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The Anti-Heart Attack Diet

June 7, 2010 Written by JP    [Font too small?]

Many conventional nutritionists and physicians pass along a standard piece of advice with regard to managing heart disease via diet: follow the guidelines set forth by the American Heart Association (AHA). After all, who better to offer guidance than an organization that specializes in matters relating to cardiovascular disease? My Health Monday tip of the day is to discuss different, and I think, more promising, dietary options with your health care team.

The eating model recommended by the AHA is basically a low-fat menu plan that is rich in fruits, grains and vegetables. It allows for some fat-free or low-fat dairy and one average sized serving of lean meat, poultry or seafood per day. This “no-fad diet” discourages the regular consumption of calorically dense foods including nuts, seeds and sweets. But new research presented in The American Journal of Clinical Nutrition suggests that a significantly different way of eating may be more effective in reducing the risk of heart complications in patients with pre-exisitng cardiovascular disease. (1)

The first of the two investigations examined the effects of a Mediterranean diet in 1,000 men and women who had already had a heart attack or suffered from severe angina (chest pain) upon physical exertion. Roughly half of the study volunteers experienced a myocardial infarction during the 2 year evaluation period. However, those consuming a Mediterranean style diet rich in dairy products, fish, fruits, legumes, nuts, olive oil, vegetables and whole grains exhibited a 12% lower risk of “recurrent cardiovascular disease events”. The men and women who adhered closest to this eating plan were also 40% less likely to report heart problems than those who ate diets with the least amount of Mediterranean elements. A specific analysis of the dietary components suggests that nuts, salad and vegetables were probably responsible for most of the benefits noted in this examination. (2,3)

A similar diet referred to as the “Southern European Atlantic Diet” (SEAD), a traditional Portuguese eating regimen, also appears to confer cardiovascular benefits. SEAD is rich in cod and other fish, dairy products, legumes, pork, red meat and wine. Researchers from the University of Porto Medical School in Portugal studied the diets of 820 heart attack survivors and 2,196 men and women who had never had a cardiovascular event. All of the participants resided in a region where the SEAD diet is commonly practiced. The results indicate that those who most closely followed the SEAD diet were 33% less likely to have a heart attack as compared to those who were least compliant with this style of eating. A deeper analysis revealed an almost 60% reduced risk in a sub-group who followed the SEAD diet, but included lesser amounts of pork, red meat and potatoes in their daily routine. (4,5)

Olives and Olive Oil May Confer Multiple Health Benefits
Source: Int J Mol Sci. 2010; 11(2): 458–479. (link)

The secondary findings in both the Mediterranean and Portuguese studies are in line with a recent trial that found that eating a low carbohydrate, Mediterranean style diet can significantly lower multiple cardiovascular risk factors. In that research, Israeli scientists discovered that a carbohydrate-restricted version of the Mediterranean diet was more effective at promoting healthier blood sugar and lipid levels than the official diet advocated by the American Diabetic Association (ADA) and a traditional Mediterranean diet. It’s important to note that the ADA and AHA approved diets are very similar. Here are a few specifics of that study:

  • The low carbohydrate Mediterranean diet resulted in greater weight loss and lower long term blood sugar (HbA1c).
  • There was an increase in “good” (HDL) cholesterol and a larger reduction in triglycerides in the low carb Med diet as compared to the ADA diet. (6,7)

Here’s my personal take on diet and heart disease: I believe that a natural diet that emphasizes low-glycemic, whole foods and a good ratio of omega-3 fatty acids to omega-6 fatty acids is probably the most powerful approach to combating the progression of cardiovascular disease. Where I differ from the AHA is that I don’t believe that healthy fats and protein need to be generally shunned. The above referenced evidence illustrates the power of traditional diets. However, the final study goes one step beyond and suggests a way of possibly improving upon diets that are already health promoting. If you or someone you know is living with heart disease, I strongly recommend discussing this research with your health care team. Ask them if adopting a low-glycemic, Mediterranean or Portuguese style diet might be right for you.

Note: Please check out the “Comments & Updates” section of this blog – at the bottom of the page. You can find the latest research about this topic there!

Be well!


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Posted in Food and Drink, Heart Health, Nutrition

13 Comments & Updates to “The Anti-Heart Attack Diet”

  1. WB Says:

    Error? as should probably be less

    The men and women who adhered closest to this eating plan were also 40% **as** likely to report heart problems than those who ate diets with the least amount of Mediterranean elements.

  2. Iggy Dalrymple Says:

    It’s a harsh diet and I wouldn’t try it unless I had heart disease, but patients on Dr Esselstyn’s diet had zero recurrences, and that’s over 20 or more years.

  3. JP Says:

    Thank you for catching that, WB! You’re absolutely correct!

    Be well!


  4. JP Says:

    Thanks for adding that, Iggy. I believe Dr. Dean Ornish claims a similar track record.

    It would be interesting to see a head-to-head comparison of all of these different diets. It’s near impossible to do but interesting it would be interesting nonetheless!

    Be well!


  5. JP Says:

    Update 05/18/15:


    Nutrition Research – May 13, 2015

    Paleolithic nutrition improves plasma lipid concentrations of hypercholesterolemic adults to a greater extent than traditional heart-healthy dietary recommendations

    Recent research suggests that traditional grain-based heart healthy diet recommendations, which replace dietary saturated fat with carbohydrate and reduce total fat intake, may result in unfavorable plasma lipid ratios, with reduced high-density lipoprotein (HDL) and an elevation of low-density lipoprotein (LDL) and triacylglycerols (TG). The current study tested the hypothesis that a grain-free Paleolithic diet would induce weight loss and improve plasma total cholesterol (TC), HDL, LDL and TG concentrations in non-diabetic adults with hyperlipidemia to a greater extent than a grain-based heart healthy diet, based on the recommendations of the American Heart Association. Twenty volunteers (10 male, 10 female) aged 40 to 62 years were selected based on diagnosis of hypercholesterolemia. Volunteers were not taking any cholesterol-lowering medications and adhered to a traditional heart healthy diet for four months, followed by a Paleolithic diet for four months. Regression analysis was used to determine whether change in body weight contributed to observed changes in plasma lipid concentrations. Differences in dietary intakes and plasma lipid measures were assessed using repeated measures ANOVA. Four months of Paleolithic nutrition significantly lowered (P < 0.001) mean TC, LDL, and TG and increased (P < 0.001) HDL, independent of changes in body weight, relative to both baseline and the traditional heart healthy diet. Paleolithic nutrition offers promising potential for nutritional management of hyperlipidemia in adults whose lipid profiles have not improved after following more traditional heart healthy dietary recommendations. Be well! JP

  6. JP Says:

    Updated 1/8/16:


    Nutrients. 2016 Jan 4;8(1).

    Greater Total Antioxidant Capacity from Diet and Supplements Is Associated with a Less Atherogenic Blood Profile in U.S. Adults.

    Evidence from epidemiologic studies has shown that total antioxidant capacity (TAC) in the diet might be inversely associated with stroke, heart failure, and inflammatory biomarkers. However, studies on the association of TAC from both diet and supplements with cardiovascular disease (CVD) risk factors in the U.S. population are lacking. This cross-sectional population-based study aimed to investigate the association of TAC with both diet and supplements with CVD risk factors among 4039 U.S. adults in National Health and Nutrition Examination Survey (NHANES) 2007-2012. TAC from both food sources and dietary supplements was estimated from two 24-h dietary recalls using the NHANES supplement ingredient database, United States Department of Agriculture (USDA) proanthocyanidin, flavonoid, and isoflavone databases. Top contributors to TAC were tea, antioxidant supplements, vegetable mixture, orange juice, berries, and wine. Antioxidant supplement users had 1.6 times higher TAC than non-users. Greater TAC was associated with reduced triglycerides (TG) (-1.39% change; 95% CI = -2.56 to -0.21), TG to high-density lipoprotein cholesterol (HDL-C) ratio (-2.03% change; 95% CI = -3.45 to -0.60), HDL-C (0.65% change; 95% CI = 0.07 to 1.23), insulin (-1.37% change; 95% CI = -2.64 to -0.09), homeostasis model assessment of insulin resistance (HOMA-IR) (-1.57% change; 95% CI = -3.02 to -0.09) and C-reactive protein (CRP) (-0.83% change; 95% CI = -1.29 to -0.38) after adjusting for potential confounders. There was no significant association between TAC and waist circumference, BMI, blood pressure, low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), and fasting glucose. The findings of this study support the hypothesis that an antioxidant-rich diet and intake of supplements are beneficial to reduce CVD risk.

    Be well!


  7. JP Says:

    Updated 04/14/16:


    J Transl Med. 2016 Apr 12;14(1):91.

    Predictive role of the Mediterranean diet on mortality in individuals at low cardiovascular risk: a 12-year follow-up population-based cohort study.

    BACKGROUND: Adherence to the Mediterranean diet reduces the risk of all-cause and cardiovascular (CV) mortality and the incidence of CV events. However, most previous studies were performed in high-risk individuals. Our objective was to assess whether the adherence to the Mediterranean diet, evaluated by the MED score, was associated with all-cause and CV mortality and incidence of CV events in individuals at low CV risk from a population-based cohort, after a 12-year mean follow-up.

    METHODS: A cohort of 1658 individuals completed a validated food-frequency questionnaire in 2001-2003. The MED score was calculated by a 0-9 scale. Anthropometric, laboratory measurements, and the vital status were collected at baseline and during 2014. The baseline CV risk was estimated by the Framingham risk score. Participants were divided into two groups: individuals at low risk (CV < 10) and individuals with CV risk ≥10. RESULTS: During a 12-year mean follow-up, 220 deaths, 84 due to CV diseases, and 125 incident CV events occurred. The adherence to the Mediterranean diet was low in 768 (score 0-2), medium in 685 (score 4-5) and high in 205 (score >6) individuals. Values of BMI, waist circumference, fasting glucose and insulin significantly decreased from low to high diet adherence only in participants with CV risk ≥10. In a Cox-regression model, the hazard ratios (HRs) in low-risk individuals per unit of MED score were: HR = 0.83 (95 % CI 0.72-0.96) for all-cause mortality, HR = 0.75 (95 % CI 0.58-0.96) for CV mortality, and HR = 0.79 (95 % CI 0.65-0.97) for CV events, after multiple adjustments. In individuals with CV risk ≥10, the MED score predicted incident CV events (HR = 0.85; 95 % CI 0.72-0.99), while the associations with all-cause (HR = 1.02; 95 % CI 0.90-1.15) and CV mortality (0.94; 95 % CI 0.76-1.15) were not significant.

    CONCLUSIONS: Greater adherence to the Mediterranean diet was associated with reduced fatal and non fatal CV events, especially in individuals at low CV risk, thus suggesting the usefulness of promoting this nutritional pattern in particular in healthier individuals.

    Be well!


  8. JP Says:

    Updated 05/13/16:


    Heart. 2016 May 10. pii: heartjnl-2015-309218.

    Beneficial effect of a polyphenol-rich diet on cardiovascular risk: a randomised control trial.

    OBJECTIVES: There is previous epidemiological evidence that intake of polyphenol-rich foods has been associated with reduced cardiovascular disease risk. We aimed to investigate the effect of increasing dietary polyphenol intake on microvascular function in hypertensive participants.

    METHODS: All participants completed a 4-week run-in phase, consuming <2 portions of fruit and vegetables (F&V) daily and avoiding berries and dark chocolate. Subjects were then randomised to continue with the low-polyphenol diet for 8 weeks or to consume a high-polyphenol diet of six portions F&V (including one portion of berries/day and 50 g of dark chocolate). Endothelium-dependent (acetylcholine, ACh) and endothelium-independent (sodium nitroprusside) vasodilator responses were assessed by venous occlusion plethysmography. Compliance with the intervention was measured using food diaries and biochemical markers.

    RESULTS: Final analysis of the primary endpoint was conducted on 92 participants. Between-group comparison of change in maximum % response to ACh revealed a significant improvement in the high-polyphenol group (p=0.02). There was a significantly larger increase in vitamin C, carotenoids and epicatechin in the high-polyphenol group (between-group difference p<0.001; p<0.001; p=0.008, respectively).

    CONCLUSIONS: This study has shown that increasing the polyphenol content of the diet via consumption of F&V, berries and dark chocolate results in a significant improvement in an established marker of cardiovascular risk in hypertensive participants.

    Be well!


  9. JP Says:

    Updated 05/16/16:


    Atherosclerosis. 2016 Apr 27;250:30-37.

    Eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio as an associated factor of high risk plaque on coronary computed tomography in patients without coronary artery disease.

    BACKGROUND AND AIMS: Coronary computed tomography angiography (CCTA)-verified high risk plaque (HRP) characteristics including positive remodeling and low attenuation plaque have been associated with acute coronary syndromes. Several studies reported that the n-3 polyunsaturated fatty acids have been associated with cardiovascular events. However, the relationship between serum eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio and CCTA-verified HRP in patients without known coronary artery disease (CAD) is unclear. We aimed at investigating the relation between EPA/AA and CCTA-verified HRP in patients without known CAD.

    METHODS: We included 193 patients undergoing CCTA without known CAD (65.5 ± 12.0 years, 55.0% male). No patient has been treated with EPA. The relation of coronary risk factors, lipid profile, high-sensitivity C-reactive protein, coronary artery calcification score (CACS), number of vessel disease, plaque burden, and EPA/AA with the presence of HRP was evaluated by logistic regression analysis. Incremental value of EPA/AA to predict HRP was also analyzed by C-index, NRI, and IDI. A Cox proportional hazards model was used to estimate the time to cardiovascular event.

    RESULTS: HRP was observed in 37 (19%) patients. Multivariable logistic regression analysis revealed that current smoking (OR 2.58; p=0.046), number of vessel disease (OR 1.87; p=0.031), and EPA/AA ratio (OR 0.65; p=0.0006) were independent associated factors of HRP on CCTA. Although the addition of EPA/AA to the baseline model did not significantly improve C-index, both NRI (0.60, p=0.0049) and IDI (0.054, p=0.0072) were significantly improved. Patients with HRP had significantly higher rate of events compared with patients without HRP (14% vs. 3%, Logrank p=0.0004). On multivariable Cox hazard analysis, baseline EPA/AA ratio was an independent predictor (HR 0.57, p=0.047).

    CONCLUSIONS: Low EPA/AA was an associated factor of HRP on CCTA in patients without CAD. In addition to conventional coronary risk factors and CACS, EPA/AA and CCTA might be useful for risk stratification of CAD.

    Be well!


  10. JP Says:

    Updated 06/02/16:


    Am J Clin Nutr. 2016 May 25.

    Dietary epicatechin intake and 25-y risk of cardiovascular mortality: the Zutphen Elderly Study.

    BACKGROUND: Prospective cohort studies have shown that the consumption of cocoa and tea is associated with lower risk of cardiovascular diseases (CVDs), and cocoa and tea have been shown to improve CVD risk factors in randomized controlled trials. Cocoa and tea are major dietary sources of the flavan-3-ol epicatechin.

    OBJECTIVE: We investigated the associations of dietary epicatechin intake with 25-y CVD mortality in elderly Dutch men.

    DESIGN: We used data from the Zutphen Elderly Study, which was a prospective cohort study of 774 men aged 65-84 y in 1985. Epicatechin intake was estimated 4 times in 15 y with the use of the crosscheck dietary history method. Time-dependent Cox proportional hazards models were used to investigate repeated measures of epicatechin intake in relation to 25-y CVD mortality.

    RESULTS: Mean intake of epicatechin was 15.2 ± 7.7 mg/d, and the major dietary sources were tea (51%), apples (28%), and cocoa (7%). During 25 y of follow-up, 329 men died from CVD, 148 died from coronary heart disease (CHD), and 72 men died from stroke. Risk of CHD mortality was 38% lower in men in the top tertile of epicatechin intake than in men in the bottom tertile of epicatechin intake (HR: 0.62; 95% CI: 0.39, 0.98). Epicatechin intake was also significantly associated with 46% lower risk of CVD mortality in men with prevalent CVD (HR: 0.54; 95% CI: 0.31, 0.96) but not in men who were free of CVD.

    CONCLUSIONS: We show, for the first time to our knowledge, that epicatechin intake is inversely related to CHD mortality in elderly men and to CVD mortality in prevalent cases of CVD. More studies are needed before conclusions can be drawn.

    Be well!


  11. JP Says:

    Updated 04/04/17:


    Mol Nutr Food Res. 2017 Apr 3.

    The Mediterranean Diet decreases LDL atherogenicity in high cardiovascular risk individuals: a randomized controlled trial.

    SCOPE: Traditional Mediterranean Diet (TMD) protects against cardiovascular disease through several mechanisms such as decreasing LDL cholesterol levels. However, evidence regarding TMD effects on LDL atherogenic traits (resistance against oxidation, size, composition, cytotoxicity) is scarce.

    METHODS AND RESULTS: We assessed the effects of a 1-year intervention with a TMD on LDL atherogenic traits in a random sub-sample of individuals from the PREDIMED Study (N = 210). We compared two TMDs: one enriched with virgin olive oil (TMD-VOO, N = 71) and another with nuts (TMD-Nuts, N = 68), versus a low-fat control diet (N = 71). After the TMD-VOO intervention, LDL resistance against oxidation increased (+6.46%, P = 0.007), the degree of LDL oxidative modifications decreased (-36.3%, P<0.05), estimated LDL particle size augmented (+3.06%, P = 0.021), and LDL particles became cholesterol-rich (+2.41% P = 0.013) relative to the low-fat control diet. LDL lipoproteins became less cytotoxic for macrophages only relative to baseline (-13.4%, P = 0.019). No significant effects of the TMD-Nuts intervention on LDL traits were observed versus the control diet.

    CONCLUSION: Adherence to a TMD, particularly when enriched with virgin olive oil, decreased LDL atherogenicity in high cardiovascular risk individuals. The development of less atherogenic LDLs could contribute to explaining some of the cardioprotective benefits of this dietary pattern.

    Be well!


  12. JP Says:

    Updated 08/10/17:


    Eur J Nutr. 2017 Aug 8.

    Dietary total antioxidant capacity is inversely associated with all-cause and cardiovascular disease death of US adults.

    PURPOSE: Although evidence strongly supports that antioxidant-rich diets reduce risk of chronic disease and mortality, findings from the previous studies on the effect of individual antioxidants on mortality have been inconsistent. The aim of this study was to assess the relationship between dietary total antioxidant capacity (TAC) and all-cause and disease-specific mortality in a representative sample of the US population.

    METHODS: A total of 23,595 US adults aged 30 years and older in NHANES 1988-1994 and 1999-2004 were selected for this study. Dietary TAC was calculated from 1-day 24-h diet recall data at baseline and all-cause, cancer and cardiovascular disease (CVD) mortality was assessed through December 31, 2011.

    RESULTS: During a mean follow-up of 13 years, deaths from all-cause, cancer and CVD were 7157, 1578, and 2155, respectively. Using cause-specific Cox proportional hazards models, inverse associations and linear trends were observed between dietary TAC and all-cause mortality [highest quartile (Q4) versus Q1 ref. HR 0.78; 95% CI 0.71-0.86], cancer mortality (Q4 versus Q1 ref. HR 0.75; 95% CI 0.60-0.93), and CVD mortality (Q4 versus Q1 ref. HR 0.83; 95% CI 0.69-0.99), respectively, after adjusting for age, sex, ethnicity, and total energy intake. The inverse association and linear trend still remained between dietary TAC and all-cause mortality (Q4 versus Q1 ref. HR 0.79; 95% CI 0.71-0.87) and CVD mortality (Q4 versus Q1 ref. HR 0.74; 95% CI 0.61-0.89) when further adjusted for relevant covariates.

    CONCLUSIONS: These findings support that antioxidant-rich diets are beneficial to reducing risk of death from all-cause and CVD.

    Be well!


  13. JP Says:

    Updated 09/19/18:


    Diseases. 2018 Sep 1;6(3).

    Wine and Olive Oil Phenolic Compounds Interaction in Humans.

    Extra virgin olive oil (EVOO) and red wine (RW) are two basic elements that form part of the so-called Mediterranean diet. Both stand out because of their high phenolic compound content and their potential related health benefits. The present study is focused on the metabolic disposition of resveratrol (RESV), tyrosol (TYR), and hydroxytyrosol (HT) following the consumption of EVOO, RW, and a combination of both. In this study, 12 healthy volunteers consumed a single dose of 25 mL of EVOO, 150 mL of RW, and a combination of both in a crossover randomized clinical trial. Urinary recovery of RESV, TYR, and HT was analysed in urine samples collected over a 6-h period following the intake of each treatment. Higher HT levels were observed following EVOO compared to RW (3788 ± 1751 nmols and 2308 ± 847 nmols respectively). After the combination of EVOO and RW, the recovery of TYR and HT metabolites increased statistically compared to their separate consumption (4925 ± 1751 nmols of TYR and 6286 ± 3198 nmols of HT). EVOO triggered an increase in glucuronide conjugates, while RW intake raised sulfate metabolites. Marginal effects were observed in RESV increased bioavailability after the combination of RW with the fat matrix provided by EVOO.

    Be well!


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