Despite being nearly always preventable, cardiovascular disease (CVD) continues to be the dominant cause of death for American men and women. In 2020, one of every five deaths in the U.S. was related to CVDs like coronary heart disease (clogged arteries) and peripheral vascular disease (a blood circulation disorder). And it's estimated that by the year 2035, 45% of American adults will be living with some form of CVD, which could cost the country upwards of a trillion dollars.
While there may be a genetic component underlying CVD, the empowering truth here is that diet and lifestyle are the major contributors. In fact, nutritional considerations are widely regarded as the number one modifiable risk factor for CVD. So, changing the food you eat can be one of the most impactful strategies for creating and keeping a healthy heart. But since the definition of a heart healthy diet has changed over the years, it's difficult to know what you should and shouldn't be eating.
In this article, I'll discuss the specifics about heart disease, including what it is and what puts you at risk. I'll also dive into the evolution of the heart healthy diet and what current research says about what foods to include and what foods to avoid for a healthy heart.
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What is a Heart Healthy Diet?
There's no one perfect heart healthy diet. Instead, working with an integrative provider who can personalize your nutrition recommendations is best. Nevertheless, certain dietary patterns seem to provide protection from heart disease. The Mediterranean diet, a diet rich in plant-based foods like fruits, vegetables, beans, nuts, seeds, and whole grains, is one example. This diet also includes olive oil as the primary source of fat, moderate amounts of dairy, poultry, and seafood, and minimal amounts of red meat and sweets. Before getting into the specifics of who needs to follow a heart healthy diet, let's take a look at the history of heart healthy diets.
Since heart disease was first identified as the number one killer of Americans, many definitions of a heart healthy diet have been used. Initially, the 1948 Framingham Heart Study and the 1957 Seven Countries Study were both used to draw conclusions about which diet and lifestyle factors contribute to heart disease. These studies ultimately led to the "diet-heart hypothesis," which drew a correlation between saturated fats and cholesterol and heart disease. This message took off, and Americans were encouraged to limit all dietary fat and cholesterol.
By the 1980s, the Dietary Guidelines for Americans emerged. We were encouraged to obtain most of our calories from grains, choose low-fat dairy products, and limit fat intake to less than 30% of total calories. The low-fat craze ensued, and refined products with high amounts of sugar flooded the market. This low-fat message was echoed with the widely distributed Food Guide Pyramid beginning in 1992. While fat intake remained pretty consistent during this time, refined grains and sugar intake continued to increase. This, coupled with a more sedentary lifestyle, is thought to be the impetus for the sharp increase in the rates of obesity and type 2 diabetes, both of which are significant risk factors for CVD.
In the early 2000s, nutrition science began to debunk the diet-heart hypothesis. We learned from meta-analyses and systematic reviews that low-fat diets don't protect us significantly from heart disease or the other risk factors for heart disease like obesity. And in 2013, the American Heart Association reversed its decades-long recommendation to limit dietary cholesterol intake to less than 300 milligrams per day, citing a lack of scientific evidence that this type of measure reduces heart disease risk.
Fast forward to today, and the most current Dietary Guidelines for Americans recommend a more personalized approach with limits set on added sugars, saturated fats, alcohol, and sodium. In addition, the 2021 American College of Cardiology and American Heart Association guidelines recommend a more plant-based or Mediterranean-type diet where ultra-processed foods and alcohol are avoided and refined grains, added sugars, salt, and processed meats are limited. The guidelines also recommend using plant-based oils instead of tropical oils, hydrogenated fats, and animal fats.
Who Should Follow a Heart Healthy Diet?
Since CVD generally develops over time, following a heart healthy diet is an excellent idea for anyone. But it's crucial for those with a family history of early heart disease or who have any of these common risk factors:
- High blood pressure or history of preeclampsia (sudden rise in blood pressure during pregnancy)
- High cholesterol
- Overweight
- Obesity
- Prediabetes
- Diabetes
- Smoking
- Sedentary lifestyle
- Consuming an inflammatory diet
- Female age 55 or older
- Male age 45 or older
To better understand why choosing a healthy diet is essential early in life, I want to expand on how the most common type of heart disease develops.
Coronary artery disease (CAD) results from the buildup of plaques containing fat, cholesterol, fibrin, calcium, and cellular waste in the arteries. Contributors to this process are triglycerides (TGs) and cholesterol, which are carried around in the blood by lipoproteins like low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and apolipoprotein B (apo B).
Too much LDL, VLDL, and apo-B can cross the delicate layer of cells lining the arteries and get caught in the extracellular matrix (a network of materials that provides support). When this happens, an inflammatory response that degrades the artery wall ensues. As this process repeats over time, large atherosclerotic plaques are formed, leading to heart attacks, strokes, and heart failure.
While dietary fat and cholesterol have been vilified for years, we now know elevated insulin and glucose levels are the more likely culprits of this type of heart disease. Diets high in sugar and refined carbohydrates (both of which can increase insulin and glucose levels) encourage the production of triglycerides (TGs) in the liver, which enters the circulation as VLDL and contribute to plaque formation.
How to Follow a Heart Healthy Diet
It's important to note that any dietary pattern that encourages the consumption of whole foods, supports a healthy weight, and controls blood sugar and inflammation is likely to be heart healthy. Below are some foods you may want to include and how they protect your heart.
Foods to Enjoy on a Heart Healthy Diet
Fruits and Vegetables
Including a diverse range of fruits and vegetables appears to be protective against heart disease as they provide nutrients like fiber, magnesium, potassium, and polyphenols, which are important for great heart health. The current recommendation is to include a minimum of 5 servings of fruits and vegetables every day. One serving is equivalent to one-half cup cooked or one cup raw.
Whole Grains
A meta-analysis of prospective studies found people who consume more whole grains have a reduced risk of CVD. Whole grains contain fiber, which can help control cholesterol levels and weight. Examples of whole grains to include in your diet are amaranth, barley, brown rice, buckwheat, bulgur, millet, oats, quinoa (considered a pseudo-cereal), popcorn, and whole wheat.
Eggs, Red Meat, and Poultry
All types of skinless poultry can be included on a heart healthy diet. The research surrounding eggs and red meat is controversial, but some observational studies do show an increased risk of adverse cardiovascular outcomes with high consumption of both. So, it’s best to practice moderation.
Beans and Legumes
People who eat more beans and legumes tend to have a lower risk of CVD. These plant-based proteins are high in fiber but also include a variety of other heart healthy nutrients. Beans and legumes to enjoy include black beans, chickpeas, navy beans, kidney beans, great northern beans, lentils, and soybeans.
Foods to Avoid on a Heart Healthy Diet
There are a few categories of foods to avoid when following a heart healthy diet, but context is important. Consuming these in small amounts sporadically won't likely increase your risk of CVD, assuming your overall diet is based on whole foods and your lifestyle generally promotes wellness. Much of the research on these types of foods is observational in nature, so we can't draw cause-and-effect conclusions.
Ultra-Processed Foods
Observational data have found people who consume more highly processed foods like pre-packaged snacks, chips, fast food, sugary beverages, breakfast cereals, candy, and energy bars are at greater risk of CVD. These foods add calories, industrial seed oils, salt, and sugar, which may lead to unwanted weight gain, an altered omega-6 to omega-3 fatty acid ratio, and poor blood sugar control.
Alcohol
While the research is mixed on alcohol and heart disease, it's probably best to avoid it as it adds calories to your diet, which can lead to weight gain. And high alcohol intake has been found to increase circulating TGs, which increases your CVD risk.
Added Sugars
Consuming more than 15% of your daily calories from added sugar increases your risk of CVD. The Food and Drug Administration recommends limiting added sugars to less than 10% of your daily calories, and the added sugar content of a food is now listed on the nutrition facts panel. Examples of added sugars to limit include agave, brown sugar, coconut sugar, high fructose corn syrup, honey, maple syrup, molasses, powdered sugar, and white sugar. Foods commonly containing added sugars include soda, energy drinks and other sugar-sweetened beverages, candies, cakes, cookies, granola bars, pies, and ice cream.
Processed Meats
Many studies show an increased risk of CVD when processed meats are consumed. It is recommended to limit or avoid bacon, bologna, deli meat, ham, hot dogs, salami, and sausage.
Refined Grains
While one meta-analysis found no association between refined grain intake and CVD, refined grains consumed in excess may contribute to weight gain. And when refined grains are replaced with whole grains, total cholesterol and LDL cholesterol levels improve, and blood sugar is better controlled. Refined grains to limit include white flour, white rice, white pasta, packaged crackers and cookies, and enriched flour.
Functional Medicine Labs to Consider When Transitioning to a Heart Healthy Diet
Conventional providers often order a standard lipid panel that includes triglycerides, total cholesterol, and HDL cholesterol. Outside of the TGs, this panel doesn't provide much meaningful information about your overall CVD risk. And it doesn't fully assess metabolic dysfunction, which is a significant risk factor for CVD. Functional medicine labs can be valuable in identifying and managing the risk factors for CVD. Advanced lipid panels, inflammatory markers, and other labs to assess for underlying conditions like prediabetes that can lead to CVD are some functional medicine labs that can be used to better evaluate your CVD risk. Here are some options to consider:
NMR LipoProfile
The NMR LipoProfile® test directly measures the amount of LDL circulating in the body. It's used in conjunction with other lipid measurements to aid in managing lipoprotein disorders associated with cardiovascular disease.
Glucose Testing
It's estimated that roughly 96 million U.S. adults have prediabetes, with many of them being unaware. Since people with diabetes and prediabetes have an increased risk of cardiovascular disease (heart disease), it's important to detect and address blood sugar dysregulation as early as possible. Markers, like glucose, insulin, and hemoglobin A1c (HbA1c) are valuable for diagnosing the risk of developing diabetes.
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Summary
While cardiovascular disease remains the number one killer of Americans, the majority of cases of coronary artery disease are preventable with nutrition and lifestyle. In fact, research confirms that modifying your diet is one of the most impactful measures you can take to improve your heart health. This means you no longer have to assume you'll have heart disease simply because it runs in your family. Rather you can harness the power of food and lifestyle to modify your risk significantly.
The definition of a heart healthy diet has changed over the past several decades. We've learned that dietary fat and cholesterol aren't the enemy. Instead, the type and amount of dietary fat, added sugar, and refined grains are the more critical nutritional considerations when it comes to heart disease.
There's no perfect heart healthy diet that's appropriate for everyone, but the Mediterranean diet is a well-researched dietary pattern that's been found to promote overall heart health. In general, though, any diet that encourages the consumption of whole foods and limits ultra-processed foods, alcohol, processed meats, added sugars, and refined grains can be considered heart healthy.
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