Purpose of Review
Plant-based diets have been widely promoted for cardiovascular disease (CVD) risk reduction. This review discusses the various definitions of plant-based diets and summarizes their associations with CVD risk, specifically distinguishing between healthy and unhealthy plant-based diets.
Despite wide variation in definition, most studies suggest that plant-based diets are generally beneficial for cardiovascular health. Many previous studies have defined plant-based diets by the complete exclusion of meat or animal products, while others have accounted for plant-based diets including moderate amounts of animal-source foods. Only a few studies have considered the healthfulness of the specific plant foods included in these dietary patterns. In these studies, plant-based diets containing higher amounts of healthy foods such as whole grains, fruits, vegetables, nuts, legumes, oils, tea, and coffee are associated with lower CVD risk. However, plant-based diets including higher amounts of less healthy plant foods, such as refined grains, potatoes/fries, and foods and beverages high in added sugar, are linked to increased risk.
A wide spectrum of plant-based diets can be nutritionally adequate and confer cardiovascular benefits, as long as they are planned appropriately and include high-quality foods. Contrary to popular belief, plant-based diets do not have to be vegan or vegetarian. For most people, complete elimination of meat or animal products is unrealistic and not necessary for cardiovascular health. Quality of the specific components of plant-based diets is also important to consider, as not all plant-source foods have beneficial cardiovascular effects. Healthy plant-based diets can be customized to fit individual and cultural preferences and, with large-scale adoption, could concurrently mitigate threats to both human and environmental health.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
World Health Organization. Cardiovascular diseases. 2017. http://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). Accessed Nov 30 2018.
GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet (London, England). 2018;392(10159):1736–88. https://doi.org/10.1016/s0140-6736(18)32203-7.
Mokdad AH, Ballestros K, Echko M, Glenn S, Olsen HE, Mullany E, et al. The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states. Jama. 2018;319(14):1444–72. https://doi.org/10.1001/jama.2018.0158.
• Satija A, Hu FB. Plant-based diets and cardiovascular health. Trends Cardiovasc Med. 2018. https://doi.org/10.1016/j.tcm.2018.02.004 A recent review providing a comprehensive overview of definitions of plant-based diets and their relationships with cardiovascular outcomes.
Aune D, Giovannucci E, Boffetta P, Fadnes LT, Keum N, Norat T, et al. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol. 2017;46(3):1029–56. https://doi.org/10.1093/ije/dyw319.
Luo C, Zhang Y, Ding Y, Shan Z, Chen S, Yu M, et al. Nut consumption and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):256–69. https://doi.org/10.3945/ajcn.113.076109.
Marventano S, Izquierdo Pulido M, Sanchez-Gonzalez C, Godos J, Speciani A, Galvano F, et al. Legume consumption and CVD risk: a systematic review and meta-analysis. Public Health Nutr. 2017;20(2):245–54. https://doi.org/10.1017/s1368980016002299.
Zong G, Gao A, Hu FB, Sun Q. Whole grain intake and mortality from all causes, cardiovascular disease, and cancer: a meta-analysis of prospective cohort studies. Circulation. 2016;133(24):2370–80. https://doi.org/10.1161/CIRCULATIONAHA.115.021101.
Poole R, Kennedy OJ, Roderick P, Fallowfield JA, Hayes PC, Parkes J. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. Bmj. 2017;359:j5024. https://doi.org/10.1136/bmj.j5024.
Zhang C, Qin YY, Wei X, Yu FF, Zhou YH, He J. Tea consumption and risk of cardiovascular outcomes and total mortality: a systematic review and meta-analysis of prospective observational studies. Eur J Epidemiol. 2015;30(2):103–13. https://doi.org/10.1007/s10654-014-9960-x.
• Bechthold A, Boeing H, Schwedhelm C, Hoffmann G, Knuppel S, Iqbal K, et al. Food groups and risk of coronary heart disease, stroke and heart failure: a systematic review and dose-response meta-analysis of prospective studies. Crit Rev Food Sci Nutr. 2017:1–20. https://doi.org/10.1080/10408398.2017.1392288 This series of meta-analyses demonstrates positive associatations between cardiovascular outcomes and specific healthy plant food groups, as well as negative associations for certain animal and less healthy plant foods.
Schulze MB, Martinez-Gonzalez MA, Fung TT, Lichtenstein AH, Forouhi NG. Food based dietary patterns and chronic disease prevention. Bmj. 2018;361:k2396. https://doi.org/10.1136/bmj.k2396.
Dietary Guidelines Advisory Committee. Scientific report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: US Department of Agriculture and US Department of Health and Human Services; 2015.
Yokoyama Y, Nishimura K, Barnard ND, Takegami M, Watanabe M, Sekikawa A, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med. 2014;174(4):577–87. https://doi.org/10.1001/jamainternmed.2013.14547.
Wang F, Zheng J, Yang B, Jiang J, Fu Y, Li D. Effects of vegetarian diets on blood lipids: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2015;4(10):e002408. https://doi.org/10.1161/jaha.115.002408.
Huang RY, Huang CC, Hu FB, Chavarro JE. Vegetarian diets and weight reduction: a meta-analysis of randomized controlled trials. J Gen Intern Med. 2016;31(1):109–16. https://doi.org/10.1007/s11606-015-3390-7.
Yokoyama Y, Barnard ND, Levin SM, Watanabe M. Vegetarian diets and glycemic control in diabetes: a systematic review and meta-analysis. Cardiovasc Diagn Ther. 2014;4(5):373–82. https://doi.org/10.3978/j.issn.2223-3652.2014.10.04.
Key TJ, Fraser GE, Thorogood M, Appleby PN, Beral V, Reeves G, et al. Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Am J Clin Nutr. 1999;70(3 Suppl):516s–24s. https://doi.org/10.1093/ajcn/70.3.516s.
Huang T, Yang B, Zheng J, Li G, Wahlqvist ML, Li D. Cardiovascular disease mortality and cancer incidence in vegetarians: a meta-analysis and systematic review. Ann Nutr Metab. 2012;60(4):233–40. https://doi.org/10.1159/000337301.
Kwok CS, Umar S, Myint PK, Mamas MA, Loke YK. Vegetarian diet, Seventh Day Adventists and risk of cardiovascular mortality: a systematic review and meta-analysis. Int J Cardiol. 2014;176(3):680–6. https://doi.org/10.1016/j.ijcard.2014.07.080.
Martinez-Gonzalez MA, Sanchez-Tainta A, Corella D, Salas-Salvado J, Ros E, Aros F, et al. A provegetarian food pattern and reduction in total mortality in the Prevencion con Dieta Mediterranea (PREDIMED) study. Am J Clin Nutr. 2014;100(Suppl 1):320s–8s. https://doi.org/10.3945/ajcn.113.071431.
Lassale C, Beulens J, Van der Schouw Y, Roswall N, Weiderpass E, Romaguera D, et al. Abstract 16: a pro-vegetarian food pattern and cardiovascular mortality in the epic study. Circulation. 2015;131. https://www.ahajournals.org/doi/abs/10.1161/circ.131.suppl_1.16.
Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC, Hu FB. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med. 2010;153(5):289–98. https://doi.org/10.7326/0003-4819-153-5-201009070-00003.
• Song M, Fung TT, Hu FB, Willett WC, Longo VD, Chan AT, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med. 2016;176(10):1453–63. https://doi.org/10.1001/jamainternmed.2016.4182 Comprehensive analysis suggesting cardiovascular benefits of replacing animal protein with plant protein.
• Zong G, Li Y, Sampson L, Dougherty LW, Willett WC, Wanders AJ, et al. Monounsaturated fats from plant and animal sources in relation to risk of coronary heart disease among US men and women. Am J Clin Nutr. 2018;107(3):445–53. https://doi.org/10.1093/ajcn/nqx004 This study demonstrates potential cardiovascular benefits of replacing monunsaturated fats from animal sources with monunsaturated fats from plant sources.
Liu X, Li Y, Tobias DK, Wang DD, Manson JE, Willett WC, et al. Changes in types of dietary fats influence long-term weight change in US women and men. J Nutr. 2018;148(11):1821–9. https://doi.org/10.1093/jn/nxy183.
• Wang DD, Li Y, Chiuve SE, Stampfer MJ, Manson JE, Rimm EB, et al. Association of specific dietary fats with total and cause-specific mortality. JAMA Intern Med. 2016;176(8):1134–45. https://doi.org/10.1001/jamainternmed.2016.2417 Comprehensive analysis suggesting cardiovascular benefits of replacing saturated fats with unsaturated fats.
Li Y, Hruby A, Bernstein AM, Ley SH, Wang DD, Chiuve SE, et al. Saturated fats compared with unsaturated fats and sources of carbohydrates in relation to risk of coronary heart disease: a prospective cohort study. J Am Coll Cardiol. 2015;66(14):1538–48. https://doi.org/10.1016/j.jacc.2015.07.055.
Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77(5):1146–55. https://doi.org/10.1093/ajcn/77.5.1146.
Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010;7(3):e1000252. https://doi.org/10.1371/journal.pmed.1000252.
•• Satija A, Bhupathiraju SN, Spiegelman D, Chiuve SE, Manson JE, Willett W, et al. Healthful and unhealthful plant-based diets and the risk of coronary heart disease in U.S. adults. J Am Coll Cardiol. 2017;70(4):411–22. https://doi.org/10.1016/j.jacc.2017.05.047 The first study to demonstrate the divergent effects of healthy and unhealthy plant-based diets on coronary heart disease risk.
•• Satija A, Bhupathiraju SN, Rimm EB, Spiegelman D, Chiuve SE, Borgi L, et al. Plant-based dietary patterns and incidence of type 2 diabetes in US men and women: results from three prospective cohort studies. PLoS Med. 2016;13(6):e1002039. https://doi.org/10.1371/journal.pmed.1002039 One of the first studies to consider specific plant foods included in plant-based diets, by creating overall, healthful, and unhealthful plant-based diet indices.
Mazidi M, Kengne AP. Higher adherence to plant-based diets are associated with lower likelihood of fatty liver. Clin Nutr. 2018. https://doi.org/10.1016/j.clnu.2018.08.010.
Misra VL, Khashab M, Chalasani N. Nonalcoholic fatty liver disease and cardiovascular risk. Current gastroenterology reports. 2009;11(1):50–5.
Kim H, Caulfield LE, Rebholz CM. Healthy plant-based diets are associated with lower risk of all-cause mortality in US adults. J Nutr. 2018;148(4):624–31. https://doi.org/10.1093/jn/nxy019.
•• Baden MY, Satija A, Hu FB, Huang T. Change in plant-based diet quality is associated with changes in plasma adiposity-associated biomarker concentrations in women. J Nutr. 2019; In Press. This study suggests divergent effects of healthy and unhealthy plant-based diets on systemic inflammation and insulin resistance.
Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr. 1999;69(1):30–42. https://doi.org/10.1093/ajcn/69.1.30.
Reynolds A, Mann J, Cummings J, Winter N, Mete E, Te Morenga L. Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet (London, England). 2019. https://doi.org/10.1016/s0140-6736(18)31809-9.
Melina V, Craig W, Levin S. Position of the academy of nutrition and dietetics: vegetarian diets. J Acad Nutr Diet. 2016;116(12):1970–80. https://doi.org/10.1016/j.jand.2016.09.025.
Zheng J, Huang T, Yu Y, Hu X, Yang B, Li D. Fish consumption and CHD mortality: an updated meta-analysis of seventeen cohort studies. Public Health Nutr. 2012;15(4):725–37. https://doi.org/10.1017/s1368980011002254.
Kim K, Hyeon J, Lee SA, Kwon SO, Lee H, Keum N, et al. Role of total, red, processed, and white meat consumption in stroke incidence and mortality: a systematic review and meta-analysis of prospective cohort studies. J Am Heart Assoc. 2017;6(9). https://doi.org/10.1161/jaha.117.005983.
Bernstein AM, Sun Q, Hu FB, Stampfer MJ, Manson JE, Willett WC. Major dietary protein sources and risk of coronary heart disease in women. Circulation. 2010;122(9):876–83. https://doi.org/10.1161/circulationaha.109.915165.
•• Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet (London, England). 2019. https://doi.org/10.1016/s0140-6736(18)31788-4 This review creates the first ever scientific targets for a healthy diet and sustainable food production within planetary boundaries and discusses the potential health and environmental benefits that could be achieved from a reference plant-based diet.
U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. 2015.
Hu FB. Nutrient supplementation no substitute for healthy diets. Nat Rev Cardiol. 2019;16(2):77–9. https://doi.org/10.1038/s41569-018-0143-4.
Springmann M, Wiebe K, Mason-D’Croz D, Sulser TB, Rayner M, Scarborough P. Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail. Lancet Planet Health. 2018;2(10):e451–e61. https://doi.org/10.1016/s2542-5196(18)30206-7.
Conflict of Interest
Elena Hemler has no conflict of interest to disclose. Dr. Hu reports receiving research support from the California Walnut Commission and personal fees from Standard Process, Diet Quality Photo Navigation, and Metagenics, outside the submitted work.
Source of support: FBH’s research is supported by NIH grants HL60712, HL118264, and DK112940.
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.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Nutrition
About this article
Cite this article
Hemler, E.C., Hu, F.B. Plant-Based Diets for Cardiovascular Disease Prevention: All Plant Foods Are Not Created Equal. Curr Atheroscler Rep 21, 18 (2019). https://doi.org/10.1007/s11883-019-0779-5
- Plant-based dietary patterns
- Cardiovascular disease
- Diet quality
- Healthy plant-based diets