There is so much misinformation out there about what’s the best heart healthy diet. From keto to Mediterranean to Paleo, many are left confused as to what changes to make to create the ultimate cardiac diet. Whether you have a family history of heart disease, other risk factors like high cholesterol, or already have heart disease and want to avoid another heart attack, there are several major shifts you can make to decrease your blood pressure, cholesterol, waistline, and risk of heart disease.

1. Eat more plants for heart health

   We know from an overwhelming amount of evidence that eating more plants reduces our risk of heart attacks and stroke.

   Plants contain an abundance of fiber as well as vitamins, minerals, micronutrients, polyphenols and antioxidants.

   Evidence suggests we should aim to eat a diet that is rich in quantity and variety of vegetables, fruits, whole grains, legumes (beans), nuts and seeds. Many trials have demonstrated lower rates of high blood pressure, cholesterol, obesity, inflammation and heart disease in those following a plant-predominant or plant-based diet. 

   While a wide variety of plants is recommended, a handful have emerged in the literature as particularly heart-healthy. I recommend ensuring green, leafy vegetables, antioxidant-rich berries, plant proteins (beans and soy-based products), and nuts play prominent roles in your diet when possible.  

2. Switch to heart healthy fats

   We now have robust evidence that polyunsaturated and monounsaturated fats (mostly found in plant foods and fish) are heart-healthy compared to their counterparts, trans fats and saturated fats. 

   One particularly important study compared a low-fat diet to a Mediterranean diet supplemented with extra virgin olive oil or nuts. The group of individuals who consumed the plant-predominant Mediterranean diet high in monounsaturated and polyunsaturated fats reduced their cardiovascular events by 30% compared to the standard low-fat group.

   In particular, omega-3’s (DHA, EPA and ALA) are an essential type of polyunsaturated fatty acids and appear important for heart health. They play an essential role in brain function, inflammation, and normal growth and development. While the studies regarding the benefit of supplementation are very inconsistent (as I detailed here) obtaining adequate amounts of omega-3 in the diet is recommended.

   Long-chain fatty acids DHA and EPA can be found in fatty fish like salmon and sardines, and the short-chain fatty acid ALA can be found in many nuts and seeds (flax seeds, chia seeds, pumpkin seeds, and walnuts).

3. Aim for a high fiber diet

   Fiber is a type of carbohydrate that isn’t digestible. It’s been shown to help lower cholesterol, blood pressure, glucose and risk of heart disease. It also supports our gut microbiome and aid in weight loss.

   The American Heart Association recommends that women eat at least 21 to 25 grams of fiber a day, and men at least 30 to 38 grams a day, but evidence suggests more can have additional beneficial effects. As I detailed in this post, 20 grams of soluble fiber alone (meaning more like 40 grams of total fiber a day) is recommend in the Portfolio diet to lower LDL cholesterol by 5-10%.

   With most Americans getting somewhere around 16 grams of fiber a day, it’s a safe bet that most of us are far from our target!

   Fiber is found in - you guessed it - plants. It’s particularly high in legumes, many fruits and veggies, and whole grains. Consider using a tracker - like Chronometer or MyFitnessPal - to see where you are at right now, and then work on slowly increasing your intake to avoid GI discomfort. It’s also important to increase your water intake as you do so.

4. Ditch processed and packaged food

   While we inherently know that processed and packaged foods aren’t good for us, did you know that the average American consumes almost 60% of their daily calories from these food products? Ultra-processed foods - which are highly processed industrial formulations made with little or no whole foods - typically contain lots of sugar, saturated fat, and salt, while eliminating a lot of the good stuff, like fiber.

   A recent study found that each additional serving of ultra-processed foods was associated with a 9% increase in death from cardiovascular disease, independent of other cardiovascular risk factors.

   Importantly, this includes vegan junk food! Aim for whole foods when able, and limit the processed and packaged foods. If you do reach for processed foods (as we all do!), try to stick with foods that are made with whole grains, nuts, and seeds and limit heavily refined products.

5. Swap out animal protein for plant protein

   Replacing animal protein with plant protein, particularly red meat, is associated with a reduction in death from any cause as well as death from cardiovascular disease.

   A very large epidemiological study found a 61% increased risk of death from any cause when meat was used for protein rather than plants. Another study found that plant protein was associated with a reduction in mortality rate of 10% for every 3% energy increment in which plant protein was swapped in for animal protein.

   Why? Animal products tend to be high in saturated fat (which increases LDL cholesterol) and sodium. They also contain other bioactive molecules that appear to be detrimental to our health, including heme iron, nitrates and carnitine (which gets converted to TMAO, an active metabolite that has been linked to increased risk of cardiovascular disease).

   Intake of processed meats, which is any meat that is preserved by smoking, curing, or salting, or additional chemical preservatives (i.e., hamburgers, hotdogs and deli meats), deserves particular mention. It has been consistently demonstrated to increase the risk of heart disease quite robustly and profoundly.

   Importantly, replacing red meat with refined carbohydrates (rather than, whole food plant sources) is associated with an increased risk of heart disease, and so this should be avoided.

6. Minimize added sugar and sugar-sweetened beverages

   Diets high in added sugar has been shown to increase the risk of heart disease and diabetes. Consuming added sugar more than 10% of daily calories has been associated with a higher risk of death!

   For this reason, the American Heart Association sets a limit of no more than 9 teaspoons (36 grams) for men and 6 teaspoons (25 grams) for women per day.

   The top sources of sugar in the American diet include beverages such as soft drinks (one can of soda contains 8 teaspoons of soda!), juices, and sports/energy drinks. Snacks and desserts follow closely behind.

   Added sugar is processed by your body very differently than sugar naturally found in fruits - the inherent fiber in whole fruits helps the sugar to be absorbed much more slowly and controlled. Consuming sugar in whole fruits has not been associated with an increase in diabetes or heart disease, and in contrast, has been associated with a reduced risk.

   “Natural” sugar, on the other hand, is not necessarily healthier. Recipes and packaged foods with “no refined sugar” that instead use honey, maple syrup, coconut sugar, turbinado sugar, or agave still have added sugar! While it’s true that some of these other sugar contain additional nutrients and antioxidants, in the amounts that we should be consuming, there’s likely no massive health benefit. And they still count toward our daily sugar max.

7. Be mindful of your salt intake

   High dietary sodium intake (>2000 mg per day) has been associated with an increased risk of death from heart disease.

   A seminal, randomized controlled trial called the Dietary Approaches to Stop Hypertension found that by reducing intake of sodium, along with consuming a diet that is high in plants, blood pressure was significantly reduced. Reducing sodium intake to below 1500 mg of sodium resulted in reductions in systolic blood pressure of 12 mmHg in those with hypertension, with smaller reductions in blood pressure seen with sodium intake below 2300 mg of sodium.

   While reducing how much salt you add in your cooking is important, be mindful that the average person gets 75% of their sodium from processed and packaged foods. Be particularly mindful of canned foods (particularly canned soups), frozen entrees, chips, cookies, crackers, breads, dressings, and sauces.

The best cardiac diet

While it can be quite confusing how to structure the most healthful diet given how much noise is out there, it ultimately comes back to the basics. Eating a diet rich in veggies, fruits, whole grains, legumes, nuts and seeds, while minimizing animal products and packaged foods, will hit all of the basic tenets described above. While there may be personalized and individual decisions to make within this context based on individual risk factors, genetics, and preferences, sticking to this general foundation is a good, evidence-based dietary plan. Reading labels, being more mindful of intake by tracking certain nutrients (ie fiber), and working with a registered dietician or nutritionally-focused doctor can be helpful for many to fine tune and optimize.