A Heart-Healthy Diet: Recent Insights and Practical Recommendations

Abstract

Purpose of review:
The purpose of this study is to review the current evidence on the relationship between diet and heart, giving practical recommendations for cardiovascular prevention.

Recent findings:
A heart-healthy diet should maximize the consumption of whole grains, vegetables, fruit, and legumes and discourage the consumption of meat and meat products as well as refined and processed foods. Plant-based diets fully meet these criteria, and the evidence supporting the protective effect of these dietary patterns evolved rapidly in recent years. Among plant-based diets, the Mediterranean and vegetarian diets gained the greater interest, having been associated with numerous health benefits such as reduced levels of traditional and novel risk factors and lower risk of cardiovascular disease. These positive effects may be explained by their high content of dietary fiber, complex carbohydrate, vitamins, minerals, polyunsaturated fatty acids, and phytochemicals. Current evidence suggests that both Mediterranean and vegetarian diets are consistently beneficial with respect to cardiovascular disease.

Full text

LIPID ABNORMALITIES AND CARDIOVASCULAR PREVENTION (G DE BACKER, SECTION EDITOR)
A Heart-Healthy Diet: Recent Insights
and Practical Recommendations
Monica Dinu
1
&Giuditta Pagliai
1
&Francesco Sofi
1,2,3
#Springer Science+Business Media, LLC 2017
Abstract
Purpose of Review The purpose of this study is to review the
current evidence on the relationship between diet and heart,
giving practical recommendations for cardiovascular
prevention.
Recent Findings A heart-healthy diet should maximize the
consumption of whole grains, vegetables, fruit, and legumes
and discourage the consumption of meat and meat products as
well as refined and processed foods. Plant-based diets fully
meet these criteria, and the evidence supporting the protective
effect of these dietary patterns evolved rapidly in recent years.
Among plant-based diets, the Mediterranean and vegetarian
diets gained the greater interest, having been associated with
numerous health benefits such as reduced levels of traditional
and novel riskfactors and lower risk of cardiovascular disease.
These positive effects may be explained by their high content
of dietary fiber, complex carbohydrate, vitamins, minerals,
polyunsaturated fatty acids, and phytochemicals.
Summary Current evidence suggests that both Mediterranean
and vegetarian diets are consistently beneficial with respect to
cardiovascular disease.
Keywords Diet .Heart .Mediterranean diet .Vegetarian
diet .Cardiovascular disease
Abbreviations
AHS Adventist Health Study
AMS Adventist Mortality Study
BMI Body mass index
DHA Docosahexaenoic acid
EPA Eicosapentaenoic acid
EPIC European Prospective Investigation into Cancer
and Nutrition
HDL High-density lipoprotein
HFSS Health Food Shopper Study
LDL Low-density lipoprotein
NHANES National Health and Nutrition Examination
Survey
OVS Oxford Vegetarian Study
WHO World Health Organization
Introduction
The relationship between dietary factors and cardiovascular
disease has been a major issue of research for decades, since
the first results of the pioneering “Seven Countries’Study”
conducted by Ancel Keys have been released [1]. The reduced
prevalence of cardiovascular disease reported by the
Mediterranean countries during this study stimulated the clin-
ical research to evaluate the possible association between diet
and dietary habits and main chronic degenerative diseases.
A vast abundance of literature demonstrates that both inci-
dence and mortality from cardiovascular disease can be easily
prevented with adequate dietary choices and correctlifestyles,
such as moderate physical activity, abstinence from tobacco
smoking, and from harmful use of alcohol [2]. A balanced
diet, in terms of both quantity and quality, represents a key
factor for the optimal prevention of cardiovascular disease, by
reducing the risk of occurrence of the first ischemic event and
This article is part of the Topical Collection on Lipid Abnormalities and
Cardiovascular Prevention
*Francesco Sofi
francesco.sofi@unifi.it
1
Department of Experimental and Clinical Medicine, University of
Florence, Largo Brambilla 3, 50134 Florence, Italy
2
Clinical Nutrition Unit, Careggi University Hospital, Florence, Italy
3
Don Carlo Gnocchi Foundation Italy, Onlus IRCCS, Florence, Italy
Curr Cardiol Rep (2017) 19:95
DOI 10.1007/s11886-017-0908-0

improving the prognosis after the first event [3]. In the last few
decades, several dietary patterns have attracted public atten-
tion, but those that got the most interest were two plant-based
diets such as Mediterranean diet and the vegetarian diets.
Indeed, these dietary profiles have a common background
since they are both aimed at maximizing the consumption of
whole, plant-based foods and discouraging consumption of
meat and meat products as well as refined and processed
foods. Being rich in dietary fiber, complex carbohydrate, vi-
tamins, minerals, polyunsaturated fatty acids and phytochem-
icals, plant-based diets represent a useful instrument for
preventing heart disease [4].
Recent meta-analyses conducted in the last years showed a
consistent reduced risk of occurrence of cardiovascular dis-
ease for both Mediterranean and vegetarian diets [5••,6]. The
aim of this review was to examine the scientific evidence on
the beneficial effects of these two diets on heart health, giving
practical and evidence-based recommendations for cardiovas-
cular disease prevention.
Mediterranean Diet
The Mediterranean diet is considered one of the healthiest
dietary patterns for preventing diseases and maintaining the
health status, as several studies have shown that greater ad-
herence to a Mediterranean-like dietary pattern is associated
with a significant reduced risk of occurrence for chronic de-
generative diseases [7••]. The Mediterranean diet is a typical
dietary pattern traditionally followed by the people living in
the countries bordering the Mediterranean Sea. The main
characteristics of this dietary pattern include a high consump-
tion of vegetables, fruits, whole grains, legumes, nuts and
seeds and olive oil, fish, dairy products, poultry, and eggs
consumed in low-to-moderate amounts, and low intake of
red meat with a regular but moderate consumption of ethanol
(mainly as red wine). Although it is not clear which compo-
nents of the diet provide the greatest health benefits, it is
likely that certain components, when consumed collectively,
provide a protection versus chronic diseases [8].
Numerous prospective cohort studies and some clinical
trials are exponentially increasing the level and the quality of
the scientific evidence on the Mediterranean diet. Subjects in
the highest quantile of adherence to the Mediterranean diet
had a 24% lower incidence and mortality from cardiovascular
disease compared to those least adherent [6]. A significant
reduction of risk was also found for stroke (−24%), myocar-
dial infarction (−33%), and coronary heart disease (−28%) [6].
A recent umbrella review summarizing the evidence available
from all the published meta-analysis that studied the adher-
ence to the Mediterranean diet and different health outcomes
demonstrated the existence of a robust evidence on the rela-
tionship between a greater adherence to this dietary pattern
and cardiovascular outcomes [7••]. In fact, a reduced risk for
cardiovascular disease incidence and mortality, myocardial
infarction, and coronary heart disease was evidenced in both
meta-analyses of prospective cohort studies and intervention
studies [7••]. This positive effect is likely related to greater
effectiveness of the Mediterranean diet in lowering main car-
diovascular risk factors such as body mass index, lipid, and
glycemic profile, as well as inflammatory parameters when
compared with other diets. Regarding lipid profile, several
meta-analyses and intervention studies demonstrated a bene-
ficial effect of a Mediterranean diet on lipid variables, includ-
ing total and low-density lipoprotein (LDL)-cholesterol [7••].
In addition, a recent study reported that, even though the
Mediterranean diet was not able to raise high-density lipopro-
tein (HDL) levels, it enhanced the cardio protective capacity
of HDL cholesterol by improving HDL oxidative status and
composition [9]. Suggestive evidence also supports an effect
on improving glycaemic control and insulin sensitivity in peo-
ple following a Mediterranean diet [7••]. Insulin resistance
and diabetes, which are independent risk factors for cardio-
vascular disease, are linked to sugars and saturated fatty acids
consumption, excess energy intake and increased adiposity
[10]. Moreover, recent findings on the beneficial effects of
the Mediterranean on inflammatory parameters have been ob-
tained [11]. Inflammation has a key role at all the stages of the
cardiovascular disease and is crucial in the development and
rupture of the atheromatous plaque. Mediterranean diet has
been found to determine a significant reduction of circulating
levels of C-reactive protein, interleukin-6, and cell adhesion
molecules, determining a downregulation of cellular and hu-
moral inflammatory pathways related to atherosclerosis [12].
Vegetarian Diets
Over the last decades, the growing evidence about the rela-
tionship between consumption of animal productsand the risk
of chronic diseases has determined a greater interest in the
vegetarian diets. The number of people who, in recent years,
began to follow a food profile characterized by the absence of
animal flesh such as meat and fish, has progressively and
continuously increased, especially among industrialized coun-
tries [13].
The positive effect of the vegetarian diet on heart health is
mainly due to a greater variety and amount of plant foods.
Abundant consumption of vegetable, fruit, legumes, unrefined
cereals, and nuts, essential components of the vegetarian die-
tary pattern, has consistently been associated with a lower risk
of cardiovascular disease [14••]. The complex mixture of phy-
tochemicals, highly present in this diet, possess potent antiox-
idant activity and show synergistic and additive effects [14••].
Furthermore, compared to omnivores, vegetarians tend to
have lower BMI, lower total and LDL-cholesterol levels,
95 Page 2 of 7 Curr Cardiol Rep (2017) 19:95

lower blood pressure, improved glycaemic control, and in-
creased insulin sensitivity [5••]. Because obesity and
dyslipidaemia are significant risk factors for heart disease,
the lower BMI and the lower intake of cholesterol in vegetar-
ians may be a significant protective factor for lowering blood
lipids and reducing the risk of cardiovascular disease.
Although the number of studies that investigate the effects
of a vegetarian diet on health is increasing, the amount of
evidence is still limited with respect to the evidence for the
Mediterranean diet. To the best of our knowledge, seven pro-
spective cohort studies evaluated the relationship between the
vegetarian diet and cardiovascular health so far. Overall, the
studies included almost 240,000 participants, half of which
were vegetarians at the time of the evaluation.
The first study, established in 1960, was the AMS that
recruited 27,529 members of the Seventh-day Adventist
church in California [15]. Seventh-day Adventists have been
increasingly subject to epidemiological studies since they
tend to be more homogenous in many aspects of lifestyle
and more heterogeneous in eating habits than the general
population. Adventists have a lower risk of chronic diseases
than the general population, and many researchers hypothe-
size that this is due to their diet and lifestyle habits [16]. In
fact, in addition to the high prevalence of vegetarianism,
such populations generally present low rates of smoking,
consume little amount of alcohol, and possibly have a high
level of physical activity. In this study, after 5.6 years of
follow-up, the death rate ratios for heart disease and for
cerebrovascular disease were significantly lower in vegetar-
ians compared with the regular meat eaters [15].
Other two studies on Adventists, the AHS-1 and the AHS-
2, involving 34,000 and 96,000 subjects respectively, were
conducted over the last 40 years [17,18]. In the AHS-1, veg-
etarians showed a lower mortality rate for heart disease
(−38%) when compared to omnivores. Contrariwise, in omni-
vores, a greater incidence of obesity, hypertension, and type 2
diabetes mellitus has been observed [17]. The AHS-2, which
started in 2002, is still in progress. Preliminary data show that
vegetarians tend to have less cardiovascular risk factors (i.e.,
lower BMI, lower cholesterol and blood glucose levels, and a
lower prevalence of hypertension, overweight and obesity,
type 2 diabetes mellitus, and metabolic syndrome). In men, a
29% significant reduction of cardiovascular events has been
observed [18].
While Adventist cohorts suggested a potential relationship
between the vegetarian diet and the reduction of cardiovascu-
lar disease, the other cohorts demonstrated a modest effect.
For example, the HFSS highlighted not significant differences
in heart disease and cerebrovascular disease between British
vegetarians and omnivores [19]. Similar results were observed
in the Heidelberg Study, a German prospective study that has
followed for 21 years—from 1984 to 2005—a total of 1225
vegetarians and 679 “health-conscious”omnivores. The
overall mortality rate for heart disease between the two groups
did not show significant differences, but it was reduced com-
pared to the general population [20].
The OVS, a prospective study conducted on 11,040 British
participants recruited between 1980 and 1984, found lower
BMI and lower levels of total and LDL-cholesterol in vege-
tarians, but significant differences between vegetarians and
omnivores have not been highlighted in terms of cardiovascu-
lar outcomes [19]. Finally, the Oxford component of the EPIC
study monitored 65,000 men and women living in the UK,
recruited between 1993 and 1999 through collaboration with
family physicians and through the postal service. After
11.6 years of follow-up, vegetarians had a 32% lower risk of
heart disease than omnivores. This result was only slightly
attenuated after adjustment for BMI and did not differ by
sex, age, BMI, smoking, or the presence of cardiovascular risk
factors [21]. According to the authors, the risk difference was
probably mediated through the effect of the vegetarian diet on
cholesterol levels and blood pressure. However, a recent study
that analyzed pooled mortality data from the EPIC-Oxford
cohort and the OVS found no difference in mortality from
cardiovascular and cerebrovascular diseases between vegetar-
ians and omnivores [22].
A recent meta-analysis conducted by our group confirmed
a protective effect of the vegetarian diet versus cardiovascular
diseases in a population of over 65,000 vegetarians [5••]. A
significant 25% reduced risk of ischemic heart disease was
obtained, most probably determined by the reduction of main
traditional cardiovascular risk factors, including BMI, lipid
variables, and glucose levels [5••].
Practical Recommendations for a Heart-Healthy
Diet
Despite the spread of information on diet and dietary habits,
progressive change in eating habits has been observed in re-
cent years with a progressive worsening of nutritional quality
in terms of prevention [23]. Therefore, the main scientific
associations have indicated some major recommendations to
follow a healthy diet, especially for preventing cardiovascular
diseases.
&Reduce the calories. Given the importance of obesity and
overweight in the pathogenesis of cardiovascular disease,
avoiding excessive calorie consumption is of paramount
importance. Since calories consumed with beverages are
less visible than calories from solid foods, limiting bever-
age consumption is particularly important [24].
&Increase the consumption of fruit and vegetables (at least
five servings per day). A high consumption of fruits and
vegetables is associated with a reduction in the risk of
cardiovascular diseases as well as many of the most
Curr Cardiol Rep (2017) 19:95 Page 3 of 7 95

important neoplasms [25•]. In addition, fruits and vegeta-
bles represent the main source of fiber and an important
source of vitamins, especially the B group and antioxi-
dants. In randomized controlled trials, fruit and vegetable
consumption has shown substantial improvements in var-
ious risk factors such as blood pressure, plasma lipid
levels, pro-inflammatory parameters, endothelial function,
weight control, and circulating insulin levels [26]. The
benefits do not appear to be reproducible with equivalent
amounts of minerals, vitamins, and with fiber supple-
ments, nor are dependent on the composition of macronu-
trients in the diet [27]. This evidence suggests that the
benefits could be derived from a more complex set of
micronutrients, phytochemicals, and fibers present in
fruits and vegetables and not in multivitamin preparations,
greater bioavailability of these substances in their natural
state, and substitution of less foods healthy in the diet [27].
In long-term observational studies, the consumption of
200 g/day of fruit and vegetables has been associated with
lower incidence of coronary heart disease (−8%), stroke
(−16%), and cardiovascular disease (−8%) [25•].
&Increase the consumption of legumes. Eating legumes as
part of a healthy diet may help improving blood choles-
terol, a leading cause of cardiovascular disease [28], as
well as body weight [29•]. Legumes are the best source
of vegetable protein and contain minerals and fiber. High
plant protein intake was inversely associated with cardio-
vascular mortality, especially in subjects with at least one
unhealthy lifestyle factor [30]. Results from the NHANES
study clearly showed that legumes’consumption ≥4times
a week is associated with an 11% lower risk of cardiovas-
cular disease and a 22% reduced risk of coronary heart
disease compared to once per week [31]. A recent meta-
analysis reported a 14% reduction of ischemic heart dis-
ease risk for a consumption of legumes that reach four
portions (100 g/serving) per week [32].
&Increase the consumption of whole grain products.The
consumption of whole grain cereals with high fiber con-
tent has a double benefit on health. First, fiber consump-
tion from cereal products is associated with lower risk of
cardiovascular risk factors and heart disease [33,34].
Secondly, increased dietary fiber consumption reduces
the risk of developing type 2 diabetes, facilitates weight
control, and helps prevent constipation [35]. Whole grains
are foods that include bran, germ, and endosperm of nat-
ural cereal. Such composite products contain soluble and
insoluble food fibers, group B vitamins, minerals, flavo-
noids, and tocopherols, as well as numerous fatty acids,
antioxidants, and phytochemicals. In randomized clinical
trials, it has been demonstrated that whole grain consump-
tion improves insulin resistance and endothelial function
and reduces inflammatory parameters [36]. Whole grain
consumption reduces LDL-cholesterol, without reducing
HDL cholesterol or triggering triglycerides [37].
Consistently with the physiological benefits, a greater
consumption of whole grains is associated with a lower
incidence of cardiovascular disease, coronary heart dis-
ease and diabetes mellitus [38].
&Reduce the consumption of fresh and processed meat.
Diets rich in meat and derivatives have been associated
with an increased risk of developing cardiovascular dis-
ease and stroke [39,40]. This association, particularly
strong for processed red meat, may be explained by the
harmful effect of several compounds in meat, such as so-
dium, nitrates, heme iron, as well as saturated fat and
dietary cholesterol [41••]. As current evidence suggests
that each serving per day (50 g)of processed meat increase
the cardiovascular mortality by 24%, it would be prudent
to minimize or avoid processed meats such as sausage,
salami, bacon, and low-fat deli-meats (1 or less serving/
week) and consume small amounts of unprocessed red
meat (1 serving/week) [42]. Relatively few studies have
been focused on poultry as a risk factor for cardiovascular
disease, showing mixed results [42]. In the context of a
balanced diet, poultry consumption should be limited to
2–3servings/week.
&Replace saturated and trans fats with unsaturated fats.
The relationship between different types of dietary fats
and risk of cardiovascular disease has been extensively
evaluated inepidemiological studies and randomized clin-
ical trials. Although recent meta-analyses did not find a
significant relationship between higher saturated fat intake
and risk of cardiovascular disease in a large population
[43,44], available evidence puts a great emphasis on the
replacement of saturated fats with unsaturated fats [2,45].
Consistent and strong evidence from randomized con-
trolled trials and prospective cohort studies shows that
replacing saturated fatty acid with unsaturated fats signif-
icantly reduce total and LDL-cholesterol, as well as the
risk of cardiovascular disease and coronary mortality [2,
45]. For every 1% of energy intake from saturated fats
replaced with unsaturated fats, incidence of coronary heart
disease is reduced by 2–3% [2]. Therefore, animal fats
(e.g., lard, butter, cream, beef tallow) or tropical oils
(e.g., coconut and palm oils) should be replaced by non-
hydrogenated vegetable oils and nuts. The positive effect
of this replacement may derive not only from the reduc-
tion of intake of saturated fatty acids, but also from the
widely reported beneficial associated with the consump-
tion of nuts and olive oil. In fact, a recent meta-analysis of
prospective studies supports inverse associations between
eating nuts (28 g/day) and incident coronary heart disease,
stroke, and cardiovascular disease [46]. Similar results
were observed in the largest Mediterranean diet trial,
where a Mediterranean diet plus extra virgin olive oil or
nuts determined an approximately 30% decrease in risk of
95 Page 4 of 7 Curr Cardiol Rep (2017) 19:95

major cardiovascular events [47]. On the other hand, trans
fatty acids produced by partial hydrogenation of vegetable
oils that have been used to make some commercially pre-
pared baked goods, fried foods, snack foods, or margarine
have adverse effects on cardiovascular health and should
be avoided [44].
&Increase food sources of omega-3 fatty acids. Being es-
sential fatty acids that cannot be synthesized by humans,
tissue levels of omega-3 are heavily influenced by diet.
Primary sources of omega-3 fatty acids in the form of
alpha-linolenic acid are flaxseeds, walnuts, chia seeds, ca-
nola, and soybean oils [2]. Fish, seafood, and fish oil rep-
resent the primarily source of EPA and DHA, very long
chain omega-3 fatty acids that are also synthesized in low
(5%) amount from their plant precursor, the alpha-
linolenic acid [48]. The content of EPA and DHA varies
considerably from fish to fish: fish such as anchovies,
herring, wild salmon, sardines, trout, and white tuna tend
to have higher concentrations. In order to improve their
omega-3 nutritional status, subjects following avegetarian
diet should regularly consume good sources of alpha-
linolenic acid and limit the intake of linoleic acid, as high
intakes of linoleic acid may suppress alpha-linolenic acid
conversionto EPA and DHA [49]. In human experiments,
fish oil is able to lower triglyceride levels, systolic and
diastolic blood pressure, and resting heart rate [50].
Observational evidence and randomized clinical trials
suggest that fish oil or fish consumption can reduce in-
flammation, improve endothelial function, normalize
heart rate variability, improve myocardial relaxation and
efficiency, and, at high doses, platelet aggregation [48].
Consistent with these physiological benefits, habitual con-
sumption of fish is associated with a lower incidence of
coronary heart disease and ischemic stroke, particularly
heart failure [48]. In fact, the consumption of 250 mg/d
of EPA and DHA from fish is associated with a 36%
reduction in mortality for cardiovascular disease [48].
Overall, these results are consistent with observational ob-
servations of long-term follow-up cohorts about fish in-
take 2–3 times/week.
&Limit the consumption of added sugar and sugar-
sweetened beverages. Sugar has no nutritional value ex-
cept for calorie intake and thus has negative health impli-
cations for people at risk of overweight. Added sugar and
sugar-sweetened beverages contribute to increase the
cardio-metabolic risk including weight gain, diabetes,
and metabolic syndrome, as well as cardiovascular disease
outcomes [51]. The 2015 Dietary Guidelines Advisory
Committee suggests the maximum restriction of added
sugars and sweetened beverages [2], while the WHO rec-
ommends a maximum limit of 10% of energy from free
sugar [52]. A further reduction to < 5% per day would
provide additional benefits.
&Limit sodium intake. The main justification for sodium
limitation is its effect on systolic blood pressure, an im-
portant risk factor for cardiovascular events and death
[53]. The WHO suggests a maximum limit of 2 g of sodi-
um per day (5 g of salt per day) [54], while average habit-
ual consumption in Western countries is currently about
double. A recent meta-analysis of cohort’s prospective
studies revealed a significant relationship between higher
sodium intake and cardiovascular disease. For every in-
crease of 10 mmol/d in sodium intake, cardiovascular dis-
ease mortality increased significantly by 1% [55].
Conclusions
The identification of the best heart-healthy diet is still a chal-
lenging and highly relevant preventive health issue. A large
body of literature has evaluated associations between dietary
exposures and cardiovascular disease. Evidence-based
healthy dietary patterns are high in fruits, vegetables, whole
grains, legumes, and nuts in moderation, although some may
include limited quantities oflean meats (including poultry and
seafood), low-fat dairy products, and liquid vegetable oils.
These dietary patterns are also low in saturated, trans, and
solid fats, sodium, added sugars, and refined grains. These
characteristics are shared by both the Mediterranean and veg-
etarian diets.
Compliance with Ethical Standards
Conflict of Interest Monica Dinu, Giuditta Pagliai, and Francesco Sofi
declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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