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DOI: 10.1161/01.HYP.0000202568.01167.B6
2006;47;296-308 Hypertension
Elmer and Frank M. Sacks
Lawrence J. Appel, Michael W. Brands, Stephen R. Daniels, Njeri Karanja, Patricia J.
From the American Heart Association
Dietary Approaches to Prevent and Treat Hypertension: A Scientific Statement
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Dietary Approaches to Prevent and Treat Hypertension
A Scientific Statement From the American Heart Association
Lawrence J. Appel, MD, MPH; Michael W. Brands, PhD; Stephen R. Daniels, MD, PhD;
Njeri Karanja, PhD; Patricia J. Elmer, PhD; Frank M. Sacks, MD
Abstract—A substantial body of evidence strongly supports the concept that multiple dietary factors affect blood pressure
(BP). Well-established dietary modifications that lower BP are reduced salt intake, weight loss, and moderation of
alcohol consumption (among those who drink). Over the past decade, increased potassium intake and consumption of
dietary patterns based on the “DASH diet” have emerged as effective strategies that also lower BP. Of substantial public
health relevance are findings related to blacks and older individuals. Specifically, blacks are especially sensitive to the
BP-lowering effects of reduced salt intake, increased potassium intake, and the DASH diet. Furthermore, it is well
documented that older individuals, a group at high risk for BP-related cardiovascular and renal diseases, can make and
sustain dietary changes. The risk of cardiovascular disease increases progressively throughout the range of BP,
beginning at 115/75 mm Hg. In view of the continuing epidemic of BP-related diseases and the increasing prevalence
of hypertension, efforts to reduce BP in both nonhypertensive and hypertensive individuals are warranted. In
nonhypertensive individuals, dietary changes can lower BP and prevent hypertension. In uncomplicated stage I
hypertension (systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg), dietary changes serve as initial
treatment before drug therapy. In those hypertensive patients already on drug therapy, lifestyle modifications,
particularly a reduced salt intake, can further lower BP. The current challenge to healthcare providers, researchers,
government officials, and the general public is developing and implementing effective clinical and public health
strategies that lead to sustained dietary changes among individuals and more broadly among whole populations.
(Hypertension. 2006;47:296-308.)
Key Words: AHA Scientific Statements � blood pressure � diet � hypertension
Elevated blood pressure (BP) remains an extraordinarilycommon and important risk factor for cardiovascular and
renal diseases, including stroke, coronary heart disease, heart
failure, and kidney failure. According to the most recent
NHANES survey (1999 to 2000), 27% of adult Americans
have hypertension (systolic BP �140 mm Hg, diastolic BP
�90 mm Hg, or use of antihypertensive medication), and
another 31% have prehypertension (systolic BP of 120 to
139 mm Hg or diastolic BP of 80 to 89 mm Hg, not on
medication).1 Prehypertensive individuals have a high prob-
ability of developing hypertension and carry an excess risk of
cardiovascular disease as compared with those with a normal
BP (systolic BP �120 mm Hg and diastolic BP
�80 mm Hg).2 It has been estimated that among adults �50
years of age, the lifetime risk of developing hypertension
approaches 90%.3 Recent data indicate that the prevalence of
hypertension is increasing4 and that control rates among those
with hypertension remain low.5 On average, blacks have
higher BP than nonblacks,4 as well as an increased risk of
BP-related complications, particularly stroke6,7 and kidney
failure.8
BP is a strong, consistent, continuous, independent, and
etiologically relevant risk factor for cardiovascular and renal
disease.9 Notably, no evidence of a BP threshold exists; ie,
the risk of cardiovascular disease increases progressively
throughout the range of BP, including the prehypertensive
range.10 It has been estimated that almost a third of BP-related
deaths from coronary heart disease occur in individuals with
BP in the nonhypertensive range.11
Elevated BP results from environmental factors, genetic
factors, and interactions among these factors. Of the environ-
mental factors that affect BP (diet, physical inactivity, toxins,
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on November 4, 2005. A single reprint
is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX
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© 2006 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org DOI: 10.1161/01.HYP.0000202568.01167.B6
296
AHA Scientific Statement
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and psychosocial factors), dietary factors have a prominent,
and likely predominant, role in BP homeostasis. In nonhy-
pertensive individuals, including those with prehypertension,
dietary changes that lower BP have the potential to prevent
hypertension and more broadly to reduce BP and thereby
lower the risk of BP-related clinical complications. Indeed,
even an apparently small reduction in BP, if applied to an
entire population, could have an enormous beneficial impact.
For instance, it has been estimated that a 3–mm Hg reduction
in systolic BP could lead to an 8% reduction in stroke
mortality and a 5% reduction in mortality from coronary heart
disease (see Figure 1).12 In uncomplicated stage I hyperten-
sion (systolic BP of 140 to 159 mm Hg or diastolic BP of 90
to 99 mm Hg), dietary changes can serve as initial treatment
before the start of drug therapy. Among hypertensive indi-
viduals who are already on drug therapy, dietary changes,
particularly a reduced salt intake, can further lower BP and
facilitate medication step-down. In general, the extent of BP
reduction from dietary therapies is greater in hypertensive
than in nonhypertensive individuals.
The purpose of this scientific statement, which updates
prior AHA recommendations,13 is to summarize evidence on
the efficacy of diet-related factors that lower BP and to
present recommendations for healthcare providers, policy
makers, and the general public. This document relies primar-
ily on evidence as compiled in systematic reviews. Individual
studies that document seminal findings are also discussed.
Recommendations in this document are broadly consistent
with those expressed in federal policy documents.9,14
Dietary Factors That Lower BP
See Table 1 for a summary of diet-related lifestyle modifica-
tions that effectively lower BP.
Weight Loss
A substantial and largely consistent body of evidence from
observational studies and clinical trials documents that
weight is directly associated with BP. The importance of this
relationship is reinforced by the high and increasing preva-
lence of overweight and obesity in the United States and
throughout the world. Approximately 65% of US adults have
a body mass index (BMI) �25 kg/m2 and therefore are
classified as either overweight or obese; �30% of US adults
are clinically obese (BMI �30 kg/m2).15 In US children and
adolescents, the prevalence of overweight has increased over
the past decade, as have levels of BP.16
With rare exception, clinical trials have documented that
weight loss lowers BP. Importantly, reductions in BP occur
before, and without, attainment of a desirable body weight. In
one meta-analysis that aggregated results across 25 trials,
mean systolic and diastolic BP reductions from an average
weight loss of 5.1 kg were 4.4 and 3.6 mm Hg, respectively.17
In subgroup analyses, BP reductions were similar for nonhy-
pertensive and hypertensive subjects but were greater in those
who lost more weight. Within-trial dose–response analy-
ses18,19 and prospective observational studies20 also document
that greater weight loss leads to greater BP reduction.
Additional trials have documented that modest weight loss,
with or without sodium reduction, can prevent hypertension
by �20% among overweight, prehypertensive individuals21
and can facilitate medication step-down and drug withdraw-
al.22,23 Lifestyle intervention trials have uniformly achieved
short-term weight loss, primarily through a reduction in total
caloric intake. In several instances, substantial weight loss
has been sustained over �3 years.23,24 Maintaining a high
level of physical activity is well recognized as a critical factor
in sustaining weight loss. Whether weight loss can blunt the
age-related rise in BP is unclear. In one trial with long-term
follow-up, those individuals who sustained a �10-lb weight
loss achieved a lower BP that nonetheless rose over time.19
In aggregate, available evidence strongly supports weight
reduction, ideally attainment of a BMI �25 kg/m2, as an
effective approach to prevent and treat hypertension. More
importantly, in view of the well-recognized difficulties of
sustaining weight loss, efforts to prevent weight gain among
those who have normal body weight are critically important.
Figure 1. Estimated effects of population-wide shifts in systolic
BP distributions on mortality. Adapted with permission from
Stamler.12
TABLE 1. Diet-Related Lifestyle Modifications That Effectively Lower BP
Lifestyle Modification Recommendation
Weight loss For overweight or obese persons, lose weight, ideally attaining a BMI �25 kg/m2; for nonoverweight persons, maintain
desirable BMI �25 kg/m2
Reduced salt intake Lower salt (sodium chloride) intake as much as possible, ideally to �65 mmol/d sodium (corresponding to 1.5 g/d of sodium or
3.8 g/d sodium chloride)
DASH-type dietary patterns Consume a diet rich in fruits and vegetables (8–10 servings/d), rich in low-fat dairy products (2–3 servings/d), and reduced in
saturated fat and cholesterol
Increased potassium intake Increase potassium intake to 120 mmol/d (4.7 g/d), which is also the level provided in DASH-type diets
Moderation of alcohol intake For those who drink alcohol, consume �2 alcoholic drinks/d (men) and �1 alcoholic drink/d (women)
Appel et al Dietary Prevention and Treatment of Hypertension 297
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Reduced Salt Intake
On average, as dietary salt (sodium chloride) intake rises, so
does BP. Evidence includes results from animal studies,
epidemiological studies, clinical trials, and meta-analyses of
trials. To date, �50 randomized trials have been conducted.
In one of the most recent meta-analyses,25 a median reduction
in urinary sodium of �1.8 g/d (78 mmol/d) lowered systolic
BP and diastolic BP by 2.0 and 1.0 mm Hg in nonhyperten-
sive and by 5.0 and 2.7 mm Hg in hypertensive individuals.
The most persuasive evidence about the effects of salt on
BP comes from rigorously controlled, dose–response tri-
als.26–28 Each of these 3 trials tested at least 3 sodium levels,
and each documented statistically significant, direct, progres-
sive dose–response relationships. The largest of the dose–
response trials, the DASH-Sodium trial, tested the effects of
3 different sodium intakes separately in 2 distinct diets: the
DASH (Dietary Approaches to Stop Hypertension) diet (see
subsequent section for a complete description) and a control
diet more typical of what Americans eat. As estimated from
24-hour urine collections, the 3 sodium levels (lower, inter-
mediate, and higher) provided 65, 107, and 142 mmol/d,
respectively, corresponding to approximate intakes of 1.5,
2.5, and 3.3 g, respectively.
The main results of the DASH-Sodium trial are shown in
Figure 2. The BP response to sodium reduction, while direct
and progressive, was nonlinear. Specifically, decreasing so-
dium intake by �0.9 g/d (40 mmol/d) caused a greater
lowering of BP when the starting sodium intake was
100 mmol/d than when it was above this level. In subgroup
analyses of the DASH-Sodium trial,29,30 reduced sodium
intake significantly lowered BP in each of the major sub-
groups studied (ie, men, women, blacks, and nonblacks).
Importantly, sodium reduction significantly lowered BP in
nonhypertensive individuals on both diets.
In addition to reduced BP, clinical trials have documented
that a reduced sodium intake can prevent hypertension
(relative risk reduction of�20% with or without concomitant
weight loss),21 can lower BP in the setting of antihypertensive
medication,31,32 and can facilitate hypertension control.22,23 In
observational studies, reduced sodium intake is associated
with a blunted age-related rise in systolic BP.33 In other
observational studies, reduced salt intake is associated with a
reduced risk of atherosclerotic cardiovascular events34,35 and
congestive heart failure.36
The BP response to changes in dietary sodium intake is
heterogeneous37 (as is the BP response to other dietary
changes). Despite use of the terms “salt sensitive” and “salt
resistant” to classify individuals in research studies, the
change in BP in response to a change in salt intake is not
binary.38 Rather, the reduction in BP from a reduced sodium
intake has a continuous distribution, with individuals having
greater or lesser degrees of BP reduction. In general, the
effects of sodium reduction on BP tend to be greater in
blacks; middle-aged and older persons; and individuals with
hypertension, diabetes, or chronic kidney disease. These
groups tend to have a less responsive renin-angiotensin-
aldosterone system.39 It has been hypothesized that salt
sensitivity is a phenotype that reflects subclinical renal
disease.40 As discussed later in this statement, genetic and
dietary factors also influence the response to sodium reduc-
tion. For example, the rise in BP for a given increase in
sodium intake is blunted in the setting of either the DASH
diet28 or high potassium intake.41,42
Some salt intake is required. Recently, an Institute of
Medicine committee set 1.5 g/d (65 mmol/d) sodium as an
adequate intake level, primarily to ensure nutrient adequa-
cy.43 Although a sodium intake below this level is associated
with lower BP,44 little information is available about the
nutrient content of diets that provide �1.5 g/d of sodium.
From the DASH-Sodium trial, it is apparent that Western-
type diets can provide this level of sodium intake and that
such a diet can also provide adequate levels of other nutri-
ents.45 Because the relationship between sodium intake and
BP is direct and progressive without an apparent threshold, it
is difficult to set an upper level of sodium intake, which also
could be 1.5 g/d (65 mmol/d). However, in view of the
available food supply and the currently high levels of sodium
consumption, a reduction in sodium intake to 1.5 g/d
(65 mmol/d) is not easily achievable at present. In the interim,
a reasonable recommendation is an upper limit of 2.3 g/d
(100 mmol/d), which is similar to earlier recommendations
for the prevention and treatment of hypertension.9,14
In aggregate, available data strongly support current,
population-wide recommendations to lower salt intake. To
reduce salt intake, consumers should choose foods low in salt
and limit the amount of salt added to food. However, because
�75% of consumed salt comes from processed foods,46 any
meaningful strategy to reduce salt intake must involve the
efforts of food manufacturers and restaurants, which should
progressively reduce the salt added to foods by 50% over the
next 10 years.9,47
Increased Potassium Intake
High potassium intake is associated with reduced BP. Evi-
dence includes animal studies, observational epidemiological
studies, �30 clinical trials, and meta-analyses of these trials.
Although data from individual trials have been inconsistent, 3
meta-analyses of these trials have documented a significant
inverse relationship between potassium intake and BP in
nonhypertensive and hypertensive individuals.48–50 In the
meta-analysis by Whelton et al,49 average systolic and dia-
Figure 2. Mean systolic BP changes in the DASH-Sodium trial.
Solid lines indicate the effects of sodium reduction in the 2
diets; hatched lines, the effects of the DASH diet at each
sodium level. Adapted with permission from Sacks et al.28
298 Hypertension February 2006
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stolic BP reductions associated with a net increase in urinary
potassium excretion of 2 g/d (50 mmol/d) were 4.4 and
2.5 mm Hg in hypertensive and 1.8 and 1.0 mm Hg in
nonhypertensive individuals.
Because no trial has tested the effects of �3 levels of
dietary potassium intake on BP, inferences on the dose–
response relationship between potassium and BP must be
drawn from individual trials. Available data suggest that
increased potassium has beneficial effects on BP in the
setting of a low intake (eg, 1.3 to 1.4 g/d, or 35 to
40 mmol/d)51 or a much higher intake (eg, 3.3 g/d, or
84 mmol/d).52 Potassium reduces BP to a greater extent in
blacks than in whites.49 In several trials, the effects of
increased potassium intake in blacks have been particularly
striking.53
Because a high potassium intake can be achieved through
diet rather than pills and because potassium derived from
foods is also accompanied by a variety of other nutrients, the
preferred strategy to increase potassium intake is to consume
foods such as fruits and vegetables that are rich in potassium,
rather than supplements. In the DASH trial, the 2 groups that
increased fruit and vegetable consumption both lowered
BP.28,54 The 2100-kcal version of the DASH diet provides
�4.7 g/d (120 mmol/d) potassium.55 Another trial docu-
mented that increased fruit and vegetable consumption lowers
BP, but it did not specify the amount of potassium provided
in the fruits and vegetables.56
The effects of potassium on BP depend on the concurrent
intake of salt and vice versa. Specifically, an increased intake
of potassium has a greater BP-lowering effect in the context
of a higher salt intake and lesser BP reduction in the setting
of a lower salt intake. Conversely, the BP reduction from a
reduced