the encore study cardiovascular benefits associated with the dash diet alone and in combination with...
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The ENCORE StudyThe ENCORE StudyCardiovascular Benefits Associated With the Cardiovascular Benefits Associated With the DASH Diet Alone and in Combination with DASH Diet Alone and in Combination with
Exercise and Weight Reduction in Men and Exercise and Weight Reduction in Men and Women with High Blood PressureWomen with High Blood Pressure
The American College of Cardiology 58th Annual Scientific Session
Alan L. Hinderliter, MD
Conflicts of Interest
The authors have no relevant conflicts of interest
Background
Lifestyle modifications are recommended for blood pressure lowering in patients with pre-hypertension and as an initial strategy in treating Stage I hypertension
The DASH diet is effective in lowering blood pressure
In patients on the DASH diet, the incremental benefits of weight loss and exercise are uncertain
The effects of lifestyle modifications on cardiovascular manifestations of high blood pressure have not been extensively studied
Objectives
To examine the effects of 1) the DASH diet, and 2) the DASH diet plus exercise and weight loss on blood pressure in overweight patients with high blood pressure
To examine the effects of lifestyle modifications on cardiovascular manifestations of high blood pressure
Study population
Overweight but otherwise generally healthy adults with above-optimal blood pressureInclusion criteria– Age > 35 years– BMI 25-40 kg/m2– Sedentary (not engaged in regular exercise)– BP 130-159/85-99 mmHg
Exclusion criteria– Treatment with antihypertensive medication– Secondary hypertension– Cardiac disease, diabetes, or chronic kidney disease
Interventions
Subjects were randomized to one of three interventions for 16 weeks:– DASH diet alone
2-week feeding period plus weekly group sessions
Diet designed to maintain weight
– DASH diet plus behavioral weight management programDASH diet plus weekly sessions to implement cognitive behavioral weight loss program
Supervised exercise three times weekly
– Usual Care
Outcome measures
Primary outcome measure– Resting blood pressure
Secondary outcome measure– Ambulatory blood pressure– Vascular stiffness (pulse wave velocity)– Endothelial function (flow-mediated dilation)– Left ventricular mass (echocardiography)
Baseline characteristicsBaseline characteristics
DASH + WM
N=49
DASH Alone
N = 46
Usual Care
N = 49
Age (years) 52.3 (10) 51.8 (10) 52.0 (10)
Gender: Female (%) 69 63 69
Ethnicity: Caucasian (%) 69 50 59
BMI (kg/m2) 33.5 (4.4) 32.8 (3.4) 33.0 (3.9)
Systolic BP (mmHg) 139 (8) 138 (9) 138 (10)
Diastolic BP (mmHg) 86 (7) 86 (6) 86 (6)
Values are mean (SD) unless otherwise specified
Subject retention and adherence
Drop-outs: 4– 3 in DASH + WM– 1 in Usual Care
DASH dietary class attendance: 92%
Exercise session attendance: 90%
Dietary IntakeDietary Intake
DASH + WM
N=49
DASH Alone
N = 46
Usual Care
N = 49
Fruit servings/day 4.0 3.7 2.6
Vegetable servings/day 5.5 5.6 2.6
Dairy servings/day 1.8 1.9 0.9
% Fat calories 26 28 37
Calorie (kcal) 1648 1962 2095
Values are medians unless otherwise specified
Weight Adjusted means after treatment
170
180
190
200
210
220
230
DASH + WM DASH Alone Usual Care
lbs
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p < .001
Aerobic Capacity Adjusted means after treatment
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p < .001
20
21
22
23
24
25
26
27
28
29
30
DASH + WM DASH Alone Usual Care
ml/k
g/m
inut
e
6
7
8
9
10
11
12
13
14
15
16
DASH + WM DASH Alone Usual Care
Min
utes
Peak VO2Treadmill Time
Resting Blood PressureAdjusted means after treatment
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p = .023
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p = .048
115
120
125
130
135
140
145
DASH + WM DASH Alone Usual Care
mm
Hg
70
75
80
85
90
DASH + WM DASH Alone Usual Care
mm
Hg
Systolic Diastolic
Resting Blood PressureChange in Blood Pressure from Baseline
-4
-8
-10
-3
-11
-16
-20 -15 -10 -5 0 5
UsualCare
DASHAlone
DASH +WM
Change in BP (mmHg)
Systolic BP
Diastolic BP
Ambulatory Blood PressureAdjusted Means After Treatment
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p = .012
Treatment v Usual Care: p < .001DASH + WM v DASH Alone: p = .026
115
120
125
130
135
140
145
DASH + WM DASH Alone Usual Care
mm
Hg
70
75
80
85
90
DASH + WM DASH Alone Usual Care
mm
Hg
Systolic Diastolic
Vascular stiffness and endothelial function Adjusted Means After Treatment
Treatment v Usual Care: p = .002DASH + WM v DASH Alone: p = .033
Treatment v Usual Care: p < .059DASH + WM v DASH Alone: p = .989
5
6
7
8
9
DASH + WM DASH Alone Usual Care
m/s
Pulse Wave Velocity Flow-Mediated Dilation
1
2
3
4
5
6
DASH + WM DASH Alone Usual Care
%
Left ventricular mass index Adjusted Means After Treatment
Treatment v Usual Care: p = .202DASH + WM v DASH Alone: p = .016
34
36
38
40
42
44
DASH + WM DASH Alone Usual Care
g/m
**2.
7
Conclusions
In our study of overweight patients with high blood pressure,– The DASH diet resulted in significant blood pressure
lowering– Exercise and weight loss in addition to the DASH
diet resulted in an incremental decrease in blood pressure, as well as greater improvements in cardiovascular manifestations of high blood pressure
Additional slides
Resting Blood PressurePairwise Group Differences After Treatment
-20
-15
-10
-5
0
5
(DASH + WM) -Usual Care
DASH Alone -Usual Care
(DASH + WM) -DASH Alone
mm
Hg
-10
-8
-6
-4
-2
0
2
(DASH + WM) -Usual Care
DASH Alone -Usual Care
(DASH + WM) -DASH Alone
mm
Hg
Systolic Diastolic
Autonomic Function Adjusted Means After Treatment
3
4
5
6
7
8
DASH + WM DASH Alone Usual Care
mse
c/m
mH
g
Baroreflex Sensitivity
Treatment v Usual Care: p = .216DASH + WM v DASH Alone: p = .047
Glucose MetabolismGlucose Metabolism80
100
120
140
160
18
0Glucose Tolerance Test
Minutes
mg/
dL 135
134
113
8790
92
0 30 60 90 120
DASH + WMDASH AloneUsual Care
115
120
125
130
135
140
145
mm
Hg
Scrn PostFeed After Treatment
DASH + Behavioral Wgt. LossDASH AloneUsual Care
Resting Systolic Blood Pressure
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