Cover Story | By Debra L. Beck

If the Mediterranean diet could be captured in a pill, it would be a blockbuster drug. Each year, more than $33 billion in medical costs and $9 billion in lost productivity can be traced to poor nutrition that has subsequently led to heart disease, cancer, stroke, and diabetes.¹ The latest National Health and Nutrition Examination Survey (NHANES) data show that fewer than 1% of U.S. adults age 50 years and older have an ideal diet score. At least they do better than kids, because according to NHANES data, essentially no children meet the definition of following an ideal diet. No surprise: 69% of Americans are overweight or obese. Obesity alone affects approximately 35% of Americans, meaning there is a staggering 100 million obese people in the U.S.

Even among coronary patients, the numbers are grim. The latest EUROASPIRE IV data, published in February 2015, showed that a median 1.35 years after an index coronary event or revascularization, 82% and 38% of patients were overweight and obese, respectively.² About 60% of patients reported partaking in little or no physical activity and fewer than half (48%) of obese patients said they had followed dietary recommendations since their coronary event. With more than 16,000 participants from 24 countries, EUROASPIRE IV is the largest survey of coronary care in Europe.

"One out of every three people will die from cardiovascular disease, but this is not some kind of Russian roulette," said Miguel A. Martinez-Gonzalez, MD, PhD, MPH, during an ACC.15 presentation on dietary approaches to health. Rather, the level of risk he said is "perfectly attributed" to the ideal cardiovascular (CV) health metrics with which we are all familiar, including six of seven that are related to diet.

It seems we need to reinvent the whole eating thing.

The Best Diet? One That's Not

One change may be to think less of weight loss diets and more about a livable diet. Much of modern American eating equals suicide on the installment plan. In our culture, losing weight is connected to the idea of going on a diet rather than changing one's diet. Going on a diet means eventually coming off that diet, which—for the vast majority of individuals—means a slow (or sometimes a quick) return of that hard-fought lost weight.

America's diet is not very conducive to stable weight. In an evaluation of about 4 years-worth of grocery store purchases by more than 157,000 households, investigators at the University of North Carolina at Chapel Hill just reported that highly processed foods account for more than 60% of the calories in America's grocery bags (Federation of American Societies for Experimental Biology Annual Meeting, March 28, 2015). As for trying to lose excess weight, physicians and patients alike seem to be eschewing a new generation of weight-loss medications that suppress patients' appetites and make them feel full, as evidenced by the fact that they are falling way short of anticipated sales. As the Wall Street Journal noted on March 16, 2015, these new agents are facing reluctance because of safety issues with past diet drugs, including CV-related side effects. Remember the so-called fen-phen combination (linked to heart-valve damage) and sibutramine (pulled from the market because it increased risk of myocardial infarction and stroke)?

Systematic research into the role of eating habits in health maintenance and disease incidence started after World War II.³ In the late 1950s, interest in the Mediterranean diet as a means of lowering heart disease risk spurred the Seven Countries Study of Cardiovascular Diseases. The study enrolled 16 cohorts of 12,763 middle-aged men (40-59 years old) from the U.S., Finland, the Netherlands, Italy, Croatia, Serbia, Greece, and Japan.

Seven Countries generated great interest in the Mediterranean diet when it reported that 15-year cardiovascular disease (CVD) mortality in Southern Europe was two to three times lower than that in Northern Europe or the U.S. in the 1980s.⁴ Long-term follow-up continues to show a protective role of the Mediterranean diet.3 Sadly, a recent analysis of time trends in eating habits shows that while diets in Finland and the Netherlands have become somewhat more "Mediterranean," the opposite is seen in Italy: they are abandoning their natural menu and adopting the much less healthy Western diet.

Non-Randomized Trial Evidence for CVD Prevention

Several prospective cohort studies support the cardioprotective effect of the Mediterranean diet.⁵ Such studies are appearing with some regularity, including one on stroke incidence presented at the International Stroke Congress in February 2015. The Mediterranean Diet and Incidence of Stroke in the California Teachers study found that among 104,268 participants (mean age 52 years; 87.4% white), greater adherence to a Mediterranean diet pattern was associated with a 10% to 18% decreased risk in total and ischemic stroke incidence after adjusting for confounding factors such as physical activity, hormone use, menopausal status, and vascular risk factors. There was no association between diet score and hemorrhagic stroke.

"The implications of this study are big given that the treatment of stroke is limited and the global and national burden of the disease is very high," said principal investigator Ayesha Sherzai, MD. "It's very important for all of us to understand that diet plays a very important role in modifying the risk of stroke: it's feasible, it does not cost much and, hopefully in the future, we will be able to replicate (these) data and also look at other dietary patterns, not specifically the Mediterranean diet. Overall, it seems like essentially a plant-based diet seems to be protective," said Dr Sherzai, a fellow in vascular neurology and neuroepidemiology at Columbia University Medical Center, New York City.

Another cohort study, this one presented at ACC.15, showed that among 2,583 adults living in Athens, Greece, those who closely adhered to a Mediterranean-style diet were 47% less likely to develop CVD compared with those who did not follow the diet.⁶ "Our study shows that the Mediterranean diet is a beneficial intervention for all types of people—in both genders, in all age groups, and in both healthy people and those with health conditions," according to study co-author Ekavi Georgousopoulou, PhD candidate at Harokopio University in Athens.

Researchers scored participants' diets on a scale of 1 to 55 based on their self-reported frequency and level of intake of 11 food groups. Each 1-point improvement in dietary score was associated with a 3% drop in CVD risk. The difference in CVD risk was independent of age, sex, family history, education level, body mass index, smoking habits, hypertension, diabetes, and lipid levels. (For comparison, early on in the investigation of the effects of lipid-lowering, each 1% reduction in blood cholesterol level yielded about a 2% reduction in coronary heart disease rates.⁷)

Really, there are several heart-healthy dietary patterns, of which the Mediterranean diet is just one option. According to Geeta Sikand, RDN, what matters most is that the diet is highly nutritious and low in saturated fat, sugar, and excess salt.

"You can give it any label you want: Mediterranean, DASH, vegetarian, vegan. If the diet is high in intake of vegetables, fruits, whole grains, legumes, and high in olive oil or another heart-healthy oil—which we call non-tropical oils—and limited in red meat, then you're looking at a diet that's going to give you a lower cardiovascular risk," said Ms. Sikand, who is director of nutrition, University of California Irvine Preventive Cardiology Program.

PREDIMED and the Lyon Heart Study

Despite this ever-broadening positive compendium of cohort studies, there have only been two major controlled clinical trials looking at the effect of dietary pattern on total CVD: the primary prevention PREDIMED study and secondary prevention Lyon Heart Study. The good news: both were positive.

Dr. Martinez-Gonzalez, mentioned earlier, is from the University of Navarra in Spain and one of the principal investigators of the PREDIMED (Prevención con Dieta Mediterránea) and PREDIMED-PLUS trials. In PREDIMED, there was a 28% to 30% reduction in risk for the composite endpoint of cardiovascular death, myocardial infarction, and stroke in patients who followed a Mediterranean-style diet supplemented with extra virgin olive oil or mixed nuts compared with a low-fat diet.⁸ Of note, the difference was seen despite no energy restriction in the Mediterranean diet groups. There was also a significant reduction in stroke incidence in the two intervention groups compared with controls.

PREDIMED has been criticized for not giving the low-fat diet control group a fair shake at good compliance. So 3 years into the trial, investigators attempted to improve adherence in the control arm by offering more training and personalized advice. Nevertheless, they found "no significant interaction between the period of trial enrollment (before vs. after the protocol change) and the benefit in the Mediterranean-diet groups." In other words, even when they ramped up efforts to improve adherence to a low-fat diet, it still didn't beat the Mediterranean diet.

The same research group is conducting a second study that should offer more information on the cardioprotective effects of the Mediterranean diet. PREDIMED-PLUS is an ongoing multicenter primary prevention trial scheduled to finish enrollment of 6,000 participants in December 2015 with results expected in 2020. The trial is randomizing men (55-75 years) and women (60-75 years) with metabolic syndrome who are overweight or obese to an intensive weight loss lifestyle program (energy-restricted Mediterranean diet and physical activity) or a less intensive program (Mediterranean diet without energy restriction or physical activity). The primary endpoint is a composite of hard clinical cardiovascular events.

The Lyon Diet Heart Study was the first (and to date only) randomized controlled trial to demonstrate the benefits of the Mediterranean diet in the secondary prevention of cardiac events. After 48 months, participants in the Mediterranean diet arm had a 50% to 70% reduction in the risk of CV mortality compared with controls.⁹ This study compared the effectiveness of a Mediterranean diet enriched with alpha-linolenic acid with a prudent post-infarct diet typically prescribed for CV health. Controls received only "usual dietary advice" from their attending physician. Sounds like that usual advice needs to change.

Affordable – or Mostly So

The long-standing dietary pattern Keys first described in the 1950s (see the sidebar Food Wise) was actually an artifact of postwar impoverishment and food restriction. Lentils, for example, were affordable and widely used as a substitute for meat. Today, whole foods have become an excuse to mark up prices, leaving a perception that healthier food is more expensive. Consequently, the Mediterranean diet is now thought by some to be out of reach for many Americans. However, the evidence is conflicting, making it a ripe opportunity for research.

In December 2013, a group from Harvard published a systematic review and meta-analysis in the British Medical Journal.¹⁰ Based on 27 studies from 10 countries, it costs about $1.50 more a day per person to maintain a dietary pattern at the highest end of the "healthful" spectrum versus the lowest. Over a year, the cost would be about $550 more per person for the healthier choices—and the gap may be widening.¹¹

However, the data really represent the extremes of eating: the best versus the worst. Not surprisingly, this was the only data point repeated in most of the media coverage of the recent meta-analysis, but one might argue that most people are neither the best nor the worst of eaters. And, as discovered four decades ago in studies of people's garbage (!), most people claim to eat better than they actually do.

"We decided to compare the two extremes in order to aggregate the results across studies in a standardized and meaningful way," said Mayuree Rao, MD candidate at The Warren Alpert Medical School of Brown University. "The price differences between the least healthy diet patterns and slightly healthier diet patterns may indeed be smaller, but we didn't analyze all possible comparisons."

Also, there was less of a cost difference when different metrics of healthfulness were used. For example, when healthier versus less healthy nutrient-based diet patterns were compared, price was not significantly different based on a day's intake. Also, not all food groups showed cost differences.

In particular, fresh fruits and vegetables are perceived as more expensive than processed snacks, which is likely an impediment to eating more healthy food in lower income homes, an issue that the U.S. Department of Agriculture (USDA) has studied.

"We put out the Dietary Guidelines for Americans and ... wanted to be able to answer the question of how much does it cost to meet fruit and vegetable recommendations," said Hayden Stewart, PhD, an agricultural economist with the USDA's Economic Research Service. Her group found that, in 2008, an adult on a 2,000-calorie per day diet could satisfy recommendations for vegetable and fruit consumption in the 2010 Dietary Guidelines for Americans (amounts and variety) at an average cost of $2 to $2.50 per day, or approximately 50 cents per edible cup equivalent. (These numbers are being updated to reflect more current produce pricing.)

Dr. Stewart and colleagues also looked at costs associated with swapping out snack foods for fruits and vegetables and found that swapping is, at least, cost neutral.

Vegetarian and Vegan: Good, Better, Best?

If a predominantly plant-based diet is good, might a vegetarian diet be better? What about vegan? Lacto-ovo-vegetarian? Pescatarian? Raw vegan? Pollotarian (fowl, but not red meat)?

Much of the research on vegetarian diets comes from the North American Seventh Day Adventist community, which has several lifestyle factors that may confer CV benefit. They are a homogeneous population, many of whom have adopted the plant-based diets mentioned above. In a recent analysis of approximately 75,000 Seventh Day Adventists, 7.6% were vegans, 28.9% lacto-ovo–vegetarians, 9.8% fish-eating pescatarians, 5.5% semi-vegetarians (non-fish meat consumption at least once per month), and 48.2%—nearly half—were non-vegetarians. Thus, they offer an opportunity to study specific dietary effects.

In the large, prospective Adventist Health Study 2 (AHS-2), vegetarian and vegan dietary patterns were associated with less hypertension compared with omnivores, a finding partially attributed to lower body mass,¹² as well as a lower prevalence of obesity, metabolic syndrome, type 2 diabetes, and some cancers.¹³ Among the participants, 2,570 died during 5.79 years of follow-up. Those who died most likely were the meat eaters (Table). The pesco-vegetarians were 19% less likely to die during the study period than the meat eaters and vegans were 15% less likely to die. Men benefited more than women from the vegetarian diet. (Hazard ratio for men was 0.82 [95% CI, 0.72–0.94] versus 0.93 [0.82–1.05] for women.)

At this point, the numbers are far too close to speculate in terms of recommending a specific vegetarian diet over another. However, in coming years, as follow-up continues and the number of deaths increase, there should be statistical power to more reliably compare dietary patterns. Until then, the AHS-2 study suggests that vegan and other vegetarian diets are safe and that a range of vegetarian diets—from strict to somewhat lax—appears to be healthier than a diet dominated by processed foods and meats.

In a 12-year follow-up of the EPIC-Oxford trial, a vegetarian diet was associated with lower ischemic heart disease risk compared with a nonvegetarian diet, a difference likely mediated by a better lipid profile and systolic blood pressure.¹⁴

There is less research done in vegans, but a study published last summer indicated veganism may be a viable alternative to conventional diet therapies for improving blood lipids in those with hypercholesterolemia and glycemic control in those with type 2 diabetes.¹⁵

Kim A. Williams, MD, the new ACC president, is a staunch and vocal advocate of a vegan diet. After switching to the Dean Ornish diet 13 years ago, his low-density lipoprotein cholesterol dropped from 170 to 90 mg/dl in 6 weeks.

"Not everyone is as diet sensitive as I am, but there are plenty of people who are," said Dr. Williams told CSWN. Although he thinks the Mediterranean and DASH diets are good options, they allow consumption of animal flesh, which "even if it is reduced, is not as good as a vegetable or plant-based diet," at least not according to the prevailing literature, such as the Adventist studies. "But we need a good randomized trial here."

Not only has Dr. Williams found a vegan diet personally beneficial; he's seen great results in patients, but only when they carefully follow instructions. "Vegan dieting can be dangerous," he cautioned, particularly if a patients is taking antihypertensive or anti-diabetic drugs. He has seen several cases of hypotension and dizziness in patients who switched to a vegan diet because their blood pressure dropped but they were still taking their medications.

Recently, Dr. Williams had a patient with hypoglycemia. A low protein intake is associated with a major decline in insulin-like growth factor-1 (IGF-1). In mice and humans, IGF-1 deficiencies are linked to major reductions in age-related diseases. Since higher levels of IGF-1 decrease insulin sensitivity and increase abdominal fat, a big drop in IGF-1 is a good thing. Indeed, when Dr. Wiliams' patient stopped eating meat, his weight and belly size started to go down and his insulin sensitivity improved. The problem: "He became hypoglycemic on his usual dose of insulin and he ended up in the hospital emergency room," said Dr. Williams.

In a recent study examining the links between protein intake and mortality, investigators studied 6,381 adults with a median age of 65. For people ages 50-65 years, a high protein intake produced a 75% increase in overall mortality and a 4-fold increase in cancer and diabetes mortality during an 18 year follow-up period. Interestingly, the opposite was seen among individuals older than 65 years: for them, high protein intake was associated with reduced cancer and lower overall mortality.¹⁶ The authors concluded that it may be important for people older than 65 to avoid low protein intake and gradually adopt a moderate to high protein diet, mostly plant based if possible, to allow the maintenance of a healthy weight and protection from frailty.

Patient Ambivalence and Busy Physicians

Of course, the best heart-healthy diet does little good if patients don't follow it. As a dietician with more than 30 years of experience, Ms. Sikand helps patients work through their ambivalence to change using motivational interviewing.

"It's not enough to just give someone the DASH or Mediterranean diet and expect them to follow it," she said. In her broad experience, she's found three tools "that really work:" food journaling, daily self-weighing, and keeping appointments with a nutrition professional. "I tell them just walking through the door is great."

For the busy physician, however, there may seem little option but to give patients quick dietary advice and hope for the best. Indeed, a small study presented at ACC.15 showed that although cardiologists and other doctors rate nutrition as being as important as statin therapy for reducing CV risk, only 13.5% felt they had the training to discuss nutrition with patients. And although most knew about the blood pressure-lowering effects of fruits and vegetables, only 70% were able to correctly identify food high in soluble fiber and only 31% could correctly identify an oily fish.

"It's one thing to know oily fish is a good thing, but being able to advise patients on which types of fish are high in omega-3 fatty acid is another," said Eugenia Gianos, MD, assistant professor of medicine in the Leon H. Charney Division of Cardiology at NYU Langone Medical Center in New York City.

For his part, Dr. Williams has been known to be straightforward with his patients, staring pointedly at the feet of a smoker with diabetes while explaining the risk of lower limb ischemia and suggesting a change in diet.

Beyond Nutrition

Diaita, the Classical Greek word from which diet is derived, means "way of living." What's often ignored is that the Mediterranean diet isn't just a dietary pattern but a balanced lifestyle. It's a way of eating based on local agriculture, recipes, and cooking methods passed from generation to generation, a deep appreciation of the pleasure of eating healthy fresh food and shared meals, as well as daily physical activity.

It was for these reasons that the United Nations Educational, Scientific and Cultural Organization agreed to include the Mediterranean diet on its Representative List of Intangible Cultural Heritage of Humanity in November 2010. And the new Mediterranean diet pyramid¹⁷ reflects the importance of lifestyle by including aspects of healthy living and number of colors in the diet (to refer to the variety of foods in the diet, mainly fruits and vegetables).

But here's an interesting observation: While studies have evaluated the reliability of the many indices of adherence to the Mediterranean diet,¹⁸ none have assessed adherence to the Mediterranean lifestyle.

"Probably, when the indices of adherence ... were built, [researchers] were only thinking about the Mediterranean diet and not the Mediterranean lifestyle," said Mediterranean diet researcher Raimon Mila, PhD, from the Universitat Central de Catalunya, Barcelona, Spain. "Today, we are talking about how important lifestyle is—moderate exercise, low stress, etc."

Although the exact mechanism of action for the Mediterranean diet's benefits remains unclear, based on a wealth of other research on behavioral aspects of cardiovascular health, scarfing a lentil and kale salad while living a stressful, 'Western-type' lifestyle might not have the same effect as savoring the same meal with family and friends on the back porch of a Tuscan villa. Maybe the impact of living in the proverbial Tuscan village—as a marker of the Mediterranean lifestyle—on cardiovascular outcomes should be the next research hurdle.

References

1. Mozaffarian D, Benjamin EJ, Go AS, et al. Circulation. 2015;131:e29-e322.
2. Kotseva K, Wood D, De Bacquer D, et al. Eur J Prev Card. 2015 Feb 16. [Epub ahead of print]
3. Menotti A, Puddu PE. Nutr Metab Cardiovasc Dis. 2014 Dec 12. [Epub ahead of print]
4. Keys A, Menotti A, Karvonen MJ, et al. Am J Epidemiol. 1986;124:903-15.
5. Karageorgou D, Micha R, Zampelas A, authors. Chapter 9 Mediterranean Diet and Cardiovascular Disease: An overview of recent evidence. In The Mediterranean Diet. 2015 Elsevier.
6. Georgousopoulou EN, Pitsavos C, Panagiotakos D, et al. J Am Coll Cardiol. 2015;65:abstr. 1178-117.
7. [No authors listed.] NIH Consensus Statement 1984;5:1-11. http://consensus.nih.gov/1984/1984Cholesterol047html.htm
8. Estruch R, Ros E, Salas-Salvado J, et al. N Engl J Med. 2013;368:1279-90.
9. de Lorgeril M, Salen P, Martin JL, et al. Circulation. 1999; 99:779-85.
10. Rao M, Afshin A, Singh G, Mozaffarian D. BMJ Open. 2013;3:e004277.
11. Jones NR, Conklin AI, Suhrcke M, Monsivais P. PLoS ONE. 2014;9:e109343.
12. Pettersen BJ, Anousheh R, Fan J, Jaceldo-Siegl K, Fraser GE. Public Health Nutr. 2012;15:1909-16.
13. Orlich MJ, Singh PN, Sabaté J, et al. JAMA Intern Med. 2013;173:1230-8.
14. Crowe FL, Appleby PN, Travis RC, Key TJ. Am J Clin Nutr. 2013;97:597-603.
15. Trepanowski JF, Varady KA. Crit Rev Food Sci Nutr. 2014 Jun 12. [Epub ahead of print]
16. Levine ME, Suarez JA, Brandhorst S, et al. Cell Metabolism. 2014;19:407-17.
17. Fundación Dieta Mediterránea. The New Mediterranean Diet Pyramid. http://dietamediterranea.com/en/the-fdm-presents-the-new-mediterranean-diet-pyramid/. Accessed on March 11, 2015.
18. Mila-Villarroel R, Bach-Faig A, Puig J, et al. Public Health Nutr. 2011;14:2338-45.

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10 Basic Mediterranean Diet Recommendations

• Use olive oil as your main source of added fat.
• Eat plenty of fruits and vegetables, legumes, and nuts.
• Make bread and other grain products (especially whole grains) part of your everyday diet.
• Eat foods that have undergone minimal processing.
• Consume dairy products on a daily basis, mainly yogurt and cheese.
• Consume red meat in moderation and, if possible, as part of stews and other recipes.
• Consume dark-skinned fish abundantly and eggs in moderation.
• Fresh fruit should be your everyday dessert, with sweets, cakes and dairy desserts consumed only occasionally.
• Water is the beverage par excellence in the Mediterranean Diet. Wine is used in moderation with meals.
• Be physically active every day, since it is just as important as eating well.

Adapted from the Mediterranean Diet Foundation, Barcelona, Spain.

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Food Wise: "Let food be thy medicine and medicine be thy food."

Hippocrates, right? Actually, no. Although often attributed to Hippocrates, the quote is nowhere to be found in the 60 texts known as the Corpus Hippocraticum.¹

Well, at least we know that the Mediterranean diet originated in Ancient Greece, right? Uh, no, another myth busted: it is much more recent, emerging in modern Greece, Italy, and Spain in the decade after World War II.

The merits of the diet were first recognized in the early 1950s by Ancel Keys, PhD, who became concerned about diet as a public health problem. He noted the very low incidences of coronary heart disease in regions that adhered to a mainly vegetarian diet, with much lower consumption of meat and dairy products than North American diets.² However, it was not until 1975 that he coined the term the "good Mediterranean diet" in his book How to Eat Well and Stay Well the Mediterranean Way.

While his work has elicited some criticism, his observations about dietary patterns appear prescient today, and it has been noted that there are strong similarities between the dietary recommendations Keys made in 1959 and those of current dietary guidelines.³ It's a shame it's taken so long to listen.

References:

1. Cardenas D. e-SPEN Journal. 2013;8:e260-2.
2. Keys A. Am J Clin Nutr. 1995;61:1321S-3S.
3. Tracy SW. N Engl J Med. 2013;368:1274-6

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ACC President Comments on New U.S. Dietary Guidelines

In an interview with CSWN, ACC President Kim Williams, MD, chief of cardiology and James B. Herrick Professor at Rush University Medical Center in Chicago, expressed concern over the new 2015 U.S. Dietary Guidelines for Americans, specifically the removal of a recommendation from the previous Guidelines suggesting that dietary cholesterol intake be limited to no more than 300 mg/day. The reason given: "Because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol, consistent with the conclusions of the (2013) AHA/ACC report."

What was the basis for removing the dietary cholesterol limit from the new Dietary Guidelines for Americans?

"If you look at the original document, you'll see that there are two references given for that recommendation. The first was our 2013 ACC/AHA Lifestyle guidelines,¹ but that's not what our guidelines concluded. The ACC/AHA guidelines clearly say: 'There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C.' That is partly based on the desire to have 50 as the minimum size of each group for the randomized trials, so with that limitation there are few data that were convincing one way or the other about the effect of (dietary) cholesterol on serum cholesterol. Also, any discussion of dietary cholesterol should include incidence of myocardial infarction, death, stroke, and other nutrients that accompany cholesterol, making it even more difficult to make a conclusion."

"The ACC/AHA guidelines do state that the DASH diet, which is lower in cholesterol, decreases serum cholesterol more than the 'typical American diet' of the 1990s. The DASH diet lowers blood pressure and has more minerals and fiber."

What was the second reference?

"The second reference they cited was a systematic review and meta-analysis by Shin et al.,² where they compiled all of the egg consumption data—not cholesterol from all sources, but eggs only. They didn't see any differences in cardiovascular disease and stroke in those who ate one or more eggs a day compared to those who ate less than one egg per week or never ate eggs. These authors noted a 42% increased risk of diabetes in the egg eaters and, in the studies conducted in diabetic patients, a 69% increase in overall cardiovascular disease. This clearly was not vegetarian versus non-vegetarian; much of this data could have been 'bacon and eggs' versus bacon alone."

"This is a grave concern—no pun intended—for future cardiac risk. We have a growing problem with obesity and diabetes. If their referenced source is accurate, their recommendation could add to this problem."

Is there any good aspect of the new U.S. dietary guidelines?

"They did recommend eating less red meat and far less sugar. We can agree with those, but we wish there was more input by people, patient groups, cardiology societies, and medical societies."

References:

1. Eckel RH, et al. J Am Coll Cardiol. 2014;63(25_PA):2960-84.
2. Shin JY, et al. Am J Clin Nutr. 2013;98:146-59.

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