ArticlePDF Available

Cardiovascular Benefits of Plant-Based Diets

December 2021
International Journal of Cardiovascular Sciences 35(1):11-13

DOI:10.36660/ijcs.20210262

License
CC BY 4.0

Authors:

Márcia Regina Simas Torres Klein

Rio de Janeiro State University

Available via license: CC BY

Content may be subject to copyright.

Increasing evidence suggests that plant-based

dietary patterns, characterized by higher intake of

plant foods and lower intake of animal foods, confer

benefits to cardiovascular health.1-4 Vegetarian diets

are a subset of plant-based diets that exclude some

or all animal products (vegan diets).5

A meta-analysis of 86 cross-sectional and 10 cohort

prospective studies evaluated the association between

vegetarian, vegan diets, risk factors for chronic

diseases, risk of all-cause mortality, incidence, and

mortality from cardio-cerebrovascular diseases. The

overall analysis of cross-sectional studies revealed

significantly reduced levels of body mass index, total

cholesterol, LDL-cholesterol, and glucose levels in

vegetarians and vegans compared with omnivores.

In relation to cohort studies, the analysis showed

a significantly reduced risk of incidence and/or

mortality from ischemic heart disease by 25%.6

Yokoyama et al.,7 conducted a meta-analysis of 30

observational studies and 19 clinical trials to assess

the association of plant-based diets and plasma

lipids. The authors concluded that plant-based diets

are associated with decreased total cholesterol,

LDL-cholesterol, and HDL-cholesterol, but not

with decreased triglycerides. Eichelmann et al.,8

observed that plant-based diets are associated with

an improvement in obesity-related inflammatory

profiles, with reductions in the concentrations

of C-reactive protein, interleukin-6, and soluble

intercellular adhesion molecule-1.8

Recently, the European Society of Cardiology

highlighted that a shift from a more animal-based

to a plant-based dietary pattern may reduce the risk

of atherosclerotic cardiovascular disease.3 In line

with this, the American Heart Association (AHA)

published a dietary guidance recommending the

consumption of healthy sources of protein, mostly

from plants, as soybeans, other beans, lentils,

chickpeas, and peas to reduce cardiovascular risk.9

In addition, there is a growing concern about the

impact of the food system on the environment and

climate change. A plant-based dietary pattern is

more sustainable as it contributes to the reduction of

greenhouse gas emissions.10 The AHA also reinforced

that the replacement if animal-source foods by

plant-based whole foods has additional benefits to

planetary health. Conversely, a sustainable dietary

pattern is not necessarily associated with a lower

cardiovascular risk, since a plant-based diet, high in

refined carbohydrate and added sugar, may increase

the risk of type 2 diabetes and cardiovascular

disease (CVD).9

Baden et al.,11 investigated the associations

between 12-year changes (from 1986 to 1998) in

plant-based diet quality assessed by three indices)

– an overall plant-based diet index (PDI), a healthful

plant-based diet index (hPDI), and an unhealthful

plant-based diet index (uPDI) (score range: 18 to 90)

– and subsequent total and cause-specific mortality

(from 1998 to 2014). The study concluded that

improving plant-based diet quality over a 12-year

period was associated with a lower risk of total

and cardiovascular mortality, whereas increased

consumption of an unhealthful plant-based diet

was associated with a higher risk of total and CVD

mortality.11 In another cohort, it was observed that

DOI: https://doi.org/10.36660/ijcs.20210262

Mailing Address: Márcia Regina Simas Torres Klein

Rua São Francisco Xavier, 524 – Pavilhão João Lyra Filho. Postal Code: 20559-900, 12º andar, Bloco D – Rio de Janeiro, RJ – Brazil.

Email: marciarsimas@gmail.com

Int J Cardiovasc Sci. 2022; 35(1):11-13

EDITORIAL

Plant-based diet, vegetarian diet, cardiovascular

health.

Keywords

Cardiovascular Benefits of Plant-Based Diets

Marcella Rodrigues Guedes1 and Márcia Regina Simas Torres Klein1

Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brazil

Editorial referring to the article: Better Adequacy of Food Intake According to Dietary Recommendations of National Cholesterol Education

Program in Vegetarian Compared to Omnivorous Men

improving adherence to overall and healthful plant-

based diets was associated with a lower risk of type 2

diabetes, whereas decreased adherence to such diets

was associated with a higher risk.12

In addition to the known benefits of increased fiber

intake, the positive effects of healthy vegetarian and plant-

based diets also might be attributed by the modulation

of gut microbiota composition. Increasing evidence

has shown that different dietary patterns affect the gut

microbiota, and differences in this ecosystem between

vegetarian and omnivores have been documented.

Plant-based diets seem to contribute to greater diversity

in gut microbiota, which is associated with lower risk of

developing metabolic disorders and CVD.13 This positive

impact may be due to the higher amount of fermentable

fibers, polyphenols and polyunsaturated fatty acids in

the diet, that act as prebiotics and selectively stimulate

the increase of beneficial species.14

In this issue of the Journal, Antoniazzi et al.,15 in a cross-

sectional study, compare dietary adequacy, according

to the recommendations of the National Cholesterol

Education Program (NCEP), between apparently healthy

vegetarians and omnivorous men. Several cardiovascular

risk markers were significantly lower in vegetarians

compared to omnivores, including, body mass index,

waist circumference, blood pressure, total cholesterol,

LDL cholesterol, triglycerides, apolipoprotein B, fasting

glucose, glycated hemoglobin, pulse wave velocity, and

carotid intima-media thickness. Vegetarians consumed

significantly more dietary fibers, polyunsaturated fats

and plant stanols, and significantly less protein, total

fat, monounsaturated fat, saturated fat and dietary

cholesterol. The NCEP recommendations for saturated

fat (<7% of total calories), dietary cholesterol (<200mg/

day) and fiber (20-30g/day) were met, respectively by

77%, 95% and 39% of vegetarians vs. 48%, 43% and 25%

of omnivores (p<0.01). All vegetarians and omnivores

consumed monounsaturated and polyunsaturated fatty

acids within NCEP recommendations. Logistic regression

analysis showed that, compared with omnivorous diets,

vegetarian dietary patterns were associated (p<0.05)

with an adequate intake of saturated fat and dietary

cholesterol, even after adjustment for energy intake

and age. The authors concluded that vegetarians were

more likely to consume saturated fat, cholesterol, and

fibers according to NCEP recommendations, which may

contribute to lower levels of cardiovascular risk markers.

In summary, the findings of the study conducted

by Antoniazzi et al.,15 are in line with recent evidence

suggesting beneficial effects of plant-based diets, and

highlight that achieving nutritional recommendations for

CVD prevention may be easier for vegetarians compared

to omnivores.

1. Kim H, Caulfield LE, Garcia-Larsen V, Steffen LM, Coresh J, Rebholz

CM. Plant-Based Diets Are Associated With a Lower Risk of Incident

Cardiovascular Disease, Cardiovascular Disease Mortality, and All-Cause

Mortality in a General Population of Middle-Aged Adults. J Am Heart

Assoc. 2019 Aug 20;8(16):e012865. doi: 10.1161/JAHA.119.012865.

2. Glenn AJ, Lo K, Jenkins DJA, Boucher BA, Hanley AJ, Kendall CWC,

et al. Relationship Between a Plant-Based Dietary Portfolio and Risk of

Cardiovascular Disease: Findings From the Women's Health Initiative

Prospective Cohort Study. J Am Heart Assoc. 2021 Aug 17;10(16):e021515.

doi: 10.1161/JAHA.121.021515.

3. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck

M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in

clinical practice. Eur Heart J. 2021 Sep 7;42(34):3227-337. doi: 10.1093/

eurheartj/ehab484.

4. Choi Y, Larson N, Steffen LM, Schreiner PJ, Gallaher DD, Duprez DA,

et al. Plant-Centered Diet and Risk of Incident Cardiovascular Disease

During Young to Middle Adulthood. J Am Heart Assoc. 2021 Aug

17;10(16):e020718. doi: 10.1161/JAHA.120.020718.

5. Satija A, Hu FB. Plant-based diets and cardiovascular health. Trends

Cardiovasc Med. 2018 Oct;28(7):437-41. doi: 10.1016/j.tcm.2018.02.004.

6. Dinu M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian, vegan diets

and multiple health outcomes: A systematic review with meta-analysis of

observational studies. Crit Rev Food Sci Nutr. 2017 Nov 22;57(17):3640-

9. doi: 10.1080/10408398.2016.1138447.

7. Yokoyama Y, Levin SM, Barnard ND. Association between plant-based

diets and plasma lipids: a systematic review and meta-analysis. Nutr

Rev. 2017 Sep 1;75(9):683-98. doi: 10.1093/nutrit/nux030.

8. Eichelmann F, Schwingshackl L, Fedirko V, Aleksandrova K. Effect of

plant-based diets on obesity-related inflammatory profiles: a systematic

review and meta-analysis of intervention trials. Obes Rev. 2016

Nov;17(11):1067-79. doi: 10.1111/obr.12439.

9. Lichtenstein AH, Appel LJ, Vadiveloo M, Hu FB, Kris-Etherton

PM, Rebholz CM, et al. 2021 Dietary Guidance to Improve Cardiovascular

Health: A Scientific Statement From the American Heart Association.

Circulation. 2021 Nov 2;CIR0000000000001031. doi: 10.1161/

CIR.0000000000001031.

10. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al.

The Global Syndemic of Obesity, Undernutrition, and Climate Change:

The Lancet Commission report. Lancet. 2019 Feb 23;393(10173):791-

846. doi: 10.1016/S0140-6736(18)32822-8.

11. Baden MY, Liu G, Satija A, Li Y, Sun Q, Fung TT, et al. Changes in Plant-Based

Diet Quality and Total and Cause-Specific Mortality. Circulation. 2019

Sep 17;140(12):979-91. doi: 10.1161/CIRCULATIONAHA.119.041014.

12. Chen Z, Drouin-Chartier J, Li Y, Baden MY, Manson JE, Willett WC,et

al. Changes in Plant-Based Diet Indices and Subsequent Risk of Type 2

Diabetes in Women and Men: Three U.S. Prospective Cohorts. Diabetes

Care. 2021 Mar; 44(3): 663-71. doi.org/10.2337/dc20-1636.

References

Int J Cardiovasc Sci. 2022; 35(1):11-13

Guedes & Klein

Cardiovascular benefits of plant-based dietsEditorial

13. Tang WHW, Bäckhed F, Landmesser U, Hazen SL. Intestinal

Microbiota in Cardiovascular Health and Disease: JACC State-of-the-

Art Review. J Am Coll Cardiol. 2019;73(16):2089-105. doi:10.1016/j.

jacc.2019.03.024.

14. Gibson GR, Hutkins R, Sanders ME, Prescott SL, Reimer RA, Salminen SJ,

et al. Expert consensus document: The International Scientific Association

for Probiotics and Prebiotics (ISAPP) consensus statement on the

definition and scope of prebiotics. Nat Rev Gastroenterol Hepatol. 2017

Aug;14(8):491-502. doi: 10.1038/nrgastro.2017.75.

15. Antoniazzi L, Acosta-Navarro J, Oki AM, Bonfim MC, Gaspar MCA.

Better Adequacy of Food Intake According to Dietary Recommendations

of National Cholesterol Education Program in Vegetarian Compared to

Omnivorous Men. Int J Cardiovasc Sci. 2022; 35(1):1-10. Doi: https://doi.

org/10.36660/ ijcs.20200258.

Int J Cardiovasc Sci. 2022; 35(1):11-13

Guedes & Klein

Cardiovascular benefits of plant-based diets Editorial

This is an open-access article distributed under the terms of the Creative Commons Attribution License

The Benefits of Plant-Based Diets in Lowering Cholesterol Levels and Promoting Heart Health

Article

Full-text available

Apr 2025

Icha Elyanida

This article examines the benefits of plant-based diets in lowering cholesterol levels and promoting heart health. A growing body of evidence suggests that diets rich in fruits, vegetables, whole grains, legumes, nuts, and seeds can significantly improve lipid profiles and reduce the risk of cardiovascular diseases. The mechanisms through which plant-based diets exert their effects include the high content of dietary fiber, antioxidants, and healthy fats, which collectively contribute to the reduction of low-density lipoprotein (LDL) cholesterol and inflammation. Furthermore, the article discusses the role of specific plant-based foods, such as oats, beans, and avocados, in heart health, highlighting their ability to enhance endothelial function and improve overall cardiovascular outcomes. By adopting a plant-based dietary pattern, individuals can not only lower their cholesterol levels but also embrace a lifestyle that supports long-term heart health.

2021 ESC Guidelines on cardiovascular disease prevention in clinical practice

Article

Full-text available

Sep 2021

2021 ESC Guidelines on cardiovascular disease prevention in clinical practice

Article

Full-text available

Aug 2021

Plant‐Centered Diet and Risk of Incident Cardiovascular Disease During Young to Middle Adulthood

Article

Full-text available

Dec 2020

Background The association between diets that focus on plant foods and restrict animal products and cardiovascular disease (CVD) is inconclusive. We investigated whether cumulative intake of a plant‐centered diet and shifting toward such a diet are associated with incident CVD. Methods and Results Participants were 4946 adults in the CARDIA (Coronary Artery Risk Development in Young Adults) prospective study. They were initially 18 to 30 years old and free of CVD (1985–1986, exam year [year 0]) and followed until 2018. Diet was assessed by an interviewer‐administered, validated diet history. Plant‐centered diet quality was assessed using the A Priori Diet Quality Score (APDQS), in which higher scores indicate higher consumption of nutritionally rich plant foods and limited consumption of high‐fat meat products and less healthy plant foods. Proportional hazards models estimated hazard ratios of CVD associated with both time‐varying average APDQS and a 13‐year change in APDQS score (difference between the year 7 and year 20 assessments). During the 32‐year follow‐up, 289 incident CVD cases were identified. Both long‐term consumption and a change toward such a diet were associated with a lower risk of CVD. Multivariable‐adjusted hazard ratio was 0.48 (95% CI, 0.28–0.81) when comparing the highest quintile of the time‐varying average ADPQS with lowest quintiles. The 13‐year change in APDQS was associated with a lower subsequent risk of CVD, with a hazard ratio of 0.39 (95% CI, 0.19–0.81) comparing the extreme quintiles. Similarly, strong inverse associations were found for coronary heart disease and hypertension‐related CVD with either the time‐varying average or change APDQS. Conclusions Consumption of a plant‐centered, high‐quality diet starting in young adulthood is associated with a lower risk of CVD by middle age.

Relationship Between a Plant-Based Dietary Portfolio and Risk of Cardiovascular Disease: Findings From the Women's Health Initiative Prospective Cohort Study

Article

Full-text available

Aug 2021

Background The plant‐based Dietary Portfolio combines established cholesterol‐lowering foods (plant protein, nuts, viscous fiber, and phytosterols), plus monounsaturated fat, and has been shown to improve low‐density lipoprotein cholesterol and other cardiovascular disease (CVD) risk factors. No studies have evaluated the relation of the Dietary Portfolio with incident CVD events. Methods and Results We followed 123 330 postmenopausal women initially free of CVD in the Women's Health Initiative from 1993 through 2017. We used Cox proportional‐hazard models to estimate adjusted hazard ratios (HRs) and 95% CI of the association of adherence to a Portfolio Diet score with CVD outcomes. Primary outcomes were total CVD, coronary heart disease, and stroke. Secondary outcomes were heart failure and atrial fibrillation. Over a mean follow‐up of 15.3 years, 13 365 total CVD, 5640 coronary heart disease, 4440 strokes, 1907 heart failure, and 929 atrial fibrillation events occurred. After multiple adjustments, adherence to the Portfolio Diet score was associated with lower risk of total CVD (HR, 0.89; 95% CI, 0.83–0.94), coronary heart disease (HR, 0.86; 95% CI, 0.78–0.95), and heart failure (HR, 0.83; 95% CI, 0.71–0.99), comparing the highest to lowest quartile of adherence. There was no association with stroke (HR, 0.97; 95% CI, 0.87–1.08) or atrial fibrillation (HR, 1.10; 95% CI, 0.87–1.38). These results remained statistically significant after several sensitivity analyses. Conclusions In this prospective cohort of postmenopausal women in the United States, higher adherence to the Portfolio Diet was associated with a reduction in incident cardiovascular and coronary events, as well as heart failure. These findings warrant further investigation in other populations.

Plant-Based Diets Are Associated With a Lower Risk of Incident Cardiovascular Disease, Cardiovascular Disease Mortality, and All-Cause Mortality in a General Population of Middle-Aged Adults

Article

Full-text available

Aug 2019

Background 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.

2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association

Article

Nov 2021

Poor diet quality is strongly associated with elevated risk of cardiovascular disease morbidity and mortality. This scientific statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. Evidence-based dietary pattern guidance to promote cardiometabolic health includes the following: (1) adjust energy intake and expenditure to achieve and maintain a healthy body weight; (2) eat plenty and a variety of fruits and vegetables; (3) choose whole grain foods and products; (4) choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms); (5) use liquid plant oils rather than tropical oils and partially hydrogenated fats; (6) choose minimally processed foods instead of ultra-processed foods; (7) minimize the intake of beverages and foods with added sugars; (8) choose and prepare foods with little or no salt; (9) if you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake; and (10) adhere to this guidance regardless of where food is prepared or consumed. Challenges that impede adherence to heart-healthy dietary patterns include targeted marketing of unhealthy foods, neighborhood segregation, food and nutrition insecurity, and structural racism. Creating an environment that facilitates, rather than impedes, adherence to heart-healthy dietary patterns among all individuals is a public health imperative.

Changes in Plant-Based Diet Indices and Subsequent Risk of Type 2 Diabetes in Women and Men: Three U.S. Prospective Cohorts

Article

Jan 2021
DIABETES CARE

Objective: We evaluated the associations between changes in plant-based diets and subsequent risk of type 2 diabetes. Research design and methods: We prospectively followed 76,530 women in the Nurses' Health Study (NHS) (1986-2012), 81,569 women in NHS II (1991-2017), and 34,468 men in the Health Professionals Follow-up Study (1986-2016). Adherence to plant-based diets was assessed every 4 years with the overall plant-based diet index (PDI), healthful PDI (hPDI), and unhealthful PDI (uPDI). We used multivariable Cox proportional hazards models to estimate hazard ratios (HRs). We pooled results of the three cohorts using meta-analysis. Results: We documented 12,627 cases of type 2 diabetes during 2,955,350 person-years of follow-up. After adjustment for initial BMI and initial and 4-year changes in alcohol intake, smoking, physical activity, and other factors, compared with participants whose indices remained relatively stable (±3%), participants with the largest decrease (>10%) in PDI and hPDI over 4 years had a 12-23% higher diabetes risk in the subsequent 4 years (pooled HR, PDI 1.12 [95% CI 1.05, 1.20], hPDI 1.23 [1.16, 1.31]). Each 10% increment in PDI and hPDI over 4 years was associated with a 7-9% lower risk (PDI 0.93 [0.91, 0.95], hPDI 0.91 [0.87, 0.95]). Changes in uPDI were not associated with diabetes risk. Weight changes accounted for 6.0-35.6% of the associations between changes in PDI and hPDI and diabetes risk. Conclusions: Improving adherence to overall and healthful plant-based diets was associated with a lower risk of type 2 diabetes, whereas decreased adherence to such diets was associated with a higher risk.

Changes in Plant-Based Diet Quality and Total and Cause-Specific Mortality

Article

Aug 2019

Background: Plant-based diets have been associated with lower risk of type 2 diabetes and cardiovascular disease (CVD) and are recommended for both health and environmental benefits. However, the association between changes in plant-based diet quality and mortality remains unclear. Methods: We investigated the associations between 12-year changes (from 1986 to 1998) in plant-based diet quality assessed by three plant-based diet indices (score range: 18 to 90)-an overall plant-based diet index (PDI), a healthful plant-based diet index (hPDI), and an unhealthful plant-based diet index (uPDI)-and subsequent total and cause-specific mortality (from 1998 to 2014). Participants were 49,407 women in the Nurses' Health Study (NHS) and 25,907 men in the Health Professionals Follow-Up Study (HPFS) who were free from CVD and cancer at 1998. Multivariable-adjusted Cox proportional-hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: We documented 10,686 deaths including 2,046 CVD deaths and 3,091 cancer deaths in the NHS over 725,316 person-years of follow-up, and 6,490 deaths including 1,872 CVD deaths and 1,772 cancer deaths in the HPFS over 371,322 person-years of follow-up. Compared with participants whose indices remained stable, among those with the greatest increases in diet scores (highest quintile), the pooled multivariable-adjusted HRs for total mortality were 0.95 (95% CI, 0.90-1.00) for PDI, 0.90 (95% CI, 0.85-0.95) for hPDI, and 1.12 (95% CI, 1.07-1.18) for uPDI. Among participants with the greatest decrease (lowest quintile), the multivariable-adjusted HRs were 1.09 (95% CI, 1.04-1.15) for PDI, 1.10 (95% CI, 1.05-1.15) for hPDI, and 0.93 (95% CI, 0.88-0.98) for uPDI. For CVD mortality, the risk associated with a 10-point increase in each plant-based diet index was 7% lower (95% CI, 1-12%) for PDI, 9% lower (95% CI, 4-14%) for hPDI, and 8% higher (95% CI, 2-14%) for uPDI. There were no consistent associations between changes in plant-based diet indices and cancer mortality. Conclusions: Improving plant-based diet quality over a 12-year period was associated with a lower risk of total and CVD mortality, whereas increased consumption of an unhealthful plantbased diet was associated with a higher risk of total and CVD mortality.

The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report

Article

Feb 2019

Executive summary Malnutrition in all its forms, including obesity, undernutrition, and other dietary risks, is the leading cause of poor health globally. In the near future, the health effects of climate change will considerably compound these health challenges. Climate change can be considered a pandemic because of its sweeping effects on the health of humans and the natural systems we depend on (ie, planetary health). These three pandemics—obesity, undernutrition, and climate change—represent The Global Syndemic that affects most people in every country and region worldwide. They constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers. This Commission recommends comprehensive actions to address obesity within the context of The Global Syndemic, which represents the paramount health challenge for humans, the environment, and our planet in the 21st century. The Global Syndemic Although the Commission's mandate was to address obesity, a deliberative process led to reframing of the problem and expansion of the mandate to offer recommendations to collectively address the triple-burden challenges of The Global Syndemic. We reframed the problem of obesity as having four parts. First, the prevalence of obesity is increasing in every region of the world. No country has successfully reversed its epidemic because the systemic and institutional drivers of obesity remain largely unabated. Second, many evidence-based policy recommendations to halt and reverse obesity rates have been endorsed by Member States at successive World Health Assembly meetings over nearly three decades, but have not yet been translated into meaningful and measurable change. Such patchy progress is due to what the Commission calls policy inertia, a collective term for the combined effects of inadequate political leadership and governance to enact policies to respond to The Global Syndemic, strong opposition to those policies by powerful commercial interests, and a lack of demand for policy action by the public. Third, similar to the 2015 Paris Agreement on Climate Change, the enormous health and economic burdens caused by obesity are not seen as urgent enough to generate the public demand or political will to implement the recommendations of expert bodies for effective action. Finally, obesity has historically been considered in isolation from other major global challenges. Linking obesity with undernutrition and climate change into a single Global Syndemic framework focuses attention on the scale and urgency of addressing these combined challenges and emphasises the need for common solutions. Syndemic drivers The Commission applied a systems perspective to understand and address the underlying drivers of The Global Syndemic within the context of achieving the broad global outcomes of human health and wellbeing, ecological health and wellbeing, social equity, and economic prosperity. The major systems driving The Global Syndemic are food and agriculture, transportation, urban design, and land use. An analysis of the dynamics of these systems sheds light on the answers to some fundamental questions. Why do these systems operate the way they do? Why do they need to change? Why are they so hard to change? What leverage points (or levers) are required to overcome policy inertia and address The Global Syndemic? The Commission identified five sets of feedback loops as the dominant dynamics underlying the answers to these questions. They include: (1) governance feedback loops that determine how political power translates into the policies and economic incentives and disincentives for companies to operate within; (2) business feedback loops that determine the dynamics for creating profitable goods and services, including the externalities associated with damage to human health, the environment, and the planet; (3) supply and demand feedback loops showing the relationships that determine current consumption practices; (4) ecological feedback loops that show the unsustainable environmental damage that the food and transportation systems impose on natural ecosystems; and (5) human health feedback loops that show the positive and negative effects that these systems have on human health. These interactions need to be elucidated and methods for reorienting these feedback systems prioritised to mitigate The Global Syndemic. Double-duty or triple-duty actions The common drivers of obesity, undernutrition, and climate change indicate that many systems-level interventions could serve as double-duty or triple-duty actions to change the trajectory of all three pandemics simultaneously. Although these actions could produce win-win, or even win-win-win, results, they are difficult to achieve. A seemingly simple example shows how challenging these actions can be. National dietary guidelines serve as a basis for the development of food and nutrition policies and public education to reduce obesity and undernutrition and could be extended to include sustainability by moving populations towards consuming largely plant-based diets. However, many countries' efforts to include environmental sustainability principles within their dietary guidelines failed due to pressure from strong food industry lobbies, especially the beef, dairy, sugar, and ultra-processed food and beverage industry sectors. Only a few countries (ie, Sweden, Germany, Qatar, and Brazil) have developed dietary guidelines that promote environmentally sustainable diets and eating patterns that ensure food security, improve diet quality, human health and wellbeing, social equity, and respond to climate change challenges. The engagement of people, communities, and diverse groups is crucial for achieving these changes. Personal behaviours are heavily influenced by environments that are obesogenic, food insecure, and promote greenhouse-gas emissions. However, people can act as agents of change in their roles as elected officials, employers, parents, customers, and citizens and influence the societal norms and institutional policies of worksites, schools, food retailers, and communities to address The Global Syndemic. Across systems and institutions, people are decision makers who can vote for, advocate for, and communicate their preferences with other decision-makers about the policies and actions needed to address The Global Syndemic. Within the natural ecosystems, people travel, recreate, build, and work in ways that can preserve or restore the environment. Collective actions can generate the momentum for change. The Commission believes that the collective influence of individuals, civil society organisations, and the public can stimulate the reorientation of human systems to promote health, equity, economic prosperity, and sustainability. Changing trends in obesity, undernutrition, and climate change Historically, the most widespread form of malnutrition has been undernutrition, including wasting, stunting, and micronutrient deficiencies. The Global Hunger Index (1992–2017) showed substantial declines in under-5 child mortality in all regions of the world but less substantial declines in the prevalence of wasting and stunting among children. However, the rates of decline in undernutrition for children and adults are still too slow to meet the Sustainable Development Goal (SDG) targets by 2030. In the past 40 years, the obesity pandemic has shifted the patterns of malnutrition. Starting in the early 1980s, rapid increases in the prevalence of overweight and obesity began in high-income countries. In 2015, obesity was estimated to affect 2 billion people worldwide. Obesity and its determinants are risk factors for three of the four leading causes of non-communicable diseases (NCDs) worldwide, including cardiovascular diseases, type 2 diabetes, and certain cancers. Extensive research on the developmental origins of health and disease has shown that fetal and infant undernutrition are risk factors for obesity and its adverse consequences throughout the life course. Low-income and middle-income countries (LMICs) carry the greatest burdens of malnutrition. In LMICs, the prevalence of overweight in children less than 5 years of age is rising on the background of an already high prevalence of stunting (28%), wasting (8·8%), and underweight (17·4%). The prevalence of obesity among stunted children is 3% and is higher among children in middle-income countries than in lower-income countries. The work of the Intergovernmental Panel on Climate Change (IPCC), three previous Lancet Commissions related to climate change and planetary health (2009–15), and the current Lancet Countdown, which is tracking progress on health and climate change from 2017 to 2030, have provided extensive and compelling projections on the major human health effects related to climate change. Chief among them are increasing food insecurity and undernutrition among vulnerable populations in many LMICs due to crop failures, reduced food production, extreme weather events that produce droughts and flooding, increased food-borne and other infectious diseases, and civil unrest. Severe food insecurity and hunger are associated with lower obesity prevalence, but mild to moderate food insecurity is paradoxically associated with higher obesity prevalence among vulnerable populations. Wealthy countries already have higher burdens of obesity and larger carbon footprints compared with LMICs. Countries transitioning from lower to higher incomes experience rapid urbanisation and shifts towards motorised transportation with consequent lower physical activity, higher prevalence of obesity, and higher greenhouse-gas emissions. Changes in the dietary patterns of populations include increasing consumption of ultra-processed food and beverage products and beef and dairy products, whose production is associated with high greenhouse-gas emissions. Agricultural production is a leading source of greenhouse-gas emissions. The economic burden of The Global Syndemic The economic burden of The Global Syndemic is substantial and will have the greatest effect on the poorest of the 8·5 billion people who will inhabit the earth by 2030. The current costs of obesity are estimated at about

2 trillion annually from direct health-care costs and lost economic productivity. These costs represent 2·8% of the world's gross domestic product (GDP) and are roughly the equivalent of the costs of smoking or armed violence and war. Economic losses attributable to undernutrition are equivalent to 11% of the GDP in Africa and Asia, or approximately

3·5 trillion annually. The World Bank estimates that an investment of

70 billion over 10 years is needed to achieve SDG targets related to undernutrition, and that achieving them would create an estimated

850 billion in economic return. The economic effects of climate change include, among others, the costs of environmental disasters (eg, drought and wildfires), changes in habitat (eg, biosecurity and sea-level rises), health effects (eg, hunger and diarrhoeal infections), industry stress in sectors such as agriculture and fisheries, and the costs of reducing greenhouse-gas emissions. Continued inaction towards the global mitigation of climate change is predicted to cost 5–10% of global GDP, whereas just 1% of the world's GDP could arrest the increase in climate change. Actions to address The Global Syndemic Many authoritative policy documents have proposed specific, evidence-informed policies to address each of the components of The Global Syndemic. Therefore, the Commission decided to focus on the common, enabling actions that would support the implementation of these policies across The Global Syndemic. A set of principles guided the Commission's recommendations to enable the implementation of existing recommended policies: be systemic in nature, address the underlying causes of The Global Syndemic and its policy inertia, forge synergies to promote health and equity, and create benefits through double-duty or triple-duty actions. The Commission identified multiple levers to strengthen governance at the global, regional, national, and local levels. The Commission proposed the use of international human rights law and to apply the concept of a right to wellbeing, which encompasses the rights of children and the rights of all people to health, adequate food, culture, and healthy environments. Global intergovernmental organisations, such as the World Trade Organization, the World Economic Forum, the World Bank, and large philanthropic foundations and regional platforms, such as the European Union, Association of Southeastern Nations, and the Pacific Forum, should play much stronger roles to support national policies that address The Global Syndemic. Many states and municipalities are leading efforts to reduce greenhouse-gas emissions by incentivising less motorised travel and improving urban food systems. Civil society organisations can create a greater demand for national policy actions with increases in capacity and funding. Therefore, in addition to the World Bank's call for

70 billion for undernutrition and the Green Climate Fund of

100 billion for LMICs to address climate change, the Commission calls for

1 billion to support the efforts of civil society organisations to advocate for policy initiatives that mitigate The Global Syndemic. A principal source of policy inertia related to addressing obesity and climate change is the power of vested interests by commercial actors whose engagement in policy often constitutes a conflict of interest that is at odds with the public good and planetary health. Countering this power to assure unbiased decision making requires strong processes to manage conflicts of interest. On the business side, new sustainable models are needed to shift outcomes from a profit-only model to a socially and environmentally viable profit model that incorporates the health of people and the environment. The fossil fuel and food industries that are responsible for driving The Global Syndemic receive more than

5 trillion in annual subsidies from governments. The Commission recommends that governments redirect these subsidies into more sustainable energy, agricultural, and food system practices. A Framework Convention on Food Systems would provide the global legal structure and direction for countries to act on improving their food systems so that they become engines for better health, environmental sustainability, greater equity, and ongoing prosperity. Stronger accountability systems are needed to ensure that governments and private-sector actors respond adequately to The Global Syndemic. Upstream monitoring is needed to measure implementation of policies, examine the commercial, political, economic and sociocultural determinants of obesity, evaluate the impact of policies and actions, and establish mechanisms to hold governments and powerful private-sector actors to account for their actions. Similarly, platforms for stakeholders to interact and secure funding, such as that provided by the EAT Forum for global food system transformation, are needed to allow collaborations of scientists, policy makers, and practitioners to co-create policy-relevant empirical, and modelling studies of The Global Syndemic and the effects of double-duty and triple-duty actions. Bringing indigenous and traditional knowledge to this effort will also be important because this knowledge is often based on principles of environmental stewardship, collective responsibilities, and the interconnectedness of people with their environments. The challenges facing action on obesity, undernutrition, and climate change are closely aligned with each other. Bringing them together under the umbrella concept of The Global Syndemic creates the potential to strengthen the action and accountabilities for all three challenges. Our health, the health of our children and future generations, and the health of the planet will depend on the implementation of comprehensive and systems-oriented responses to The Global Syndemic.

Plant-based diets and cardiovascular health

Article

Feb 2018
TRENDS CARDIOVAS MED

Plant-based diets, defined in terms of low frequency of animal food consumption, have been increasingly recommended for their health benefits. Numerous studies have found plant-based diets, especially when rich in high quality plant foods such as whole grains, fruits, vegetables, and nuts, to be associated with lower risk of cardiovascular outcomes and intermediate risk factors. This review summarizes the current evidence base examining the associations of plant-based diets with cardiovascular endpoints, and discusses the potential biological mechanisms underlying their health effects, practical recommendations and applications of this research, and directions for future research. Healthful plant-based diets should be recommended as an environmentally sustainable dietary option for improved cardiovascular health.