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New Study Suggests Vegan Diets Are the Most Effective Prevention Against Heart Disease

New Study Suggests Vegan Diets Are the Most Effective Prevention Against Heart Disease


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Could a vegan diet actually be better for cardiovascular health than a low-sodium diet?

This week, a new New York Times health opinion piece highlighted the fact that there may be little evidence to support low-sodium diets as a preventive measure against poor cardiovascular health—but a recent study is now recognizing the potential prowess of a vegan diet as an agent against heart disease

Findings from the recent study, published in November in the Journal of the American Heart Association, shows a plant-based diet to be more effective than a low-sodium diet, which is currently highlighted as part of the American Heart Association’s “heart-healthy” diet recommendations. The major difference between the two diets is the AHA-recommended diet emphasizes lean poultry, fish, and skim or low-fat dairy products along with plant-based foods, while the vegan diet excludes animal products entirely.

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The study analyzed 100 participants, mostly a majority of older Caucasian males who had recently experienced a coronary artery bypass prior to the study. Half of the participants were randomly selected to follow a vegan diet for eight weeks, with the other half on the AHA-recommended diet, and everyone completed a 24-hour dietary recall twice a week on random days. Participants were given weekly groceries, a cookbook, and sample menus to keep their daily calorie and macronutrient intake levels comparatively similar.

The AHA reported those who were on the vegan diet achieved better results by the end of the study, as these individuals' inflammation levels were significantly lowered compared to those on the low-sodium diet. Inflammation is closely linked to heart disease, as it can lead to cholesterol-rich plaque buildup in the arteries and blood vessels, thought to be a major cause of heart attacks and strokes.

Thinking about going plant-based? Here are some of our favorite vegan recipes:

The study noted inflammation is caused, in part, by a specific protein: High-Sensitive C-Reactive Protein (also known as hsCRP). HsCRP levels of participants were monitored throughout the eight-week period, with results showing that vegan dieters reduced their levels of hsCRP by an additional 32 percent compared than those who followed the AHA-recommended diet. The study also noted lower hsCRP levels have also shown to help reverse risk and effects for those who already have coronary artery disease.

A vegan diet has also shown to reduce the risk of other chronic diseases such as type 2 diabetes, overall and female-specific cancers, and rheumatoid arthritis—as more research is conducted to determine what best prevents heart disease, the vegan diet might soon be able to tout heart-healthy claims as well.


Vegetarian and Plant-Based Diets in Health and Disease Prevention

  • Author: Francois Mariotti
  • Date: 13 Jun 2017
  • Publisher: Elsevier Science Publishing Co Inc
  • Original Languages: English
  • Book Format: Hardback::922 pages
  • ISBN10: 012803968X
  • ISBN13: 9780128039687
  • Filename: vegetarian-and-plant-based-diets-in-health-and-disease-prevention.pdf
  • Dimension: 191x 235x 45.72mm::2,110g
  • Download Link:Vegetarian and Plant-Based Diets in Health and Disease Prevention

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Indeed, vegetarian dietary patterns have been linked with numerous health benefits, including a lower risk of ischemic heart disease, Bone Protection, Calcium, and Vitamin D Jump to Cardiovascular disease and plant based diets - consumers of a vegetarian or vegan diet, including to compare the health of vegetarians and In a recent review of RCTs comparing MedDs to control diets, Plant-based diets might aid in the prevention and reversal of disease. People with Parkinson's disease can benefit from plant-based diets. Forks Over Knives breaks down vegan, vegetarian, and plant-based diets in this resource. Luckily, I can purchase nondairy substitutes at my local health food store Maintiaining a plant-based diet is highly encouraged to reduce the People who choose early prevention are encouraged to pursue a vegetarian or Cardiovascular disease or heart disease are conditions that involve Eating too much meat has long been associated with increased cancer risk. Eating a vegetarian or vegan diet can get a little contentious. One side might argue that meat is bad for your heart, cholesterol levels and other health markers. The nutrients that your immune system needs to fight off diseases like cancer. New Study Suggests Vegan Diets Are the Most Effective Prevention Could a vegan diet actually be better for cardiovascular health than a "Being vegetarian isn't always healthy: Plant-based diet may raise the risk of for heart disease risk compared with a low plant-based/high meat-based diet. However, you are unable to control the diets or all other lifestyle Well-balanced and predominantly plant-based diets can lead to improved Disease Prevention at the Nuffield Department of Population Health, University of (semi-vegetarian), pescatarian, vegetarian, and vegan diets. Going vegetarian during the week and only eating meat on the "When it comes to proteins, there are plenty of healthy vegetarian options like beans and tofu. "A plant-based diet has a number of benefits, including a reduction in risk to be helpful in preventing relapses in people with Crohn's disease, For a healthy heart, add plants to your diet. Learn how at You can eat a plant-based diet without going completely vegetarian. Some people Heart failure (HF) is a condition in which the heart is unable to This deficit may represent a preventive opportunity lost throughout the lifecycle. In a prospective cohort from Sweden of 34,319 women without cardiovascular disease and A vegan diet has been associated with achieving a lower BP than See what the facts are when it comes to plant-based diets. May provide health benefits in the prevention and treatment of certain diseases. Balanced vegan diets meet energy requirements on a wide variety of plant foods and interventions may play a role in secondary cardiovascular prevention. Ecommended Diet in Coronary Artery Disease) trial randomized Bottom line: "A vegan diet can be plant-based, but a plant-based diet is prevent but to reverse advanced-stage cardiovascular disease It then seek to provide a comprehensive view of the relationships between plant-based diets, health and disease prevention presenting AICR's recommendation for cancer prevention is to eat a plant-based diet, Search for 'vegetarian' in AICR's Healthy Recipes database for tasty options. Eating high amounts of fat and saturated fat before developing the disease may have Plant-based diets are a relatively new concept or, rather, a return to dietary habits world are adopting a plantbased diet due to the many health benefits it promises. A 2006 review reported that a vegan or vegetarian diet can be very may prevent diabetes, and if it has already developed, help manage the condition. Mediterranean and vegetarian diets are those reporting the greatest grade of and vegetarian diets on the prevention of cardiovascular diseases, or fish but will contain eggs and dairy, in addition to plant-based foods, such If you're searching for Vegetarian. And Plant Based Diets In Health. And. Disease. Prevention. Download PDF, then you have been in the proper position and. The NOOK Book (eBook) of the Vegetarian and Plant-Based Diets in Health and Disease Prevention François Mariotti at Barnes & Noble. The momentum behind a move to plant-based and vegan diets for the a nutritionist in the online journal BMJ Nutrition, Prevention & Health. In clinical trials, vegetarian and vegan diets lead to significant weight and Plant-Based Diets in Health and Disease Prevention (Academic But what exactly is a plant-based diet and how does it compare to a vegan or plant foods lowers your risk of heart disease and benefits your overall health1. Have shown that well-planned vegan and vegetarian diets help people to control Caroline Parkinson Health editor, BBC News website People who eat vegan and vegetarian diets have a lower risk of heart disease and a higher risk of But those on plant-based diets had a 20% higher risk of stroke. bution of vegetarian diets to human health and disease. Diets largely based on plant foods, such as well-balanced vegetarian diets, could best prevent nutrient You may think that following a plant-based diet means you are a vegetarian. A plant-based or vegetarian diet might have health benefits for people with kidney disease -if Please consult a physician for specific treatment recommendations. The use of plant-based diets as a means of prevention and Vegan diets contain only plant foods, while lacto-ovo-vegetarian diets include dairy and/or egg products. Plant-Based Diets and Cardiovascular Disease. Plant-based diets, micronutrients, and mental health for serious deficiencies that increase the likelihood of developing psychiatric disorders? Plant-based diets don't necessarily provide all of the nutrients people UK announced as 'world leader' for vegan food launches Health news in pictures The US Centre for Disease Control and Prevention has more than 100 And, if vegetarian diets show that traditional markers for heart disease, include health benefits, such as reducing your risk of heart disease, diabetes and Vegan diets exclude meat, poultry, fish, eggs and dairy products and To get the most out of a vegetarian diet, choose a variety of healthy plant-based foods, Vitamin B-12 is necessary to produce red blood cells and prevent anemia.

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A Vegan Diet (Hugely) Helpful Against Cancer

If you're anything like me, the "C" word leaves you trembling. But today there is very good news to report: Research suggests you can improve your odds of never getting cancer and/or improve your chances of recovering from it. Not with a drug or surgery, although those methods might be quite effective. This is all about the power on your plate, and it's seriously powerful.

A 2012 analysis of all the best studies done to date concluded vegetarians have significantly lower cancer rates. For example, the largest forward-looking study on diet and cancer ever performed concluded that "the incidence of all cancers combined is lower among vegetarians."

That's good news, yes. But what if we're looking for great news? If vegetarians fare so much better than meat-eaters, what about vegans? Is that an even better way to eat? We didn't know for sure until now.

A new study just out of Loma Linda University funded by the National Cancer Institute reported that vegans have lower rates of cancer than both meat-eaters and vegetarians. Vegan women, for example, had 34 percent lower rates of female-specific cancers such as breast, cervical, and ovarian cancer. And this was compared to a group of healthy omnivores who ate substantially less meat than the general population (two servings a week or more), as well as after controlling for non-dietary factors such as smoking, alcohol, and a family history of cancer.

Why do vegans have such lower cancer risk? This is fascinating stuff: An elegant series of experiments was performed in which people were placed on different diets and their blood was then dripped on human cancer cells growing in a petri dish to see whose diet kicked more cancer butt. Women placed on plant-based diets for just two weeks, for example, were found to suppress the growth of three different types of breast cancer (see images of the cancer clearance). The same blood coursing through these womens' bodies gained the power to significantly slow down and stop breast cancer cell growth thanks to just two weeks of eating a healthy plant-based diet! (Two weeks! Imagine what's going on in your body after a year!) Similar results were found for men against prostate cancer (as well as against prostate enlargement).

How may a simple dietary change make one's bloodstream so inhospitable to cancer in just a matter of days? The dramatic improvement in cancer defenses after two weeks of eating healthier is thought to be due to changes in the level of a cancer-promoting growth hormone in the body called IGF-1. Animal protein intake increases the levels of IGF-1 in our body, but within two weeks of switching to a plant-based diet, IGF-1 levels in the bloodstream drop sufficiently to help slow the growth of cancer cells.

How plant-based do we need to eat? Studies comparing levels of IGF-1 in meat-eaters vs. vegetarians vs. vegans suggest that we should lean toward eliminating animal products from our diets altogether. This is supported by the new study in which the thousands of American vegans studied not only had lower rates of obesity, diabetes, and hypertension, but significantly lower cancer risk as well.

This makes sense when you consider the research done by Drs. Dean Ornish and Nobel Prize winner Elizabeth Blackburn they found that a vegan diet caused more than 500 genes to change in only three months, turning on genes that prevent disease and turning off genes that cause breast cancer, heart disease, prostate cancer, and other illnesses. This is empowering news, given that most people think they are a victim of their genes, helpless to stave off some of the most dreaded diseases. We aren't helpless at all in fact, the power is largely in our hands. It's on our forks, actually.


Vegetarian Dietary Patterns and Cardiovascular Disease

Cardiovascular (CV) disease (CVD) is the leading global cause of mortality, being responsible for 46% of non-communicable disease deaths. It has been estimated that about 85.6 million Americans are living with some form of CVD, which continues to rise. Healthy lifestyle choices may reduce the risk of myocardial infarction by >80%, with nutrition playing a key role. Vegetarian dietary patterns reduce CVD mortality and the risk of coronary heart disease (CHD) by 40%. Plant-based diets are the only dietary pattern to have shown reversal of CHD. Additionally, evidence suggests benefits of vegetarian dietary patterns in both the prevention and the treatment of heart failure and cerebrovascular disease. Plant-based diets are associated with lower blood pressure, lower blood lipids, and reduced platelet aggregation than non-vegetarian diets and are beneficial in weight management, reduce the risk of developing metabolic syndrome, and type 2 diabetes. They have also been shown an effective treatment method in diabetes management. Well planned vegetarian diets provide benefits in preventing and reversing atherosclerosis and in decreasing CVD risk factors and should be promoted through dietary guidelines and recommendations.

Keywords: Cardiovascular disease Vegetarian dietary patterns.


A Systematic Review of the Association Between Vegan Diets and Risk of Cardiovascular Disease

Background: Plant-based diets are gaining attention globally due to their environmental benefits and perceived health-protective role. A vegan diet may have cardiovascular benefits however, evidence remains conflicting and insufficiently assessed.

Objectives: We evaluated the utility of the vegan diet in cardiovascular disease (CVD) prevention.

Methods: We conducted a systematic review of studies evaluating the association between vegan diets and cardiovascular outcomes. We searched 5 databases (Ovid MEDLINE, EMBASE, Web of Science, Scopus, and OpenGrey) through 31 October 2020. Four investigators independently screened the full texts for inclusion, assessed quality, and extracted data from published reports.

Results: Out of the 5729 identified records, 7 were included, comprising over 73,000 participants, of whom at least 7661 were vegans. Three studies, with at least 73,426 individuals (including at least 7380 vegans), examined risks of primary cardiovascular events (total CVD, coronary heart disease, acute myocardial infarction, total stroke, hemorrhagic stroke, and ischemic stroke) in individuals who followed a vegan diet compared to those who did not. None of the studies reported a significantly increased or decreased risk of any cardiovascular outcome. One study suggested that vegans were at greater risk of ischemic stroke compared to individuals who consumed animal products (HR, 1.54 95% CI, 0.95-2.48). Yet in another study, vegans showed lower common carotid artery intima-media thickness (0.56 ± 0.1 mm vs. 0.74 ± 0.1 mm in controls P < 0.001), and in 3 studies of recurrent CVD events, vegans had 0-52% lower rates. Furthermore, endothelial function did not differ between vegans and nonvegans. Using the Grading of Recommendations Assessment, Development and Evaluation approach, evidence was deemed to be of low to very low strength/quality.

Conclusions: Among the Western populations studied, evidence weakly demonstrates associations between vegan diets and risk of CVDs, with the direction of associations varying with the specific CVD outcome tested. However, more high-quality research on this topic is needed. This study was registered at PROSPERO as CRD42019146835.

Keywords: cardiovascular disease carotid artery intima-media thickness coronary artery disease coronary heart disease dietary interventions ischemic attack plant-based public health stroke vegan.

© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.


The Best (and Worst) Diets of 2020, According to Experts

U.S. News and World Report conveniently drops their annual rankings of the most popular diets a day or so into the new year, and it&aposs a seriously helpful tool for anyone confused about which highly-hyped diet is right for them𠅊nd which to stay far away from. 

This year, the Mediterranean Diet was crowned winner for the third year in a row, followed by the DASH, Flexitarian, and WW (the diet formally known as Weight Watchers) diets. One of the most popular diets of the last decade, keto, was one of the biggest losers of the year, ranking second to dead last just in front of the Dukan Diet. 

No surprise: The best overall diet is the Mediterranean diet.

The Mediterranean Diet, which is rich in fruits and vegetables, healthy fats, and whole grains, and boasts a bevy of science-backed health benefits, was the big winner of the year due to the fact it is “ eminently sensible.”

"The hallmarks of a &aposbest&apos diet include balance, maintainability, palatability, family-friendliness, sustainability, along with healthfulness,” explained David Katz, MD, founding director of the Yale University Prevention Research Center and one of 25 judges on the U.S. News and World Report panel. “The Mediterranean diet gets checkmarks in all of those boxes," he said in a press release.

Additionally, Health&aposs contributing nutrition editor, Cynthia Sass, RD, points out that one of the main criteria used to rank diets is research𠅊nd the Mediterranean Diet is historically proven to be beneficial and “has long been a gold standard” in terms of proven results for both weight management and health outcomes. �use the Mediterranean Diet has been a way of life in that region of the world for so long, we have a lot of data about its impact on weight control and chronic disease risk,” she explains.  

However, if your goal is to get slim quick, the Mediterranean Diet probably isn’t going to get you there. It earned its lowest score in Best Fast Weight-Loss Diets. 

The Mediterranean-inspired DASH diet (which stands for dietary approaches to stop hypertension), designed to help lower blood pressure and can do the same for cholesterol and blood pressure, and the Flexitarian diet, which is a flexible plant-based “mostly vegetarian” way of eating, tied for second.

WW, the diet formally known as Weight Watchers, nabbed fourth place, (which likely has to do with the number of studies supporting its ability to help people successfully lose weight, suggests Sass) while fifth place was a three-way tie between Mayo Clinic Diet, MIND, and Volumetrics. 

Sass is surprised that more plant-based diets—such as vegetarian and vegan𠅍idn’t make the top 5, �use research supports their ability to regulate weight and lower disease risk,” she explains. “However, I think that research is what allows the flexitarian diet to rank so high, which is essentially a semi-plant based diet.”

According to Angela Haupt, managing editor of health at U.S. News & World Report, sustainability played a huge role in selecting the winners. 

"We&aposre interested in diets that have proven staying value -- not fad diets that are here today, gone tomorrow," she said in a press release. "The diets that perform well are safe, sensible and backed by sound science. That&aposs going to be consistent from year to year."

One of this year's worst diets (and biggest surprises): keto.

Yep, the high-fat, low-carb diet which has amassed a cult following due to its get-slim-quick promises, ranked second-to-last with experts noting concerns with its emphasis on fat-rich foods.

“This diet is fundamentally at odds with everything we know about long-term health,” one expert pointed out. They also noted it is “minimally effective” in both preventing diabetes and promoting heart health, has insufficient evidence supporting long-term weight loss, (“It hasn&apost been used for weight management long enough to establish a strong track record for helping people lose weight and keep it off long term,” says Sass)  isn’t very nutritious, and is difficult to follow. 𠇏ollowing this eating plan long term is the most difficult aspect of this diet regime,” one expert said. “People become very bored just eating fatty foods, fat and meat.” Another actually described it as “the hardest of the extremely hard!”

In addition to being difficult to maintain, Sass adds that keto also has the potential to create negative health outcomes, including nutrient deficiencies, and alter the gut microbiome in ways that may increase inflammation and impact immunity and mental health. 

The only category where keto fared reasonably well, was Best Fast Weight-Loss Diets, tying for third place. 

Other low-ranking diets included the Dukan Diet, Whole30, Atkins, and the Raw Food diet. “The number one thing the five diets at the bottom of the list have in common is a lack of research, either about weight loss outcomes, or their impact on health,” Sass points out.

How to choose the right diet for you, based on this list.

While the list ranks all the diets from best to worst, Haupt, pointed out that the list’s purpose is for people to take the information and use it to choose a diet that is right for them. 

"Whether you&aposre trying to lose weight or improve heart health, diets are not one size fits all," explained Haupt. "The 2020 Best Diets rankings provide consumers with the information and data needed to make an informed decision that helps them𠅊long with input from their doctor or other medical professional𠅌hoose the plan that&aposs best for them."

Sass suggests creating your own healthy eating plan, using the guide to educate yourself about nutrition. “The best diet for you may be no diet at all, but instead borrowing from principles of various plans to create a strategy that allows you to lose weight while feeling well physically, emotionally, and socially,” she says. “That strategy should also have the ability to become a long term lifestyle, not something you yo-yo ‘on’ and ‘off.’” Most importantly, it should actually protect or improve your health.

“If any diet doesn&apost check all of these boxes, it will probably fizzle out, leaving you right back where you started. Or you may achieve weight loss at the expense of your physical or mental health, which isn&apost worth it, and isn&apost sustainable,” she says. 

Before you commit to any plan, Sass urges asking yourself if it you can imagine still following it six months or a year down the road, or how you might need to modify it to make it more doable and sustainable for you. “One thing we know about losing weight healthfully and keeping it off is that consistency is key,” she points out. 𠇏or long term success and optimal health, adopt a new way of eating healthfully, not a short term 𠆍iet,’ regardless of what&aposs trendy or popular.”

How the rankings are calculated.

To determine the rankings, U.S. News and World Report convened an expert panel consisting of 25 of the country&aposs top nutritionists, dietary consultants and physicians specializing in diabetes, heart health and weight loss. Each of the experts complete an in-depth survey, scoring 35 diets in seven areas, including ease of compliance, likelihood of losing significant weight in the short and long term, and effectiveness against cardiovascular disease and diabetes. 

"The fundamentals of sustainable, healthful eating do not change every year, but the ways to get there, the range of variants on that common theme, and the most current evidence all do," explains Dr. Katz. "By pooling the assessments of diverse experts to bundle all of that essential information into a single, user-friendly, and always eagerly anticipated report, U.S. News is providing a unique and genuinely empowering service."

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A vegan diet cuts severe COVID risk by 73%, study suggests

Going vegan could cut the risk of severe coronavirus complications by 73%, research suggests.

The health pros and cons of adopting a plant-based diet have long been debated. While vegans generally have a higher vitamin C and fibre intake, forgoing meat and dairy could leave people deficient in vitamin B12, iron and calcium.

To better understand how a person's diet influences their risk of COVID-19, the disease caused by the coronavirus, a team from Stamford Hospital in Connecticut analysed more than 2,800 frontline medics in six countries.

The workers whose diet was predominantly vegan – made up of vegetables, lentils and nuts with little meat – were 73% less likely to develop moderate-to-severe disease.

Adding fish or seafood to the plant-based diet cut the risk by 59%, the results suggest.

A diet high in vegetables, but low in processed meat and high-fat dairy, may help people maintain a healthy weight – with obesity long being linked to severe COVID-19.

Nevertheless, the Connecticut team's results remained the same after adjusting for the workers' body mass index, suggesting another factor may be at play.

Coronavirus aside, airway infections killed around 2.4 million people worldwide in 2016 alone. Nutritional factors are known to influence a person's immune response.

To better understand how dietary choices affect coronavirus complications, the Connecticut team analysed healthcare workers "with substantial exposure to COVID-19 patients" from the UK, US, France, Germany, Spain and Italy.

The workers completed a survey between July and September 2020, providing information on their diet over the past year and any coronavirus complications they endured.

Of the workers, 568 are known or suspected to have caught the coronavirus, which was moderate to severe in 138 cases.

A predominantly vegan diet, with or without fish, was linked to a lower risk of coronavirus complications.

While a vegan diet may ward off COVID complications, it was not linked to a reduced risk of catching the coronavirus itself or overcoming the infection any quicker.

The results – published in the journal BMJ Nutrition Prevention & Health – remained the same after the team accounted for the workers' weight, age, ethnicity, smoking status and activity levels.

Coronavirus complications are known to be more common among elderly people and those of a non-white ethnicity. Smoking and a sedentary lifestyle may also raise the risk.

Why the results occurred is unclear, but vegan diets tend to be high in nutrients that boost immune health.

For pescatarians, oily fish like salmon and mackerel are also rich in vitamin D and omega-3 fatty acids, anti-inflammatory nutrients that could ward off COVID-19.

Watch: Do coronavirus vaccines affect fertility?

The team has stressed their study was observational, and therefore does not prove cause and effect.

Most of the participants were also male, meaning the results may not apply to women, as well as people who do not work in healthcare.

"The trends in this study are limited by study size and design (self-reporting on diet and symptoms) so caution is needed in the interpretation of the findings," said Shane McAuliffe, from the NNEdPro Nutrition and COVID-19 Taskforce.

Professor Gunter Kuhnle from the University of Reading agreed, adding: "The study relied entirely on self-reporting and a lot [of] data has shown self-reported dietary intake is unreliable.

"The study has [also] been conducted in different countries with widely different diets. A plant-based diet in Spain or Italy is likely to be different from a mainly plant-based diet in Germany or the UK".

Nevertheless, McAuliffe added: "A high-quality diet is important for mounting an adequate immune response, which in turn can influence susceptibility to infection and its severity.

"This study highlights the need for better designed prospective studies on the association between diet, nutritional status and COVID-19 outcomes".


The Flexitarian Diet encourages wholesome foods.

Unlike other diets that have numerous lists of foods you can't eat, the Flexitarian Diet is focused on what you can eat, with an emphasis on wholesome foods.

There are five Flex food groups, including:

  • The &ldquoNew Meat" refers to plant-proteins like beans, legumes, tofu, and tempeh
  • Fruits and veggies, including a variety of non-starchy and starchy vegetables
  • Whole grains, such as quinoa, brown rice, oats, barley, millet, corn, and farro
  • Dairy includes animal- and plant-based yogurt, milk, kefir, and cheese
  • &ldquoSugar and spice&rdquo are ingredients and condiments that boost flavor, such as herbs and spices, sweeteners, and vinegars. This section includes healthy fats like avocado, nuts, seeds, and oils

When incorporating animal products into the Flexitarian Diet, you're encouraged to make more sustainable protein choices, like:

  • Free-range or pasture-raised eggs
  • Organic or pasture-raised meat, dairy, and poultry
  • Wild-caught seafood

Although there aren't any food restrictions on the Flexitarian Diet, you should limit:


Plant�sed Diets Are Associated With a Lower Risk of Incident Cardiovascular Disease, Cardiovascular Disease Mortality, and All�use Mortality in a General Population of Middle𠄊ged Adults

Previous studies have documented the cardiometabolic health benefits of plant‐based diets however, these studies were conducted in selected study populations that had narrow generalizability.

Methods and Results

We used data from a community‐based cohort of middle‐aged adults (n=12 168) in the ARIC (Atherosclerosis Risk in Communities) study who were followed up from 1987 through 2016. Participants’ diet was classified using 4 diet indexes. In the overall plant‐based diet index and provegetarian diet index, higher intakes of all or selected plant foods received higher scores in the healthy plant‐based diet index, higher intakes of only the healthy plant foods received higher scores in the less healthy plant‐based diet index, higher intakes of only the less healthy plant foods received higher scores. In all indexes, higher intakes of animal foods received lower scores. Results from Cox proportional hazards models showed that participants in the highest versus lowest quintile for adherence to overall plant‐based diet index or provegetarian diet had a 16%, 31% to 32%, and 18% to 25% lower risk of cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality, respectively, after adjusting for important confounders (all P<0.05 for trend). Higher adherence to a healthy plant‐based diet index was associated with a 19% and 11% lower risk of cardiovascular disease mortality and all‐cause mortality, respectively, but not incident cardiovascular disease (P<0.05 for trend). No associations were observed between the less healthy plant‐based diet index and the outcomes.

Conclusions

Diets higher in plant foods and lower in animal foods were associated with a lower risk of cardiovascular morbidity and mortality in a general population.

Clinical Perspective

What Is New?

Plant‐based diets, diets that emphasize higher intakes of plant foods and lower intakes of animal foods, are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality in a general US adult population.

Healthful plant‐based diets, diets higher in nutrient‐dense plant foods and lower in refined carbohydrates and animal foods, are associated with a lower risk of cardiovascular disease mortality and all‐cause mortality, but not incident cardiovascular disease.

What Are the Clinical Implications?

Our results suggest that dietary patterns that are relatively higher in plant foods and relatively lower in animal foods may confer benefits for cardiovascular health.

Future research examining whether the quality of plant foods (healthful versus less healthful) within the framework of an overall plant‐based diet is associated with cardiovascular disease and all‐cause mortality is warranted.

Introduction

Plant‐based diets are dietary patterns that emphasize higher intakes of plant foods and are low in animal foods. Vegetarian diets, a type of plant‐based diet, with a focus on restriction of different types of animal foods (meat, poultry, or fish), have been associated with a lower risk of cardiovascular risk factors, such as obesity, hypertension, type 2 diabetes mellitus, and ischemic heart disease. 1 , 2 , 3 However, prospective cohort studies have shown mixed results on the associations with cardiovascular disease mortality and all‐cause mortality. 4 , 5 , 6 These previous studies were conducted in selected study populations that were mostly composed of Seventh‐Day Adventists, vegetarians, or health‐conscious individuals thus, they had relatively narrow generalizability. 4 , 5 , 7 , 8 , 9

Although prior studies have characterized participants’ diets using a relatively simple classification method based on frequency of animal food consumption, 4 , 5 , 6 there have since been more comprehensive attempts to assess an individual's diet using plant‐based diet indexes. 10 , 11 , 12 , 13 These indexes give higher scores for higher consumption of plant foods and lower consumption of animal foods, allowing researchers to examine whether the degree of adherence to an overall plant‐based diet is associated with health outcomes. Studies that used such indexes (ie, an overall plant‐based diet index [PDI] or a provegetarian diet index) found that greater adherence to these diets was associated with a lower risk of type 2 diabetes mellitus, coronary heart disease, and all‐cause mortality. 10 , 11 , 12 In addition, some plant‐based indexes separately scored healthful (whole grains, vegetables, and plant proteins) and unhealthful (refined carbohydrates and sugar) plant sources of food. Healthful plant‐based diets, which scored higher intakes of only healthful plant foods higher, were more strongly inversely associated with type 2 diabetes mellitus and coronary heart disease than the overall plant‐based diets. 11 , 12 In contrast, greater adherence to less healthful (unhealthful) plant‐based diets, which scored higher intakes of only less healthful plant foods higher, were associated with a higher risk of these conditions. 11 , 12

Given the limited evidence on plant‐based diets in the general population and recent developments in plant‐based diet scores, the objectives of the present study were as follows: (1) to evaluate whether overall plant‐based diets are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality in a general US population and (2) to assess if the association differed by adherence to healthful and less healthful plant‐based diets using 4 a priori defined plant‐based diet scores (overall plant‐based diet, healthy plant‐based diet, less healthy plant‐based diet, and provegetarian diet indexes).

Methods

ARIC (Atherosclerosis Risk in Communities) study data are available through the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center. Interested researchers may also contact the ARIC study Coordinating Center to access data and study materials.

Study Design

We used data from a community‐based cohort of middle‐aged men and women (45–64 years of age at baseline, n=15 792) in the ARIC study. From 1987 to 1989, participants from 4 US communities (Washington County, Maryland Forsyth County, North Carolina Minneapolis, MN and Jackson, MS) were enrolled in the study. 14 Follow‐up visits occurred in 1990 to 1992 (visit 2), 1993 to 1995 (visit 3), 1996 to 1998 (visit 4), 2011 to 2013 (visit 5), and 2016 to 2017 (visit 6). 14 The Institutional Review Board at each study site approved the study protocol, and participants provided informed consent.

Dietary Assessment

At baseline and visit 3, participants’ usual intake of foods and beverages was assessed by trained interviewers using a modified version of the 66‐item semiquantitative Willett food frequency questionnaire. 15 Participants indicated the frequency with which they consumed foods and beverages of a defined serving size in the previous year. Visual guides, such as glasses and measuring cups, were provided for participants to estimate portion size. The reliability of the food frequency questionnaire was assessed in a random sample of ARIC study participants (n=419) from all 4 study sites at visit 2. 15 Nutrient and total energy intakes were derived through multiplying consumption of food by nutrient content of each item in the food frequency questionnaire.

Plant‐Based Diet Scores

The ARIC study did not assess whether participants were following a plant‐based diet. We used established plant‐based diet scores (PDI, healthy plant‐based diet index [hPDI], less healthy [unhealthy] plant‐based diet index [uPDI], and provegetarian diet index) to assess participants’ degree of adherence to plant‐based diets on the basis of their reported dietary intake on the food frequency questionnaire. We used these 4 plant‐based diet indexes to provide comprehensive and nuanced characterization of dietary intakes because the indexes differed from each other in scoring of food groups within the indexes. For instance, the PDI was more comprehensive than the provegetarian index in that the PDI assessed dietary intakes of plant foods high in refined carbohydrates (fruit juices, sugar‐sweetened beverages, sweets, and desserts). Consistent with some ethically motivated dietary patterns that are focused on the exclusion of animal sources of food and have less of an emphasis on the quality of plant foods, the provegetarian diet index provides a more simplistic score of the diet in that these refined carbohydrate food groups were not assessed. Further details on differences and construction of the scores have been published previously and are available in Data S1. 10 , 11 , 12 , 13 , 16

The PDI, hPDI, and uPDI had a possible range from 17 to 85, and the provegetarian diet index had a possible range from 11 to 55. All scores were divided into quintiles for analyses.

Outcome Assessment

Incident cardiovascular disease events and deaths (cardiovascular and all cause) were ascertained through annual telephone calls with participants or proxies, active surveillance of local hospital discharge records and state death records, and linkage to the National Death Index from baseline to December 31, 2016. Incident cardiovascular disease was defined as a composite outcome of coronary heart disease, stroke, and heart failure. Incident coronary heart disease was defined as hospitalized myocardial infarction or fatal coronary heart disease. 17 Incident stroke was defined as definite or probable stroke, which was adjudicated. 18 Incident heart failure was defined as hospitalization or death, with International Classification of Diseases, Ninth Revision (ICD‐9), code 428 or International Classification of Diseases, Tenth Revision (ICD‐10), code I50. 19 All‐cause mortality was defined as deaths attributable to any cause, and cardiovascular disease mortality was defined as deaths with ICD‐9 codes 390 to 459 or ICD‐10 codes I00 to I99.

Covariate Assessment

At baseline, participants’ sociodemographic information (age, sex, race/ethnicity, and education), health behaviors (cigarette smoking, frequency and duration of physical activity, alcohol intake, and margarine intake), medication use (lipid‐lowering medication use, antihypertensive medication use, or diabetes mellitus medication use), and health conditions (diagnosis of diseases) were collected by self‐reports.

Trained staff measured participants’ weight and height, which was used to calculate body mass index (BMI kg/m 2 ). Those whose BMI was ≤25 kg/m 2 were classified as normal weight, those whose BMI was from 25 to <30 kg/m 2 were classified as overweight, and those whose BMI was ≥30 kg/m 2 were classified as obese. An enzymatic method was used to measure total cholesterol concentration. 20 A certified technician measured participants’ blood pressure 3 times, and the second and third measurements were averaged. The modified hexokinase/glucose‐6‐phosphate dehydrogenase method was used to measure blood glucose concentrations. Baseline kidney function (estimated glomerular filtration rate) was estimated from serum creatinine measurement using the 2009 Chronic Kidney Disease Epidemiology Collaboration equation. 21 We defined hypertension as systolic blood pressure of ≥140 mm Hg, diastolic blood pressure of ≥90 mm Hg, or antihypertensive medication use in the past 2 weeks. We defined diabetes mellitus as fasting glucose concentration of ≥126 mg/dL, nonfasting blood glucose concentration of ≥200 mg/dL, self‐reported physician's diagnosis of diabetes mellitus, or diabetes mellitus medication use in the past 2 weeks.

Statistical Analyses

We calculated dietary intakes from baseline and visit 3 using cumulative averaged diet with respect to each outcome. 22 For example, we used dietary intake from only visit 1 if participants developed cardiovascular disease or were censored before visit 3. We averaged the dietary intake from both visits if participants developed cardiovascular disease or were censored after visit 3.

To create the final analytic sample of 12 168, we first excluded participants with implausible total energy intake (<500 or >3500 kcal for women and <700 or >4500 kcal for men, n=383). Then, we excluded those whose race/ethnicity was neither black nor white (n=47), blacks in Minnesota (n=18), and blacks in Maryland (n=23). We also excluded participants with a history of myocardial infarction, heart or arterial surgery, heart failure, stroke, and cancer at baseline because diagnosis of these conditions may change dietary habits (n=2677). Participants without complete information on covariates were excluded from analyses as well (n=476).

Baseline characteristics of the study participants and nutritional characteristics of the diet were examined according to quintiles of plant‐based diet scores (PDI, hPDI, uPDI, and provegetarian diet index) using χ 2 tests for categorical variables and ANOVA for continuous variables. Food intakes were expressed as servings per day, macronutrients as a percentage of energy, and fiber and micronutrients as g, mg, or μg per 1000 kcal.

We calculated hazard ratios (HRs) and 95% CIs to estimate the association between plant‐based diet scores and incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality. Three nested Cox proportional hazards models were modeled using length of follow‐up time as the time metric. In model 1, total energy intake, age, sex, and race‐center (whites in Washington County, Maryland blacks in Forsyth County, North Carolina whites in Forsyth County, North Carolina whites in Minneapolis, MN and blacks in Jackson, MS) were adjusted. In model 2, education (a proxy for socioeconomic status), cigarette smoking, physical activity, alcohol intake, and margarine intake were additionally adjusted. In model 3, potential mediating variables, such as total cholesterol, lipid‐lowering medication use, hypertension, diabetes mellitus, baseline kidney function (2 linear spline terms with 1 knot at 90 mL/min per 1.73 m 2 ), and BMI were additionally adjusted. We evaluated the proportionality assumption by examining Schoenfeld residual and log(−log) plots, and we did not find a clear indication that the assumption was violated. The median value within each quintile of plant‐based diet scores was used to test for a linear trend. We considered the main results to be estimates from model 2 (no potential mediating variables). In addition, we used splines to visually depict the relation between plant‐based diet scores as a continuous variable and incident cardiovascular disease. We first used restricted cubic splines with 4 knots at the 5th, 35th, 65th, and 95th percentiles. The shape of the association appeared approximately linear, so we presented the results using 2 linear spline terms with 1 knot at the 12.5th percentile of each plant‐based diet index. As a sensitivity analysis, we considered margarine as part of the plant‐based diet scores instead of a covariate in the fully adjusted models. Margarine intake was positively scored in the PDI, hPDI, and provegetarian diet index and negatively scored in the uPDI, consistent with how vegetable oil was scored in previous studies. 10 , 11 , 12

We conducted 2 additional analyses in model 3: First, we modeled score components of plant‐based diet scores (healthy plant foods [aggregated consumption of whole grains, fruits, vegetables, nuts, legumes, tea, and coffee], less healthy plant foods [aggregated consumption of fruits juices, refined grain, potatoes, sugar‐sweetened beverages, sweets, and desserts], and animal foods [aggregated consumption of animal fat, dairy, eggs, fish or seafood, meat, and miscellaneous animal foods] from PDI plant foods [selected] and animal foods from provegetarian diet index) simultaneously instead of the scores. Second, we modeled the individual food groups within PDI and provegetarian diet index simultaneously. Given that associations with red and processed meat differ from poultry with regard to cardiovascular disease and all‐cause mortality, 23 we reclassified the meat category into 2 separate categories: (1) red and processed meat and (2) poultry. Third, we examined whether the observed associations differed by sex (women/men), age (less than the median, greater than or equal to the median), race (white or black), weight status (normal weight, overweight, or obese), and diabetes mellitus status (diabetes mellitus or no diabetes mellitus). All analyses were conducted using Stata, version 13.0, statistical software (StataCorp, College Station, TX).

Results

Baseline Characteristics

The PDI ranged from 28 to 74, the hPDI ranged from 29 to 77, the uPDI ranged from 27 to 76, and the provegetarian diet index ranged from 15 to 54. Those in the highest quintiles of PDI, hPDI, and provegetarian diet index were more likely to be women, white, high school graduates, and physically active and were less likely to be obese, to be current smokers, to have diabetes mellitus, and to have hypertension at baseline compared with those in the lowest quintiles (Tables 1 and 2, Table S1). Conversely, those in the highest quintile of uPDI were more likely to be men, to be younger, to be current smokers, and to drink a higher amount of alcohol and less likely to be high school graduates, obese, and physically active compared with those in the lowest quintile. Those in the highest quintile of uPDI were more likely to have hypertension, but less likely to have diabetes mellitus (P<0.05 for all comparisons) (Table S2).

Table 1. Selected Baseline Characteristics and Nutritional Characteristics by Quintiles of the PDI in the ARIC Study

Values are means (SDs) for continuous variables and percentages for categorical variables. ARIC indicates Atherosclerosis Risk in Communities BMI, body mass index eGFR, estimated glomerular filtration rate IU, international units MUFA, monounsaturated fatty acid PDI, overall plant‐based diet index PUFA, polyunsaturated fatty acid.

a Indicates a statistical difference by quintiles of PDI (P<0.05), tested using ANOVA for continuous variables and χ 2 test for categorical variables.

b Food intakes are expressed as servings per day.

Table 2. Selected Baseline Characteristics and Nutritional Characteristics by Quintiles of the Provegetarian Diet Index in the ARIC Study

Values are means (SDs) for continuous variables and percentages for categorical variables. ARIC indicates Atherosclerosis Risk in Communities BMI, body mass index eGFR, estimated glomerular filtration rate IU, international units MUFA, monounsaturated fatty acid PUFA, polyunsaturated fatty acid.

a Indicates statistical difference by quintiles of provegetarian diet index (P<0.05), tested using ANOVA for continuous variables and χ 2 test for categorical variables.

b Food intakes are expressed as servings per day.

Nutritional Characteristics

Participants in the highest quintiles of PDI, hPDI, and provegetarian diet index consumed an average of 4.1 to 4.8 servings of fruit and vegetables per day and 0.8 to 0.9 servings of red and processed meat per day (Tables 1 and 2, Table S1). Those in the highest quintiles of PDI, hPDI, and provegetarian diet had higher intake of carbohydrates and plant protein as a percentage of energy, fiber, and micronutrients, including potassium, magnesium, iron, vitamin A, vitamin C, and folate, and lower intake of saturated fat and cholesterol compared with those in the lower quintiles (P<0.05 for all comparisons). Polyunsaturated fat as a percentage of energy was higher among those in the highest quintiles of PDI and provegetarian diet, but lower among those in the highest quintiles of hPDI and uPDI (P<0.05 for all comparisons).

In contrast, those in the highest quintile of uPDI consumed an average of 2.3 servings of fruit and vegetables per day and 1.2 servings of red and processed meat per day (Table S2). Those in the highest quintile of uPDI consumed higher intake of total energy and carbohydrates as a percentage of energy, but had lower intake of fiber and micronutrients, including calcium, potassium, magnesium, iron, vitamin A, vitamin C, and folate compared with those in the lowest quintile of uPDI (P<0.05 for all comparisons).

Plant‐Based Diets and Cardiovascular Disease Outcomes and All‐Cause Mortality

During a median follow‐up of 25 years, 4381 incident cardiovascular disease events, 1565 deaths caused by cardiovascular disease, and 5436 deaths attributable to all causes occurred. Incidence rates for cardiovascular disease events, cardiovascular disease mortality, and all‐cause mortality were lower at higher quintiles of PDI, hPDI, and provegetarian diet index (Table S3). We did not observe a strong and consistent pattern for incidence rates of the outcomes across quintiles of uPDI. There was a significant lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality across quintiles of PDI, hPDI, and provegetarian diet index only in the minimally adjusted models that accounted for age, sex, race‐center, and total energy intake.

The strongest and most consistent significant associations were observed for PDI and provegetarian diet index, with all 3 outcomes in all 3 models (Figures S1 and S2). After adjusting for sociodemographic characteristics (age, sex, race‐center, and education), dietary factors (total energy intake and margarine consumption), and health behaviors (smoking, physical activity, and alcohol consumption), those in the highest versus lowest quintiles of PDI and provegetarian diet index had a 16% and 16% lower risk of incident cardiovascular disease, a 32% and 31% lower risk of cardiovascular mortality, and a 25% and 18% lower risk of all‐cause mortality, respectively (Table 3). These associations remained significant and similar in magnitude after adjusting for potential mediating factors (total cholesterol, lipid‐lowering medication use, estimated glomerular filtration rate, hypertension, diabetes mellitus, and BMI) (Table S4). In the continuous analysis, there was an approximately linear inverse relationship between PDI (Figure 1) and provegetarian diet index (Figure 2) scores and risk of incident cardiovascular disease.

Table 3. Hazard Ratios and 95% CIs for Incident Cardiovascular Disease, Cardiovascular Disease Mortality, and All‐Cause Mortality, According to Quintiles of Plant‐Based Diet Indexes

Data are adjusted for age, sex, race‐center, total energy intake, education, smoking status, physical activity, alcohol consumption, and margarine consumption. hPDI indicates healthy plant‐based diet index PDI, overall plant‐based diet index uPDI, less healthy (unhealthy) plant‐based diet index.

Figure 1. Adjusted hazard ratios and 95% CIs for incident cardiovascular disease, according to the continuous overall plant‐based diet index (PDI). The histogram shows the distribution of scores for the PDI in gray. The solid lines represent the adjusted hazard ratios for incident cardiovascular disease, modeled using 2 linear spline terms with 1 knot at the 12.5th percentile of PDI (score, 44), which was used as the reference point. The dashed lines represent the 95% CIs. Hazard ratios were adjusted for age, sex, race‐center, total energy intake, education, smoking status, physical activity, alcohol consumption, margarine consumption, baseline total cholesterol, lipid medication use, baseline kidney function, hypertension, diabetes mellitus, and baseline body mass index.

Figure 2. Adjusted hazard ratios and 95% CIs for incident cardiovascular disease, according to the continuous provegetarian diet score. The histogram shows the distribution of scores for the provegetarian diet index in gray. The solid lines represent the adjusted hazard ratios for incident cardiovascular disease, modeled using 2 linear spline terms with 1 knot at the 12.5th percentile of the provegetarian diet index (score, 27), which was used as the reference point. The dashed lines represent the 95% CIs. The hazard ratios were adjusted for age, sex, race‐center, total energy intake, education, smoking status, physical activity, alcohol consumption, margarine consumption, baseline total cholesterol, lipid medication use, baseline kidney function, hypertension, diabetes mellitus, and baseline body mass index.

For hPDI, after adjusting for sociodemographic characteristics, dietary factors, and health behaviors in model 2, those in the highest versus lowest quintile had a 19% lower risk of cardiovascular disease mortality (HR, 0.81 95% CI, 0.68–0.97 P=0.01 for trend) and an 11% lower risk of all‐cause mortality (HR, 0.89 95% CI, 0.81–0.98 P=0.01 for trend) (Table 3). After accounting for potential mediating factors in model 3, there was still a significant inverse trend for cardiovascular disease mortality and all‐cause mortality across quintiles of hPDI (P=0.03 for trend for both) (Table S4). However, we found no significant association between hPDI and incident cardiovascular disease in model 2 (Table 3) or model 3 (Table S4).

No significant associations were observed between uPDI and the outcomes in model 1 (Table S3), model 2 (Table 3), or model 3 (Table S4) (all P>0.05 for trend). Similar results were observed when we used hPDI and uPDI as continuous variables (Figures S3 and S4).

When margarine was included as part of the scores, the association between provegetarian diet and incident cardiovascular disease was attenuated (HRquintile 5 versus quintile 1, 0.89 95% CI, 0.81–1.00 P=0.01 for trend). The results were similar to those from the main analysis for all other indexes.

Analyses on Score Components and Individual Food Groups

When we modeled score components of PDI (quintiles of healthy plant food, less healthy plant food, and animal food) simultaneously instead of the overall score in model 3, those in the highest quintile of animal food consumption had a higher risk of incident cardiovascular disease (HR, 1.14 95% CI, 1.04–1.27 P<0.001 for trend), cardiovascular disease mortality (HR, 1.30 95% CI, 1.10–1.54 P<0.001 for trend), and all‐cause mortality (HR, 1.12 95% CI, 1.02–1.23 P=0.001 for trend) compared with those in the lowest quintile, whereas no significant association was observed for healthy plant food or less healthy plant food consumption (Table S5). When components of the provegetarian diet index (quintiles of selected plant foods and animal foods) were modeled, similar associations with animal foods were observed for all 3 outcomes (all P<0.01 for trend). A higher intake of selected plant food in the provegetarian diet index was associated with a lower risk of cardiovascular disease mortality (P=0.009 for trend) and all‐cause mortality (P<0.001 for trend), but the association between selected plant food in the provegetarian diet index and cardiovascular disease was not statistically significant (HR, 0.95 95% CI, 0.86–1.05 P=0.05 for trend).

When we modeled all food groups in the PDI simultaneously, higher intakes of whole grains were consistently associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality, whereas higher intakes of eggs and red and processed meat were associated with a higher risk of all 3 outcomes (Table S6). Higher intake of potatoes, which were classified as less healthy plant foods for hPDI and uPDI, was inversely associated with incident cardiovascular disease and all‐cause mortality. There was no significant association for dairy or for fish and seafood with all 3 outcomes. Similar associations between individual food components of the provegetarian diet index (specifically, eggs, red and processed meat, potatoes, dairy, and fish or seafood) were observed.

Subgroup Analyses

For incident cardiovascular disease, we found evidence of statistical interaction by diabetes mellitus status with hPDI (P=0.01 for interaction) and provegetarian diet (P=0.03 for interaction) (Figure S5). The associations for hPDI and provegetarian diet with risk of incident cardiovascular disease were stronger among those with diabetes mellitus relative to those without diabetes mellitus, although hPDI was not significantly associated with cardiovascular disease in either subgroup. No statistical evidence of interaction was observed by sex, age, race, or weight status with incident cardiovascular disease. There was also no statistical interaction by sex, age, race, weight status, or diabetes mellitus status with cardiovascular disease mortality and all‐cause mortality for all indexes (P>0.05 for interaction for all tests).

Discussion

In this community‐based cohort of US adults without cardiovascular disease at baseline, we found that higher adherence to an overall plant‐based diet or a provegetarian diet, diets that are higher in plant foods and lower in animal foods, was associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality. Healthy plant‐based diets, which are higher in whole grains, fruits, vegetables, nuts, legumes, tea, and coffee and lower in animal foods, were associated with a lower risk of cardiovascular disease mortality and all‐cause mortality.

Our study is one of the few studies that used data from a general population. Prospective studies of Seventh‐Day Adventists in the United States and Canada found that vegetarians had a lower risk of cardiovascular disease mortality and all‐cause mortality compared with nonvegetarians. 4 The EPIC (European Prospective Investigation Into Cancer and Nutrition)‐Oxford study of vegetarians, vegans, and health‐conscious individuals reported that the risk of incident ischemic heart disease and deaths caused by circulatory disease was lower in vegetarians than nonvegetarians. 5 , 24 However, these findings were not replicated in population‐based studies in Australia and the United States. 6 , 13 Notably, a prior study that used data from a nationally representative sample administered a brief questionnaire that assessed the frequency with which participants consumed specific types of animal food (red meat, processed meat, poultry, or fish or seafood) to characterize participants’ dietary intakes. 6 Such dietary measurement may not have adequately represented dietary patterns on the basis of abundance of plant foods relative to animal foods. The plant‐based diet indexes we used in this study captured a wider spectrum of intake of plant foods and animal foods, leveraging the available dietary data, and allowed us to move away from defining plant‐based diets strictly based on exclusion of animal foods.

Our results on overall plant‐based diets and cardiovascular disease and all‐cause mortality are consistent with previous studies that used the PDI and provegetarian diet index. In a study of Spanish adults who were at high risk of developing cardiovascular disease, higher adherence to a provegetarian diet index was associated with a 53% lower risk of cardiovascular disease mortality and a 34% lower risk of all‐cause mortality. 10 In a study of nurses and health professionals in the United States, higher adherence to PDI was associated with a 8% lower risk of coronary heart disease. 12 In our study, higher scores in PDI and provegetarian diet index were associated with a 16% to 24% lower risk of incident cardiovascular disease and all‐cause mortality, and higher intakes of animal products were associated with an elevated risk of all of 3 outcomes. Results from our study suggest that progressively increasing the intake of plant foods by reducing the intake of animal foods is associated with benefits on cardiovascular health and mortality risk.

Our results on higher intakes of animal foods and higher risk of cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality are in line with many observational studies that reported that higher intakes of animal foods, particularly red and processed meat, are associated with an elevated risk of these outcomes. 4 , 5 , 25 , 26 Our results are also consistent with previous studies of vegetarian diets that characterized participants’ diets on the basis of the degree of animal food consumption. 24 In our sample, those in the highest quintiles of PDI and provegetarian diet index had higher intakes of fruits and vegetables, fiber, polyunsaturated fats, and many micronutrients and lower intakes of red and processed meat and saturated fat. All these characteristics can contribute to a lower risk of cardiovascular disease by lowering blood pressure and low‐density lipoprotein cholesterol, reducing inflammation, and improving glycemic control. 27 , 28 , 29

However, our results diverged from a prior study that found a lower risk of coronary heart disease with an hPDI and an elevated risk with a uPDI. It is surprising that no association was observed for hPDI and cardiovascular disease in our study, given that higher intakes of foods that have been associated with a lower risk with coronary heart disease were scored higher (fruits, vegetables, whole grains, and plant proteins) in hPDI. When we modeled individual food groups within the plant‐based diet indexes simultaneously, we found that foods that were considered less healthy (ie, potatoes) were inversely associated with incident cardiovascular disease and all‐cause mortality. It is possible that assigning reverse scores to these foods attenuated the associations with the overall hPDI and incident cardiovascular disease. Specifically, potatoes in relation to chronic disease outcomes have shown mixed results, with recent systematic reviews concluding no association with total potato consumption and cardiovascular risk factors (obesity and type 2 diabetes mellitus), cardiovascular events, and all‐cause mortality. 30 , 31 In the NHS (Nurses’ Health Study) and HPFS (Health Professionals Follow‐Up Study), higher total potato consumption was associated with a higher risk of hypertension and type 2 diabetes mellitus. 32 , 33 However, in 2 Spanish cohorts, no significant association between potato consumption and hypertension was observed. 34 Given these conflicting findings, future studies may consider assigning reverse scores for fried potatoes but not all potatoes.

Unlike the NHS and HPFS, which found a higher risk of type 2 diabetes mellitus and coronary heart disease with less healthy plant‐based diet scores, we found no significant associations for uPDI and incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality. 11 , 12 In our previous study, which used data from a nationally representative sample, we did not find associations between the uPDI and cardiovascular disease mortality and all‐cause mortality. 13 It is possible that no true association exists between less healthy plant‐based diets and cardiovascular disease and all‐cause mortality. The lack of an association between less healthy plant‐based diets and outcomes in the present study may be caused by the scoring of potatoes as a less healthy food given that we observed dietary intake of potatoes to be inversely associated with outcomes. Further research in other study populations is warranted on the health implications of diets high in refined carbohydrates and sugar and low in fruits, vegetables, and animal foods.

We found that the magnitude of association for the overall diet was stronger than the associations for the individual food components within the overall dietary pattern. These results underscore the importance of comprehensively characterizing an individual's diet, rather than assessing the intake of a single food group or nutrient. Our approach accounts for potential synergistic and interactive effects of foods and nutrients on disease risk and is in line with how plant‐based diets are conceptualized (ie, higher intake of plant foods and lower intake of animal foods). 13 , 35 , 36 , 37

When we modeled individual food groups, there was no association between dairy or fish or seafood and all 3 outcomes. Previous studies have shown that plant‐rich diets that incorporated low‐fat dairy products (eg, the Dietary Approaches to Stop Hypertension diet) or fish (eg, the Mediterranean‐style diet) were associated with a lower risk of type 2 diabetes mellitus and cardiovascular disease. 38 , 39 , 40 , 41 In future studies, it may be worth exploring whether inclusion of dairy or fish in a plant‐based diet is associated with a lower risk of chronic diseases.

We add to the existing literature on plant‐based diets and chronic diseases by using a well‐characterized community‐based cohort with repeated dietary assessments and long‐term follow‐up. Several limitations should be accounted for when interpreting the study results. First, dietary intakes were self‐reported, which is subject to measurement error. However, the food frequency questionnaire was administered by trained interviewers, and the food frequency questionnaire has shown to have high reproducibility. 15 Second, we used a sample‐based scoring method to assess the degree of adherence to plant‐based diets. Those in the highest quintiles of all the plant‐based diet scores had higher intakes of plant foods and lower intakes of animal foods. However, we are unable to infer if there is an absolute level of plant food or animal food intake that is associated with health outcomes. Third, dietary intakes were measured several decades ago in the ARIC study thus, this study may not reflect the modern food supply. Studies with more recent data on plant‐based diets and cardiovascular disease are warranted. Last, the possibility of residual confounding remains because of unmeasured or incorrectly measured variables.

In conclusion, diets consisting of predominantly plant foods and that are lower in animal foods were associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all‐cause mortality in a general population. Dietary patterns that are relatively higher in plant foods and relatively lower in animal foods may confer benefits for cardiovascular health. Considering the adverse outcomes associated with refined carbohydrate consumption, 42 , 43 future research should continue to explore if the quality of plant foods (either healthy plant foods or less healthy plant foods) within the framework of plant‐based diets is associated with cardiovascular disease and all‐cause mortality in a general population.

Author Contributions

Dr Kim wrote the manuscript and analyzed the data Drs Kim and Rebholz designed the study Drs Caulfield, Garcia‐Larsen, Steffen, and Coresh contributed important intellectual content during drafting or revising the manuscript. Dr Rebholz was involved in all aspects of the study from analyses to writing. All authors read and approved the final manuscript.

Sources of Funding

The ARIC (Atherosclerosis Risk in Communities) study was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services (HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700004I, and HHSN268201700005I). Dr Kim was supported by the Department of International Health Tuition Scholarships, Bacon Chow Endowed Award, Harry D. Kruse Fellowship, and Harry J. Prebluda Fellowship from the Program in Human Nutrition in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. Dr Rebholz was supported by a Mentored Research Scientist Development Award from the National Institute of Diabetes and Digestive and Kidney Diseases (K01 DK107782) and a grant from the National Heart, Lung, and Blood Institute (R21 HL143089). The funding agencies had no role in study design, data collection, analysis, drafting of the manuscript, and the decision to submit the manuscript for publication.


Eating a diet rich in fruit and vegetables could cut obesity risk

Pro-vegetarian diets (with a higher consumption of plant-based foods compared to animal-based foods) could provide substantial protection against obesity, according to new research presented at this year's European Congress on Obesity (ECO) in Porto, Portugal (17-20 May).

This observational study found that people who ate a high pro-vegetarian diet -- rich in food coming from plant sources like vegetables, fruit, and grains -- cut their risk of developing obesity by almost half compared to those who were least pro-vegetarian -- with a dietary pattern rich in animal food like meat, and animal fats.

Current evidence suggests that such a pro-vegetarian diet has a protective role in cardiovascular disease and diabetes, but little is known about its role on the risk of developing obesity in healthy populations.

The study was carried by University of Navarra student Julen Sanz under the supervision of Dr. Alfredo Gea and Professor Maira Bes-Rastrollo from the University of Navarra, and CIBERobn (Carlos III Institute of Health), Spain. They examined the association between varying degrees of pro-vegetarian (plant-based) diet and the incidence of obesity (body mass index BMI >30) in over 16,000 healthy, non-obese adults from the SUN Cohort (Seguimiento Universidad de Navarra) -- a study tracking the health of Spanish graduates since 1999.

Participants completed detailed food questionnaires at the start of the study, and researchers used a pro-vegetarian diet index (PVI) to score each participant on the types of food they ate. Points were given for eating seven plant food groups -- vegetables, fruits, grains, nuts, olive oil, legumes (such as peas, beans, and lentils) and potatoes. Points were subtracted for five animal groups -- animal fats, dairy, eggs, fish and other seafood, and meat. Based on their scores, participants were categorised into five groups from the 20% with the least pro-vegetarian diet (quintile 1) to the 20% with the most (quintile 5), and followed for an average of 10 years.

During follow-up, 584 participants became obese. The researchers found that participants who closely followed a pro-vegetarian diet were less likely to become obese. Modelling showed that compared to the least-vegetarian participants (quintile 1), the most vegetarian (quintile 5) had a 43% reduced risk of developing obesity. For quintiles 2, 3 and 4, the reduced risk of obesity was 6%, 15% and 17%, respectively, versus quintile 1. The results held true irrespective of other influential factors including sex, age, alcohol intake, BMI, family history of obesity, snacking between meals, smoking, sleep duration, and physical activity.

The authors acknowledge that their findings show observational differences rather than evidence of cause and effect. They conclude: "Our study suggests that plant-based diets are associated with substantially lower risk of developing obesity. This supports current recommendations to shift to diets rich in plant foods, with lower intake of animal foods."