Which is the Heart Healthiest Diet: Mediterranean or Plant-Based?

We’re so obsessed with finding the best of everything—constantly Googling “best restaurant,” “best vacation spot,” “best computer”—yet so many of us settle for the runner-up Mediterranean diet when it comes to eating for our heart health.

The Mediterranean diet improves or helps prevent heart disease, there's no disputing that, but so does a low-fat, plant-based diet, and it can actually reverse coronary artery disease (CAD). So, why do the 2019 guidelines for prevention from the American College of Cardiologists  (ACC) and The American Heart Association (AHA) continue to recommend both?  It’s because “America typically eats crap,” says holistic cardiologist Joel Kahn, MD. “Mediterranean is healthier than a meat-based diet.” In other words, they’re being practical—bad habits, especially bad eating habits, die-hard for many people. Healthcare professionals want to see some improvement. But ultimately, how you choose to care for your heart isn’t up to your cardiologist. It’s up to you, and you can do better by choosing low-fat, plant-based eating.

Isn’t Mediterranean plant-based?

It’s more plant-forward. While you get many of the benefits, you don’t get all of them. Most heart disease is caused by plaque in the arteries. That plaque comes from cholesterol and saturated fat, something meat, cheese, and eggs have in abundance. Plants, on the other hand, contain no dietary cholesterol, very little saturated fat, and tons of fiber. Recent research published in the Journal of the American Heart Association examined whether the degree of adherence to an overall plant‐based diet is associated with better health outcomes. After tracking middle-aged adults eating four different diets and comparing mortality rates, it concluded that diets higher in plant foods and lower in animal foods were associated with a lower risk of cardiovascular morbidity and mortality.

How will I get my omega-3s without fish?

The only essential omega-3, meaning the body can’t make it on its own, is alpha-linolenic acid  (ALA), which is found in flaxseeds, walnuts, chia seeds, hemp seeds, soybeans, and wheat germ. The body uses ALA to make the longer-chain omega-3 fatty acids EPA and DHA. The question is, can it make enough without supplementing with fish and fish oil tablets? A British study published in the American Journal of Clinical Nutrition suggests our bodies can adapt to low or no intake of fish fats by increasing the rate at which we convert ALA into EPA and DHA. The large population study compared the omega-3 intake (ALA, EPA, and DHA) of people with very different diets to the actual EPA and DHA in their blood. It found that despite eating significantly less EPA and DHA (from fish or fish oil), blood levels of those two long-chain omega-3s in vegans and vegetarians were approximately the same as in regular fish eaters.

What about eggs?

Eggs are packed with cholesterol, with a large one containing approximately 186 mg of the waxy stuff. Earlier this year, a study published in JAMA associated the cholesterol in eggs with a heightened risk of Cardio Vascular Disease (aka CVD) and early death. Researchers analyzed the diets of almost 30,000 people for 35 years. They found that each additional half an egg consumed per day was significantly associated with a higher risk of CVD and all-cause mortality. Further, the risk was similar for those who consumed a higher-quality diet and those who did not, suggesting that people may need to minimize dietary cholesterol and egg yolk intake even when everything else in their diet is healthy.

I love my cheese!

Cheese and other dairy products are among the top sources of saturated fat in the American diet. Saturated fat turns into cholesterol, and additional cholesterol your body does not need. (It travels through the blood and leads to plaque, which can block arteries and cause high blood pressure, blockages and ultimately heart attack or stroke.) It turns out you can get all the calcium you need from leafy greens without the added sat fat, cholesterol, or hormones.

Will I still need medicine to control my high cholesterol?

A low-fat, plant-based diet naturally contains loads of soluble fiber, and fiber has a superpower: it lowers cholesterol and blood pressure (BP). To reap the benefits, the AHA recommends eating 20 to 35 grams of fiber per day, but on average, Americans fall short, consuming just 10 to 15 grams/day. One reason why: Animal products contain no fiber. So, the only way to get more fiber into your diet is to eat more plants. As a bonus: Fiber fills you up, which may help you lose or maintain weight, also crucial for heart health and long-term health and wellbeing.

My cholesterol is fine. It's my blood pressure that’s worrisome.

In the United States, hypertension accounts for more atherosclerotic CVD deaths than any other modifiable risk factor, according to the ACC/AHA. The key here is modifiable. Dietary modifications have been shown to be particularly effective in preventing and managing hypertension. Plant-based eating, in particular, gives you the BP-lowering properties of fiber, as well as more potassium and less salt. Proof: A meta-analysis published in JAMA Internal Medine indicates that a vegetarian diet is associated with lower blood pressure, compared to an omnivorous diet, and “such diets could be a useful non-pharmacologic means for reducing BP.” Meaning you could get to the point where no meds are required.