Research Article| Volume 56, ISSUE 6, P819-826, June 2019

Dietary Approaches to Stop Hypertension Diet Concordance and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis


      In observational studies, the association between the Dietary Approaches to Stop Hypertension (DASH) diet and incident heart failure has been inconsistent. It was hypothesized that higher DASH diet concordance has a protective effect on heart failure in a multi-ethnic cohort.


      The Multi-Ethnic Study of Atherosclerosis cohort includes men and women of multiple ethnicities who were aged 45–84 years and free of clinical cardiovascular disease at baseline. Participants were recruited between 2000 and 2002 from six U.S. communities and followed for incident cardiovascular health events through 2015 for the purpose of this data set. Diet was measured using food-frequency questionnaires. Cox proportional hazards analysis was used to investigate the associations of the DASH diet concordance with incident heart failure in 2017–2018.


      During a median 13 years of follow-up, 179 of 4,478 participants developed heart failure, corresponding to a rate of 3.4 per 1,000 person years. Heart failure incidence rates did not vary significantly by DASH quintile for the population as a whole. In participants younger than 75 years, highest DASH concordance was associated with a lower risk of incident heart failure compared with those in the lowest quintile (hazard ratio=0.4, 95% CI=0.2, 0.9 vs all participants hazard ratio=1.0, 95% CI=0.2, 0.9) after adjusting for demographics, energy consumption, and known cardiovascular confounders.


      This study supports the hypothesis that DASH is beneficial in heart failure prevention within the individuals aged less than 75 years subgroup, an idea that to date was substantiated only by much smaller studies or in less diverse patient populations.
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        • National Heart, Lung, and Blood Institute, NIH
        Your Guide to Lowering Your Blood Pressure With DASH.
        HHS, Rockville, MD2006
        • Appel LJ
        • Champagne CM
        • Harsha DW
        • et al.
        Effects of comprehensive lifestyle modification on blood pressure: control main results of the PREMIER clinical trial.
        JAMA. 2003; 289: 2083-2093
        • Appel LJ
        • Moore TJ
        • Obarzanek E
        • et al.
        A clinical trial of the effects of dietary patterns on blood pressure.
        N Engl J Med. 1997; 336: 1117-1124
        • Sacks FM
        • Svetkey LP
        • Vollmer WM
        • 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: 3-10
        • Eckel RH
        • Jakicic JM
        • Ard JD
        • et al.
        2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (vol 129, pg S76, 2014).
        Circulation. 2015; 131: E326
        • He J
        • Ogden LG
        • Bazzano LA
        • Vupputuri S
        • Loria C
        • Whelton PK
        Risk factors for congestive heart failure in U.S. men and women: NHANES I epidemiologic follow-up study.
        Arch Intern Med. 2001; 161: 996-1002
        • Levy D
        • Larson MG
        • Vasan RS
        • Kannel WB
        • Ho KKL
        The progression from hypertension to congestive heart failure.
        JAMA. 1996; 275: 1557-1562
        • Fung TT
        • Chiuve SE
        • McCullough ML
        • Rexrode KM
        • Logroscino G
        • Hu FB
        Adherence to a DASH-Style diet and risk of coronary heart disease and stroke in women.
        Arch Intern Med. 2008; 168: 713-720
        • Levitan EB
        • Wolk A
        • Mittleman MA
        Consistency with the DASH diet and incidence of heart failure.
        Arch Intern Med. 2009; 169: 851-857
        • Levitan EB
        • Wolk A
        • Mittleman MA
        Relation of consistency with the Dietary Approaches to Stop Hypertension diet and incidence of heart failure in men aged 45 to 79 years.
        Am J Cardiol. 2009; 104: 1416-1420
        • Del Gobbo LC
        • Kalantarian S
        • Imamura F
        • et al.
        Contribution of major lifestyle risk factors for incident heart failure in older adults: the Cardiovascular Health Study.
        JACC Heart Fail. 2015; 3: 520-528
        • Nguyen HT
        • Bertoni AG
        • Nettleton JA
        • Bluemke DA
        • Levitan EB
        • Burke GL
        DASH eating pattern is associated with favorable left ventricular function in the Multi-Ethnic Study of Atherosclerosis.
        J Am Coll Nutr. 2012; 31: 401-407
        • Seliger SL
        • Hong SN
        • Christenson RH
        • et al.
        High-sensitive cardiac troponin T as an early biochemical signature for clinical and subclinical heart failure: MESA (Multi-Ethnic Study of Atherosclerosis).
        Circulation. 2017; 135: 1494-1505
        • Nettleton JA
        • Steffen LM
        • Mayer-Davis EJ
        • et al.
        Dietary patterns are associated with biochemical markers of inflammation and endothelial activation in the Multi-Ethnic Study of Atherosclerosis (MESA).
        Am J Clin Nutr. 2006; 83: 1369-1379
        • Wagenknecht LE
        • Mayer EJ
        • Rewers M
        • et al.
        The Insulin Resistance Atherosclerosis Study (IRAS) objectives, design, and recruitment results.
        Ann Epidemiol. 1995; 5: 464-472
        • Mayer-Davis EJ
        • Vitolins MZ
        • Carmichael SL
        • et al.
        Validity and reproducibility of a food frequency interview in a multi-cultural epidemiologic study.
        Ann Epidemiol. 1999; 9: 314-324
        • Natori S
        • Lai SH
        • Finn JP
        • et al.
        Cardiovascular function in Multi-Ethnic Study of Atherosclerosis: normal values by age, sex, and ethnicity.
        AJR Am J Roentgenol. 2006; 186: S357-S365
        • Chahal H
        • Bluemke DA
        • Wu CO
        • et al.
        Heart failure risk prediction in the Multi-Ethnic Study of Atherosclerosis.
        Heart. 2015; 101: 58-64
        • Bertoni AG
        • Whitt-Glover MC
        • Chung HJ
        The association between physical activity and subclinical atherosclerosis.
        Am J Epidemiol. 2009; 169: 444-454
        • Bahrarni H
        • Kronmal R
        • Bluemke DA
        • et al.
        Differences in the incidence of congestive heart failure by ethnicity: the Multi-Ethnic Study of Atherosclerosis.
        Arch Intern Med. 2008; 168: 2138-2145
        • Hummel SL
        • Seymour EM
        • Brook RD
        • et al.
        Low-sodium DASH diet improves diastolic function and ventricular-arterial coupling in hypertensive heart failure with preserved ejection fraction.
        Circ Heart Fail. 2013; 6: 1165-1171
        • Nettleton JA
        • Steffen LM
        • Loehr LR
        • Rosamond WD
        • Folsom AR
        Incident heart failure is associated with lower whole-grain intake and greater high-fat dairy and egg intake in the Atherosclerosis Risk in Communities (ARIC) Study.
        J Am Diet Assoc. 2008; 108: 1881-1887
        • Tektonidis TG
        • Akesson A
        • Gigante B
        • Wolk A
        • Larsson SC
        A Mediterranean diet and risk of myocardial infarction, heart failure and stroke: a population-based cohort study.
        Atherosclerosis. 2015; 243: 93-98
        • Wirth J
        • di Giuseppe R
        • Boeing H
        • Weikert C
        A Mediterranean-style diet, its components and the risk of heart failure: a prospective population-based study in a non-Mediterranean country.
        Eur J Clin Nutr. 2016; 70: 1015-1021
        • Soedamah-Muthu SS
        • Ding EL
        • Al-Delaimy WK
        • et al.
        Milk and dairy consumption and incidence of cardiovascular diseases and all-cause mortality: dose-response meta-analysis of prospective cohort studies.
        Am J Clin Nutr. 2011; 93: 158-171
        • Drouin-Chartier JP
        • Gigleux I
        • Tremblay AJ
        • Poirier L
        • Lamarche B
        • Couture P
        Impact of dairy consumption on essential hypertension: a clinical study.
        Nutr J. 2014; 13: 83
        • Shah P
        • Maxwell K
        • Shapiro J
        Dashing away hypertension: evaluating the efficacy of the Dietary Approaches to Stop Hypertension diet in controlling high blood pressure.
        World J Hypertens. 2015; 5: 119-128
        • Soltani S
        • Chitsazi M
        • Salehi-Abargouei A
        The effect of Dietary Approaches to Stop Hypertension (DASH) on serum inflammatory markers: a systematic review and meta-analysis of randomized trials.
        Clin Nutr. 2018; 37: 542-550
        • Kritchevsky SB
        • Cesari M
        • Pahor M
        Inflammatory markers and cardiovascular health in older adults.
        Cardiovasc Res. 2005; 66: 265-275
        • Cesari M
        • Penninx B
        • Newman AB
        • et al.
        Inflammatory markers and cardiovascular disease (The Health, Aging and Body Composition Health ABC Study).
        Am J Cardiol. 2003; 92: 522-528