Redefining Plant-Based Diets For CVD Primary Prevention

Nutrition is a cornerstone of cardiovascular disease (CVD) primary prevention. Both the 2019 American Heart Association (AHA)/American College of Cardiology (ACC) CVD primary prevention guidelines and recently updated 2021 ESC CVD Primary Prevention Guidelines recommend dietary patterns with higher plant-based food intake and lower animal product intake (Figure 1).1-2

Traditional plant-based diets (PBDs) are dietary patterns defined by animal consumption. For example, vegan diets exclude animal consumption while other modified vegetarian diets allow dairy, eggs, fish, and other combinations of animal product consumption.3 In contrast, newer PBDs measure plant-based food consumption rather than animal product limitation, positively reinforcing dietary adherence. For example, the "pro-vegetarian" diet evaluates plant-based foods positively and animal products negatively rather than including or excluding food groups.3

Figure 1Click the image above for a larger view.

Benefits For General Population

Literature supports the cardiovascular (CV) health benefits of PBDs, including reductions in obesity, hypertension, Type 2 Diabetes mellitus, and ischemic heart disease4-8 (Figure 1) as well as all-cause and CV mortality risk.9-10 Per the AHA/ACC CVD Primary Prevention Guidelines, PBDs are recommended based on various studies including the PREDIMED (Prevención con Dieta Mediterránea) trial, with an approximately 30% reduction in MI, stroke, or CV mortality with the Mediterranean diet; a post-hoc analysis showed a 41% mortality rate reduction with more plant-based food intake over animal product intake.11 Furthermore, the Adventist Health Study-2, which showed a 61% increase in mortality with animal protein versus plant-based protein.12 The 2021 ESC CVD primary prevention guidelines cite a 26% stroke risk reduction with three to five daily servings of fruits and vegetables and a 4% CVD risk reduction with additional servings.13-15

Benefits For Women

While most PBD research applies to mixed-gender populations, its impact on women remains unclear. Sex differences in CV health between men and women, including vascular biology and hormonal influences, may result in sex-differences in CV outcomes when using a PBD. Most recently, a 2021 prospective cohort study in the Women's Health Initiative evaluated over 120,000 post-menopausal women on the Portfolio diet (seen in Figure 1). The Portfolio diet contains 4 cholesterol-lowering foods with known CVD benefits, including improvement in dyslipidemia. This study found an 11%, 14%, and 17% risk reduction in CVD, coronary heart disease, and heart failure, respectively,16 highlighting CV health benefits in post-menopausal women.

Future Research Directions

Although current literature encourages PBDs for CVD primary prevention, further studies are needed to compare different PBDs. Recently, studies have adopted indices to evaluate PBD quality: the healthful plant-based index and unhealthful plant-based index2 (Figure 1). The healthful plant-based index weighs healthy plant-based foods positively and less healthy plant-based foods negatively. In contrast, unhealthful plant-based index weighs less healthy plant-based foods positively and healthy plant-based foods and animal products negatively. While these indices are useful for research studies, they are not patient friendly. Furthermore, it is necessary to determine ideal PBDs for different women: post-menopausal, pregnant, pre-menopausal non-pregnant, with and without CVD risk factors, etc.

Tools For Access and Adherence

In addition, interventions are needed to promote PBDs (seen in Figure 1). Clinicians and researchers will need to develop patient-friendly tools to create custom PBDs based on their CVD risk profile, including other cardiometabolic, psycho-social, and genomic risk factors. These tools may involve mobile applications for women to determine their CVD risk and ideal PBD; mobile applications are shown to improve CVD modifiable risk factors.17 Additionally, improving access to PBDs for women limited by time and resources is important (Figure 1). It is time nutrition went from a "one size fits all" approach to a personalized component of CVD primary prevention.


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Najah Khan, MD
Bindu Chebrolu, MBBS, FACC

This article was authored by Najah Khan, MD, and edited by Bindu Chebrolu, MBBS, FACC.

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