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Should you go vegetarian or vegan for your heart?

animal- and plant-based protein sources

At almost every talk I give, somebody asks me about a vegan diet. Shouldn't we be telling our patients to go vegan, given the evidence against red meat in particular and animal protein in general?

What I tell them is that it is all very well to tell someone to follow a vegan diet, but the real question is whether they will actually follow it. Certainly some patients will switch to a vegan or vegetarian diet and stick with it - but many won't. And the reasons they won't will range from cost to unfamiliarity to simple disinclination to eat that way.

That said, the evidence isn't as conclusive as folks would like to believe: Do people really have to go vegetarian or vegan to protect their heart?

Frank Hu and his team at Harvard analyzed data gathered data through three large-scale, long-term observational studies: the Nurses' Health Study (~75,000 women), the Nurses' Health Study II (~91,000 women), and the Health Professionals Follow-up Study (~43,000 men) (JAMA Intern Med oi:10.1001/jamainternmed.2020.2176). These studies began gathering data in 1984, 1991, and 1986, respectively, and are ongoing.

These prospective studies asked their participants to respond to validated food-frequency questionnaires every 2-4 years, allowing Hu and his colleagues to analyze each participant's diet and judge how closely it matched different dietary patterns.

The team focused on four healthy dietary patterns: the Healthy Eating Index-2015 (HEI-2015), the Alternate Mediterranean Diet Score (AMED), the Healthful Plant-Based Diet Index (HPDI), and the Alternate Healthy Eating Index (AHEI).

While these four scoring systems share some similarities, including "higher intake of whole grains, vegetables, fruits, legumes, and nuts," the Healthful Plant-Based Diet Index places more of an emphasis on avoiding animal proteins.

In short, what we're looking at here are 3 very similar dietary patterns that include fish and lean red meats - and one that's vegetarian.

Did any of the four do any better than the others?

Practically speaking, no.

After analyzing each participant's customary diet and determining which dietary pattern it most closely resembled, the authors further grouped the participants into 5 increasing levels of adherence to that diet. After comparing the highest levels of adherence to the lowest, the authors found that those whose diets most closely matched any of the four dietary patterns were far less likely to experience cardiovascular disease, heart attack, or stroke or to require a stent put in than those whose diets least closely matched any of the 4 healthy diets.

To be specific:

The HEI-2015 reduced risk of cardiovascular disease by 17%, reduced risk of coronary heart disease by 22%, and stroke by 12%.

The AMED reduced risk of cardiovascular disease by 10%, reduced risk of coronary heart disease by 11%, and stroke by 10%.

The HPDI reduced risk of cardiovascular disease by 14%, reduced risk of coronary heart disease by 16%, and stroke by 8%.

The AHEI reduced risk of cardiovascular disease by 9%, reduced risk of coronary heart disease by 21%, and stroke by 10%.

While statisticians and academics might argue that one dietary pattern is "better" than another, I'm a physician who sees patients every day, from the homeless to the CEOs of multinational corporations. And I know that no matter what I might say, some of my patients are never going to stop eating their Popeyes or their bologna sandwiches - and they certainly are never going to stop eating meat completely.

And I'm okay with that.

My job is to help my patients eat better. Not to berate them into some "perfect" diet. (As my wife likes to say, "'Perfect' is the enemy of 'better'.")

What this means for you

And this is where this research is so important: it shows that there are multiple ways to eat healthier and protect your heart - and you don't have to go vegan or even vegetarian if that's something that doesn't fit into your lifestyle. As the authors of this paper put it, "These results support the notion that individuals could choose different healthy eating patterns based on their personal food traditions or preferences for prevention of CVD [cardiovascular disease]."

First posted: June 17, 2020