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Background: Excess adiposity and dietary factors may be important determinants of urinary albumin excretion (UAE)., Study Design: Observational analysis of PREMIER, a randomized trial designed to lower blood pressure using behavioral interventions (counseling on weight loss, healthy diet, and exercise)., Setting & Participants: 481 participants with normal kidney function who provided adequate 24-hour urine collections at baseline and 6 months., Predictors: Change in waist circumference; 24-hour urine sodium, potassium, and phosphorus excretion; and protein intake estimated from urea nitrogen., Outcomes & Measurements: The primary outcome was change in log-transformed 24-hour UAE over 6 months., Results: After 6 months, the proportion of individuals with UAE ≥10 mg/d decreased from 18.7% to 12.7% (P < 0.001). Changes in mean waist circumference (-4.2 ± 6.6 [SD] cm), 24-hour excretion of sodium (-28.2 ± 71.7 mmol/d), potassium (+8.4 ± 27.8 mmol/d), phosphorus (-27.7 ± 314.1 mg/d), and protein intake (-1.7 ± 19.4 g/d) were observed. After adjustment for relevant covariates, the following variables were associated significantly with reduction in ln(UAE) in separate models: decrease in waist circumference (P = 0.001), decrease in 24-hour urine phosphorus excretion (P < 0.001), and decrease in protein intake (P = 0.01). In a multivariable model including these 3 predictors, decreases in waist circumference (P = 0.002) and 24-hour urine phosphorus excretion (P = 0.03), but not change in protein intake (P = 0.5), remained associated significantly with reduction in ln(UAE). These associations remained significant even after adjustment for changes in blood pressure and insulin resistance. Baseline UAE and metabolic syndrome modified the relationship of waist circumference with ln(UAE); specifically, individuals with higher UAE and baseline metabolic syndrome experienced greater reductions in ln(UAE) from decreases in waist circumference., Limitations: Observational study with potential for confounding., Conclusions: In adults with normal kidney function, decreases in waist circumference and 24-hour urine phosphorus excretion are associated with reductions in UAE. These findings support the rationale for clinical trials to determine whether reducing dietary phosphorus intake or waist circumference could prevent chronic kidney disease or slow its progression., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Essential hypertension results from the interaction of several genetic and environmental factors. Identification of genetic factors that modulate blood pressure (BP) response to interventions can lead to improved strategies for prevention and control. The purpose of this study was to identify genes that modulate BP response to dietary interventions., Methods: We used data and samples collected in two randomized feeding studies to determine the extent to which genetic architecture is associated with the effect on BP of sodium intake and the Dietary Approaches to Stop Hypertension (DASH) dietary pattern. Participants in both trials were adults with above-optimal BP or unmedicated stage 1 hypertension. Genomic DNA was typed for several candidate genes., Results: The effect of sodium intake on BP differed by genotype at the angiotensinogen, β2-adrenergic receptor, and kallikrein loci. The effect of DASH dietary pattern on BP differed by genotype at the β2-adrenergic receptor locus., Conclusions: These findings have implications for understanding the mechanism(s) through which diet affects BP, the heterogeneity of these effects, and the extent to which dietary interventions can modulate genetic predisposition.

Objectives: To examine whether participants with the most behavioral goals to achieve were more likely to meet more goals than those given fewer goals., Methods: Eight hundred ten participants were randomly assigned to advice-only, established guidelines for blood pressure control (reduced sodium, increased physical activity), or established guidelines plus the DASH diet (increased fruits, vegetables, low-fat dairy, reduced fat)., Results: At 6 months, 11.7% of Advice-Only, 19.3% of Established, and 44.6% of Established plus DASH met at least 3 goals (P<0.0001). At 18 months, 33.5% of Established plus DASH met at least 3 goals., Conclusions: Those with the most goals to achieve reached the most goals.

Background: Dietary studies designed to decrease the urinary albumin excretion rate (AER) typically reduce protein by increasing lower protein plant foods and decreasing higher protein animal products., Study Design: We evaluated AER while increasing protein intake in the Dietary Approaches to Stop Hypertension (DASH) Trial (randomized, parallel group, 8 week controlled feeding)., Setting & Participants: 378 individuals without diabetes with prehypertension or stage I hypertension., Intervention: The DASH diet, 18% energy from protein, emphasizes, among other features, low-fat dairy products; and the fruit/vegetable (FV) and control diets, each with 15% energy from protein., Outcome: AER., Measurements: We measured AER by using immunoassay and covariates at baseline and after 8 weeks., Results: Baseline AER had a geometric mean value of 4.0 +/- 0.2 (SE) mg/24 h. In 285 participants with baseline AER less than 7 mg/24 h, AER was unchanged by diet treatment (geometric mean, 2.5 +/- 0.2 mg/24 h in the control diet, 3.0 +/- 0.2 mg/24 h in the FV diet, and 2.8 +/- 0.2 mg/24 h in the DASH diet). Conversely, in 93 participants with baseline AER of 7 mg/24 h or greater, end-of-feeding AER was lower in the FV diet (6.6 +/- 1.0 mg/24 h) than in the control (11.4 +/- 1.8 mg/24 h; P = 0.01) or DASH diets (11.7 +/- 1.6 mg/24 h; P = 0.005). The DASH and control diets were not different (P = 0.9)., Limitations: Long-term AER change not studied., Conclusions: The decrease in AER after 8 weeks occurred in only those with high-normal baseline AER in the FV diet, in a pattern distinct from the blood pressure decrease. The DASH diet did not increase AER despite a 3% increase in energy from protein.

Objective: Examine the acceptability of sodium-reduced research diets., Design: Randomized crossover trial of three sodium levels for 30 days each among participants randomly assigned to one of two dietary patterns., Participants/setting: Three hundred fifty-four adults with prehypertension or stage 1 hypertension who were participants in the Dietary Approaches to Stop Hypertension (DASH-Sodium) outpatient feeding trial., Intervention: Participants received their assigned diet (control or DASH, rich in fruits, vegetables, and low-fat dairy products), each at three levels of sodium (higher, intermediate, and lower) corresponding to 3,500, 2,300, and 1,200 mg/day (150, 100, and 50 mmol/day) per 2,100 kcal., Main Outcome Measures: Nine-item questionnaire on liking and willingness to continue the assigned diet and its level of saltiness using a nine-point scale, ranging from one to nine., Statistical Analyses Performed: Generalized estimating equations to test participant ratings as a function of sodium level and diet while adjusting for site, feeding cohort, carryover effects, and ratings during run-in., Results: Overall, participants rated the saltiness of the intermediate level sodium as most acceptable (DASH group: 5.5 for intermediate vs 4.5 and 4.4 for higher and lower sodium; control group: 5.7 for intermediate vs 4.9 and 4.7 for higher and lower sodium) and rated liking and willing to continue the DASH diet more than the control diet by about one point (ratings range from 5.6 to 6.6 for DASH diet and 5.2 to 6.1 for control diet). Small race differences were observed in sodium and diet acceptability., Conclusions: Both the intermediate and lower sodium levels of each diet are at least as acceptable as the higher sodium level in persons with or at risk for hypertension.

Objectives: To assess contributions of individual lifestyle changes on systolic blood pressure (SBP) changes., Methods: We examined associations between lifestyle behavior changes and SBP after 6 and 18 months in 782 PREMIER trial participants., Results: In multivariate models omitting weight, predicted SBP reductions ranged from (1)/2 to 1(1)/2 mm Hg for reduced urinary sodium, improved fitness, and adherence to the DASH diet (except sodium at 18 months). With weight included, only fitness change additionally predicted SBP at 18 months., Conclusions: Several lifestyle behavior changes are important for BP lowering, but are difficult to detect when weight is included in multivariate models.

Background: The main 6-month results from the PREMIER trial showed that comprehensive behavioral intervention programs improve lifestyle behaviors and lower blood pressure., Objective: To compare the 18-month effects of 2 multicomponent behavioral interventions versus advice only on hypertension status, lifestyle changes, and blood pressure., Design: Multicenter, 3-arm, randomized trial conducted from January 2000 through November 2002., Setting: 4 clinical centers and a coordinating center., Patients: 810 adult volunteers with prehypertension or stage 1 hypertension (systolic blood pressure, 120 to 159 mm Hg; diastolic blood pressure, 80 to 95 mm Hg)., Interventions: A multicomponent behavioral intervention that implemented long-established recommendations ("established"); a multicomponent behavioral intervention that implemented the established recommendations plus the Dietary Approaches to Stop Hypertension (DASH) diet ("established plus DASH"); and advice only., Measurements: Lifestyle variables and blood pressure status. Follow-up for blood pressure measurement at 18 months was 94%., Results: Compared with advice only, both behavioral interventions statistically significantly reduced weight, fat intake, and sodium intake. The established plus DASH intervention also statistically significantly increased fruit, vegetable, dairy, fiber, and mineral intakes. Relative to the advice only group, the odds ratios for hypertension at 18 months were 0.83 (95% CI, 0.67 to 1.04) for the established group and 0.77 (CI, 0.62 to 0.97) for the established plus DASH group. Although reductions in absolute blood pressure at 18 months were greater for participants in the established and the established plus DASH groups than for the advice only group, the differences were not statistically significant., Limitations: The exclusion criteria and the volunteer nature of this cohort may limit generalizability. Although blood pressure is a well-accepted risk factor for cardiovascular disease, the authors were not able to assess intervention effects on clinical cardiovascular events in this limited time and with this sample size., Conclusions: Over 18 months, persons with prehypertension and stage 1 hypertension can sustain multiple lifestyle modifications that improve control of blood pressure and could reduce the risk for chronic disease.

High blood pressure (also called hypertension) is one of the most important and common risk factors for atherosclerotic cardiovascular disease (CVD) and other chronic diseases. National guidelines recommend that all individuals with blood pressure readings of 120/80 mm Hg or higher adopt healthy lifestyle habits, including the Dietary Approaches to Stop Hypertension (DASH) diet, to manage their blood pressure. The DASH diet, which is high in fruits, vegetables, and low-fat dairy products and reduced in fat, has been shown in large, randomized, controlled trials to reduce blood pressure significantly. The DASH diet also has been shown to reduce blood cholesterol and homocysteine levels and to enhance the benefits of antihypertensive drug therapy. The DASH diet should be promoted, along with maintaining healthy weight, reducing sodium intake, increasing regular physical activity, and limiting alcohol intake, for lowering blood pressure and reducing the risk of CVD.

Although group characteristics are known to influence average blood pressure response to changes in salt intake, predictability of individual responses is less clear. We examined variability and consistency of individual systolic blood pressure responses to changes in salt intake in 188 participants who ate the same diet at higher, medium, and lower (140, 104, 62 mmol/d) sodium levels for 30 days each, in random order, after 2 weeks of run-in at the higher sodium level. Regarding variability in systolic blood pressure changes over time, changes from run-in to higher sodium (no sodium level change) ranged from -24 to +25 mm Hg; 8.0% of participants decreased > or =10 mm Hg. Regarding variability in systolic blood pressure response to change in sodium intake, with higher versus lower sodium levels (78-mmol sodium difference), the range of systolic blood pressure change was -32 to +17 mm Hg; 33.5% decreased > or =10 mm Hg. Regarding consistency of response, systolic blood pressure change with run-in versus lower sodium was modestly correlated with systolic blood pressure change with higher versus medium sodium; systolic blood pressure change with higher versus lower sodium was similarly correlated with run-in versus medium sodium (combined Spearman r=0.27, P=0.002). These results show low-order consistency of response and confirm that identifying individuals as sodium responders is difficult. They support current recommendations for lower salt intake directed at the general public rather than "susceptible" individuals as one of several strategies to prevent and control adverse blood pressures widely prevalent in the adult population.

Background: Previous estimates of the population-wide impact of nonpharmacologic interventions that lower blood pressure (BP) have typically assumed a uniform response to the intervention. However, several nonpharmacologic interventions reduce BP to a greater degree in hypertensives and African-Americans., Methods: We used the Framingham risk equation and data from the Third National Health and Nutrition Examination Survey (NHANES III) to estimate the number of coronary heart disease (CHD) events that would be prevented in the United States assuming a population-wide adoption of the DASH (Dietary Approaches to Stop Hypertension) diet under three scenarios: (1) an overall uniform systolic blood pressure (SBP) shift, (2) race-specific uniform SBP shifts, and (3) race-specific progressive SBP shifts. The uniform shifts were the mean SBP reductions from the DASH trial. The progressive shifts were derived by modeling the change in SBP as a function of baseline SBP in DASH., Results: Applying an overall uniform SBP reduction of 5.5 mm Hg (the mean reduction in DASH), we predicted a reduction of 668,426 CHD events over 10 years (60,230 in African-Americans and 608,196 in whites). Applying race-specific uniform SBP reductions (6.8 mm Hg for African-Americans and 3.0 mm Hg for whites), we predicted a reduction of 406,432 CHD events (74,401 in African-Americans and 332,031 in whites). After accounting for race and baseline SBP, we predicted a reduction of 416,514 CHD events (94,828 in African-Americans and 321,080 in whites). While whites would be expected to have a greater absolute reduction in CHD events, African-Americans would be expected to experience a greater relative reduction in CHD events., Conclusion: Models that estimate the population-wide impact of BP reduction strategies should take into account the baseline distribution of BP and differential effects in subgroups. Population-wide adoption of a healthy dietary pattern should have a substantial impact on the incidence of CHD in the United States, especially among African-Americans. Additional studies are needed to assess the impact of the DASH diet on CHD risk in free-living subjects.

Purpose: To describe PREMIER, a randomized trial to determine the effects of multi-component lifestyle interventions on blood pressure (BP)., Methods: Participants with above optimal BP through stage 1 hypertension were randomized to: 1) a behavioral lifestyle (BLS) intervention that implements established recommendations, 2) a BLS intervention that implements established recommendations plus the DASH diet, or 3) an advice only standard of care group. The two BLS interventions consist of group and individual counseling sessions for 18 months. The primary outcome is systolic BP at 6 months. Additional outcomes include diastolic BP and homocysteine at 6 months; systolic and diastolic BP at 18 months; fasting lipids, glucose and insulin at 6 and 18 months; and effects in subgroup., Conclusion: Results from the PREMIER trial will provide scientific rationale for implementing multi-component behavioral lifestyle intervention programs to control BP and prevent CVD.

Context: Weight loss, sodium reduction, increased physical activity, and limited alcohol intake are established recommendations that reduce blood pressure (BP). The Dietary Approaches to Stop Hypertension (DASH) diet also lowers BP. To date, no trial has evaluated the effects of simultaneously implementing these lifestyle recommendations., Objective: To determine the effect on BP of 2 multicomponent, behavioral interventions., Design, Setting, and Participants: Randomized trial with enrollment at 4 clinical centers (January 2000-June 2001) among 810 adults (mean [SD] age, 50 [8.9] years; 62% women; 34% African American) with above-optimal BP, including stage 1 hypertension (120-159 mm Hg systolic and 80-95 mm Hg diastolic), and who were not taking antihypertensive medications., Intervention: Participants were randomized to one of 3 intervention groups: (1) "established," a behavioral intervention that implemented established recommendations (n = 268); (2) "established plus DASH,"which also implemented the DASH diet (n = 269); and (3) an "advice only" comparison group (n = 273)., Main Outcome Measures: Blood pressure measurement and hypertension status at 6 months., Results: Both behavioral interventions significantly reduced weight, improved fitness, and lowered sodium intake. The established plus DASH intervention also increased fruit, vegetable, and dairy intake. Across the groups, gradients in BP and hypertensive status were evident. After subtracting change in advice only, the mean net reduction in systolic BP was 3.7 mm Hg (P<.001) in the established group and 4.3 mm Hg (P<.001) in the established plus DASH group; the systolic BP difference between the established and established plus DASH groups was 0.6 mm Hg (P =.43). Compared with the baseline hypertension prevalence of 38%, the prevalence at 6 months was 26% in the advice only group, 17% in the established group (P =.01 compared with the advice only group), and 12% in the established plus DASH group (P<.001 compared with the advice only group; P =.12 compared with the established group). The prevalence of optimal BP (<120 mm Hg systolic and <80 mm Hg diastolic) was 19% in the advice only group, 30% in the established group (P =.005 compared with the advice only group), and 35% in the established plus DASH group (P<.001 compared with the advice only group; P =.24 compared with the established group)., Conclusion: Individuals with above-optimal BP, including stage 1 hypertension, can make multiple lifestyle changes that lower BP and reduce their cardiovascular disease risk.

Abstract Results from the recent Dietary Approaches to Stop Hypertension (DASH)-Sodium trial provide the latest evidence concerning the effects of dietary patterns and sodium intake on blood pressure. Participants ate either the DASH diet (high in fruits, vegetables and low-fat dairy products, and reduced in saturated and total fat) or a typical US diet. Within each diet arm, participants ate higher, intermediate, and lower sodium levels, each for 30 days. The results indicated lower blood pressure with lower sodium intake for both diet groups. Although some critics would argue otherwise, these findings provide important new evidence for the value of the DASH diet and sodium reduction in controlling blood pressure.

Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction and often co-exists with cardiovascular disease (CVD), hypertension and diabetes. This international study assessed the association between airflow obstruction and these comorbidities. 23,623 participants (47.5% males, 19.0% current smokers, age: 55.1 ± 10.8 years) in 33 centers in the Burden of Obstructive Lung Disease (BOLD) initiative were included. 10.4% of subjects had airflow obstruction. Self-reports of physician-diagnosed CVD (heart disease or stroke), hypertension and diabetes were regressed against airflow obstruction (post-bronchodilator FEV1/FVC < 5th percentile of reference values), adjusting for age, sex, smoking (including pack-years), body mass index and education. Analyses were undertaken within center and meta-analyzed across centers checking heterogeneity using the I2-statistic. Crude odds ratios for the association with airflow obstruction were 1.42 (95% CI: 1.20–1.69) for CVD, 1.24 (1.02–1.51) for hypertension, and 0.93 (0.76–1.15) for diabetes. After adjustment these were 1.00 (0.86–1.16) (I2:6%) for CVD, 1.14 (0.99–1.31) (I2:53%) for hypertension, and 0.76 (0.64–0.89) (I2:1%) for diabetes with similar results for men and women, smokers and nonsmokers, in richer and poorer centers. Alternatively defining airflow obstruction by FEV1/FVC < 2.5th percentile or 0.70, did not yield significant other results. In conclusion, the associations of CVD and hypertension with airflow obstruction in the general population are largely explained by age and smoking habits. The adjusted risk for diabetes is lower in subjects with airflow obstruction. These findings emphasize the role of common risk factors in explaining the coexistence of cardio-metabolic comorbidities and COPD. [ABSTRACT FROM AUTHOR]

Objective To determine the effect of age on weight loss and weight loss maintenance in participants in the Weight Loss Maintenance trial (WLM). Design and Methods Secondary analysis of a randomized controlled trial of overweight/obese adults with CVD risk factors was conducted. Participants were 1685 adults with baseline BMI 25-45 kg m2 with hypertension and/or dyslipidemia. Those who lost at least 4kg in an initial 6-month behavioral weight loss intervention ( N = 1,032) were randomly assigned to a 30-month maintenance phase of self-directed control (SD), monthly personal counseling (PC), or unlimited access to an internet-based intervention (IT). Age groups were defined post-hoc and weight change was compared among age groups. Results Participants ≥60 years old initially lost more weight than younger individuals, and sustained greater weight loss in IT and PC but not in SD ( P value for trend 0.024, 0.002, and 0.36, respectively). Conclusions In WLM, adults age ≥60 years had greater initial weight loss and greater sustained weight loss over 3 years, compared to younger adults. Older adults had greater weight loss maintenance with either personal counseling or internet-based intervention. Future research should determine optimal implementation strategies and effects of weight loss on health outcomes in older adults. [ABSTRACT FROM AUTHOR]

Objective: We have previously shown that racial composition of behavioral intervention groups does not affect achieved weight loss. However, it is unclear if the race of the interventionist affects intervention outcomes. The objective of this analysis is to estimate the impact of race concordance between participant and interventionist on weight change in the initial weight loss phase (phase I) of the Weight Loss Maintenance trial (WLM). Design and Methods: A total of 1,685 overweight or obese adults (BMI 25-45 kg/m2) who were taking medication for hypertension and/or dyslipidemia participated in phase I of the WLM trial. All participants received a 6-month intensive behavioral intervention in groups of 15-20 facilitated by a trained interventionist. The main outcome is change in weight at 6 months. Results: Participants were on average 55 years of age, 67% female and 44% African American (AA). Three of seventeen interventionists were AA, 14 were non-AA. Seventy-three percent of participants shared race concordance with the interventionist. There was a small but statistically significant difference in weight change of participants who were the same race as the interventionist (−5.84 kg, s.e. 0.17) as compared with those who were not race concordant (−5.04 kg, s.e. 0.33), a difference of 0.8 kg, ( P = 0.04). The impact of concordance on weight change differed by race (i.e., interaction of race and concordance was significant, P = 0.02). Conclusions: In a post hoc analysis of a group-based behavioral intervention, race concordance for non-AA participants was associated with slightly greater weight loss. Race concordance was not associated with weight loss for AA participants. [ABSTRACT FROM AUTHOR]

The article provides information on the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER) randomized clinical trial. A total of 810 healthy adults with prehypertension participated in the study in which they were randomly divided into three groups. Based on the results, the researchers concluded that lifestyle changes can be achieved and continued over 18 months which can lead to improved hypertension control.

Presents information on a study that summarized the recruitment of participants for the Dietary Approaches to Stop Hypertension (DASH) trial. Information on the participants of the study; Details on the methods of the study; Description of the results.

Background: The effect of dietary composition on blood pressure is a subject of public health importance. We studied the effect of different levels of dietary sodium, in conjunction with the Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in vegetables, fruits, and low-fat dairy products, in persons with and in those without hypertension. Methods: 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. Within the assigned diet, participants ate foods with high, intermediate, and low levels of sodium for 30 consecutive days each, in random order. Results: Reducing the sodium intake from the high to the intermediate level reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet and by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the intermediate to the low level caused additional reductions of 4.6 mm Hg during the control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The effects of sodium were observed in participants with and in those without hypertension, blacks and those of other races, and women and men. The DASH diet was associated with a significantly lower systolic blood pressure at each sodium level; and the difference was greater with high sodium levels than with low ones. As compared with the control diet with a high sodium level, the DASH diet with a low sodium level led to a mean systolic blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5 mm Hg lower in participants with hypertension. Conclusions: The reduction of sodium intake to levels below the current recommendation of 100 mmol per day and the DASH diet both lower blood pressure substantially, with greater effects in combination than singly. Long-term health benefits will depend on the ability of people to make long-lasting dietary changes and the increased availability of lower-sodium foods. (N Engl J Med 2001;344:3-10.) [ABSTRACT FROM AUTHOR]