The Best and Worst Diets for Heart Health

It’s better to choose healthy ways of eating that allow for variety, rather than overly restrictive fad diets, experts say.

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The DASH-style diet — or Dietary Approaches to Stop Hypertension — focuses on plenty of fruit and vegetables, whole grains, lean proteins, and healthy fats.iStock

The American Heart Association (AHA) scored 10 popular diets based on how well the eating patterns align with the association’s guidelines on eating for heart health.

The recommendations, published Thursday in the AHA’s journal, Circulation, debunked misinformation about restrictive fad diets that scored the lowest when it came to heart health.

Diet trends like keto and paleo plans, which may restrict carbs and emphasize protein without considering saturated fat, have exploded in number in recent years. Social media has exacerbated both the diets and misinformation about their health benefits, the authors of the AHA statement noted.

“The public — and even many healthcare professionals — may rightfully be confused about heart-healthy eating, and they may feel that they don’t have the time or the training to evaluate the different diets. We hope this statement serves as a tool for clinicians and the public to understand which diets promote good cardiometabolic health,” Christopher Gardner, PhD, the Rehnborg Farquhar Professor of Medicine at Stanford University in California, and one of the experts who drafted the recommendations, said in an AHA press release.

What Is Cardiometabolic Health, and Why Is It Important?

Cardiometabolic health is the combination of factors that affect metabolism, or how the body breaks down and uses nutrients in food, and how these factors relate to cardiovascular disease — one of the leading causes of death in the United States. Some of those factors include blood glucose levels, cholesterol and other lipids, blood pressure, and body weight.

The best way to maintain cardiometabolic health is by adopting lifestyle and diet habits you can stick with long-term, according to experts.

“Some diet plans are hard to maintain long term. It's better to pick a diet that becomes part of your overall healthy lifestyle, something you can maintain throughout your life, rather than jump from fad diet to fad diet,” says Nicholas Ruthmann, MD, MPH, a staff cardiologist at Cleveland Clinic, who was not involved in the new guidance.

How the AHA Scored the Diets for Heart Health

The researchers scored each of the 10 diets based on how well the recommended eating pattern aligned with features of the AHA's heart-healthy eating pattern. These include:

The Best and Worst Diets for Heart Health, Ranked by the AHA

Tier 1 (Scored Higher Than 85)

Tier 2 (Scored 75 to 85)

Tier 3 (Scored 55 to 74)

  • Very low-fat diet
  • Low-carb

Tier 4 (Scored Less Than 55)

  • Paleo diet
  • Keto

Keto and Paleo Ranked Lowest for Heart Health

Although these ultra low-carb diets direct followers to eat nonstarchy vegetables, nuts, and fish, and to keep alcohol and added sugar intake to a minimum, the diets are high in fat, including saturated fat, and low in fiber.

The authors noted that research has also shown that although people who follow keto and paleo diets usually lose weight in the first six months of starting the diet, after one year, this benefit was the same as people who followed less restrictive diets that are easier to adopt for life.

“For many of my patients, I’ve found that keto and paleo-based diets are often not sustainable,” says Dr. Ruthmann, adding that if you’re already at higher risk for heart disease, these diets can raise that risk even more. Risk factors for heart disease besides poor diet include being overweight or obese, smoking, physical inactivity, and having diabetes.

While it is important to eat some fat — and good fats like the mono- and polyunsaturated kinds found in avocados are included in these diets — these eating plans also push eating high amounts of saturated fats and animal protein, which can lead to plaque buildup in the arteries, Ruthmann says.

The Mediterranean Style Diet Still Ranked Among the Best, But With a Caveat

The Mediterranean way of eating, which emphasizes whole grains, lean meats, and lots of vegetables, has long been championed by the AHA as one of the best ways to eat to support heart health. In the updated guidelines, the authors noted that a few points were deducted based on the diet’s recommendation to include moderate alcohol consumption, specifically red wine, which goes against the AHA’s recommendation for limiting or eliminating alcohol.

“I never recommend drinking wine to actively protect against having a heart attack or stroke,” Ruthmann says. “This said, you really have to look at the total picture. If you're eating a healthy diet, exercising, and your blood pressure and blood sugar are under control, I think a glass of red wine a couple times a week is probably fine. Everything in moderation, of course.”

He doesn’t recommend alcohol for people who are at higher risk for developing heart disease or those who have already had a cardiac event, such as a heart attack or stroke. Regularly drinking alcohol also may thwart weight loss efforts.

“If you’re focused on a diet with hopes for weight loss, wine and most alcohol contain more sugar than you may realize and are full of empty calories, neither of which will help lose and keep that weight off over time,” says Ruthmann.

The DASH Diet Received a Perfect Score

The DASH-style eating pattern met all of the AHA’s guidelines for heart-healthy eating. This diet includes foods that are low in salt, added sugar, alcohol, tropical oils, and processed foods, and rich in nonstarchy vegetables, fruits, whole grains, and legumes. Protein mostly comes from plant sources such as beans, nuts, or legumes, or from fish or seafood, lean meat, and low-fat or fat-free dairy products.

Essentially, the eating pattern follows the Mediterranean diet’s way of eating, just without the moderate alcohol consumption.

AHA Emphasizes Variety for Long-Term Success and Heart Health

All four eating patterns that scored in the highest tier — The DASH diet, Mediterranean diet, pescatarian (eating fish but no other meat), and vegetarian diets that include eggs — allow people to eat a variety of foods, which is key to their benefit.

Vegan and low-fat diets scored in the second tier because they can lack variety, which can make them hard to stick to and may cause nutrient deficiencies. Very low-fat and very low-carb diets both scored in the third tier, just before keto and paleo diets, because both restrict important foods the AHA guidelines recommend.

Low-carb diets tell people to avoid fruits, whole grains, and legumes, which inadvertently leads to low fiber intake and could cause nutrient deficiencies. While low-fat diets avoid saturated animal fats that are bad for heart health, they can result in deficits in vitamin B-12, essential fatty acids, and protein, leading to anemia and muscle weakness, the evaluation stated.

“A more holistic, plant-based, fish-forward diet that is part of a larger heart-healthy lifestyle is going to be better for your heart long term and, actually, much easier to stick with for life,” Ruthmann says. “Literally, just a few months of fad dieting could lead to lifelong detrimental consequences for your heart.”