Special Diets

DASH Diet

Dietary Approach to Stop Hypertension (DASH) Diet

Healthy nutrition plays an essential role in reducing cardiovascular risk and heart disease. In 2015, an estimated 630,000 Americans died from heart disease, of which 366,000 died due to coronary artery disease. The mortality rate secondary to heart disease rose in 2015 by 1%, although it gradually declined over four decades, most likely due to the obesity epidemic [1].

Conventional diets generally include a macronutrient composition of 30% fat, 50% carbohydrate, and 20% protein. Although all individuals should be encouraged to follow a heart-healthy lifestyle, the limitation of scientific evidence with a variety of available diet formats leads the public more confused about choosing the best diet type. Here, we will discuss various diet types available and their effect on heart disease with published scientific evidence.

Hypertension in the United States

In 2018, nearly half a million deaths in the United States included hypertension as a primary or contributing cause [1]. Almost half of all adults in the United States (108 million, or 45%) have hypertension, defined as a systolic blood pressure ≥ 130 mm Hg or a diastolic blood pressure ≥ 80 mm Hg, or are taking medication hypertension [2]. Only about 1 in 4 adults (24%) with hypertension have their condition under control [2].

What is normal blood pressure?

Normal blood pressure is defined as a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg.

Potential benefits DASH

Obesity and high blood pressure are well-known risk factors for coronary artery disease. Although DASH is not designed to reduce weight, one could use it to control blood pressure and body weight by simply adding exercise or controlling calorie deficit [5,6].

Given the tremendous burden of high blood pressure in the United States, DASH-Sodium Collaborative Research Group performed a high-quality trial to understand daily food’s impact on blood pressure control. A total of 412 participants were randomly assigned to eat either a control diet typical of intake in the United States or the DASH diet. Low salt DASH diets showed an incredible result with a reduction of 7.1 mm Hg lower in participants without hypertension and 11.5 mm Hg lower in participants with hypertension [3].

An interesting finding from the DASH trial was that diet control alone could reduce blood pressure even in those with normal blood pressure [3]. Another trial, TOHP, verified the reduction in dietary sodium was associated with a better cardiovascular outcome [4].

As the DASH diet includes fruit and vegetable content primarily, it could potentially decrease the risk of cancer, metabolic syndrome, and diabetes [7-9]. Moreover, a DASH-like diet can significantly protect against coronary heart disease, stroke, and heart failure risk by 21%, 19%, and 29%, respectively [10].

How to apply it in daily life and what to eat?

DASH diet doesn’t apply to any specific type of food; instead, it recommends different food groups. 2019 AHA guidelines on lifestyle management to reduce cardiovascular risk suggests no more than 1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults.[11]

Need to remind that dietary sodium can be difficult to track for patients, and patients must understand that limiting processed and fast foods will reduce their sodium intake to a far greater extent than ceasing to use salt in their cooking.

How to calculate a serving?

A serving should include: 1 slice of whole-grain bread 1 ounce (28 grams) of dry, whole-grain cereal 1/2 cup (95 grams) of cooked rice, pasta, or cereal

Original DASH diet plan [12]

Grains and grain products (include at least three whole-grain foods each day):

Number of servings for 1600 – 3100 Calorie diets: 6 – 12
Servings on a 2000 Calorie diet: 7 – 8

Fruits:

Number of servings for 1600 – 3100 Calorie diets: 3 – 6
Servings on a 2000 Calorie diet: 3 – 5

Vegetables:

Number of servings for 1600 – 3100 Calorie diets: 4 – 6
Servings on a 2000 Calorie diet: 4 – 5

Mostly low fat or non-fat dairy foods:

Number of servings for 1600 – 3100 Calorie diets: 2 – 4
Servings on a 2000 Calorie diet: 2 – 3

Lean meats, fish, or poultry:

Number of servings for 1600 – 3100 Calorie diets: 1.5 – 2.5
Servings on a 2000 Calorie diet: Two or less

Nuts, seeds, and legumes:

Number of servings for 1600 – 3100 Calorie diets: 3 – 6 per week
Servings on a 2000 Calorie diet: 4 – 5 per week

Fats and sweets:

Number of servings for 1600 – 3100 Calorie diets: 2 – 4 per week
Servings on a 2000 Calorie diet: limited

Heart Healthy Diet

Heart disease is the leading cause of death in United States and one person dies every 36 seconds in USA [1]. Moreover, the burden on health care is tremendous and cost about $219 billion each year from 2014 to 2015 [2]. Coronary artery disease is the most common type of heart disease, killing 365,914 people in 2017 [3].

What is a heart healthy diet?

1. Heart healthy diet is an art of balancing your foods: what you should eat vs can’t eat (most likely your favorite foods). Heart healthy diet should include the following:

Fresh fruits, Nuts, and vegetables
Leafy greens (spinach, collard greens, kale, cabbage, broccoli, and carrots)
Fruits: apples, bananas, oranges, pears, grapes, and prunes
Various Nuts: walnuts, almonds, and pine nuts
Seeds (sesame, sunflower, pumpkin, or flax), tofu

2. Whole grains:

plain oatmeal, brown rice, and whole-grain bread or tortillas

3. Healthy fats:

Canola, corn, olive, safflower, sesame, sunflower, and soybean oils (not coconut or palm oil)
Avocados

4. Low fat protein:

95% lean ground beef or pork tenderloin or skinless chicken or turkey
Eggs
Legumes
Fish (salmon, tuna, and trout)

What to limit?

Heart healthy food should limit saturated and trans fats, salt, alcohol, and sugars such as sweetened drinks, snacks and sweets. If you drink alcohol, you should do it in moderation. 2019 AHA guidelines recommend no more than 1500 mg/day of sodium but aim for at least a 1000-mg/d reduction in most adults.

Maintain a Healthy Body Weight

One way to track your body weight is to use BMI, called body mass index. The ideal BMI should be 18-24.9, and everyone should attempt to achieve the goal weight. However, the benefit of weight loss can be seen even if there is a loss of ~5-10% of your weight.

Obesity & Weight Loss Diet

In the last decades, the global prevalence of overweight and obesity rose by about 28% in adults and 47% in children, from 857 million in 1980 to 2.1 billion in 2013 [1]. Data from the National Health and Nutrition Examination Survey reveal that the prevalence of abdominal obesity in the United States increased by about 6% in men and women over the period of 10 years (1999-2008) [2]. In a simple term, obesity is mostly due to excess calorie intake for an extended period. Extra calories intake in USA is considered due to calories rich dietary patterns, as well as increase in sedentary lifestyle and overall, it has been estimated to be ~400 kcal/day in the United States [3].

How to Lose Weight Safely

First, you should replace refined carbs with whole grains. If you start eating more complex carbohydrates along with a low carb diet plan, it will be beneficial not only from higher fiber content with slow digestion but also keep you stratified without feeling hungry.

Vegetables

Leafy vegetables are known to be rich sources of vitamins, and nutrients without significantly increasing calories

Protein Healthy protein is an essential component of foods to keep you healthy and provide adequate nutrition to your muscles. Due to slower digestion of protein, it can help to reduce food cravings, late night snack without feeling hungry. Daily recommended protein intake: 0.8g per kg of body weight, regardless of age [4]. Red meat (Beef, lamb, and pork) may have more unhealthy fat (saturated fat) that Fish, chicken, legumes. Therefore, choosing healthy protein source is important.

Healthy protein sources include:

Meat: Chicken, Trimmed lean meats, Turkey
Fish and seafood: salmon, trout, and shrimp
Eggs: whole eggs with the yolk
Plant-based: beans, legumes, quinoa, tofu
Healthy Fats

Not all fats are unhealthy. Our body needs healthy fats daily, so choosing healthy fats source is important. Of these, olive oil and avocado oil are the good choices to start in your diet plan.

The benefit of being active and exercising is undeniable. Even though you have been sedentary for years, we all must start from somewhere. First, walking, swimming, cycling are good exercises to start.

Lifting weight also has a very good effect on your body’s metabolism while burning a lot of calories.

Renal Diet for Kidney Diseases

There are five stages of kidney disease. Stage 1 and 2 are the early stages of kidney disease. When you get to stage 3, only half of the kidney is left. In Stage 4 and Stage 5, your kidneys have suffered a lot of damage and may eventually require hemodialysis.

As the kidney plays a significant role in handling electrolytes and fluid balances in the body, it is imperative to closely watch the diets to reduce electrolyte imbalances and prevent wastes accumulation.

The renal diet is low in sodium, phosphorus, potassium, and calcium while emphasizing consuming high-quality protein and limiting fluid intake.

What does the renal diet compromise of?

What should be included in renal diets?

Consume smaller portion of meat, poultry and fish
avoid alcohol
limit fat, sugars and added sugars
Avoid sodium

As a damaged kidney cannot filter out extra sodium, it can cause elevated blood pressure. It’s recommended to limit sodium to less than 2,000 mg per day [1,2].

If the potassium level is high in your blood test (a common finding in a renal patient), try to limit on;

bananas, melons, oranges, and dried fruit
potatoes, tomatoes, and avocados
dark leafy vegetables
brown and wild rice
dairy foods
beans, peas, and nuts
bran cereal, whole wheat bread, and pasta
salt substitutes
meat, poultry, pork, and fish Recommended daily potassium limit is less than 2,000 mg per day [3].

If the phosphorus level is high in the blood test, the following food should be avoided or consume only a minimal amount if possible;

dairy products
nuts
peanut butter
dried beans, peas, and lentils
cocoa, beer, and dark cola
bran Recommended dietary phosphorus limit is less than 800–1,000 mg per day [4].

Do I need to limit fluid intake?

It depends on the stage of your kidney disease. Fluid restriction is very important in a higher degree of kidney disease, increasing the risk of fluid retention in the body.

Lifestyle Modification

Daily exercise
Avoid smoking or stop smoking
Follow up with your physician regularly and take all prescribed medications

References

DASH Diet

Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. http://wonder.cdc.gov/ucd-icd10.html. Accessed March 12, 2020.
Centers for Disease Control and Prevention (CDC). Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association's 2017 Hypertension Guideline—NHANES 2013–2016. Atlanta, GA: US Department of Health and Human Services; 2019.
Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, 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(1):3-10.
Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ 2007;334:885-8.
Shenoy SF, Poston WS, Reeves RS, et al. Weight loss in individuals with metabolic syndrome given DASH diet counseling when provided a low sodium vegetable juice: a randomized controlled trial. Nutr J. 2010;9:8. doi: 10.1186/1475-2891-9-8. PMID: 20178625; PMCID: PMC2841082.
Blumenthal JA, Babyak MA, Hinderliter A, et al. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch Intern Med. 2010;170(2):126-35. doi: 10.1001/archinternmed.2009.470. PMID: 20101007; PMCID: PMC3633078.
Onvani S, Haghighatdoost F, Azadbakht L. Dietary approach to stop hypertension (DASH): diet components may be related to lower prevalence of different kinds of cancer: A review on the related documents. J Res Med Sci. 2015;20(7):707-13. doi: 10.4103/1735-1995.166233. PMID: 26622263; PMCID: PMC4638076.
Asghari G, Yuzbashian E, Mirmiran P, Hooshmand F, Najafi R, Azizi F. Dietary Approaches to Stop Hypertension (DASH) Dietary Pattern Is Associated with Reduced Incidence of Metabolic Syndrome in Children and Adolescents. J Pediatr. 2016;174:178–184.e1. doi: 10.1016/j.jpeds.2016.03.077. PMID: 27156186.
Shirani F, Salehi-Abargouei A, Azadbakht L. 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. Nutrition. 2013;29(7-8):939-47. doi: 10.1016/j.nut.2012.12.021. PMID: 23473733.
Salehi-Abargouei A, Maghsoudi Z, Shirani F, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH)-style diet on fatal or nonfatal cardiovascular diseases–incidence: a systematic review and meta-analysis on observational prospective studies. Nutrition. 2013;29(4):611-8. doi: 10.1016/j.nut.2012.12.018. PMID: 23466047.
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11):e596-e646. doi: 10.1161/CIR.0000000000000678. PMID: 30879355; PMCID: PMC7734661.
Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash-diettips.html. Accessed January 6, 2019.

Heart Healthy Diet

Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. Accessed March 12, 2020.
Fryar CD, Chen T-C, Li X. Prevalence of uncontrolled risk factors for cardiovascular disease: United States, 1999–2010. NCHS data brief, no. 103. Hyattsville, MD: National Center for Health Statistics; 2012. Accessed May 9, 2019.
Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–528.

Obesity & Weight Loss Diet

Ng M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781. doi: 10.1016/S0140-6736(14)60460-8.
Ford ES, Li C, Zhao G, Tsai J. Trends in obesity and abdominal obesity among adults in the United States from 1999 to 2008. Int J Obes. 2011;35:736–743. doi: 10.1038/ijo.2010.186.
Blackburn GL, Wollner S, Heymsfield SB. Lifestyle interventions for the treatment of class III obesity: a primary target for nutrition medicine in the obesity epidemic. Am J Clin Nutr. 2010;91:289S–292S. doi: 10.3945/ajcn.2009.28473D.
World Health Organisation (WHO). Dietary Reference Intakes for Energy, Carbohydrate, Fibre, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (Macronutrients); WHO Technical Report Series 935; WHO: Geneva, Switzerland, 2007.

Renal Diet for Kidney Diseases

Humalda JK, Navis G. Dietary sodium restriction: a neglected therapeutic opportunity in chronic kidney disease. Curr Opin Nephrol Hypertens. 2014;23(6):533.
Garofalo C, Borrelli S, Provenzano M, et al. Dietary Salt Restriction in Chronic Kidney Disease: A Meta-Analysis of Randomized Clinical Trials. Nutrients. 2018;10(6):732. doi:10.3390/nu10060732.
Kovesdy CP. Management of hyperkalaemia in chronic kidney disease. Nat Rev Nephrol. 2014;10(11):653-662. doi:10.1038/nrneph.2014.168.
González-Parra E, Gracia-Iguacel C, Egido J, Ortiz A. Phosphorus and nutrition in chronic kidney disease. Int J Nephrol. 2012;2012:597605. doi:10.1155/2012/597605.