A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet
Stewart Rose* and Amanda Strombom
Plant-based diets in Medicine, USA
Submission: November 22, 2018; Published: December 14, 2018
*Corresponding author: Stewart Rose, Plant-Based Diets in Medicine, 12819 SE 38th St, #427, Bellevue, WA 98006, USA.
How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847
Epidemiological studies show that vegetarians have a much lower risk of myocardial infarction. Reductions of risk factors, and comorbidities such as angina, hypercholesterolemia, hypertension, diabetes, metabolic syndrome and obesity, have also been shown.
A low-fat plant-based diet can reverse or prevent further progression of coronary atheroma, improve endothelial dysfunction and is effective even in cases of severe stenosis. Studies show that in addition to regression, there is a remolding of the geometry of the stenosis with consequent improvement in coronary flow reserve.
Those following a plant-based diet have much lower total cholesterol and LDL. They also have lower levels of cardio-reactive protein, apolipoprotein (a) and apolipoprotein (b), plus levels of MPO, MMP-9, MMP-2 and MMP-9/TIMP-1 ratios. In addition, studies have determined that vegans produce less TMAO than their omnivorous counterparts after dietary challenge.
Long term exposure to persistent organic pollutants can drastically affect the circulatory system. The consumption of animal products is the greatest source of exposure to these toxins, due to bioaccumulation of these lipophilic toxins in animal tissues.
Interventional studies confirm that a plant-based diet is as effective in lowering cholesterol as statin drugs. Such studies also show that a plant-based diet can help treat heart failure and is very efficacious in treating angina pectoris. Vegetarians also show better improvements in cardiac rehab. Follow-up studies at one and four years confirm continued benefit to the patient, and patient compliance has been demonstrated over several years. Treatment with a plant-based diet is devoid of side effects and contraindications.
It has long been known from epidemiological studies that vegetarians have lower incidences of several common chronic diseases including ischemic heart disease. Epidemiological studies have also shown that they have lower incidences of risk factors for ischemic heart disease such as hypercholestrolemia, type 2 diabetes and essential hypertension.
This prompted research on using a vegetarian diet as a treatment for coronary artery disease. For over 45 years, evidence from interventional studies has strongly indicated that a low-fat plant-based diet is both safe and efficacious in the treatment of coronary artery disease (CAD). It’s particularly effective in the treatment angina pectoris. Interventional studies have shown that a low-fat plant-based diet is a safe and efficacious alternative to other treatments.
This treatment can be used alone or in combination with standard treatment regimens, including medication, stenting and CABG. Treatment with the plant-based diet has the distinct advantages of having no adverse reactions or contraindications, is affordable, effectively treats common comorbidities and has been shown to have a high patient compliance.
Hypercholesterolemia is a well-known risk factor for CAD. Dietary saturated fat and cholesterol intake are shown to be strongly correlated with serum cholesterol levels. Less well-known is the fact that both apolipoproteins (a) and (b) are significant risk factors for CAD. While statin drugs are effective at lowering serum cholesterol levels, they are not effective at lowering Apolipoprotein (a).
Vegetarians, and most especially vegans, have a much lower
risk of hypercholesterolemia (for both total cholesterol and LDL)
and a less atherogenic profile. They have been found to have lower
total and LDL cholesterol levels on average. The following chart
shows the average cholesterol levels among three dietary groups.
[1,2] Vegans, or total vegetarians, have the lowest levels (Figure
The main reason for this is that animal products are high in
both saturated fats and cholesterol. While saturated and trans-fat
intake have the greatest effect on blood cholesterol concentrations,
serum cholesterol concentrations also rise in response to dietary
cholesterol intake. This relationship is linear within the range
of cholesterol intakes in typical omnivorous diets, but at higher
cholesterol intakes, the relationship is curvilinear; changes in
dietary cholesterol have less impact on serum cholesterol .
Another reason why low-fat vegetarian and vegan diets
result in lower serum cholesterol levels is that they improve
insulin sensitivity, which in turn can reduce cholesterol synthesis.
This may account for a portion of the lower prevalence of
hypercholesterolemia among vegetarians and vegans and for the
results obtained in interventional studies [4,5].
The fact that vegetarians and especially vegans have lower
cholesterol levels, and better cholesterol ratios, leads to much
less atherosclerosis. One of the important mechanisms whereby
LDL cholesterol results in atherosclerotic lesions involves the
oxidation of LDL cholesterol [6,7]. There is evidence that the LDL
cholesterol in vegetarians is much less oxidizable 
Vegans have also been found to have better regulation of the
metabolism of triglyceride-rich lipoproteins than omnivores,
because they are more efficient in removing remnants that are
potentially atherogenic. In addition, the diminished cholesteryl
ester transfer shown in the study, and the diminished LDL
cholesterol levels that have been previously documented in other
published studies, clearly suggest that a vegan diet offers some
protection against atherogenesis . A vegetarian diet also results
in lower levels of C-reactive protein [10,11].
In a cross-sectional study of apparently healthy vegetarian
and non- vegetarian men, all over 35 years old, the vegetarian
men had lower body mass index, systolic and diastolic blood
pressures, fasting serum total cholesterol, LDL and non-HDLcholesterol,
apolipoprotein B, glucose and glycated hemoglobin
values in comparison with non- vegetarian men. The vegetarian
men had better arterial function as measured by arterial stiffness
determined by carotid-femoral pulse wave velocity, relative
carotid distensibility and carotid intima-media thickness than
non-vegetarian men .
Several large population studies have shown a strong
independent relationship between high apolipoprotein (a)
(Lp(a)) levels and heart disease. This has led to the consensus
agreement that it is a very important risk factor for cardiovascular
disease, even when cholesterol levels and other classical risk
factors such as elevated cholesterol, hypertension and diabetes
have been taken into account. It is thought to increase the risk of
cardiovascular disease by two different mechanisms:
1. It promotes atherosclerosis. Research studies have
shown that Lp(a) may accelerate atherosclerotic damage. It
is thought to increase the size of plaque atheroma in artery
walls, causing inflammation, instability and growth of smooth
muscle cells. It is retained in the artery wall more than LDL
cholesterol as it binds to the artery lining through its “sticky”
2. It can trigger blockage of arteries by formation of clots.
Lp(a) is thought to increase risk of heart attacks by interfering
with clotting mechanisms and therefore promoting clot
development on the inner surface of blood vessels. Lp(a)
appears similar to proteins involved in clotting, such as plasminogen. It is thought to form a link between lipids and
the coagulation system by preventing fibrinolysis.
Existing data show that elevated Lp(a) levels are associated
with increased risk of coronary heart disease (CHD), stroke,
peripheral arterial disease, and calcific aortic valve stenosis [13-
15]. In a recent individual-patient data meta-analysis of statintreated
patients, elevated baseline and on-statin Lp(a) showed an
independent approximately linear relation with cardiovascular
disease risk. This study provides a rationale for lowering Lp(a)
even in statin-treated patients 
Not only does a plant-based diet reduce serum cholesterol,
but a recent study showed that Lp(a) could also be reduced.
In a four-week study on patients following a plant-based diet,
significant reductions were observed for serum Lp(a) with an
average reduction of -32.0 nmol/L. Lp(a) had been considered
resistant to change by lifestyle modification making this result
very notable . In contrast, initiation of statin therapy reduced
LDL cholesterol (mean change −39% [95% CI −43 to −35])
without a significant change in Lp(a) .
It is also evident that an increased serum apolipoprotein
(b) (Lp(b)) concentration is an important CHD risk factor .
Lp(b) is the primary apolipoprotein of chylomicrons, VLDL,
intermediate-density lipoprotein, and LDL particles. Prospective
studies suggest that concentrations of Lp(b) are indicators of
vascular heart disease and CVD risk [19,20].
Studies have also shown that vegetarians and vegans have
lower Lp(b) than meat eaters . Several studies show that a
low-fat vegetarian diet reduces Lp(b) concentrations [22,23].
When a low-fat vegetarian diet is introduced, Lp(b) levels are
reduced more than by other diets such the Atkins and South Beach
Vegetarian and vegan diets can be very efficacious in reducing
serum cholesterol. Patients in a 4-week plant-based diet program
had significant reductions in total cholesterol (34mg/dl), LDL-C
(25 mg/dl), triglycerides (20mg/dl), hs‐CRP (2.5 mg/dl), systolic
BP (16 mmHg), and diastolic BP (9 mmHg) .
One study showed that a low-fat vegetarian diet was as effective
at lowering serum cholesterol as the Standard Heart Association
diet plus Lovostatin . This study is notable because it contains
nuts in the treatment regimen. (See Clinical Considerations for
more information about the benefit of including nuts in the diet.).
Another study examining children and their adult parents
found that a plant-based, or vegan, diet reduced total cholesterol,
LDL cholesterol and C-reactive protein more than the American
Heart Association diet. This study is especially important given
the recent increase in the incidence of hypercholesterolemia in
children and the fact that atherosclerosis seems to start early in
The increasing deterioration of the natural environment is
having serious consequences on human health. The circulation
system is the major organ exposed to xenobiotics and endobiotics
during metabolic homeostasis [28-30] and exposure to persistent
organic pollutants can drastically alter this system, resulting in
cardiovascular diseases such as hypertension, atherosclerosis,
and ischemic heart disease [30-36].
Exposure to persistent organic pollutants such as dioxins and
dioxin-like polychlorinated biphenyls (PCBs) is associated with
increased risk of multiple pro-inflammatory human diseases
including diabetes, cancer, and cardiovascular disease [37-45].
High quality studies found consistent and significant doserelated
increases in ischemic heart disease with dioxin . Given
the large worldwide burden of CAD, the potential role of dioxin
exposure as a preventable risk factor could be of substantial
public health and clinical interest .
The aryl-hydrocarbon receptor (AhR) is a well-known
environmental sensor. Because many environmental pollutants
contain exogenous AhR ligands, increasing attention is being
given to the relationship between AhR and cardiovascular
diseases. Recent evidence from gene knock-out studies and
clinical trials suggests that not only does AhR have a major impact
on general physiological functions, including immune responses,
reproduction, oxidative stress, tumor promotion, the cell cycle,
and proliferation, but also influences cardiovascular physiological
AhR is a ligand activated transcription factor that mediates
the cellular response to environmental contaminants, including
dioxin and Polycyclic Aromatic Hydrocarbons (PAH) (from meat
or cigarette smoke), and has recently been associated with CAD
[47,48]. Exposure to pollutants containing ligands of AhR, such as
dioxins, Tetrachlorodibenzo-p-dioxin (TCDD), PAH, and benzo(α)
pyrene, is thought to promote the development and progression
of atherosclerosis, indicating that AhR may play a role in the
regulation of atherosclerosis . These environmental toxins, as
well as endogenous activators such as ox-LDL, activate the AhR
pathway, leading to increased inflammatory burden in the plaque
Studies have shown that dioxin-like PCBs may also increase
oxidative stress and subsequent chronic inflammatory states
which can lead to glucose intolerance, alterations of lipid and
cholesterol homeostasis, and other risk factors for multiple
metabolic diseases [37,49].
Dioxin-like PCBs can lead to increased levels of the known proatherogenic
nutrient biomarker Trimethylamine N-oxide (TMAO)
. A strong link between plasma levels of nutrient-derived TMAO and coronary artery disease has been identified. Dietary
precursors of TMAO include carnitine and phosphatidylcholine,
which are abundant in animal-derived foods .
TMAO levels are strongly linked to human diseases, and
plasma concentrations are correlated to dietary choices [51,52].
For example, diets high in red meat, and specifically L-carnitine,
produce TMAO and accelerate atherosclerosis [53,54]. However,
human studies have determined that vegans and vegetarians
produce less TMAO than their omnivorous counterparts after
dietary challenge .
The Diet Connection
Significant exposure of human populations to persistent
organic pollutants (POPs) such as PCBs and dioxin occurs through
consumption of fat-containing food such as fish, dairy products,
and meat [55-57], with the highest POP concentrations being
commonly found in fatty fish [55,56,58-62].
Humans bioaccumulate these lipophilic pollutants in their
adipose tissues for many years because POPs are highly resistant
to metabolic degradation [57,63]. This is likely to be one of the
factors reducing the risk of CAD for vegans.
Epidemiological studies show a 40% risk reduction of
ischemic heart disease  and a 50% risk reduction of coronary
heart disease mortality  for vegetarians.
Myeloperoxidase (MPO) is a leukocyte-derived pro-oxidant
enzyme that is released from granules of neutrophils and
monocytes . MPO and its oxidant products, nitrotyrosine and
chlorotyrosine, have been identified in atherosclerotic plaque
and at the site of plaque rupture, and play an important role in
the genesis of atherosclerosis . MPO promotes a number of
pathological events involved in plaque formation and rupture,
including uptake of oxidized lipid by macrophages and impaired
nitric oxide bioavailability. MPO levels independently predict
outcomes in patients presenting with acute coronary syndromes
or for evaluation of chest pain of suspected cardiac etiology and
endothelial dysfunction .
Matrix Metalloproteinases (MMPs) are extracellular
enzymes that are important in many physiologic and pathologic
processes. Their activity is regulated mainly by tissue inhibitors of
metalloproteinases (TIMPs). Their expression is associated with
classical cardiovascular risk factors as well as with inflammation.
They play a central role in atherosclerosis, plaque formation,
platelet aggregation, acute coronary syndrome, restenosis, aortic
aneurysms and peripheral vascular disease. Many studies have
shown that commonly prescribed antihypertensive medications,
glitazones and statins, may influence MMPs activity .
It is known that the arterial wall consists of collagen types
I and III, macrophages and smooth muscle cells. The evolution
of the atherosclerotic plaque from the fatty streak to advanced
plaque is associated with an increase in its content of collagen
, in the number of smooth muscle cells , and in MMP-9
levels . Increased levels of MMP-9 are found more often in
patients with unstable angina compared with those with stable
angina . Human coronary plaques that are less likely to rupture
demonstrate lower MMP-9 expression . In patients with
coronary artery disease, higher MMP-9 levels are an independent
risk factor of cardiovascular mortality . Increased TIMP-1
levels have been reported consistently in human atherosclerotic
plaques, mainly in relation to areas of calcification . Increased
circulating TIMP-1 levels have also been related to stable coronary
, carotid , and peripheral artery atherosclerosis .
One study of circulating cardiovascular biomarker profiles
compared the plasma concentrations of myeloperoxidase
(MPO), matrix metalloproteinases MMP-9 and MMP-2, and
tissue inhibitors of MMP TIMP-1 and TIMP-2, between healthy
vegetarians and healthy omnivores. The study found significantly
lower concentrations of MPO, MMP-9, MMP-2 and MMP-9/TIMP-
1 ratio in vegetarians compared to omnivores. Moreover, MMP-9
concentrations were correlated positively with leukocyte and
neutrophil counts in both groups. Therefore, a vegetarian diet is
associated with a healthier profile of cardiovascular biomarkers
compared to omnivores .
E-selectin (cE-Selectin) is a cell adhesion molecule expressed
only on endothelial cells activated by cytokines. Like other
selectins, it plays an important role in inflammation .
The intercellular adhesion molecule-1 (cICAM-1) is an Ig-like
cell adhesion molecule expressed by several cell types, including
leukocytes and endothelial cells. It can be induced in a cell-specific
manner by several cytokines, for example, tumor necrosis factor
alpha, interleukin 1, and interferon gamma, and inhibited by
Upregulation of leukocyte adhesion molecules under
atherogenic conditions is accompanied by the release of soluble
forms of adhesion molecules into the bloodstream . One study
assessed the levels of circulating E-selectin (cE-selectin) and
circulating intercellular adhesion molecule-1 (cICAM-1), in both
vegetarians and subjects from the general population . In
this study vegetarians were characterized by a significantly lower
cE-selectin levels. Vegetarians also showed a tendency towards
lower cICAM-1 levels in comparison with control subjects .
Low cE-selectin levels of vegetarians may reflect the favorable
cardiovascular risk profile of this group.
The lower levels of myeloperoxidase, matrix
metalloproteinases and cE-selectin combine to give vegetarians
a less atherogenic profile and helps explain their lower levels of
For over 45 years, evidence from interventional studies has
strongly indicated that a low-fat plant-based diet is both safe and
efficacious in the treatment of coronary artery disease (CAD).
Researchers have investigated using a very low-fat vegan or nearly
vegan diet to treat CAD of varying severity, and have achieved very
A moderately low-fat vegetarian diet was studied as an
intervention for CAD as early as 1960. Morrison placed 50
patients with confirmed CAD on a moderately low-fat (25 g/day)
vegetarian diet and followed them, and the 50 patients with CAD
in the control group, for 12 years. While none of the patients in the
control group survived for that length of time, 38% of the patients
in the treatment group did . It should be noted that since in
1960 neither stent, nor CABG surgery, nor cholesterol-reducing
drugs, were available this was a very notable finding.
More recently in 1990, a prospective, randomized, controlled
trial was done to determine whether comprehensive lifestyle
changes affect coronary atherosclerosis after one year. Twentyeight
patients were assigned to an experimental group (verylow-
fat vegetarian diet, healthy lifestyle and stress management)
and 20 to a standard care control group. 195 coronary artery
lesions were analyzed by quantitative coronary angiography. The
average percentage diameter stenosis regressed from an average
40.0% to 37.8% in the experimental group yet progressed from
an average of 42.7% to 46.1% in the control group. When only
lesions greater than 50% stenosed were analyzed, the average
percentage diameter stenosis regressed from an average of
61.1% to 55.8% in the experimental group and progressed from
an average of 61.7% to 64.4% in the control group. Overall, 82%
of experimental-group patients had an average change towards
regression . In evaluating the regression, it is very important
to keep in mind that blood flow increases by the radius raised to
the 4th power according to Poiseuille’s Law, so small changes make
a big difference
This landmark study provided compelling evidence that a
low-fat vegetarian diet can not only halt the progression of CAD,
but even result in modest regressions in arterial stenosis. Given
that CAD culminating in myocardial infarction is the leading cause
of death in the developed world, and a tremendous burden on
the health care system as well as on the patients themselves, the
importance of this finding can hardly be overstated.
Following up on these results, researchers then looked to see
if the treatment effects were sustained for longer periods of time,
and if even further improvements could be obtained. The answer
to both questions seems to be yes.
In a group of patients who participated in a 4-year follow
up, the average percent diameter stenosis at baseline decreased
1.75 absolute percentage points after 1 year (a 4.5% relative
improvement) and by 3.1 absolute percentage points after 4
years (a 7.9% relative improvement). In contrast, the average
percent diameter stenosis in the control group increased by 2.3
percentage points after 1 year (a 5.4% relative worsening) and by
11.8 percentage points after 4 years (a 27.7% relative worsening).
Patients in the experimental group lost 10.9 kg (23.9 lbs) at
1 year and sustained a weight loss of 5.8 kg (12.8 lbs) at 4 years,
whereas weight in the control group changed little from baseline.
In the experimental group, LDL cholesterol levels decreased
by 40% at 1 year and remained 20% below baseline at 4 years.
Experimental group patients also had a 91% reduction in reported
frequency of angina after 1 year, and a 72% reduction after 4 years
. It is important to note that the results obtained above were
dose dependent – the more closely patients adhered to the dietary
regimen the better their results.
A smaller study also showed good results. 17 patients with
CAD treated with a low-fat vegan diet, were followed for 5 years.
Lesion analysis by percent stenosis showed that of 25 lesions,
11 regressed and 14 remained stable. Mean arterial stenosis
decreased from an average of 53.4% to 46.2% .
A larger study, though with only a 3.7 year follow up, also
showed positive results. 198 patients were placed on a lowfat
vegan, or total vegetarian diet. 93% of patients experienced
improvement or resolution of angina symptoms during the follow
up period. Radiographic or stress testing results documented
disease reversal in 22% of patients. 99.4% of adherent patients
avoided major cardiac events. 89% patients were adherent to the
treatment regimen. However, this was not a controlled study and
the self-selected patients were very motivated .
An Indian study examined 360 coronary lesions in 123 such
patients. Results were dose dependent. In CAD patients with the
greatest adherence to a low-fat vegetarian diet, percent diameter
stenosis regressed by an average of 18.23 absolute percentage
points. 91% of all patients showed a trend towards regression,
and 51.4% lesions regressed by more than 10 absolute percentage
A Dutch interventional study took patients who had at least one
50% obstruction and placed them on a vegetarian diet, although
not as low in fat and cholesterol as other studies. After 2 years,
46% of patients showed no progression of the stenosis. Dietary
changes were associated with a significant increase in linoleic acid
content of cholesteryl esters, and a significant lowering of body
weight, systolic blood pressure, serum total cholesterol, and the
ratio of total to high-density lipoprotein (total/HDL) cholesterol
Coronary Perfusion Study
As might be expected, patients on a low-fat vegetarian
diet experience improvement in coronary perfusion as well.
In one study after 4 years, the size and severity of perfusion
abnormalities on dipyridamole PET images decreased after risk
factor modification in the experimental group, compared with an
increase of size and severity in controls. The percentage of left ventricle perfusion abnormalities, on the dipyridamole PET image
of normalized counts outside 2.5 SDs of those of normal persons,
worsened in controls by an average of 10.3% and improved in
the experimental group by an average of 5.1%. The percentage of
left ventricle with activity less than 60% of the maximum activity
worsened in controls by an average 13.5% and improved in the
experimental group 4.2%. The myocardial quadrant on the PET
image with the lowest average activity, expressed as a percentage
of maximum activity, worsened in controls by an average of 8.8%
and improved in the experimental group by an average of 4.9%.
The size and severity of perfusion abnormalities on resting PET
images were also significantly improved in the experimental group
as compared with controls. The relative magnitude of changes in
size and severity of PET perfusion abnormalities was comparable
to, or greater than, the magnitude of changes in percent diameter
stenosis, absolute stenosis lumen area, or stenosis flow reserve
documented by quantitative coronary arteriography .
Stenotic Morphology Study
In 1992, an interesting study looked at the change of the
geometric shape of the stenosis, in addition to the degree of
stenosis, and their combined effect on flow reserve. Percent
stenosis is an incomplete measure of stenosis because length,
absolute lumen area and shape effects are not accounted for,
and correlate poorly with the functional measure of coronary
stenosis, coronary reserve flow . Patients treated with a lowfat
vegetarian diet show complex stenosis shape change, with
profound effects on fluid dynamic severity, not accounted for
by simple percent narrowing in a dose dependent manner. This
effect is most pronounced with patients with severe pretreatment
stenosis, with stenosis flow reserve less than 3. In this study, the
minimal diameter increased by 18%. Patients with a pretreatment
average of 67% stenosis showed a 14% improvement in diameter
. As mentioned earlier, coronary blood flow effects are a
function of arterial radius raised to the 4th power, so small changes
in the radius have proportionately much larger effects on flow
capacity and functional severity of stenosis, thus contributing to
the greater significance of stenosis flow reserve as a measure of
change in severity.
An all-too-common comorbidity, angina, can also be treated
with a low-fat plant-based diet. One study examined over 100
patients with CAD at 22 different clinics throughout the U.S. After
12 weeks, 74% of these patients placed on a plant-based diet were
angina free, and an additional 9% moved from limiting to mild
angina . Another study of patients placed on a vegetarian diet
found that 91% of patients had a reduction in the frequency of
angina episodes . Using a purely vegan diet, one small study
found complete remission of symptoms in all patients by the 6th
Several epidemiological investigations have identified the
following key risk factors for heart failure (HF): increasing age,
hypertension, coronary artery disease, diabetes, obesity, valvular
heart disease, and the metabolic syndrome .
Coronary artery disease, which can lead to heart failure, may
be the underlying cause in most cases of heart failure patients with
low ejection fraction. Coronary artery disease may also play a role
in the progression of heart failure through mechanisms such as
endothelial dysfunction, ischemia, and infarction, among others.
Since those following a plant-based diet are at lower risk of
coronary artery disease, diabetes and obesity, they can be expected
to be at lower of heart failure as well. Several population-based
cohort studies that have demonstrated an inverse relationship
between increased consumption of plant-based foods and
incidence of heart failure [91-95].
Five prospective studies examined the association between
meat consumption and HF incidence in separate medium to large,
middle-aged cohorts. All of these studies found increased HF risk
with meat consumption [96-100].
In a prospective cohort study of 21,275 participants from
the Physicians’ Health Study I, consumption of one egg a day
increased the risk of heart failure by 28% and consuming two
eggs a day increased the risk of heart failure by 64% . In
another prospective study of over 15,000 participants, those who
ate a plant-based diet most of the time had a 42% reduced risk of
heart failure .
The beneficial effects of a low-fat vegetarian diet are indicated
for patients at risk of heart failure and who also have CAD. One
study showed significant improvements in such patients with
documented CHD, regardless of ejection fraction, in lifestyle
behaviors, body weight, body fat, blood pressure, resting heart
rate, total and LDL-cholesterol, exercise capacity, and quality of
life by 3 months. Most improvements were maintained over 12
A recent case report demonstrated the effects of a plant-based
diet in a 79-year-old male with documented triple vessel disease
(80–95 % stenosis) and left ventricular systolic dysfunction
(ejection fraction 35%) in the context of progressive dyspnea.
Two months on a plant-based diet led to clinically significant
reductions in body weight and lipids, with improved exercise
tolerance and ejection fraction (+15 %) .
Researchers have also studied the effects of a low-fat
vegetarian diet on patients who had already had standard
treatments and were ready for post op cardiac rehabilitation.
One study compared patients in cardiac rehabilitation
programs using either the standard treatment or a low-fat
vegetarian diet (combined with stress reduction). Low-fat
vegetarian program participants had significantly greater
reductions in anginal frequency, body weight, body mass index,
systolic blood pressure, total cholesterol, low-density lipoprotein
cholesterol, glucose and dietary fat .
Another study looked at psychosocial risk factors and quality of
life variables for patients in cardiac rehabilitation programs, using
either the standard treatment or a low-fat vegetarian program. At
3 and 6 months, vegetarian participants demonstrated significant
improvements in all 12 outcome measures, while the standard
rehabilitation group improved in only 7 of the 12 .
Substantial evidence indicates that plant-based diets can
play an important role in preventing and treating CVD and its
risk factors . This suggests that a plant-based diet should be
recommended as a prophylaxis to all patients, given that CAD is
such a frequent cause of disability and death.
Dietary intervention is an extremely cost-effective treatment
and may be the only viable treatment for those patients struggling
with the affordability of other options. Some patients are either
unwilling, fearful of or not good candidates for surgery. This
treatment also offers them a nonsurgical option of proven efficacy.
One of the key advantages of the treatment of coronary heart
disease with a low-fat vegetarian diet is the very low restenosis
rate. One study reports the following average restenosis rates:
balloon angioplasty 30-60%, bare metal stents, 16-44%, drug
eluting stents <10% . Compare this with the low-fat vegan
diet, which resulted in a zero-percentage restenosis rate in a study
by Dean Ornish .
A low-fat vegetarian treatment regimen has also been shown
suitable for diabetics with CAD. In a one-year study, diabetic
patients with comorbid CAD showed good adherence to the
treatment, and improvements in both cardiovascular and diabetic
parameters, as demonstrated by significant improvements in
weight, body fat, LDL cholesterol, and exercise capacity. About
20% of these patients were able to reduce or discontinue diabetic
medications such as insulin or oral anti-hyperglycemics .
The problem of depression is a common concomitant of
heart disease. A study using a low-fat plant-based diet in cardiac
rehab patients, found that 80% saw very significant reductions in
depression by 12 weeks, and the improvement was maintained
for at least one year . Another study of patients at high risk
also showed an improvement in depressive symptoms .
While the interventional studies stressed a low-fat dietary
regimen, there is good evidence that the inclusion of tree nuts,
despite their fat content, reduces cardiac risk [112,113]. The
research has been accumulating on the value of nuts in the
prevention and treatment of a variety of diseases, including
cardiovascular, indicating that the low-fat regimen now more
commonly employed may be enhanced by moderate amounts
of tree nuts. In one study, nut consumption was associated with
reduced prevalence of high cholesterol and high blood pressure;
having a history of heart attack, diabetes and gallstones; and
markers of diet quality. In this cross-sectional analysis, higher nut
consumption was also associated with lower body mass index and
waist circumference .
There has been an unfortunate tendency amongst some
physicians to recommend fish oils to their patients. However, this
has not been borne out by the evidence. One metastudy conducted
on the supposed benefits of fish oil reported, “All of the studies
included were the gold-standard kind of clinical trial -- with people
assigned at random to either take fish oil or a placebo. The studies
ranged in length from one to nearly five years. The authors detected
no reduction in any cardiovascular events, such as heart attacks,
sudden death, angina, heart failures, strokes or death, no matter
what dose of fish oil used .”
A recent meta-analysis of 10 randomized clinical trials also
demonstrated that randomization to trial showed that fish oil had
no significant effect on either of fatal CHD, nonfatal MI, stroke,
revascularization events, or any major vascular events. Likewise,
the study showed no significant association of omega-3 FA
supplementation with all-cause mortality or cancer .
In patients with established cardiovascular disease or an
increased risk of cardiovascular disease, omega-3 fatty acid
supplementation also had no effect on major adverse cardiac
events, all-cause mortality, sudden cardiac death, coronary artery
revascularization, or hypertension . In addition, a large,
long-term randomised trial showed that fish oil supplements
do not reduce the risk of cardiovascular events in patients with
There has also been a mistaken notion that the Eskimo had a
lower incidence of coronary heart disease, by virtue of their high
fish oil consumption. This also turns out to not be the case. One
report state, “Greenland Eskimos and the Canadian and Alaskan
Inuit have CAD as often as the non-Eskimo populations .”
Another study states, “Eskimos have CHD despite high consumption
of omega-3 fatty acids.” .
Interventional studies have shown that a low-fat (<10% of
calories) plant-based diet is a viable and highly advantageous
alternative to other interventional strategies. The low-fat
vegetarian diet also has no surgical risk of mortality, morbidity,
no post op complications, and no adverse reactions or contraindications.
The cost to the patient is minimal, and also both
treats and lowers the risk of common comorbidities such as
hypertension, diabetes and certain forms of cancer. It can serve as
a monotherapy or as an adjunct to standard treatment regimens,
including medication, stenting and CABG.
The treatment of CAD with a plant-based diet has been shown
to be very cost effective. Highmark’s Blue Cross estimated cost
savings per participant in the Ornish low-fat vegetarian cardiac
program is $16,186 measured in 1999 dollars . Estimated
savings would likely be much higher today. A Mutual of Omaha
Insurance study, also conducted in the 1990s, determined that for every dollar spent on the Ornish program there was a savings
of $5.55 in health care costs that would have otherwise accrued
According to a Kaiser Family Foundation/New York Times
survey, among people with health insurance, one in five (20%)
working age Americans report having had problems paying
medical bills in the past year, often causing serious financial
challenges and changes in employment. The situation is even
worse among people who are uninsured or underinsured: half
(53%) face problems with medical bills, bringing the overall total
to 26 percent . Many people struggle with copayments and
have high deductibles.
Coronary artery disease takes a tremendous toll in both lives
and money. Heart disease remains the leading cause of death
for both men and women . CAD costs the United States
$108.9 billion each year [125,126]. Clearly, a more cost-effective
treatment to Percutaneous Coronary Intervention and CABG
is needed. As we have seen, treatment of CAD with a low-fat
vegetarian diet would save a very considerable amount of money.
As most physicians know, many patients these days attempt
to gain health-related information and to treat themselves
based upon what they read on the internet. Such information is
often highly unreliable . In our experience, most patients
would rather get their health information and advice from their
physicians, but turn to the internet when they can’t. Therefore,
to serve the best interests and needs of their patients, physicians
should familiarize themselves with this treatment.
Research has documented the high rate of compliance with
this treatment, especially when physicians explain the rationale
behind the treatment and specifically prescribes it to their
We live in an age of advanced medical technology. These
advances have alleviated much suffering and saved countless
lives. They have an unquestioned place in modern medicine.
However, this can sometimes lead towards a kind of technological
fundamentalism. Little notice is taken of treatments that, while
lacking in technological sophistication, are nevertheless quite
efficacious. This indeed seems to be the case with treating CAD
with a low-fat vegetarian diet.
Fortunately, many doctors have already started to integrate
therapeutic plant-based diets into their patients’ prevention and
treatment of CAD. The former president of the American College
of Cardiology, Dr. Kim Williams, uses this modality of treatment
for his patients .
In a recent article, he states:
“Unlike many of our cardiovascular prevention and treatment
strategies, including antioxidants, vitamin E, folic acid and niacin
to name a few, that have disintegrated over time, the “truth” (i.e.,
evidence) for the benefits of plant-based nutrition continues to
mount. This now includes lower rates of stroke, hypertension,
diabetes mellitus, obesity, myocardial infarction and mortality,
as well as many non-cardiac issues that affect our patients in
cardiology, ranging from cancer to a variety of inflammatory
conditions. Challenges with the science are, however, less daunting
to overcome than inertia, culture, habit and widespread marketing
of unhealthy foods. Our goal must be to get data out to the medical
community and the public where it can actually change lives—
creating healthier and longer ones .”