benefits (3). Do not stop or change your hypertension medications without talking to your doctor. Remember, this is just a theory, and theories are very dangerous; we don’t have research to support them, by definition (4).

I view this as a call to arms to control and, even more importantly, treat and reverse hypertension. Presently, only 54 percent of hypertension patients are controlled with medication (5). 

Potential to control and reverse hypertension through diet

We have the capability to treat and reverse hypertension with lifestyle modifications, including diet, exercise, sleep and stress management. We are going to focus on diet.

A whole foods plant-based diet (WFPBD) that is dark green leafy vegetable-rich has been shown to help prevent, control and possibly reverse hypertension. I call this the LIFE diet, which stands for Low Inflammatory Foods Everyday. The most researched type of WFPBD is the DASH (dietary approach to stopping hypertension) diet, which emphasizes fruits, vegetables, grains and reductions in saturated fats and total fat. DASH was the first randomized control trial to show that a predominantly whole food plant-based approach reduces blood pressure (6).

Why does diet have an effect? There are several factors, including inflammation; electrolytes, specifically sodium and potassium; and phytochemicals (plant nutrients and fiber content).

Why is inflammation so important?

Inflammation is a culprit in most chronic diseases, including hypertension. It also plays a crucial role in the severity of COVID-19. Those who take a turn for the worse in COVID-19 have high inflammation. On the news, an ER doctor noted that while COVID-19 patients may come in stable, they need to be watched carefully; in 3-24 hours, they could show high inflammation and fluid in their lungs and need to be on a ventilator.

There are several studies that show a direct relationship between high sensitivity C-reactive protein, one of the most well-studied biomarkers for inflammation, and hypertension in both men and women (7)(8). In the Physicians Health Study, those men who had high hsCRP (>3 mg/L) and hypertension had a 40 percent increased risk of stroke compared to those without hypertension and with hsCRP <1, which is optimal. Not to leave women out, the CARDIA study found that premenopausal women with elevated hsCRP were significantly more likely to have hypertension.

How can we decrease inflammation?

Anti-inflammatory drugs, including NSAIDS like ibuprofen, may suppress the immune system and make patients more susceptible to COVID-19. They also worsen hypertension and may increase the risk for cardiovascular events, such as a heart attack. In fact, prescription NSAIDS carry an FDA black box warning about this dangerous side effect. Anti-inflammatory drugs should not be the “go-to” solution.

Fortunately, a WFPBD is associated with reduction in inflammation, specifically hsCRP. We recently published a study showing that the LIFE diet has an inverse relationship between blood levels of beta carotene, a phytonutrient, and hsCRP (9). As you increase the intake of dark green leafy vegetables, the higher the beta carotene and the lower the hsCRP. There was a 75 percent reduction in inflammation with those that increased their beta carotene over the normal level compared to those who were non-adherent. The DASH diet also emphasizes an increased intake of vegetables.

There are studies to suggest that, as we lower animal protein intake, we are able to better reduce blood pressure. In the EPIC study, those who at who reduced animal protein to none had the biggest impact on blood pressure. This study compared meat-eaters, fish-eaters, vegetarians and vegans (10). 

Electrolytes – sodium and potassium

The optimal approach for these electrolytes is to have a sodium to potassium ratio that is less than one. For most, this means consuming less sodium and more potassium (11). The American Heart Association emphasizes low sodium, less than 1500 mg of sodium per day and higher potassium intake (12). 

What I find in my practice is that blood levels that are south of 140 mmol/L are better and that the bottom of the range is ideal; the range is between 135-145 mmol/L. This way, whether you are sodium-sensitive or not, you can either help control blood pressure or rule it out as a factor. Potassium should be 4.5 (units) or higher. These electrolytes should come from vegetables, especially dark green leafy vegetables, which have a natural balance of potassium and sodium. Other good sources of potassium are beans and nuts.

Ultimately, the power is in your hands. By changing your diet to one that is more plant-based and vegetable-rich, you can reduce inflammation, strengthen your immune system, possibly reduce or even get off anti-hypertension medications, reverse the trend of dying from hypertension, and reduce your susceptibility to severe COVID-19.

References:

(1) N Engl J Med. Online Feb 28, 2020. (2) J Am Coll Cardiol. Online March 19, 2020). (3) Nephron. Online Mar 23, 2020.) (4) Nature. Feb 2020, 579:270–273. (5) Circulation. 2016;133:e38–e360. (6) N Engl J Med. 1997 Apr 17; 336(16):1117-24. (7) JAMA.2015 Sep:4(9):e002073 (8) Menopause. 2016 Jun; 23(6):662. (9) AJLM Online. Dec. 21, 2019. (10) Oybkuc Gektg Bytr, 2002 Oct; 5(5):645-54. (11) Circulation Online. Oct 11 2017. (12) heart.org.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.