Potential Benefits of the Dietary Approaches to Stop Hypertension in Cardiovascular Disease

Cardiovascular Diseases (CVDs) are the leading cause of mortality worldwide and a major public health concern due to their increasing prevalence, economic impact, and association with modifiable lifestyle factors such as poor diet, physical inactivity and substance use. Nutritional strategies have emerged as key tools in both the prevention and management of CVDs. Among these, the DASH diet (Dietary Approaches to Stop Hypertension), originally developed to control blood pressure, has been widely studied for its cardioprotective effects.

This narrative review analyzes and synthesizes the scientific literature from the last decade regarding the DASH diet's role in cardiovascular health. Data were obtained through a comprehensive search in major biomedical databases and institutional sources, focusing on free-access studies in English and Spanish.

The DASH diet promotes the consumption of fresh fruits and vegetables, whole grains, lean meats, low-fat dairy, and a reduced sodium intake, contributing to improved blood pressure, lipid profiles, insulin sensitivity, and weight management. Several randomized clinical trials, such as the DASH-Sodium and OMNI-Heart studies, support its efficacy. Moreover, emerging research suggests that adherence to this diet may reduce the incidence of heart failure and other cardiometabolic conditions.

However, the effectiveness of the DASH diet is strongly influenced by adherence levels, socioeconomic factors, and cultural contexts. This review also discusses the potential of personalized nutritional interventions through nutrigenetics to enhance dietary impact based on individual genetic profiles.

In conclusion, while further research is needed to elucidate mechanisms and improve adherence strategies (particularly among younger populations), the DASH diet remains a solid, evidence-based option for addressing the global burden of CVDs. Promoting healthy dietary patterns alongside multidisciplinary interventions is essential for effective, long-term cardiovascular disease prevention and control.

AHA: American Hearth Association; AHEI: Alternative Healthy Eating Index; Apo A: Apolipoprotein A; Apo E: Apolipoprotein E; BP: Blood Pressure; CVDs: Cardiovascular Diseases; DBP: Diastolic Blood Pressure; DASH diet: Dietary Approaches to Stop Hypertension; GI: Glycemic Index; HDI: Healthy Diet Indicator; hs -CRP: High-sensitivity C-Reactive Protein; INE: National Institute of Statistics; LDL: Low Density Lipoprotein; LIPC: gene that codes for hepatic lipase; NT- pro BNP: B-type Natriuretic Peptide; PPAR family: Peroxisome Proliferator-Activated Receptors; SBP: Systolic Blood Pressure; SEEN: Spanish Society of Nutrition and Endocrinology; SNP: Single Nucleotide Polymorphisms; VLDL: Very Low Density Lipoprotein; WHO: World Health Organization

The World Health Organization (WHO) defines Cardiovascular Diseases (CVDs) as “a group of disorders of the heart and blood vessels that include coronary heart disease, cerebrovascular disease, and rheumatic heart disease” [1].

These pathologies and their comorbidities are the leading cause of death worldwide and also represent a significant public health problem due to a continuous increase in their prevalence and incidence, as well as their significant economic impact.

According to the latest data published by the National Institute of Statistics, mortality from cardiovascular disease has increased significantly in recent years, ranking among the leading causes of death along with cancer and respiratory diseases in both sexes [2].

The incessant increase in the number of cases both in Spain [2] and in the rest of the world [1] is due to multiple factors and can be attributed to an older population and changes in lifestyle linked to greater urbanization, sedentary lifestyle, alcohol consumption, smoking and unhealthy eating. Trying to modify these behaviors by searching for alternatives based on healthier dietary habits, physical activity and reducing alcohol and tobacco consumption can prevent and control these types of diseases [3].

Dietary intervention, along with drug therapy and physical activity, is one of the most widely used and effective pillars today for the treatment and prevention of cardiovascular disease. It has been shown that prescribing diets based on the consumption of fresh fruits and vegetables, whole grains, nuts, lean meats, and low-fat dairy products can be a key and low-cost tool, as it could reduce potential associated comorbidities and improve quality of life [3,4].

The relationship between cardiovascular health and diet is evolving. Numerous scientific studies support the benefits of good dietary habits on cardiovascular disease. The American Heart Association (AHA) points out that the diet is within the “Life´s The Essential 8 for Cardiovascular Health. The DASH diet is one of the broadest range of dietary patterns focused on improving cardiovascular health, sharing potential cardioprotective effects with other diets such as the Mediterranean diet or the plant-based diet [5].

The DASH diet, an acronym for Dietary Approaches to Stop Hypertension, is a dietary pattern created in the late 1990s by the National Institute of Health with the purpose of keeping blood pressure under control [6].

The potential effects of the DASH diet on cardiovascular health were first observed over 20 years ago through a controlled trial evaluating three different diets (control, DASH diet and a diet rich in fruits and vegetables) and observing their impact on Blood Pressure (BP) values. The results of that study indicated that individuals who followed the DASH diet had significantly reduced their BP values compared to the other diets studied [4].

The DASH diet and its modifications have been the subject of numerous studies related to cardiovascular disease for more than two decades, giving rise to contradictory results in its effectiveness depending on the different approaches used, leading to questioning whether this type of diet is really a useful tool in the management of CVDs [3].

For all the reasons stated above, the main objective of this article is to review the existing scientific literature on the DASH diet and its role in cardiovascular disease, analyzing its characteristics, evolution and future prospects.

To carry out this work, a systematic review of the existing scientific literature was carried out, from which different documents were selected, including scientific articles and documents issued by scientific societies.

To locate and select the bibliography reflected and to cover the maximum available and updated information on the chosen topic, specific documentary sources in health sciences have been used:

Databases

PubMed, Elsevier, Google Scholar and ScienceDirect databases were consulted. The objective was to identify scientific papers published in the last ten years (2015-2025) that were free to access, comprehensive, in English or Spanish, and that investigated the potential beneficial effects of the DASH diet in patients with cardiovascular disease. The keywords “nutrition”, “cardiovascular disease”, “benefits”, “prevention”, “DASH diet” and “adherence” were used for the search. A separate search was performed in each database with the above keywords using the Boolean operators “and” and “or” yielding the necessary number of articles to screen. In most cases, a review of the abstracts was sufficient to determine whether the article was useful or not in relation to the topic of study, except for some papers where it was necessary to review the full text.

Public institutions' archives

Epidemiological data were consulted on the website of the National Institute of Statistics (INE), as well as other websites of Scientific Societies in order to obtain updated data on cardiovascular pathologies and nutrition, such as the World Health Organization (WHO), the Spanish Society of Cardiology, and the Spanish Society of Nutrition and Endocrinology (SEEN).

The first evidence that nutrition could influence the onset and progression of CVD came from Russian scientist Alexander Ingatowski in 1908, who demonstrated that high cholesterol intake was a cause of atherosclerosis in rabbits. Following these findings, the scientific community showed a growing interest in investigating which nutrients were beneficial or harmful to the development of CVD [7].

Despite decades of nutrition research, in 2013, diet was still responsible for 37% of deaths and 24% of disability-adjusted life years for all ages and both sexes. This study found that nine of the top 25 global risk factors for disability-adjusted life years were related to dietary habits, including alcohol consumption, low consumption of fruits, vegetables, nuts, and excessive sodium intake, among others [6,7].

Even so, dietary intervention in cardiovascular disease has proven to be an effective strategy against the development of new pathologies or comorbidities. Among these interventions is the DASH diet, which is characterized by promoting the consumption of fresh and minimally processed foods, within which fruits, vegetables, lean meats and dairy products should be prioritized, as shown in table 1 [6]. In addition to reducing sodium intake to 2300 mg / day, this dietary pattern involves a higher intake of dietary fiber, unsaturated fatty acids, and plant proteins compared to Western diets. It also promotes the consumption of foods rich in vitamins (such as vitamin C and folate), minerals (such as calcium, magnesium, and potassium), and amino acids such as arginine. The protective effects of this diet may be due to the synergistic or isolated effect of the physiological mechanisms of action in which the nutrients contained in foods are involved [8].

This diet began to be investigated in the 1990s, following concerns about the high prevalence of hypertension in the American population. After observing that vegetarians had lower blood pressure values than non-vegetarians, a group of researchers decided to study the effects of a diet rich in fruits, vegetables, and low-fat dairy products on blood pressure in the multicenter randomized trial " Dietary Approach to Stop Hypertension”. In order to conduct this study, 459 adult participants with Systolic Blood Pressure (SBP) were less than 160 mmHg and diastolic blood pressure between 80 and 95 mmHg were included. After 8 weeks of intervention, the diet rich in fruits, vegetables and dairy products low in saturated fat achieved significant reductions in SBP of 5.5 mmHg and DBP of 3 mmHg compared to the control diet. Greater results were seen in hypertensive subjects, with a reduction in SBP of 11.4 mmHg and 5.5 mmHg in DBP. In addition to these very promising results, this study had significant strength as all meals were prepared in the research kitchen, so the ingredient and nutrient composition of the study diets were fully known [7].

DASH - sodium assay

This trial was designed to assess whether low sodium intake could enhance the benefits of the DASH diet. Participants were grouped into high (150 mmol/day), intermediate (100 mmol/day), or low (50 mmol/day) sodium groups. Results showed that reducing sodium intake had a significant additional BP-lowering effect in combination with the DASH diet. This reduction, although present in all groups, was more significant in black subjects, hypertensive subjects, and women [7]. In a secondary analysis of this trial, which compared the influence of the DASH diet versus its low sodium modification on certain biochemical markers such as high-sensitivity cardiac troponin I, B-type natriuretic peptide (NT- proBNP) or high-sensitivity C-reactive protein (hs -CRP), it was concluded that combining a DASH dietary pattern with sodium reduction can reduce two distinct mechanisms of subclinical cardiac damage: injury and strain, while DASH only reduces inflammation [9].

Optimal Macro - Nutrient Intake Heart assay (OMNI - Heart)

This trial was conducted based on all the results obtained previously, but studying how a DASH diet with varying micronutrient content could benefit the risk of CVD. For the present study, a high-carbohydrate diet similar to the DASH diet and two modified DASH diets were used: one high in protein and one high in saturated fatty acids. The study was carried out in 164 hypertensive or prehypertensive subjects with Low Density Lipoprotein (LDL) cholesterol values < 220 mg/ dL and triglycerides < 750 mg/ dL without medication. All three dietary patterns achieved improvements in BP and LDL cholesterol values from baseline, but the diet high in protein and saturated fatty acids achieved the best results [7].

A randomized controlled trial was conducted to test the effects of replacing low-fat dairy products with full-fat dairy products in the DASH diet, with a corresponding increase in fat intake and a reduction in sugar intake, on blood pressure, plasma lipids, and lipoproteins. The trial was conducted in healthy individuals who randomly consumed a control diet, a standard DASH diet, and a higher-fat, lower-carbohydrate modification of the DASH diet (HF-DASH diet). The dietary periods were completed by 36 participants. The HF-DASH diet reduced blood pressure to the same extent as the DASH diet but also reduced plasma triglyceride and Very Low Density Lipoprotein (VLDL) cholesterol concentrations without significantly increasing LDL cholesterol [10].

This diet has many similarities with some of the dietary patterns recommended for cardiovascular health, but its peculiarity lies in the fact that it advocates a sodium intake not exceeding 1500 mg/day, making it a perfect diet for preventing or treating hypertension along with other pharmacological and non-pharmacological measures [6].

However, the DASH diet has not only been studied as a treatment for high blood pressure, but several studies have been published showing significant improvements in blood glucose, triglyceride levels, LDL cholesterol, and insulin resistance. This makes the DASH diet an essential complement to drug therapy for metabolic syndromes. It has also been a successful tool in weight control. Furthermore, in certain populations, adherence to the DASH diet has shown significant improvements in the control of type 2 diabetes [6,7].

A 22-year follow-up study in a cohort of Swedish adults, including 41,118 men and 35,004 women, sought to investigate the potential influence of the DASH diet on the development of heart failure. It was observed that those subjects with greater adherence to this diet had a lower risk of HF than those with lower adherence. Researchers associate these results primarily with a lower consumption of red and processed meat, as this could be responsible for a higher concomitant intake of sodium and a greater increase in LDL compared to the consumption of other plant-based protein sources. The importance of a lower consumption of dairy products and sugary beverages as foods linked to a higher likelihood of developing HF was also highlighted [11].

The DASH diet has also been shown to reduce the incidence of colorectal cancer, primarily in the white population. This dietary pattern has also been shown to be helpful to some extent in chronic liver disease, diverticular disease, and celiac disease [12].

Various published studies on the influence of the DASH diet on both the prevention and treatment of cardiovascular disease generally present very positive results. The authors point to low adherence, food insecurity, and socioeconomic and cultural factors affecting the population as their main concerns.

Therefore, researchers sought to investigate the role of adherence to this diet in the development of CVD. One study was conducted in the Caerphilly prospective cohort. The degree of adherence to the DASH diet was assessed in a total of 1,867 middle-aged men using the Healthy Diet Indicator (HDI), the DASH questionnaire, and the Alternative Healthy Eating Index - 2010 (AHEI - 2010). The results indicated that after 16.6 years of follow-up, a higher score on the adherence questionnaires was inversely associated with CVD and a lower incidence of stroke [13]. However, another adherence study in a subsample of the ATTICA epidemiological study of 669 adults with a 10-year follow-up showed that the mean adherence score to the DASH diet was intermediate and, in addition, no significant association could be established between the degree of adherence and the risk of CVD at 10 years [14].

Given the heterogeneous results, it is worth highlighting the results of a dose-response meta-analysis that determined the relationship between adherence to the DASH diet and all-cause and all-cause mortality. It was observed that in the case of CVD mortality, there was an inverse association in all cohorts analyzed, and this association was more significant the higher the score obtained on the evaluation questionnaires used. Furthermore, it was observed that each 5-point increase in adherence could imply a significant decrease in the risk of CVD mortality and stroke by 4% and 3%, respectively [3].

Other less popular dietary patterns have been shown to be beneficial for the prevention or treatment of CVD, such as the Japanese diet, the Nordic diet, and the vegetarian diet, all three of which are empirically based. The Japanese diet hypothesizes that its traditional diet based on the consumption of fish, seaweed, soy, vegetables, and green tea may be beneficial for health, with some of its components associated in isolation with a lower risk of developing CVD. On the other hand, the Nordic diet, which includes oily fish, vegetables, roots, legumes, fruits, berries, and whole grains, has shown quite promising studies, albeit with mixed results. The vegetarian diet, well known since 1970, advocates the consumption of plant-based foods and may be beneficial for maintaining a healthy lipid profile, also shows mixed results. Other hypothesis-based diets are also worth mentioning, such as the portfolio diet, which is focused on achieving effective cholesterol reduction through the consumption of functional foods or foods with specific therapeutic components, or the glycemic index diet, which is based on the hypothesis that the Glycemic Index (GI) of foods may play a significant role in the development of CVD, although further studies stratifying by sex, weight, and concomitant metabolic diseases are needed [7].

Not only has the DASH diet sparked interest in nutritional approaches to CVD prevention and treatment, but numerous well-designed randomized trials and meta-analyses have studied the potential beneficial effects of other diets. The Mediterranean diet, along with the plant-based diet, is known to offer sufficient scientific evidence for the prevention of cardiovascular disease. Important studies such as PREDIMED analyze the influence of the well-known Mediterranean diet, which is based on the consumption of fruits, vegetables, fatty fish, nuts, and virgin olive oil as the main source of fat. It is believed that it could have a positive effect on CVD prevention because of a possible anti-inflammatory mechanism of certain bioactive compounds in the blood vessel wall [15]. The plant-based diet is based on the consumption of foods of plant origin and within this, there are variants that exclude certain food groups (vegetarian, vegan, lacto-ovo vegetarian, pescetarian, etc.). The "danger" of this diet lies in the fact that it does not consider the consumption of foods rich in sugars, fats and sodium, which can counteract the protective effect of consuming foods of plant origin [5].

The positive influence of diets on the development of CVD has already been discussed. However, it has been shown that general recommendations on macro and micronutrients do not affect all individuals equally, as diet can "interact" with genes [16].

Therefore, there is a growing need to improve nutritional strategies. This could be achieved through personalized nutrition for the treatment of obesity and other diseases, taking into account molecular-level interactions between the genome and nutrients [17]. Thus, individualized nutritional recommendations based on knowledge of an individual's genetic background could improve the outcomes of a specific dietary intervention [16].

In addition, genetic study can reveal the presence of polymorphisms in certain genes that may predispose an individual to a higher cardiovascular risk , such as those that code for apolipoprotein A ( apo A ) or E ( apo E ), the gene that codes for hepatic lipase (LIPC) or those that code for the PPAR family (peroxisome proliferator-activated receptors) [17].

Although this may be very promising for the near future, more scientific evidence is needed to understand how interactions between genes and nutrients occur and to extrapolate this to clinical practice. Furthermore, another aspect that could limit the application of nutrigenetics is the different prevalence of Single Nucleotide Polymorphisms (SNPs) studied across different ethnic groups [16].

Healthcare professionals and scientific societies are aware of the problems surrounding cardiovascular disease and its high incidence and prevalence. The excess of information in the media, and especially on social media, which is most frequently used by young people, can lead to confusion. The most encouraging aspect is that 80% of cardiovascular diseases can be prevented through a healthy lifestyle. This problem must have a multidisciplinary approach, and the work of nutritionists, food technologists, doctors, nurses, and pharmacists is vitally important. Whether in nutrition clinics, pharmacies, health centers, hospitals, or in the media, the population must be instructed and encouraged to lead a healthy lifestyle and provided with the necessary tools for self-management of their diet without having to hesitate about which products to choose when shopping, how to cook a meal to make it healthier, or how to organize a menu. Food must be the best medicine, as it can sometimes have surprising effects on health.

For all the above, the close relationship between nutrition and CVD is more than tangible. The information contained in the existing scientific literature prioritizes healthy dietary patterns such as the DASH diet or the Mediterranean diet over unhealthy ones such as the Western diet. There is strong evidence that certain components of the diet can influence the development of CVD [15]. Some authors point out that diets with scientific evidence have more similarities than differences. Therefore, eating minimally processed whole foods, fresh fruits and vegetables, legumes and nuts could be associated with a lower risk of CVD and mortality. The continued consumption of ultra-processed foods, loaded with sugars, refined carbohydrates, low-quality saturated fats and high energy density, displaces the consumption of healthy foods and also deregulates our hunger-satiety mechanisms, potentially addictive. This, combined with emerging diets such as the ketogenic diet, or intermittent fasting, can keep the population away from establishing good eating habits [5].

Even so, further studies are still needed to clarify the mechanisms of action involved in the potential benefits of certain nutrients and bioactive compounds found in foods, as well as to develop effective strategies to raise awareness among younger populations about the importance of a healthy diet and ensure their adherence to it.

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide and represent a significant public health problem. A dietary approach to the prevention and treatment of these diseases, combined with drug therapy, has proven to be an effective strategy, yielding solid and promising results.

Published studies conclude that the DASH diet is a good strategy for preventing and combatting not only hypertension, but also other cardiovascular diseases. However, they emphasize the importance of good adherence to the diet to achieve good results.

The existence of numerous diets for CVD prevention could share ground with other intervention strategies that are on the rise, such as nutrigenetics, which advocates individualized intervention with the goal of achieving better results (Supplementary Table 1).

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