Cardiovascular Disease Prevention and Plant-Based Diets: Current Guidelines
Plant-Based Diets: What do the Heart Health Guidelines Say?
By Suzanne Morris, DVM, MWC
February is here, which means that it is American Heart Month and February 3 is National Wear Red Day.[1] Nearly half of the US population has ≥ 1 of the 3 main risk factors for cardiovascular disease (CVD): hypercholesterolemia, hypertension, and smoking. Diet is among several other risk factors for CVD.[2] Medical and health organizations have long recognized the importance of increasing fruits and vegetables and decreasing red and processed meats in the western diet.[3-5] But what are the guideline recommendations when it comes to plant-based eating?
The American Heart Association (AHA) recommends a diet rich in a variety of fruits and vegetables, whole grains, and proteins mostly from plants (ie, legumes and nuts).[3,6,7] These recommendations are based on studies showing reduced mortality associated with greater plant- than animal-based food consumption.[7] The initial results of a randomized trial of the Mediterranean diet supplemented with either nuts or extra-virgin olive oil vs a reduced fat diet in women at risk of CVD found that the major cardiovascular event incidence was lower in the Mediterranean diet groups, although no reduction in mortality was shown for these groups.[8] However, a post hoc analysis found that participants with greater adherence to a “provegetarian” diet had a lower mortality rate (hazard ratio [HR], 0.59; 95% CI, 0.40-0.88).[8,9]
Additional supporting evidence for the AHA recommendations comes from a cohort study of 81 337 participants that compared animal with plant dietary proteins in terms of cardiovascular (CV) mortality. When meat was compared with nuts and seeds as protein factors, the CV mortality hazard ratio (HR) for the meat participants was 1.61 (98.75% CI, 1.12-2.32; P-trend < .001) and for nuts and seeds participants, it was 0.60 (98.75% CI, 0.42-0.86). In other words, replacing meat with seeds and nuts reduced the mortality rate by 40%.[7,10] Another cohort study to compare protein sources in terms of mortality included participants from the Nurses’ Health Study and Health Professionals Follow-Up Study (N = 131 342). Although the study found no association between animal protein intake and all-cause mortality, it did find an association between animal protein intake and higher rate of CV-related mortality (HR, 1.08 per 10% energy increment; 95% CI, 1.01-1.16). Furthermore, the study showed an association between plant protein intake and lower rates of both all-cause and CV mortality (HR, 0.90 per 3% energy increment; 95% CI, 0.86-0.95 and HR, 0.88 per 3% energy increment; 95% CI, 0.80-0.97).[7,11]
Like the AHA dietary recommendations, the American College of Cardiology’s (ACCs) CardioSmart guide for a CV-healthy diet includes vegetable proteins first in its list of heart-healthy proteins and describes 3 heart-healthy dietary patterns: Mediterranean, vegetarian (including vegan), and the Dietary Approaches to Stop Hypertension (DASH) diet.[12] The CardioSmart website elsewhere states that guidelines recommend a “mostly plant-based diet” abundant in various fruits and vegetables.[13] In keeping with these recommendations, the American Medical Association passed a resolution in 2017 calling for the increased availability of plant-based foods in US hospitals, and specifically, calling for the elimination of processed meats from hospital menus.[14] However, uncertainty remains about plant-based meat alternatives, some of which are ultra-processed and hence have added salt, saturated fat, sugar, and preservatives.[3,15]
For more information on:
American Heart Month, see the NIH’s The Heart Truth®
Including (more) fruits and vegetables in meals, see the AHA’s All the Colors, All the Time.
References
1. National Institutes of Health (NIH). The Heart Truth®. February 2023. Accessed February 3, 2023. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-truth
2. Centers for Disease Control. Know your risk for heart disease. Reviewed December 9, 2019. Accessed October 24, 2022. https://www.cdc.gov/heartdisease/risk_factors.htm
3. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. 2021 Dec 7;144(23):e472-e487. doi: 10.1161/CIR.0000000000001031
4. Minich DM. A review of the science of colorful, plant-based food and practical strategies for "eating the rainbow". J Nutr Metab. 2019 Jun 2;2019:2125070. doi: 10.1155/2019/2125070. Erratum in: J Nutr Metab. 2020 Nov 28;2020:5631762
5. Wang DD, Li Y, Bhupathiraju SN, et al. Fruit and vegetable intake and mortality: results from 2 prospective cohort studies of US men and women and a meta-analysis of 26 cohort studies. Circulation. 2021 Apr 27;143(17):1642-1654. doi: 10.1161/CIRCULATIONAHA.120.048996
6. American Heart Association. The American Heart Association Diet and Lifestyle Recommendations. Reviewed November 1, 2021. Accessed October 24, 2022. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations
7. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Sep 10;140(11):e596-e646. doi: 10.1161/CIR.0000000000000678. Epub 2019 Mar 17. Erratum in: Circulation. 2019 Sep 10;140(11):e649-e650. Erratum in: Circulation. 2020 Jan 28;141(4):e60. Erratum in: Circulation. 2020 Apr 21;141(16):e774.
8. Estruch R, Ros E, Salas-Salvadó J, et al; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med. 2018 Jun 21;378(25):e34. doi: 10.1056/NEJMoa1800389
9. Martínez-González MA, Sánchez-Tainta A, Corella D, Salas-Salvadó J, et al; PREDIMED Group. A provegetarian food pattern and reduction in total mortality in the Prevención con Dieta Mediterránea (PREDIMED) study. Am J Clin Nutr. 2014 Jul;100 Suppl 1:320S-328S. doi: 10.3945/ajcn.113.071431. Epub 2014 May 28. Erratum in: Am J Clin Nutr. 2014 Dec;100(6):1605.
10. Tharrey M, Mariotti F, Mashchak A, Barbillon P, Delattre M, Fraser GE. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol. 2018 Oct 1;47(5):1603-1612. doi: 10.1093/ije/dyy030
11. Song M, Fung TT, Hu FB, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med. 2016 Oct 1;176(10):1453-1463. doi: 10.1001/jamainternmed.2016.4182. Erratum in: JAMA Intern Med. 2016 Nov 1;176(11):1728.
12. American College of Cardiology. CardioSmart. Heart Healthy Nutrition. [poster] 2020. Accessed October 27, 2022. https://www.cardiosmart.org/docs/default-source/assets/infographic/heart-healthy-diets.pdf?sfvrsn=cf918a6c_5
13. American College of Cardiology. CardioSmart. Dietary Guidelines. Updated March 31, 2019. Accessed October 27, 2022. https://www.cardiosmart.org/topics/healthy-living/eat-better/dietary-guidelines
14. Berg S. AMA backs comprehensive approach targeting sugary drinks. American Medical Association. Published June 14, 2017. Accessed October 24, 2022. https://www.ama-assn.org/delivering-care/public-health/ama-backs-comprehensive-approach-targeting-sugary-drinks
15. Gehring J, Touvier M, Baudry J, et al. Consumption of ultra-processed foods by pesco-vegetarians, vegetarians, and vegans: associations with duration and age at diet initiation. J Nutr. 2021 Jan 4;151(1):120-131. doi: 10.1093/jn/nxaa196