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Published in final edited form as:Arch Intern Med. 2010 January 25; 170(2): 126–135. doi:10.1001/archinternmed.2009.470.

Effects of the DASH Diet Alone and in Combination With
Exercise and Weight Loss on Blood Pressure andCardiovascular Biomarkers in Men and Women With High Blood
Pressure: The ENCORE StudyJames A. Blumenthal, PhD, Michael A. Babyak, PhD, Alan Hinderliter, MD, Lana L. Watkins,
PhD, Linda Craighead, PhD, Pao-Hwa Lin, PhD, Carla Caccia, RD, Julie Johnson, PA-C,
Robert Waugh, MD, and Andrew Sherwood, PhD
From the Department of Psychiatry and Behavioral Sciences (JAB, AS, MAB, LW, CC, JJ), theDepartment of Medicine (PL, RW), the Department of Psychology (LC), Emory University, and theDepartment of Medicine (AH), University of North Carolina

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Abstract
Background—Although the DASH (Dietary Approaches to Stop Hypertension) diet has beenshown to lower blood pressure (BP) in short-term feeding studies, it has not been shown to lower
BP among free-living individuals, nor has it been shown to alter cardiovascular biomarkers of risk.
Objective—To compare the DASH diet alone or combined with a weight management programwith usual diet controls among participants with prehypertension or stage 1 hypertension (systolic
BP, 130–159 mm Hg; or diastolic BP, 85–99 mm Hg).
Design and Setting—Randomized, controlled trial in a tertiary care medical center withassessments at baseline and 4 months. Enrollment began October 29, 2003, and ended July 28,
2008.
Participants—Overweight or obese, unmedicated outpatients with high BP (N = 144).
Interventions—Usual diet controls, DASH diet alone, and DASH diet plus weight management.

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Outcome Measures—The main outcome measure is BP measured in the clinic and byambulatory BP monitoring. Secondary outcomes included pulse wave velocity, flow-mediateddilation of the brachial artery, baroreflex sensitivity, and left ventricular mass.
Results—Clinic-measured BP was reduced by 16.1/9.9 mm Hg (DASH plus weight
management); 11.2/7.5 mm (DASH alone); and 3.4/3.8 mm (usual diet controls) (P < .001). A
similar pattern was observed for ambulatory BP (P < .05). Greater improvement was noted for
DASH plus weight management compared with DASH alone for pulse wave velocity, baroreflex
sensitivity, and left ventricular mass (all P < .05).
Conclusion—For overweight or obese persons with above-normal BP, the addition of exercise
and weight loss to the DASH diet resulted in even larger BP reductions, greater improvements invascular and autonomic function, and reduced left ventricular mass. Key words: Hypertension,
Exercise, DASH diet, Blood pressure, Left ventricular mass

Corresponding author: James A. Blumenthal, Ph.D., Department of Psychiatry and Behavioral Sciences, Box 3119, Duke University
Medical Center, Durham, NC 27710 Tele: (919) 684-3828; Fax: (919) 684-8629; Blume003@mc.duke.edu.

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Page 2INTRODUCTION
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The seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC-7)1 recommends that lifestyle modifications
should be the initial treatment strategy for lowering blood pressure (BP). In addition to
advocating weight reduction, physical activity, dietary sodium reduction, and moderation of
alcohol consumption, as recommended by earlier guidelines,2 JNC-7 endorses the DASH
(Dietary Approaches to Stop Hypertension) diet for patients with elevated BP. Evidence
supporting the efficacy of this diet comes primarily from the DASH feeding trials, in whicha diet high in low-fat dairy products, fruits, and vegetables; lower in fats; and rich in fiber
significantly lowered clinic-measured BP with or without sodium reduction.3–5 The
PREMIER study6 subsequently demonstrated that the “established”(JNC-6) lifestylemodifications and lifestyle modifications plus the DASH diet (JNC-7) were associated withlarger BP reductions compared with “advice only” controls; however, the BP differences
between the JNC-7 recommendations and the previously established (JNC-6) treatment
recommendations were small (<1 mm Hg) and not statistically significant. Therefore,
although the DASH diet has been shown to lower BP in short-term feeding studies, it has notbeen shown to lower BP independent of other lifestyle changes among free-living
individuals. Because the clinical significance of high BP is derived from morbid events thatare not directly caused by elevated BP, but rather the associated structural and functionalchanges in the heart and blood vessels, we also examined changes in cardiovascularbiomarkers of risk.

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METHODS
Participants
The sample consisted of healthy, but overweight, men and women with above-normal BP.
Persons were eligible for study inclusion if they were not taking antihypertensive medicationand had a mean systolic BP (SBP) of 130 to 159 or diastolic BP (DBP) of 85 to 99 mm Hg
based on 4 screening visits. Other inclusion criteria included age 35 years or older, bodymass index of 25 to 40 (calculated as weight in kilograms divided by height in meterssquared), being sedentary, having no other medical comorbidities that would preclude safe
participation in the trial, and use of any medications known to affect the cardiovascularsystem.
Trial Overview

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The ENCORE (Exercise and Nutrition interventions for CardiOvasculaR hEalth) study wasapproved by the Institutional Review Board at Duke University Medical Center. Written
informed consent was obtained from all participants.
Enrollment began October 29, 2003, and ended July 28, 2008. Participants were recruitedfrom physician referrals, community-based screenings, and mass media advertisements.
Eligibility was established during a series of screening visits that included a medical history
and physical examination, measurement of height and weight, and determination of baseline
clinic-measured BP. Following completion of baseline assessments, participants wererandomized to the DASH diet alone (DASH-A), the DASH diet combined with a behavioral
weight management program (DASH-WM), or to the usual diet control (UC) group. At theend of the 4-month treatment period, assessments were repeated.
Assessments
Clinic-Measured BP—Clinic-measured BP was determined according to JNC-7
guidelines. Potential participants were asked to refrain from smoking or ingesting caffeine

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for at least 30 minutes before their appointment time. Measurements were standardized forcuff size, position, environment, and time of day. After 5 minutes of quiet rest, 4 seated BP
readings, each 2 minutes apart, were obtained using a standard mercury sphygmomanometerand stethoscope. We also obtained simultaneous automated BP recordings using an Accutorr
Plus BP monitor (Datascope, Mahwah, New Jersey)7 to provide an objective secondary
approach to clinic BP measurement. This clinic BP measurement protocol was repeated on 4
screening sessions over a 3 to 4 week period.
Ambulatory BP Monitoring—To assess BP during a typical day, participants wore an
Accutracker II (Suntech Medical Inc, Raleigh, North Carolina) ambulatory BP monitor.8
The Accutracker was programmed to record BP measurements 4 times per hour throughout
the waking hours and 2 times per hour during sleep. The mean BP during the entire 24-hourmonitoring period, adjusted for posture, was used for the primary analysis.
Pulse Wave Velocity—Pulse wave velocity (PWV), measured using the Complior device(Artech Medical, Pantin, France), was used as an index of central artery stiffness.9 Pulse
pressure waveforms were recorded from the right carotid and right femoral arteries, andPWV (meters per second) was calculated from measurements of pulse transit time (inseconds) and the distance (in meters) traveled by the pulse between the 2 recording sites.

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Flow-Mediated Dilation—Brachial artery flow-mediated dilation (FMD) was assessedfollowing overnight fasting.10 Longitudinal B-mode ultrasonographic images of the brachialartery, 4- to 6-cm proximal to the antecubital crease, were obtained using an Aspen
ultrasound platform with an 11-MHz linear array transducer (Acuson, Mountain View,
California). Images were obtained after 10 minutes of supine relaxation and during reactive
hyperemia, induced by inflating a forearm occlusion cuff to suprasystolic pressure(approximately 200 mm Hg) for 5 minutes. End-diastolic arterial diameters were measured
as the distance between the proximal and distal arterial wall intima-media interfaces using
PC-based software (Brachial Analyzer, version 4.0; Medical Imaging Applications LLC,
Iowa City, Iowa). Flow-mediated dilation was defined as the maximum percentage change
in arterial diameter relative to resting baseline from 10 to 120 seconds after deflation of theocclusion cuff.

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Baroreflex Sensitivity—Beat-by-beat SBP and heart rate (HR) were collected using the
Finapres noninvasive BP monitor (model 2300; Ohmeda, Madison, Wisconsin). Recordingsof beat-by-beat SBP and R-R interval (derived as 60 000/HR) were edited for artifacts,
linearly interpolated, and resampled at a frequency of 4 Hz to generate an equally spaced
time series. A fast Fourier transform was then applied to the interpolated data after
detrending and application of a Hanning filtering window. Baroreflex sensitivity (BRS) was
estimated from the magnitude of the transfer function relating R-R interval oscillations to
SBP oscillations across the 0.07 to 0.1299 Hz, or low-frequency, band. Coherence between
SBP and R-R interval oscillations was required to be at least 0.5 for measurements to be
accepted as estimates of BRS.
Left Ventricular Mass Index—Two-dimensional echocardiograms were acquired using
an Aspen imaging system and stored in a digital format for subsequent quantification by asingle observer (A.H.) who was blinded to treatment group. Left ventricular (LV) enddiastolic diameter, posterior wall thickness, and interventricular septal thickness were
measured at end-diastole, using a leading edge–to–leading edge convention. Left ventricularmass was estimated using a cube function model with a correction factor.11 To adjust forvariations in heart size owing to differences in body size, the LV mass index was calculated
as LV mass divided by height2.7 as described by de Simone et al.12

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Nutritional and Weight Assessment—An independent assessment of dietary andnutritional content was obtained by 2 separate self-report measures of diet: a retrospective
food frequency questionnaire13 requiring participants to recall typical consumption during a
4-week period and a 4-day food diary. The food frequency questionnaire was analyzed by
NutritionQuest (Berkeley, California), and the diary data were analyzed using Food
Processor SQL Edition software, version 10.3 (ESHA Research, Salem, Oregon).14 In
addition, sodium, calcium, and potassium intake were estimated from urinary excretion
during a 24-hour period.15 Body weight was determined by a calibrated digital scale(Detecto; Cardinal Scale Manufacturing Co, Webb City, Missouri).
Cardiorespiratory Fitness—Participants underwent a maximal graded exercise treadmill
test in which workloads were increased at a rate of 1 metabolic equivalent per minute.16
Expired air was collected by mouthpiece for quantification of minute ventilation, oxygen
consumption, and carbon dioxide production with the Parvo Medics TrueOne measurement
system (model 2400; Parvo Medics, Sandy, Utah).

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Randomization—On completion of the baseline assessments, participants wererandomized in groups of 2 to 5 participants using a computer program. The size of the group
was determined by how many eligible participants were available to be randomized within 4
weeks of their baseline BP assessments. Participants were provided their treatment groupassignments in sealed envelopes; staff members performing the assessments were unawareof the group assignments. Assignments were stratified by clinic-measured BP, body massindex, and age.
Interventions—Immediately following randomization, participants entered a 2-weekcontrolled feeding period in which they ate according to the assigned dietary patterns(control diet, DASH diet, or a reduced-calorie DASH diet). For the UC and DASH-A arms,
participants consumed study meals isocalorically so they would not gain or lose weight,
whereas participants in the DASH-WM arm consumed meals at a 500-calories-per-day
deficit to allow weight loss of about 1 pound a week. During the controlled feeding period,
body weight was measured every other day to monitor participants’ weight stability or loss,
allowing for adjustments in caloric intake. In addition, participants who were assigned to
DASH-A or DASH-WM met with the nutritionist twice weekly for instruction about the
DASH pattern. A 7-day menu cycle from the DASH-Sodium study for each dietary pattern
at each of the 1600, 2100, 2600, 3100, and 3600 kcal energy levels was used as the basis forthe recommended diets.17 We based caloric intake on the Harris Benedict formula, using
screening weights and estimated physical activity levels derived from the Seven-Day
Physical Activity Recall survey.18

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The control diet contained 34% of calories from fat (the average level for Americans basedon the National Health and Nutrition Examination Survey Phase III19 data), whereas
potassium, magnesium, calcium, and fiber levels were set at approximately the 25th
percentile for average American intakes. Protein accounted for 15% of calories in thecontrol diet and 18% in the DASH diet. The DASH diet is reduced in total fat (27%),saturated fat (6%), and cholesterol and contains about 3 times as much dietary fiber,
potassium, magnesium, and calcium as the control diet. Because severe sodium restriction
made a relatively small difference for those on the DASH diet,5 we used the current national
recommended level (2400 mg/d per 2000 kcal). Following the initial 2 weeks of controlled
feeding, participants were instructed to maintain the DASH diet on their own with (DASHWM) or without (DASH-A) weight loss.

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DASH Diet Alone—Participants in the DASH-A condition only received instruction inmodifying the content of their diet to meet DASH guidelines. Participants in this group were
explicitly asked not to exercise or to attempt to lose weight and to focus their attention only
on what they ate. Participants received counseling on the DASH diet and were provided
feedback on their adherence to the diet in weekly 30- to 45-minute small group sessions led
by the study nutritionist. The goal of the weekly sessions was to assist participants inlearning how to buy and prepare the appropriate foods, to enhance their motivation tochoose to eat those foods, and to overcome obstacles to following the diet. Participants also
were weighed each week to monitor their weight and to make adjustments in therecommended servings so that their weight would remain stable during the intervention
period.
DASH Diet Plus Weight Management—Participants in the DASH-WM condition
received the same instruction in the DASH diet as the DASH-A group, but their weekly 30to 45-minute small group sessions also included a weekly cognitive-behavioral weight loss
intervention and they attended supervised exercise sessions 3 times per week.

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Cognitive-Behavioral Weight Loss—This intervention was based on cognitivebehavioral strategies20 and included Appetite Awareness Training,21 a self-monitoring
strategy in which individuals learn to identify internal cues of moderate hunger and fullness
and to use these cues to guide their eating behavior. The DASH recommendations were used
to provide guidance regarding what to eat, whereas cognitive-behavioral strategies were
designed to help individuals learn when/how to eat.
Supervised Exercise—Participants had supervised exercise sessions 3 times per week at
a level of 70% to 85% of their initial heart rate reserve determined at the time of the baseline
treadmill test. The supervised exercise routine consisted of 10 minutes of warm-up
exercises, 30 minutes of biking and/or walking or jogging, and 5 minutes of cool-down
exercises.
Usual Diet Controls—Participants in the UC condition were asked to maintain their usual
dietary and exercise habits for 4 months until they were reevaluated. On a biweekly basis,
their weight and BP were monitored and their health habits were assessed to ensure that they
had not joined any exercise or weight-loss program and had maintained their body weight.
Statistical Analysis

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The effect of treatment on the primary and secondary outcomes was evaluated using thegeneral linear model function in SAS statistical software, version 9.1 (SAS Institute, Cary,
North Carolina). Separate models were estimated for each outcome. The predictors in eachmodel were 2 indicator variables carrying the orthogonal contrasts (DASH-WM and DASHA vs UC and DASH-WM vs DASH-A) and the corresponding pretreatment value of theoutcome, age, sex, and ethnicity (white vs nonwhite). We also adjusted for posture in theanalysis of ambulatory BP and for arterial diameter at rest in the FMD analysis. With respect
to changes in aerobic capacity, exercise endurance, and weight-related variables, where
DASH-WM was expected a priori to differ from the other 2 groups, we used 2 planned
contrasts: DASH-WM vs DASH-A and DASH-WM vs UC. Data for all outcomes wereanalyzed following the intent-to-treat principle, with missing data managed using themultiple imputation method available in SAS PROC MI. We estimated that we would haveabout 80% power to detect a 0.5-SD difference between the active treatments and UC and a
0.6-SD difference between the 2 active treatments.

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Page 6RESULTS
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Participant Flow—Of the 3129 participants who initially inquired about the study, 449(32.1) met our initial inclusion criteria. After screening, 144 participants (32.2%) wererandomized: 49 to the DASH-WM condition (34.0%); 46 to DASH-A (31.9%); and 49 toUC (34.0%) (Figure 1).
Participant Characteristics—The mean age of the sample was 52 years; 38.9% ofparticipants were African American, and 67.4% were women; the mean clinic-measured BP
was 138/86 mm Hg. Most participants were college-educated and relatively affluent. The
groups were generally comparable across the background variables (Table 1).
Attendance at Diet and Exercise Sessions—Attendance at the exercise and dietclasses was excellent. Of the 42 expected exercise sessions, the median number attended
was 38 sessions (90%). The median percentage time spent in the target HR range during
exercise was 94%. The DASH class attendance also was excellent; for both intervention
groups, the median number of sessions attended was 12 (92%).

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Changes in Body Weight—Adjusting for initial weight, age, sex, and ethnicity, themean posttreatment weight for the DASH-WM group was significantly lower (84.5 kg)
compared with the DASH-A (92.9 kg; P <.001) and UC (94.1 kg; P <.001) groups. The
weight change was −8.7 kg in the DASH-WM group, −0.3 kg in the DASH-A group, and0.9 kg in the UC group.
Changes in Dietary Intake and Urinary Excretion—Participants in the 2 DASH
treatment conditions showed excellent adherence to the DASH guidelines compared withthose randomized to UC (Table 2). Participants in the DASH-WM condition also consumed
significantly fewer total calories, less total protein, and fewer carbohydrates compared withthose in DASH-A.
Compared with UC, DASH-WM resulted in significantly lower urinary sodium levels andhigher urinary potassium excretion (P < .01) (Table 3). The DASH-WM and DASH-A
participants did not differ on any of the urinary excretion measures.

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Changes in Aerobic Fitness—The DASH-WM group exhibited greater improvementsin peak V O2 (oxygen consumption) and exercise endurance compared with the DASH-A
and UC groups. Adjusting for pretreatment levels, age, sex, and ethnicity, the mean
posttreatment peak V O2 was higher among the DASH-WM participants (29 mL/kg/min)compared with those randomized to the DASH-A (23 mL/kg/min; P <.001) or UC (22 mL/
kg/min; P <.001) condition. Participants in the DASH-WM group showed a 19% increase inpeak V O2 compared with negligible changes for participants in the DASH-A (−1.2%) andUC (−3.2%) conditions.
Primary End Points
Blood Pressure—Compared with UC, the active treatments significantly lowered SBP (P< .001) and DBP (P < .001) (Figure 2). In addition, compared with DASH-A, the DASHWM intervention resulted in significantly lower SBP (P = .02) and DBP (P < .048).
Expressed as adjusted change from pretreatment to posttreatment, the reduction in SBP was
16.1 (95% confidence interval, 13.0–19.2) mm Hg in the DASH-WM group, 11.2 (8.1–14.3)mm Hg in the DASH-A group, and 3.4 (0.4–6.4) mm Hg in the UC group; the reduction in
DBP was 9.9 (8.1–11.6) mm Hg in the DASH-WM group, 7.5 (5.8–9.3) mm Hg in the
DASH-A group, and 3.8 (2.2–5.5) mm Hg in the UC group. The contrast between active
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treatments (DASH-A and DASH-WM) and UC also was significant for machine-read SBP(P < .001) and DBP (P < .001); in addition, the machine-read BP values were lower for the
DASH-WM group compared with the DASH-A group for SBP (P = .01) and DBP (P = .06).
Moreover, at the end of treatment, 19 (38.8%) UC group participants were classified as
hypertensive (clinic BP >140/90 mm Hg) compared with only 6 (12.2%) in the DASH-WM
and 7 (15.2%) in the DASH-A groups.
Eighteen participants had missing or inadequate ambulatory BP readings either at baselineor posttreatment. These missing assessments were imputed using a multiple imputation
model. Compared with the UC group, participants in the active treatment groups had
significantly lower ambulatory SBP and DBP (P < .001) (Figure 3). Ambulatory BPs werelower in the DASH-WM group compared with the DASH-A group for SBP (P = .01) andDBP (P = .03). Expressed as adjusted change from pretreatment to posttreatment, thereductions in ambulatory BP were: DASH-WM group, 10.2 (95% confidence interval, 6.8 to13.6)/5.4 (3.4 to 7.4) mm Hg; DASH-A group, 5.3 (2.0 to 8.6)/2.9 (1.0 to 4.9) mm Hg; andUC group, 0.2 (3.4 to 7.4)/0.003 (−1.8 to 1.9) mm Hg.

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Cardiovascular Biomarkers—The 2 DASH diet interventions resulted in lower PWV
compared with the UC group (P = .001), and PWV was lower in the DASH-WM groupcompared with the DASH-A group (P = .045) (Figure 4). The 2 DASH treatment groups
also tended to exhibit larger improvements in FMD than the UC group (P = .06), but they
did not differ from one another (P = .99). For BRS, posttreatment results in the active
treatment groups were not different than those in the UC group (P = .38); however, greater
improvements were seen in DASH-WM compared with DASH-A (P = .01). The active
treatment groups had lower posttreatment values for LV mass index compared with the UC
group, but this difference was not significant (P = .26); however, the DASH-WM
intervention resulted in lower LV mass than did DASH-A (P = .02).

DISCUSSION

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Results of this randomized controlled trial demonstrate that the DASH diet produces
significant reductions in BP compared with a typical American diet among unmedicated,
overweight or obese men and women with high BP and that weight loss and exercise
combined with the DASH diet produce additional BP lowering. Compared with UC, weobserved a 12.5/5.9 mm Hg net benefit in clinic-measured BP with the DASH-WM program
consisting of aerobic exercise, caloric restriction, and cognitive-behavioral intervention anda 7.7/3.6 mm Hg net benefit with DASH-A. These findings confirm the value of the DASH
diet in reducing BP and provide evidence for the significant “added value” associated with
exercise and weight loss in the context of the DASH diet.
The efficacy of the DASH diet initially was established on the basis of several controlled
feeding trials designed to examine the effects of dietary patterns on BP among unmedicatedpersons with higher-than-optimal DBP or with stage 1 hypertension; as a result of thesestudies, the DASH diet was adopted as part of current national recommendations for theprevention and treatment of high BP.1 The subsequent PREMIER study6 demonstrated thefeasibility of implementing the DASH diet in daily life, but the small and nonsignificant BP
differences between the DASH diet and the “established” intervention (which also involved
some dietary changes) raised doubts about the added value of the DASH diet in optimizing
BP. Because participants in the DASH plus “established” intervention lost more weight thanthe “established” intervention alone, the effects of the DASH diet could not be determined.
The ENCORE trial has now extended the PREMIER study by not only examining the extent
to which lifestyle modifications can be adopted in the home environment but also by
manipulating the DASH diet intervention and weight loss independently. Our results

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confirm the findings of the earlier DASH feeding studies: participants who ate the DASH
diet achieved significant BP reductions.3–5 However, adding exercise and weight loss led toan even greater decrease in BP.
The BP reductions achieved in our DASH-A and DASH-WM interventions were greaterthan those described in the PREMIER study and in other trials of lifestyle modification.22–24
The reasons for the greater benefit from the current ENCORE intervention could be
attributed to the greater weight loss and excellent adherence to the DASH diet and exercise
sessions. The 12/6 mm Hg relative reduction in BP that we observed among participants
randomized to DASH-WM is equivalent to the BP lowering that physicians could expectfrom a high dose of an antihypertensive drug.25 Similar BP reductions have been achievedin placebo-controlled treatment trials and have resulted in a lowering of stroke risk byapproximately 40% and a reduction in ischemic heart disease events by about 25%.26

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In addition to BP lowering, we demonstrated improvements in important cardiovascularbiomarkers. One of the structural consequences of high BP, left ventricular hypertrophy(LVH), is the strongest known predictor, other than advancing age, of cardiovascularmorbidity and mortality. Increased LV mass predicts these clinical outcomes inhypertensive27 and healthy individuals,28 independent of other conventional risk factors.
Drug therapy that results in LVH regression29 is associated with improved cardiovascularoutcomes. For example, Verdecchia et al30 found a lower risk of cardiovascular events in
hypertensive participants who had a decrease in LV mass during treatment, independent ofbaseline BP or the degree of BP reduction. Similarly, in a substudy of the Losartan
Intervention of Endpoint Reduction in Hypertension (LIFE) trial, lowered LV mass was
associated with decreased rates of cardiovascular events.31
Arterial stiffness also has been shown to be a strong independent predictor of cardiovascularmorbidity and mortality.32–35 The DASH-A and the DASH-WM interventions resulted ingreater reductions in PWV than did UC, with more pronounced reductions among the
DASH-WM participants. Dietary sodium intake was reduced by approximately 30%
compared with UC, and participants in the DASH-WM group achieved a 19% improvement
in aerobic capacity, which may have augmented the benefits of the DASH diet and weightloss on arterial stiffness. The observed reductions in PWV may be a result of the direct
impact of diet and exercise as well as the lower BP resulting from these lifestyle changes. A
reduction in arterial stiffness may also contribute to regression of LVH. The Ohasama study
showed that arterial stiffness measured by PWV was related to LVH, independent of age andBP, in a population of 798 older adults.36 Ongoing trials should help clarify whether
reducing arterial stiffness contributes to a lowered risk for cardiovascular events.37

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Impairment of the sensitivity of the baroreflex system is an early consequence ofhypertension38– 41 and likely reflects reduced viscoelastic properties of the vascular wall
housing the baroafferent stretch receptors owing to arterial stiffness andatherosclerosis.42– 44 The DASH-A intervention did not alter BRS, but DASH-WM
improved BRS by 33%. The improvements in BRS may result from reduced vascular
stiffness45– 47 or improved parasympathetic cardiac control through improved insulin
sensitivity and glucose metabolism secondary to exercise and weight loss.48
The present study is limited by its relatively small sample of highly motivated participants
along with a labor-intensive treatment program that may be difficult to fully implement inclinical practice. The ENCORE study was not powered to detect differences in “hard”
clinical end points, such as stroke, myocardial infarction, and death. Trials of pharmacologic
therapy, however, demonstrate that BP lowering reduces the risk of cardiovascular eventsand that the magnitude of BP reduction and reversal of cardiovascular structural changes

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associated with hypertension are key determinants of the effectiveness of therapy.49
Ultimately, the effects of the DASH diet and weight management will need to be evaluatedprospectively in a larger sample of participants; longer-term follow-up of ENCORE study
participants is currently ongoing. The present findings suggest that the DASH diet,particularly when augmented by exercise and weight loss, can offer considerable benefit topatients with high BP, not only through reductions in BP but through favorable modificationof biomarkers of disease risk.

Acknowledgments
This study was supported by grant HL074103 from the National Heart, Lung, and Blood Institute; grant M01RR-30 from the General Clinical Research Center; grant 5UL1RR024128-03 from the National Center for Research
Resources; and the National Institutes of Health Roadmap for Medical Research.
The contents of this study are solely the responsibility of the authors and do not necessarily represent the official
view of the National Center for Research Resources or the National Institutes of Health.

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The following ENCORE research staff members assisted with this trial: Lara LaCaille, PhD; Krista Barbour, PhD;
Teresa Edenfield, PhD; Emily York-Crowe, PhD; Deborah Sebring, PhD; Marquisha Green, MA; Jennifer
Jawanda, MA; Simon Bacon, PhD; Elizabeth Gullette, PhD; Steve Taxman, PA-C; Mark Feinglos, MD; Eugene
Oddone, MD; Emily Ballard, BS; Beth Polisson, BA; Brian Beckman, BA; Katie Earnhardt, BA; Catherine Wu,
BA; Kylie Stott, MA; Emily Hill, MA; Laura Jost, BA; Elizabeth Brenner, BS; Mark Taylor, MA; Jessica Tucker,
MA; Sandra Kennedy, MA; Brad Gregory, MA; Jessica Hawkins, MA; Michael Ellis, BA; Susan Rohn, MA; andElise Pangborn, MA. The data and safety monitoring board members are Mark Appelbaum, PhD; David Sheps,
MD; and David Krantz, PhD. We thank the participants in this trial for their commitment to the trial and for theircontribution to this research.

References

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Figure 1.

Participant flow in the ENCORE (Exercise and Nutrition interventions for CardiOvasculaR
hEalth) clinical trial. BMI indicates body mass index (calculated as weight in kilograms
divided by height in meters squared); BP, blood pressure; DASH, Dietary Approaches toStop Hypertension; and ITT, intent-to-treat.

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Figure 2.

Comparison of posttreatment means and 95% confidence intervals for clinic-measured bloodpressure (BP) using an intent-to-treat model, adjusted for age, sex, ethnicity, andpretreatment BP. The contrasts between all active treatment groups and the usual dietcontrol (UC) group were significant for both systolic (A) and diastolic (B) BP (P < .001), as
were the contrasts between DASH-WM (Dietary Approaches to Stop Hypertension plus
weight management) vs DASH-A (DASH alone) for systolic BP (P = .02) and diastolic BP(P = .048). The right panels display the pairwise differences (mean difference and 95%
confidence interval) between the treatment groups calculated from the adjusted
posttreatment means.

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Figure 3.

Comparison of posttreatment means and 95% confidence intervals for 24-hour ambulatory
blood pressure (BP) using an intent-to-treat model, adjusted for age, sex, ethnicity,
percentage of time in sitting or standing position, and pretreatment BP. The contrast between
all active treatment groups and the usual diet control (UC) group was significant for systolic(A) and diastolic (B) BP (P < .001), as were the contrasts between DASH-WM (Dietary
Approaches to Stop Hypertension plus weight management) vs DASH-A (DASH alone) for
systolic BP (P = .01) and diastolic BP (P = .03). The right panels display the pairwise
differences (mean difference and 95% confidence intervals) between the treatment groups
calculated from the adjusted posttreatment means.

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Figure 4.

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Comparison of posttreatment mean (95% confidence interval) values for pulse wave velocity(A), flow-mediated dilation (B), baroreflex sensitivity (C), and left ventricular (LV) massindex (D) by treatment group, adjusted for age, sex, ethnicity, and pretreatment level of
response variable. Flow-mediated dilation of the brachial artery also was adjusted for
pretreatment arterial diameter at rest. Results of contrasts were as follows: for pulse wave
velocity (A), all treatments vs usual diet controls (UC), P = .002, and DASH-WM (Dietary
Approaches to Stop Hypertension plus weight management) vs DASH-A (DASH alone), P= .045; for flow-mediated dilation (B), all treatments vs UC, P = .06, and DASH-WM vsDASH-A, P = .99; for baroreflex sensitivity (C), all treatments vs UC, P = .38, and DASHWM vs DASH-A, P = .01; and for left ventricular mass index (D), all treatments vs UC, P= .26, and DASH-WM vs DASH-A, P = .02.

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NIH-PA Author Manuscript
12% (6)

Other

Arch Intern Med. Author manuscript; available in PMC 2013 April 23.
14% (7)
6% (3)
55% (27)93.9 (14)

144
144
144
144
138
138
144
144
144

$20–50K$50–99K> $100K

Weight (kg), m (SD)BMI (kg/m2), m (SD)Clinic SBP (mmHg), m (SD)Clinic DBP (mmHg), m (SD)

Ambulatory SBP (mmHg), m (SD)

Ambulatory DBP (mmHg), m (SD)Diabetes

Hyperlipidemia

Arthritis

29% (14)33% (16)

2% (1)

79.8 (8.2)

134.3 (12.0)

85.5 (6.8)

138.7 (8.2)

33.5 (4.4)

10% (5)< $20K

123

20% (10)

Post-Graduate School

Annual Household Income

29% (14)Completed College

143

Level of Education

8% (4)

4% (2)

144

Hispanic

Some College

0% (0)

Asian

31% (15)31% (15)High School

69% (34)

144

Ethnicity

69% (34)

African American

144

Gender: Female

52.3 (10)Weight Loss + DASH N=49

Caucasian144

N

Age (years), m (SD)NIH-PA Author Manuscript

Background Characteristics of Sample

13% (6)22% (10)0% (0)

81.6 (8.8)

136.7 (12.5)

86.1 (6.1)

137.6 (9.0)

32.8 (3.4)

93.0 (14)

50% (23)

13% (6)

4% (2)

13% (6)13% (6)28% (13)30% (14)9% (4)

30% (14)2% (1)

48% (22)

50% (23)

63% (29)51.8 (10)DASH Alone N = 46

22% (11)33% (16)

0% (0)

82.7 (7.9)

139.6 (11.6)

85.6 (5.8)

138.0 (9.5)

33.0 (3.9)

92.6 (15)43% (21)18% (9)8% (4)

20% (10)2% (1)

20% (10)18% (9)14% (7)42% (20)

6% (3)

2% (1)

39% (19)

59% (29)

69% (34)51.8 (9)Control N = 49

22% (31)29% (42)< 1% (1)81.3 (8.3)

136.9 (12.1)

85.8 (6.2)

138.1 (8.8)

33.1 (3.9)

93.1 (14.1)

49% (71)

15% (18)

11% (13)

15% (21)9% (13)24% (34)22% (32)

11% (15)34% (49)3% (5)

1% (2)

39% (86)

60% (56)67% (97)52.0 (10)All N = 144

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Table 1
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1648
1521–1774
80
74–86
19.5
18.7–20.4
232
214–250
56.0
54.4–58.2
49
42–56
26.3
24.7–27.9
14
12–17
198
162–234
25
22–27
1990
1772–2208
3476
3217–3735
363
333–3941023
914–11321390
1284–1491

Calories, kcal

Protein, g% Protein Calories

Carbohydrates, g% Carb. Calories

Fat, g% Fat Calories

Saturated Fat, gDietary Cholesterol, mg

Fiber, g

Sodium, mg

Potassium, mg

Magnesium, mg

Calcium, Mg

Phosphorous, mg

Weight Loss + DASHArch Intern Med. Author manuscript; available in PMC 2013 April 23.
1632
1529–1735

1175
1065–1284

432
393–4544047
3785–4309

2044
1825–2262

26
24–29

256
220–293

18
15–20

27.8
26.1–29.4

60
53–67

53.8
51.9–55.7

266
247–284

19.4
18.6–20.3

95
89–1001962
1833–2090

DASH Alone

1361
1254–1467

861
750–972282
251–3132637
2370–2903

2922
2698–3146

16
14–19

346
309–384

29
26–31

36.8
35.1–38.6

87
79–94

46.4
44.5–48.4

241
222–259

16.7
15.9–17.6

87
81–93

2095
1961–2228

Usual Care.023

< .001< .001< .001< .001< .001< .001< .001< .001< .001< .001.475< .001.776< .001

Active Treatments vs. Usual Care< .001

.058

.008

.003

.734

.349

.023

.058

.215

.028

.071

.011

.797

< .001< .001

Weight Loss + DASH vs. DASH Alone

Daily dietary intake after treatment, adjusted for age, gender, ethnicity, and pretreatment level of outcome

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Table 2Blumenthal et al.
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113.7
97.1–130.4
71.1
63.5–78.6
783
698–868138
116–161
1.3
1.2–1.4
9.2
8.3–10.0

Sodium (mmol/day)

Potassium (mmol/day)Phosphorous (mg/day)

Calcium (mg/day)

Creatinine (g/day)Urea nitrogen (g/day)Weight Loss + DASH

10.2
9.3–10.1

1.3
1.2–1.4

167
144–189860
775–945

74.9
67.3–82.5

125
108.4–141.5

DASH

10.1
8.3–9.9

1.3
1.2–1.5

155
133–177813
731–895

52.9
45.6–60.3

145
129.3–161.3

Usual Care

.270

.599

.868

.866

.001

.010

Active Treatments vs. Usual Care

.095

.987

.216

.087

.488

.355

Weight Loss + DASH vs. DASH Alone

Urinary excretion after treatment, adjusted for age, gender, ethnicity, and pretreatment level of outcome

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Table 3Blumenthal et al.
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