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Plant-based diets

This HEART UK Nutrition Academy webpage has been funded by Novartis Pharmaceuticals UK Ltd who have had no input into the content or development of this material.
 

Plant-based diets prioritise plant foods over animal foods and encompass dietary patterns proven to improve blood lipids and cardiovascular outcomes such as DASH, Portfolio and Mediterranean diet.

Take home messages

  • ‘Plant-based diets’ is an umbrella term encompassing dietary patterns that are predominantly made up of healthy plant foods. Meat and animal products are kept to a minimum or avoided altogether. 
  • The term 'plant-based' includes anything from flexitarian diets right through to vegan diets.
  • Many diets developed specifically for lipid-lowering and cardiovascular health such as the Mediterranean diet, Portfolio diet and DASH come under the umbrella of plant-based diets.
  • The evidence strongly demonstrates that it is not plant-based diets per se that result in cardiovascular benefits, but their nutritional quality.
  • Healthy plant-based diets: 
    • are rich in whole grains, fruit and vegetables, nuts, seeds, beans and pulses
    • prioritise plant-proteins such as soya, mycoproteins, nuts, beans and pulses over animal proteins
    • use vegetable oils in place of animal fats
    • are low in refined carbohydrates such as sugars and pastries
    • are low in meat and other animal foods
    • are low in foods that are high in saturated fat, salt and/or sugars.
  • Plant-based diets have the right fat balance: they are low in saturated fat and include mainly unsaturated fats – this is the critical dietary factor to improving blood lipids.
  • Plant-based diets are:
    • rich in fibre: some fibres are proven to actively lower blood cholesterol
    • rich in fruit and vegetables: evidence supports a dose-response link between fruit and vegetable intake and lowered CVD risk
    • low in meat: red and processed meats have been associated with an increased risk of CVD.

Plant-based diets – dietary patterns that mainly rely on plant foods1,2 – have gained popularity recently amid growing concerns about our food system and the environment3,4.  As well as having environmental benefits, plant-based diets form the basis of dietary guidelines for lipid management and the primary and secondary prevention of cardiovascular disease (CVD)5,6.

The diversity of plant-based diets

Contrary to popular belief, plant-based diets vary widely and are not synonymous with vegan diets only. The umbrella term includes any dietary pattern based mainly on healthy plant foods, and where meat and animal products are kept to a minimum or completely excluded1,2

Plant-based diets include:
  • Flexitarian diets: these reflect food-based dietary guidelines – mainly based on healthy plant foods whilst allowing moderate intakes of lean meat, fish, poultry and lower fat dairy.
  • Sustainable diets: these take into account multiple factors including health, environment, animal welfare, economy and equality. They prioritise plant foods for their health and environmental benefits, actively promote plant proteins over animal proteins, and include meat in limited quantities.
  • Pescatarian diets: exclude meat and poultry but include fish and seafood. Pescatarians may also consume eggs and some dairy.
  • Vegetarian and vegan diets
    • Lacto-vegetarian: excludes meat, poultry and fish, but includes dairy products.
    • Ovo-vegetarian: excludes meat, poultry, fish and dairy, but includes eggs.
    • Lacto-ovo-vegetarian: excludes meat, poultry and fish but includes eggs and dairy.
    • Vegan: excludes all animal-derived foods, relying exclusively on plant-based foods.
Key components of healthy plant-based diets
Mainly made up of  Moderate amounts of Kept to a minimum
  • Fruit and vegetables – especially red, orange and green
  • Whole grains
  • Tubers
  • Nuts and seeds
  • Legumes
  • Plant-based meat alternatives
  • Plant oils (except coconut and palm which are high in saturated fats)
  • Optional - Fish (white and oil-rich)
  • Optional – poultry and lean meats
  • Optional – lower fat dairy
  • Red and processed meat
  • Refined carbohydrates
  • Foods high in salt, sugars and/or saturated fats
  • Coconut and palm oils

Human intervention and cohort studies

Numerous large cohort studies and randomised controlled trials (RCTs) have repeatedly demonstrated that healthy plant-based diets reduce overall CVD risk7–13. They also reduce metabolic risk factors2,14,15 including raised blood lipids, high blood pressure and high body weight.

Plant-based diets: nutritional profile

Healthy plant-based diets tend to be lower in calorie density and the nutritional profile is characterised by lower saturated fats and salt, and higher levels of fruits, vegetables, whole grains, fibre, polyunsaturated fatty acids (PUFA) and plant phytochemicals. This has been associated with improved cardiovascular outcomes1,4,13,14,16,17.

Not all plant-based diets are equal

The cardiovascular benefits of plant-based diets depend on the quality of the diet, rather than the fact that they are plant-based. Despite the health halo, 'plant-based' foods vary significantly in their nutritional quality.

If they are not well-planned, plant-based patterns' nutritional profile can resemble unhealthy omnivorous diets, with excessive refined carbs, free sugars, added salt and saturated fats from coconut and palm oils. This has been highlighted by recent research using plant-based diet healthy index scoring systems7,10,18,19:

  • Plant-based diet Index (PDI): higher scores are given to diets with a greater proportion of plant foods (healthy and unhealthy) and a lower proportion of meat and animal products.
  • Healthy plant-based diet Index (hPDI): higher scores are given to diets with a greater content of healthy plant foods (such as fruit and vegetables, nuts and whole grains) and low intakes of meat, other animal foods and unhealthy plant foods (such as refined carbohydrates, confectionary and sugars).
  • Unhealthy plant-based diet Index (uPDI): higher scores are given to diets that are high in unhealthy plant foods but low in meat, other animal foods and healthy plant foods.

Research has consistently demonstrated that diets with high PDI and hPDI scores are associated with significantly improved cardiovascular and metabolic outcomes compared to those with low scores. The evidence also shows that high uPDI scores have no benefit to cardiovascular or other health outcomes.

What is significant is the quality of plant-based diets – those that are mainly made up of unhealthy plant foods have no positive impact, whilst those that are mainly made up of healthy plant foods have clear benefits.

Plant-based diets improve lipid profiles and cardiovascular health

Plant-based diets are made up of foods and nutrients proven to benefit lipid profiles and cardiovascular health.

1. The right balance of saturated and unsaturated fats

The key factor contributing to improved blood lipids and cardiovascular protection in plant-based diets is the right balance of dietary fats6,24,25

Healthy plant-based diets tend to be: 

  • low in saturated fatty acids (SFA)
  • with most fats coming from unsaturated fats. Notably, these include polyunsaturated fatty acids (PUFA).

A diet high in saturated fat is directly linked to raised LDL cholesterol, a key risk factor for CVD6, so cutting down on saturated fat is essential for lowering the risk of CVD. More importantly, swapping saturated fats for unsaturated fats, particularly PUFA, has consistently been shown to bring about the most substantial drop in LDL cholesterol and CVD risk5,6,20–23

For every 1% dietary energy as saturated fat replaced with an equivalent amount of PUFA20:
  • Total cholesterol can fall by 0.064 mmol/L
  • LDL cholesterol can fall by 0.055 mmol/L

2.  Lower in energy density

Well planned plant-based diets tend to be lower in energy (calories) so can help manage overall calorie intake and help reduce risk of obesity – a key metabolic risk factor to CVD.

Find out more

 

Watch our e-module on energy balance and portion control

3. Fibre

Eating more fibre by eating plant foods such as whole grains, nuts, legumes, fruit and vegetables can help bridge the gap between actual intakes (19g) and daily recommendations (30g)26. A comprehensive review of the evidence has demonstrated that every 7g of total dietary fibre eaten per day can lower the risk of CVD and CHD events by 8-18%, and stroke incidence by 7%-18%27.

Beta-glucans are a viscous-gel-like fibre present in barley and oats. Extensive research shows they significantly reduce total cholesterol (TC), LDL cholesterol and fasting triglycerides. They are also associated with a 21% lower risk of type 2 diabetes, another risk factor for CVD27.

4. Plant proteins

The evidence consistently indicates that substituting red meat with healthy plant protein foods in the diet is associated with improved cardiovascular health outcomes29–32. The benefit has been attributed to the healthier and more complex nutrient profile of plant proteins compared to animal proteins8,13,30.  

Compared to animal proteins, plant proteins: 

  • tend to be lower in calories
  • tend to be lower in saturated fat 
  • provide more polyunsaturated fat
  • they are rich in different types of fibre
  • provide numerous phytochemicals such as isoflavones and phytosterols.
Specific plant proteins have been associated with both a reduced risk of CVD and improved blood lipids
  Reduced CVD risk 

Reduced CHD

risk

Total cholesterol mmol/L No. of studies LDL-C mmol/L No. of studies TG mmol/L No. of studies
Nuts33,34  19% RR = 0.81, 95% CI: 0.74-0.8935 24% RR = 0.76, 95% CI: 0.69-0.8435

-0.09
(-0.11 to -0.08)

38 -0.11
(0.13 to -0.09)
38 -0.02
(-0.04 to 0.00)
37
Soya protein36–38 13% TRR = 0.87, 95% CI: 0.81-0.9439 21% (TRR = 0.79, 95% CI: 0.71-0.88)39 -0.22
(-0.14 to -0.29)
28 -0.23
(-0.16 to 0.31)*
29 -0.09
(0.00 to 0.16)
26
Dietary pulses40 8% (RR 0.92; 95% CI 0.85-0.99)41 10% (RR 0.90; 95% CI 0.83, 0.99)41 -0.14
(-0.22 to -0.06)*
35 -0.13
(0.19 to 0.06)*
35 -0.06 (-0.09 to -0.02)* 35

5. Reduced intakes of red and processed meat

  • Meta-analyses with 43,272 to over 4 million participants, demonstrate higher CVD risk with greater intakes of processed and unprocessed red meat30,32,42.  Additionally, substituting red and processed meat with plant-proteins reduces CVD risk.  
  • RCTs have also demonstrated a correlation between higher red meat intakes and raised LDL cholesterol, non-HDL cholesterol, apolipoprotein B and type 2 diabetes42,43
Other harmful effects associated with red and processed meat13,30,31
  • The high salt content of processed meat is linked to an increased risk of hypertension.
  • Gut microflora can metabolise the high quantities of L-carnitine and choline found in red meat, producing trimethylamine-N-oxide which promotes atherosclerosis.
  • Excessive haem iron (iron present in animal foods) intake has been associated with oxidative stress and CHD risk.

6. Fruits and vegetables

Fruits and veg are44–46

  • rich in antioxidant vitamins and different fibres 
  • low in energy-density (low in calories)
  • associated with a lower risk of CVD. 

A recent meta-analysis, pooling data from 100,000 subjects, showed that fruit lowered CVD risk by 6-15%. The effect was dose-dependent – the more they ate, the greater the benefit. This reached a plateau at intakes of 600g (about eight servings) of fruit and veg daily44, where higher intakes had no further benefit. 

This aligns with an earlier meta-analysis, using data from over 4 million subjects, which found higher intakes of fruit and vegetables were associated with reduced risk of CVD (-7%), coronary heart disease (CHD) (-12%), and stroke (-18%)45

The benefits of fruit and vegetables have been attributed to their positive nutrient profile including the role of the viscous fibre pectin and its impact on lowering LDL cholesterol47–50.

7. Whole grains 

Whole grains include oats, barely, brown rice, quinoa and wholemeal flour, and products made from them.

Replacing refined carbohydrates (such as white bread, sugars, pastries and white rice) with whole grains has been associated with improved blood lipids51 and a lower risk of CVD events and mortality52. This has been attributed to whole grains' nutrient rich profile: they contain various fibres, B vitamins, zinc, magnesium, phytochemicals and vitamin E – a potent antioxidant.

Phytochemicals such as flavonoids, isoflavones and phytosterols have also been linked to improved cardiovascular outcomes4,28. Phytochemicals are found in all plant foods. Proposed mechanisms include anti-inflammatory properties, improved endothelial function and reduced oxidation of LDL cholesterol.

In summary

Healthy plant-based diets, with or without small amounts of meat and animal products, improve blood lipids and CVD outcomes. The positive nutritional profile of plant foods, characterised by low saturated fat and relatively high unsaturated fats, fibre, antioxidants, fruits, vegetables and whole grains, underscores their holistic benefits. The evidence also emphasises that the positive impact of plant-based diets on CVD outcomes is driven more by the quality of the diet than the fact that they are plant-based.

Explore our CPD e-learning modules

Learn about the impact of diet on lipid management, with lots of practical advice for you and your patients: 

  1. Why focus on diet? 
  2. The fundamentals for a heart-healthy diet
  3. Dietary fats – getting the balance right
  4. Beyond fats: other fundamental dietary considerations
  5. The four complementary cholesterol lowering foods.

Learn more 

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