Abstract Body: Background
The 2025 AHA/ACC hypertension guideline newly anchors management to PREVENT 10-year risk and calls for a 3-6 month period of nonpharmacologic therapy followed by reassessment before initiating drugs in low-risk adults with stage I hypertension. Nationally representative evidence on diet quality in updated guideline-defined classes is limited. Here we quantify DASH diet adherence across new treatment eligibility classes and run pragmatic simulations to estimate reclassification for stage I at follow-up.
Methods
We analyzed data from adults 20-79 years old from NHANES 2013-March 2020, categorized using 2025 AHA/ACC blood pressure cutoffs (Normal, Elevated, Stage I and II). Stage I pharmacologic eligibility followed updated guidelines - immediate pharmacotherapy with clinical CVD, diabetes, or CKD, or with PREVENT 10-year risk ≥7.5%. Diet quality was measured using the DASH diet score from 24-hour recall. For simulation analyses, we identified untreated Stage I adults who were ineligible for immediate pharmacotherapy and DASH non-adherent. We simulated a deterministic diet-only SBP reduction scaled by attenuation factors to account for real-world adherence, holding other risk factors constant. We then recomputed BP category to quantify the proportion and nationally weighted counts spared pharmacotherapy at 3-6 months. All analyses incorporated survey-weighting for national estimates.
Results
We analyzed 16,040 adults (weighted N = 217 million) with mean age 46.9 years and 49.3% male. Overall DASH adherence was 8.8% (19.0 million). Across blood pressure categories, DASH adherence declined from normal to higher stages (Figure). Within stage 1, DASH adherence was low across eligibility classes with least adherence noted among those newly eligible for pharmacotherapy via PREVENT risk ≥7.5%. In simulation analyses, a diet-only SBP reduction of ~5 mmHg scaled by an attenuation factor of 0.5, downgraded 12.0% (2.4 million) from ‘Stage I’ to ‘Elevated BP’, sparing pharmacotherapy at follow up. About 88.0% (17.5 million) of stage I adults remained in stage I despite simulated SBP decline, becoming eligible for pharmacotherapy at 3-6 months per updated guidelines.
Conclusion
DASH adherence was uncommon and lowest in higher BP categories, underscoring a substantial implementation gap. Simulated improvements reclassified a modest subset of stage I cases, suggesting scalable dietary support could reduce near-term pharmacotherapy initiation.