1. 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 58 th Annual Scientific Session Alan L. Hinderliter, MD

2. Conflicts of Interest The authors have no relevant conflicts of interest

3. 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

4. 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

5. 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

6. 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

7. 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)

8. Baseline characteristics DASH + WM N=49 DASH Alone N = 46 Usual Care N = 49 Age (years)52.3 (10)51.8 (10)52.0 (10) Gender: Female (%)696369 Ethnicity: Caucasian (%)695059 BMI (kg/m 2 )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) Values are mean (SD) unless otherwise specified

9. Subject retention and adherence Drop-outs: 4 –3 in DASH + WM –1 in Usual Care DASH dietary class attendance: 92% Exercise session attendance: 90%

10. Dietary Intake DASH + WM N=49 DASH Alone N = 46 Usual Care N = 49 Fruit servings/day4.03.72.6 Vegetable servings/day5.55.62.6 Dairy servings/day1.81.90.9 % Fat calories262837 Calorie (kcal)164819622095 Values are medians unless otherwise specified

11. Weight Adjusted means after treatment Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p <.001

12. Aerobic Capacity Adjusted means after treatment Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p <.001 Peak VO 2 Treadmill Time

13. Resting Blood Pressure Adjusted means after treatment Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p =.023 Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p =.048 Systolic Diastolic

14. Resting Blood Pressure Change in Blood Pressure from Baseline

15. Ambulatory Blood Pressure Adjusted Means After Treatment Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p =.012 Treatment v Usual Care: p <.001 DASH + WM v DASH Alone: p =.026 Systolic Diastolic

16. Vascular stiffness and endothelial function Adjusted Means After Treatment Treatment v Usual Care: p =.002 DASH + WM v DASH Alone: p =.033 Treatment v Usual Care: p <.059 DASH + WM v DASH Alone: p =.989 Pulse Wave Velocity Flow-Mediated Dilation

17. Left ventricular mass index Adjusted Means After Treatment Treatment v Usual Care: p =.202 DASH + WM v DASH Alone: p =.016

18. 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

20. Additional slides

21. Resting Blood Pressure Pairwise Group Differences After Treatment Systolic Diastolic

22. Autonomic Function Adjusted Means After Treatment Baroreflex Sensitivity Treatment v Usual Care: p =.216 DASH + WM v DASH Alone: p =.047

23. Glucose Metabolism 80 100 120 140 160 180 Glucose Tolerance Test Minutes mg/dL 135 134 113 87 90 92 030 60 90120 DASH + WM DASH Alone Usual Care

24. Resting Systolic Blood Pressure