How the 10 Most Popular Eating Plans Rank, According to Cardiologists

  • A new review analyzed 10 of the most popular diets regarding their heart health benefits—only one received a perfect score.
  • Diets that focused on plant-based protein, fish, and lean meats as main protein sources were ranked higher than diets that included more red meat.
  • Experts recommend finding a diet that is healthy and sustainable to keep up; a diet you cannot stick with won’t get you very far, no matter what health goals you’re striving toward.

A new study analyzed 10 of the most popular diets regarding heart health benefits—one diet received a perfect score, with the subsequent nine ranging in benefit levels.

A different diet is trending almost daily, but if you’re looking to improve your heart health, which one do you choose? The internet and social media are full of misinformation that is confusing for consumers and patients.

A significant source of confusion among different dietary patterns is the distribution of the three macronutrients, protein, carbohydrates, and fat.

Certain diets—such as the Mediterranean diet—are high in fat, while others are significantly lower in fat and higher in carbohydrates. Some popularized diets exclude major food groups. The Paleo diet excludes dairy and the ketogenic diet excludes almost all carbohydrate sources. The question becomes about diet sustainability and what factors in these diets actually contribute to cardiometabolic health.

But the recent study, published in Circulation, a scientific journal from the American Heart Association [AHA], analyzed 10 of the most popular diets to see how they stack up when it comes to protecting your heart. The results might surprise you.

Mother cooking with her children

Mother cooking with her children

Getty Images / miniseries

Comparing Diets

The study authors used the 2021 AHA Dietary Guidance as a set of criteria for heart-healthy diets that promote cardiometabolic health. They then examined popular diets and ranked them according to their alignment with these criteria.

The criteria included the following:

  • Adjust energy intake and expenditure to achieve and maintain a healthy body weight
  • Eat plenty of vegetables and fruits
  • Choose foods made mostly with whole grains rather than refined grains
  • Choose healthy sources of protein
  • Use liquid plant oils
  • Choose minimally processed foods instead of ultra-processed foods
  • Minimize intake of beverages and foods with added sugars
  • Choose and prepare foods with little or no salt
  • If you do not drink alcohol, do not start

According to Maya Vadiveloo, PhD, RD, associate professor of nutrition and food sciences at the University of Rhode Island and co-author of the statement, diets were selected based on “what was common in the popular press and partly based on the literature available from [randomized controlled trials], well-designed prospective cohort studies, and US federal agencies.”

Point values were awarded to the dietary patterns for each element of the AHA guidance they featured. The authors then grouped the diets based on how closely each pattern aligned with the AHA criteria for promoting heart health.

“By doing this, our goal was to make interpretation of the guidance even more relevant to consumers and healthcare providers who often want to more easily understand if the diet pattern they’ve selected or are interested in trying aligns with healthy dietary guidance,” Dr. Vadiveloo explained.

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The Best Diets for Heart Health

The outcome of this analysis was a grouping of the diets into four tiers with the first tier, if implemented as intended, best aligning with the 2021 AHA Dietary Guidance. The second group of dietary patterns mostly aligns with this guidance, the third tier has low to moderate alignment, and the fourth tier aligns poorly with the AHA guidance.

The report also took into account the importance of adapting these diets to cultural practices, food preferences, and budget constraints for long-term adherence.

“There’s a lot of variation from person to person in response to different diets. The best dietary pattern is one that you can stick with and enjoy,” Gregory Katz, MD, a cardiologist at NYU Langone in New York City, told Health.

Likely to no one’s surprise, the dietary patterns that scored the highest and landed in the first tier were those that promoted a diet rich in fruits, vegetables, whole grains, and plant protein sources.

Diets included in this category are DASH, Mediterranean, pescatarian, and ovo/lacto-vegetarian diets. Of these, the DASH diet got a perfect score. This eating pattern focuses on low salt, added sugar, tropical oils, and processed foods. In addition, it promotes high, non-starchy vegetable intake, fruits, whole grains, and legumes. Proteins included are primarily plant-based, fish, and lean meats.

The Mediterranean diet also includes limited alcohol intake and the pescatarian and ovo-lacto-vegetarian diets vary in how much animal protein they allow, while still promoting heart-healthy fats and high intakes of fruits and vegetables.

The fourth and lowest tier included the Paleo diet and very low carbohydrate/ketogenic diets, which align poorly with the AHA Dietary Guidance.

“The lowest scoring diets are all quite restrictive in nature and generally exclude multiple food groups while also encouraging excess consumption of food groups to limit,” Dr. Vadiveloo noted.

Dr. Katz added that “the reason that the low carb and paleo diets rank low is that they have a lot of animal protein and end up high in saturated fat, which can raise LDL cholesterol levels.”

Any eating pattern that is highly restrictive is difficult to adhere to in the long term. Further, these diets exclude many foods that contain important nutrients for heart health, including fruits, vegetables, and whole grains—exclusion may lead to nutritional deficiencies.

The diets in this study were evaluated under the assumption they were followed as intended. Of course, it is rare that an individual follows a diet perfectly in the long term and the rate of adherence decreases as the rules become more restrictive.

According to Dr. Vadiveloo, “It is critical to consider whether consuming a pattern is realistic using a Social Determinants of Health lens.”

There are several factors that go into our food choices and the food environment exerts a major impact.

“The environment dictates your behaviors, not the other way around,” Dr. Katz concluded. “If you create an environment where the default option is healthy, you’ll often be healthy.”

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