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Experts discuss encouraging patients to consider DASH, which has low adherence despite ‘Best Diet’ ratings
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For the 8th year row, U.S. News & World Report recently ranked the Dietary Approaches to Stop Hypertension, or DASH, diet ‘Best Diet Overall’, the latest evidence to suggest that it is an effective tool in lowering BP.
“This diet can lower a patient’s BP by eight to 14 points, which is as strong as some of the medications we can give to a patient,” Khaled Dajani, MD, associate professor, division of cardiology, Loyola University, Chicago, told Healio Family Medicine last year.
However, a 2017 JAMA analysis of National Health and Nutrition Examination Survey data showed the average DASH adherence score was 2.6 of a possible 9. That same JAMA piece indicated that primary care clinicians “have an opportunity to provide counseling about dietary behaviors for hypertension management.”
In light of that report, and as a courtesy to its readers, Healio Family Medicine spoke to several experts, including a past president of the American Heart Association and a faculty member where the first leader trial on the DASH diet was performed more than 2 decades ago, on ways that primary care physicians can overcome the barriers such as knowledge and limited time with patients that can hinder adherence to DASH.
Separating fact from fiction
“The misconception is that DASH is a low-salt diet. The truth is, DASH’s leader trial was not low-salt. It was rich in fruits and vegetables, in beans, legumes, low-fat dairy and lean meats. It actually had high levels of sodium. Even with high salt, DASH can lower BP,” Dori Steinberg, PhD, MS, RD, assistant professor at Duke University, where the first leader trial on the DASH diet was performed 20 years ago, said in an interview. “I don’t think that primary care physicians always see that nuance, because lowering salt is part of BP management and you can get a bigger effect if you lower your salt too. But the biggest effect is when you make major changes to your diet."
According to the Mayo Clinic’s website, the DASH diet encourages eating a variety of foods rich in nutrients that help lower BP, such as potassium, calcium and magnesium and cutting back on salt intake.
The CDC recommends that Americans consume less than 2,300 mgs of sodium per day as part of a healthy eating pattern. However, the agency also states that most adults consume an average of more than 3,400 mg daily.
Robert H. Eckel, MD, professor of medicine, University of Colorado Denver, and past president of the American Heart Association, agreed that not all health care professionals may understand the DASH diet.
“I bet if you did a survey on this, they wouldn’t know what the DASH dietary pattern is. They might be familiar with the DASH diet as being favorable, in terms of risk factors for heart disease, but they don’t know how to explain it to patients, nor do they know how to apply it routinely in their practices,” he told Healio Family Medicine in an interview. “These medical professionals need to keep in mind that the DASH diet lowers BP, and further sodium restrictions even lowers it more.”
Making time to discuss with patients
Eckel also discussed how primary care physicians can discuss DASH even though there are many other health-related items they need to cover during a 20- to 30-minute appointment window.
“Doctors can conduct what I call the 3-minute lifestyle interview, in which they ask patients, 'How many servings of fruits and vegetables do you eat a day? How many servings of whole grains do you eat a day? How many servings of fish do you get a week? Do you read food labels? Do you pay attention to saturated fat?' With those questions, I am emphasizing a dietary pattern, expecting that a person on a heart-healthy diet such as DASH, is eating five or more servings of fruits and vegetables and five or more servings of whole grains a day. That’s the way I go about the nutrition end.
“Then I ask about physical activity,” Eckel continued. “Do you have a regular activity pattern and if so, how much, how long do you spend, do you have limitations of exercise, are you meeting the guidelines of 30 to 40 minutes, three to four times a week of moderately intense physical activity?”
Dajani suggested other ways to get the DASH discussion started.
“You can give them a handout, or give them advice on how to download healthy recipes. With the proliferation of the internet and devices, patients can download apps that show them step by step in more detail the emphasis on what foods to eat, what foods to avoid and coming up with a plan that they should follow,” he told Healio Family Medicine. “The other thing I advise physicians is to lobby for better access to dietitians and nutritionists at the hospital.”
Other barriers to overcome
Another potential barrier is the patient’s financial situation, which may not be as easy to overcome.
“We all know that we need to lose weight, eat better, and exercise — but still many of us don’t. Also, especially in low-income areas, it may seem unrealistic to counsel patients on DASH diet options when fruits and vegetables are often so much more expensive than fast food,” Haitham Ahmed, MD, department of cardiovascular medicine, Cleveland Clinic, told Healio Family Medicine. “However, it’s important to remember that frozen vegetables can be included as part of a well-balanced diet relatively inexpensively. Also, dietary counseling makes a great difference in BP, weight, and many other outcomes as data from the DASH diet suggests. Therefore, it is worth the effort to counsel our patients in the same way that we do about preaching the importance of medication adherence.”
Steinberg, who co-authored the JAMA article, agreed, and suggested some pushback medical professionals can give patients who may think that adhering to DASH may cause a certain level of economic hardship.
“Many believe to follow DASH you need a lot of money and you need a lot of resources. But there have been a lot of people who have looked at this, at how DASH can be followed on a budget,” she said. “Beans and canned or frozen fruits and vegetables are both inexpensive and more easily accessible. There’s this misconception that you have a lot of money to follow DASH. You don’t need a lot of money to follow DASH. You just have to be creative. One strategy to try is to make fruits and veggies and beans the stars of your plate and make meat or potatoes the supporting cast.”
Eckel said that helping patients adhere to DASH may take a change in mindset for some medical professionals, but is worth it.
“I want general physicians to pay more attention to this. A dietitian can always come in the room and get the information he or she is looking for. But I want the physician to get more involved in asking people about their lifestyle,” he said. “Typically, people in CVD ask about smoking, and sometimes alcohol consumption, but I don’t think doctors are asking the diet-quality and physical activity questions [that I alluded to earlier] that are important for a heart-healthy diet.”
Steinberg agreed, but felt that it is appropriate to have the expertise of other health care professionals be utilized as well.
“We need a little more push for DASH to be in the spotlight of physician’s minds. It’s not just a fad diet. It’s well-established, but it’s not really being talked about and pushed as a strategy to lower BP. I don’t think that the primary care physician should be doing the counseling, but they are the gatekeeper to getting the patient to where they need to go to get that support.”
Tools to help forthcoming
Steinberg told Healio Family Medicine she is creating tools that physicians can refer to patients, so that they can learn more about DASH and get feedback and support about DASH that is not necessarily from their physician. She added that this support will be delivered through smartphones and text messages.
“Having a ‘counselor’ in your pocket in the form of your phone can provide the feedback and accountability necessary to help you change your diet,” she said.
The authors of the JAMA article concluded by indicating the DASH diet impacts the health and well-being of many people and thus, needs to be brought up with patients.
“The potential benefits of promoting DASH are substantial. As a study from 2003 suggested, if individuals with hypertension were fully adherent to DASH, an estimated 400,000 cardiovascular disease events could be prevented over 10 years. This may be an overestimate given the reduction in [CVD] events that has occurred during the past 14 years,” they wrote. “Nevertheless, considering heart disease’s long-standing position as the leading cause of death in the United States, it is essential to continue efforts to improve population-wide adoption of DASH.” – by Janel Miller
References :
DASH diet: Healthy eating to lower your blood pressure (accessed from Mayo Clinic’s Web Page on 06-28-17)
Get the Facts: Sodium and Dietary Guidelines (accessed from CDC’s Web Page on 06-28-17)
Steinberg D, et al. JAMA. 2017:doi:10.1001/jama.2017.1628.
Disclosures: Steinberg reports equity and ownership in the weight loss company Scaledown that uses digital health. Ahmed, Dajani and Eckel report no relevant financial disclosures.