Protocol
DASH dietary pattern
Randomized feeding trials with a validated surrogate endpoint A lab value or measurement used in place of the outcome that matters, such as LDL cholesterol standing in for heart attacks. Moving a surrogate does not always move the outcome., independently replicated The same finding reproduced by a separate research group. A result seen once can be chance or bias; a replicated one is harder to explain away..
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How this letter has changedLatest: October 2026 · Corrected.
The record described DASH-Sodium as a crossover A trial design in which each participant receives both the treatment and the comparison, one after the other, and serves as their own control. of three sodium levels within the DASH pattern; Sacks 2001 (PMID PubMed ID: the permanent number the US National Library of Medicine gives a published paper. Each one links to that paper's record on PubMed. 11136953) randomized participants in parallel to a control diet or DASH and crossed sodium levels within each, and the control arm is now stated. Appel 1997 (PMID 9099655) enrolled adults with systolic pressure under 160 and diastolic 80 to 95, with a larger effect in the hypertensive subgroup; both now appear. The B's replication requirement is now met on the page by Saneei 2014 (PMID 25149893) and Filippou 2020 (PMID 32330233), meta-analyses A study that pools the numbers from several trials into one combined estimate. by other groups, with Juraschek 2026 (PMID 41206973) on durability in a community setting. The 'no trial reported events' statement now cites Bensaaud 2025 (PMID 40326569), the Cochrane review that found almost no events across five small trials. Letter unchanged.PMID 11136953 PMID 9099655 PMID 25149893 PMID 32330233 PMID 41206973 PMID 40326569
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The DASH diet is an eating pattern tested for its effect on blood pressure. In a feeding trial of 459 adults, it lowered blood pressure more than a control diet. The drop was largest in people with high blood pressure. A later trial found it lowered pressure at every salt level tested, and reviews by other teams found the same effect. The trials did not measure heart attacks, strokes or deaths. One trial found the effect faded within three months of stopping.
Randomized feeding trials with a validated surrogate endpoint The outcome a trial measures to decide whether the treatment worked, such as heart attacks, blood pressure or a symptom score., independently replicated. The DASH trial fed 459 adults with systolic pressure under 160 and diastolic 80 to 95 mm Hg a control diet, a fruit-and-vegetable diet, or the combination diet, and measured blood pressure: the combination diet lowered pressure by 5.5/3.0 mm Hg more than control overall, 11.4/5.5 mm Hg in the 133 participants with hypertension and 3.5/2.1 mm Hg in the 326 without. DASH-Sodium randomized 412 adults in parallel to the control diet or the DASH diet, and within each diet crossed over three sodium levels for 30 days each. Later meta-analyses of 17 and 30 randomized trials by other groups replicate the blood-pressure effect. Blood pressure is a validated surrogate, so this is Grade B: it does not reach A because no adequate trial of the pattern has reported a hard cardiovascular endpoint, as a 2025 Cochrane review confirms.
Why this gradeThe reasoning, and what the grade does not cover.
Grade B on blood pressure. The DASH feeding trial in 459 adults lowered pressure by 5.5/3.0 mmHg more than control, and by 11.4/5.5 mmHg in those with hypertension (Appel et al., 1997; PMID 9099655). DASH-Sodium lowered systolic pressure at every sodium level (Sacks et al., 2001; PMID 11136953), and meta-analyses of 17 and 30 trials replicate the effect (PMIDs 25149893 and 32330233).
WHY NOT Ablood pressure is a validated surrogate, not a clinical event.
WHAT THIS GRADE DOES NOT COVERheart attack, stroke or mortality, which the feeding trials did not measure, and weight loss, which the feeding trials held steady by design.
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The evidence, in fullSix papers, each linked to its PubMed record.
Appel et al. (New England Journal of Medicine, 1997; PMID 9099655): randomized controlled feeding trial in 459 adults with systolic pressure under 160 and diastolic 80 to 95 mm Hg; the combination diet lowered systolic and diastolic pressure by 5.5 and 3.0 mm Hg more than the control diet, by 11.4 and 5.5 mm Hg in participants with hypertension and 3.5 and 2.1 mm Hg in those without. Sacks et al. (New England Journal of Medicine, 2001; PMID 11136953): DASH-Sodium, 412 adults randomized in parallel to a control diet or the DASH diet, with high, intermediate and low sodium crossed over for 30 days each within the assigned diet; DASH lowered systolic pressure at every sodium level, and low-sodium DASH against high-sodium control was 7.1 mm Hg lower in participants without hypertension and 11.5 mm Hg lower in those with it. Both were NIH-funded. Independent replication: Saneei et al. (Nutr Metab Cardiovasc Dis, 2014; PMID 25149893): meta-analysis of 17 randomized trials, 2,561 participants, systolic pressure 6.74 and diastolic 3.54 mm Hg lower, larger in hypertensive participants. Filippou et al. (Adv Nutr, 2020; PMID 32330233): meta-analysis of 30 randomized trials, 5,545 participants, systolic 3.2 and diastolic 2.5 mm Hg lower than control diets, in adults with and without hypertension, moderate-certainty evidence. Juraschek et al. (JAMA, 2026; PMID 41206973): GoFresh, 180 Black adults in Boston randomized to 12 weeks of home-delivered DASH-patterned groceries or grocery stipends; systolic pressure fell 3.4 mm Hg more with the DASH groceries, an effect not maintained three months after the program ended. Hard outcomes: Bensaaud et al. (Cochrane Database Syst Rev, 2025; PMID 40326569): five randomized trials, 1,397 participants, all publicly funded, with almost no myocardial infarctions, strokes or deaths recorded; the effect of the pattern on cardiovascular events is inconclusive. Graded B rather than A because the replicated endpoint is blood pressure, a validated surrogate, and no adequate trial has reported events.
Measured outcome: systolic and diastolic blood pressure at baseline and after roughly 8 weeks, which is the interval over which the two original trials reported their effect; the 2026 community trial found the effect faded within three months of stopping. No trial has adequately reported cardiovascular events, so blood pressure is the only endpoint this grade rests on.
Evidence notes: randomized trial, meta-analysis
Endpoint graded: Systolic and diastolic blood pressure (DASH, DASH-Sodium) (surrogate)
Last reviewed: August 2026
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("Dietary Approaches to Stop Hypertension"[tiab] OR DASH[tiab]) AND "blood pressure"[tiab] AND (randomized controlled trial[pt] OR meta-analysis[pt])Grades move when new trials publish. A free monthly email lists every grade EBL moved, with the reason and the trial behind it: the sign-up is on the Evidence Log →