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					       The ENCORE Study
Cardiovascular Benefits Associated With the
 DASH Diet Alone and in Combination with
Exercise and Weight Reduction in Men and
     Women with High Blood Pressure

     The American College of Cardiology
        58th Annual Scientific Session

             Alan L. Hinderliter, MD
          Conflicts of Interest
The authors have no relevant conflicts of
interest
                 Background
Lifestyle modifications are recommended for blood
pressure lowering in patients with pre-hypertension
and as an initial strategy in treating Stage I
hypertension
The DASH diet is effective in lowering blood pressure
In patients on the DASH diet, the incremental benefits
of weight loss and exercise are uncertain
The effects of lifestyle modifications on cardiovascular
manifestations of high blood pressure have not been
extensively studied
                Objectives

To examine the effects of 1) the DASH diet, and
2) the DASH diet plus exercise and weight loss
on blood pressure in overweight patients with
high blood pressure
To examine the effects of lifestyle modifications
on cardiovascular manifestations of high blood
pressure
                Study population
Overweight but otherwise generally healthy adults with
above-optimal blood pressure
Inclusion criteria
–   Age > 35 years
–   BMI 25-40 kg/m2
–   Sedentary (not engaged in regular exercise)
–   BP 130-159/85-99 mmHg
Exclusion criteria
– Treatment with antihypertensive medication
– Secondary hypertension
– Cardiac disease, diabetes, or chronic kidney disease
                   Interventions
Subjects were randomized to one of three
interventions for 16 weeks:
– DASH diet alone
    2-week feeding period plus weekly group sessions
    Diet designed to maintain weight
– DASH diet plus behavioral weight management program
    DASH diet plus weekly sessions to implement cognitive
    behavioral weight loss program
    Supervised exercise three times weekly
– Usual Care
       Outcome measures

Primary outcome measure
– Resting blood pressure
Secondary outcome measure
– Ambulatory blood pressure
– Vascular stiffness (pulse wave velocity)
– Endothelial function (flow-mediated dilation)
– Left ventricular mass (echocardiography)
              Baseline characteristics
                                 DASH + WM            DASH Alone Usual Care
                                   N=49                 N = 46     N = 49
Age (years)                        52.3 (10)           51.8 (10)    52.0 (10)
Gender: Female (%)                      69                63           69
Ethnicity: Caucasian (%)                69                50           59
BMI (kg/m2)                        33.5 (4.4)          32.8 (3.4)   33.0 (3.9)
Systolic BP (mmHg)                   139 (8)            138 (9)     138 (10)
Diastolic BP (mmHg)                  86 (7)             86 (6)       86 (6)

    Values are mean (SD) unless otherwise specified
Subject retention and adherence

 Drop-outs: 4
  – 3 in DASH + WM
  – 1 in Usual Care
 DASH dietary class attendance: 92%
 Exercise session attendance: 90%
                          Dietary Intake
                                 DASH + WM          DASH Alone   Usual Care
                                   N=49               N = 46       N = 49
Fruit servings/day                     4.0             3.7          2.6
Vegetable servings/day                 5.5             5.6          2.6
Dairy servings/day                     1.8             1.9          0.9
% Fat calories                         26              28           37
Calorie (kcal)                        1648            1962         2095


    Values are medians unless otherwise specified
                        Weight
      Adjusted means after treatment
      230

      220

      210
lbs




      200

      190

      180

      170
            DASH + WM    DASH Alone     Usual Care
                Treatment v Usual Care: p < .001
                DASH + WM v DASH Alone: p < .001
                                       Aerobic Capacity
                                Adjusted means after treatment
                                Peak VO2                                                Treadmill Time
               30                                                      16
               29                                                      15
               28                                                      14
               27                                                      13
ml/kg/minute




               26                                                      12




                                                             Minutes
               25                                                      11
               24                                                      10
               23                                                      9
               22                                                      8
               21                                                      7
               20                                                      6
                    DASH + WM   DASH Alone      Usual Care                  DASH + WM     DASH Alone     Usual Care

                                             Treatment v Usual Care: p < .001
                                             DASH + WM v DASH Alone: p < .001
                     Resting Blood Pressure
                         Adjusted means after treatment
                          Systolic                                            Diastolic
       145                                                 90

       140
                                                           85
       135
mmHg




                                                    mmHg
       130                                                 80

       125
                                                           75
       120

       115                                                 70
             DASH + WM    DASH Alone   Usual Care                 DASH + WM    DASH Alone   Usual Care
             Treatment v Usual Care: p < .001                   Treatment v Usual Care: p < .001
             DASH + WM v DASH Alone: p = .023                   DASH + WM v DASH Alone: p = .048
   Resting Blood Pressure
Change in Blood Pressure from Baseline

   DASH +         -16
    WM                         -10



    DASH                      -11                        Systolic BP
    Alone                             -8                 Diastolic BP


    Usual                                   -3
    Care                                   -4


            -20         -15         -10    -5    0   5
                        Change in BP (mmHg)
                     Ambulatory Blood Pressure
                          Adjusted Means After Treatment
                          Systolic                                           Diastolic
       145                                                 90

       140
                                                           85
       135
mmHg




                                                    mmHg
       130                                                 80

       125
                                                           75
       120

       115                                                 70
              DASH + WM   DASH Alone   Usual Care                DASH + WM    DASH Alone   Usual Care

             Treatment v Usual Care: p < .001                   Treatment v Usual Care: p < .001
             DASH + WM v DASH Alone: p = .012                   DASH + WM v DASH Alone: p = .026
Vascular stiffness and endothelial function
                       Adjusted Means After Treatment
                      Pulse Wave Velocity                         Flow-Mediated Dilation
      9                                               6


                                                      5
      8

                                                      4
m/s




                                                  %
      7
                                                      3

      6
                                                      2


      5                                               1
          DASH + WM     DASH Alone   Usual Care            DASH + WM   DASH Alone   Usual Care

          Treatment v Usual Care: p = .002                Treatment v Usual Care: p < .059
          DASH + WM v DASH Alone: p = .033                DASH + WM v DASH Alone: p = .989
Left ventricular mass index
 Adjusted Means After Treatment
               44


               42

    g/m**2.7
               40


               38


               36


               34
                      DASH + WM   DASH Alone   Usual Care

                    Treatment v Usual Care: p = .202
                    DASH + WM v DASH Alone: p = .016
               Conclusions

In our study of overweight patients with high
blood pressure,
– The DASH diet resulted in significant blood pressure
  lowering
– Exercise and weight loss in addition to the DASH
  diet resulted in an incremental decrease in blood
  pressure, as well as greater improvements in
  cardiovascular manifestations of high blood pressure
Additional slides
                        Resting Blood Pressure
             Pairwise Group Differences After Treatment
                             Systolic                                                    Diastolic
        5                                                           2

                                                                    0
        0
                                                                    -2
        -5




                                                            mmHg
mmHg




                                                                    -4
       -10
                                                                    -6

       -15                                                          -8

       -20                                                         -10
             (DASH + WM) -   DASH Alone -   (DASH + WM) -                (DASH + WM) -    DASH Alone -   (DASH + WM) -
               Usual Care     Usual Care     DASH Alone                    Usual Care      Usual Care     DASH Alone
 Autonomic Function
Adjusted Means After Treatment
                         Baroreflex Sensitivity
              8


  msec/mmHg   7


              6


              5


              4


              3
                  DASH + WM    DASH Alone         Usual Care
                  Treatment v Usual Care: p = .216
                  DASH + WM v DASH Alone: p = .047
                         Glucose Metabolism
        180
        160
        140                     Glucose Tolerance Test
mg/dL




                                                                      135
                                                                  134
        120




                                                                113
        100




                                     DASH + WM
                                     DASH Alone
                  92
                    90               Usual Care
                  87
        80




              0            30           60           90   120

                                     Minutes
                 Resting Systolic Blood Pressure
        145
        140
        135
mm Hg

        130
        125
        120




                                DASH + Behavioral Wgt. Loss
                                DASH Alone
        115




                                Usual Care

              Scrn   PostFeed                                 After Treatment

				
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posted:12/13/2011
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