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Effects of Plant-Based Diets on Plasma Lipids

      Dyslipidemia is a primary risk factor for cardiovascular disease, peripheral vascular disease, and stroke. Current guidelines recommend diet as first-line therapy for patients with elevated plasma cholesterol concentrations. However, what constitutes an optimal dietary regimen remains a matter of controversy. Large prospective trials have demonstrated that populations following plant-based diets, particularly vegetarian and vegan diets, are at lower risk for ischemic heart disease mortality. The investigators therefore reviewed the published scientific research to determine the effectiveness of plant-based diets in modifying plasma lipid concentrations. Twenty-seven randomized controlled and observational trials were included. Of the 4 types of plant-based diets considered, interventions testing a combination diet (a vegetarian or vegan diet combined with nuts, soy, and/or fiber) demonstrated the greatest effects (up to 35% plasma low-density lipoprotein cholesterol reduction), followed by vegan and ovolactovegetarian diets. Interventions allowing small amounts of lean meat demonstrated less dramatic reductions in total cholesterol and low-density lipoprotein levels. In conclusion, plant-based dietary interventions are effective in lowering plasma cholesterol concentrations.
      Dyslipidemia is a primary risk factor for heart disease, peripheral vascular disease, and stroke.
      • Pekkanen J.
      • Linn S.
      • Heiss G.
      • Suchindran C.M.
      • Leon A.
      • Rifkind B.M.
      • Tyroler H.A.
      Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease.
      • Rosengren A.
      • Hagman M.
      • Wedel H.
      • Wilhelmsen L.
      Serum cholesterol and long-term prognosis in middle-aged men with myocardial infarction and angina pectoris A 16-year follow-up of the Primary Prevention Study in Goteborg, Sweden.
      Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
      Third report of the National Cholesterol Education Program (NCEP) (Adult Treatment Panel III).
      In the United States, these diseases account for >885,000 deaths and $634.2 billion in direct and indirect costs annually.
      Heart disease and stroke statistics 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Committee.
      Cardiovascular disease and related mortality are strongly associated with elevated plasma concentrations of total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol.
      Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
      Third report of the National Cholesterol Education Program (NCEP) (Adult Treatment Panel III).
      About 1 in 500 individuals (0.2% of the general population) has familial hypercholesterolemia.
      • Austin M.A.
      • Hutter C.M.
      • Zimmern R.L.
      • Humphries S.E.
      Genetic causes of monogenic heterozygous familial hypercholesterolemia: a HuGE prevalence review.
      However, >48% of the adult population of the United States has TC levels >200 mg/dl, the desirable upper limit established by the National Cholesterol Education Program (NCEP),
      • Carroll M.D.
      • Lacher D.A.
      • Sorlie P.D.
      • Cleeman J.I.
      • Gordon D.J.
      • Wolz M.
      • Grundy S.M.
      • Johnson C.L.
      Trends in serum lipids and lipoproteins of adults, 1960–2002.
      suggesting that factors other than genetics are involved in hyperlipidemia. A summary analysis of 5 observational studies demonstrated that populations consuming plant-based (especially vegetarian and vegan) diets typically have significantly lower blood concentrations of TC and LDL cholesterol and correspondingly lower rates of coronary artery disease compared to the general population.
      • Key T.J.
      • Fraser G.E.
      • Thorogood M.
      • Appleby P.N.
      • Beral V.
      • Reeves G.
      • Burr M.L.
      • Chang-Claude J.
      • Frentzel-Beyme R.
      • Kuzma J.W.
      • Mann J.
      • McPherson K.
      Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies.
      In 2004, the NCEP and the third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults recommended the Therapeutic Lifestyle Changes plan, which calls for limiting total and saturated fats and dietary cholesterol and including plant sterols, viscous fibers, soy protein, and nuts, as the initial intervention for cholesterol reduction.
      Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
      Third report of the National Cholesterol Education Program (NCEP) (Adult Treatment Panel III).
      We reviewed the published scientific research to ascertain the extent to which a plant-based diet alters plasma and serum lipids, as well as potential mechanisms for these actions.

      Methods

      We conducted a search of the Medline and Cochrane Collaboration databases with the terms “cholesterol,” “total cholesterol,” “low density lipoprotein,” and “lipids” cross-referenced with “vegetarian,” “low-fat vegetarian,” “vegetarianism,” “plant-based diet,” and “plant diet” for reports published from 1966 to February 2009. We also used bibliographies and studies suggested by search engines to further increase the range of data collected. Reports published in languages other than English were reviewed if English translations were available. Studies were included if (1) the reported studies included human volunteers of any age, gender, or health status; (2) the number of participants as well as their ages and clinical status were delineated; (3) the duration and type of trial were reported; (4) the trials involved plant-based diets (diets with no, or almost no, meat products); (5) for longitudinal studies or clinical trials, lipid values, including at least TC and LDL cholesterol concentrations, were drawn before and after the study intervals; (6) the trials included adequate control groups; and (7) studies included information about the statistical significance of such findings. Observational and intervention studies were included. One investigators (B.M.K.) conducted the review, and this process was evaluated and confirmed by the other 2 investigators. Disagreements were resolved by consensus.

      Results

      We found 7,261 studies, of which 7,096 were excluded on the basis of screening using general criteria. The remaining 165 abstracts were reviewed, and full reports were evaluated. Of these, 27 met all inclusion criteria. Reports were excluded because they did not report the effects of diet on cholesterol, did not include LDL values, did not use plant-based diets, were not in English, or did not report human studies (Figure 1).
      Figure thumbnail gr1
      Figure 1Flowchart of study selection for trials evaluating the effects of diet on cholesterol. LDL-C = LDL cholesterol.
      Four primary dietary interventions were identified: vegan (allowing no animal products), ovolactovegetarian (allowing eggs and dairy products), primary plant (similar to the ovolactovegetarian diet but allowing small amounts of lean meat), and combination (a vegetarian or vegan diet combined with nuts, soy, and/or fiber).

      Observational studies

      Of the 13 observational studies that met the inclusion criteria, 10 were cross-sectional studies and 3 were case-control studies. Reviewed in Figure 2, Figure 3 and listed Table 1, these trials evaluated 4,772 participants from 6 countries with populations of varied age ranges, gender representation, and racial and ethnic compositions.
      Figure thumbnail gr2
      Figure 2Effects of plant-based diets on cholesterol: observational studies. HDL-C = HDL cholesterol; LDL-C = LDL cholesterol.
      Figure thumbnail gr3
      Figure 3Effects of plant-based diets on triglycerides.
      Table 1Observational studies evaluating the effects of diet on lipids
      StudyCountry, YearPopulation StudiedNo. of Participants: Men/WomenAge (years)TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Diet (mg/dl)
      TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control (mg/dl)
      p Value (Between Groups)LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Diet (mg/dl)
      LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control (mg/dl)
      p Value (Between Groups)
      Cross-sectional
       Burslem et al
      • Burslem J.
      • Schonfeld G.
      • Howald M.
      • Weidman S.
      • Miller J.P.
      Plasma apoprotein and lipoprotein lipid levels in vegetarians.
      United States, 1978Tennessee commune60 (45%)/74 (55%)17–40 (27)125 ± 19
      Results for men aged 20 to 30 years.
      , 133 ± 26
      Results for women aged 20 to 30 years.
      184 ± 34
      Results for men aged 20 to 30 years.
      , 174 ± 35
      Results for women aged 20 to 30 years.
      <0.00179 ± 14
      Results for men aged 20 to 30 years.
      , 81 ± 21
      Results for women aged 20 to 30 years.
      118 ± 31
      Results for men aged 20 to 30 years.
      , 114 ± 34
      Results for women aged 20 to 30 years.
      <0.001
       Thorogood et al
      • Thorogood M.
      • Carter R.
      • Benfield L.
      • McPherson K.
      • Mann J.I.
      Plasma lipids and lipoprotein cholesterol concentrations in people with different diets in Britain.
      United Kingdom, 1987British population1,154 (35%)/2,123 (65%)18–68 (39)166 ± 5205 ± 4<0.00188 ± 5123 ± 3<0.001
       Melby et al
      • Melby C.
      • Toohey M.L.
      • Cebrick J.
      Blood pressure and blood lipids among vegetarian, semivegetarian, and nonvegetarian African Americans.
      United States, 1994African American Seventh-Day Adventists44 (26%)/123 (74%)(47.5)182 ± 4209 ± 7<0.05120 ± 4139 ± 7<0.05
       Toohey et al
      • Toohey M.L.
      • Harris M.A.
      • DeWitt W.
      • Foster G.
      • Schmidt W.D.
      • Melby C.L.
      Cardiovascular disease risk factors are lower in African-American vegans compared to lacto-ovo-vegetarians.
      United States, 1998African American Seventh-Day Adventists65 (34%)/125 (66%)(49.7)145 ± 5174 ± 40.000280 ± 5102 ± 30.009
       Alexander et al
      • Alexander H.
      • Lockwood L.P.
      • Harris M.A.
      • Melby C.L.
      Risk factors for cardiovascular disease in two groups of Hispanic Americans with differing dietary habits.
      United States, 1999Hispanic Seventh-Day Adventists42 (45%)/52 (55%)35–44 (43)198 ± 5214 ± 6<0.05125 ± 4130 ± 6NS
       Li et al
      • Li D.
      • Sinclair A.
      • Mann N.
      • Turner A.
      • Ball M.
      • Kelly F.
      • Abedin L.
      • Wilson A.
      The association of diet and thrombotic risk factors is healthy male vegetarians and meat-eaters.
      Australia, 1999Australian men147 (100%)/0 (0%)20–55 (36)136 ± 32174 ± 28<0.00183 ± 27113 ± 36<0.001
       Fu et al
      • Fu C.H.
      • Yang C.C.H.
      • Lin C.L.
      • Kuo T.B.J.
      Effects of long-term vegetarian diets on cardiovascular autonomic functions in healthy postmenopausal women.
      China, 2006Postmenopausal Chinese women0 (0%)/70 (100%)(55 ± 1)174 ± 4204 ± 40.004112 ± 6136 ± 70.014
       De Biase et al
      • De Biase S.G.
      • Fernandes S.F.
      • Gianini R.J.
      • Duarte J.L.
      Vegetarian diet and cholesterol and triglyceride levels.
      Brazil, 2007Brazilian population28 (37%)/48 (63%)(37 ± 12)141 ± 31208 ± 49<0.00169 ± 30123 ± 43<0.001
       Teixeira et al
      • Teixeira Rde C.
      • Molina Mdel C.
      • Zandonade E.
      • Mill J.G.
      Cardiovascular risk in vegetarians and omnivores: a comparative study.
      Brazil, 2007Brazilian population96 (48%)/105 (52%)35–64 (47 ± 8)173 ± 36225 ± 45<0.0001106 ± 35151 ± 43<0.0001
       Hoffmann et al
      • Hoffmann I.
      • Groeneveld M.J.
      • Boeing H.
      • Koebnick C.
      • Golf S.
      • Katz N.
      • Leitzmann C.
      Giessen Wholesome Nutrition Study: relation between a health-conscious diet and blood lipids.
      Germany, 2001German women0 (0%)/370 (0%)25–65209 (201–218)221 (212–229)NS128 (118–139)138 (131–149)NS
      Case-control
       Sacks et al
      • Sacks F.M.
      • Castelli W.P.
      • Donner A.
      • Kaas E.H.
      Plasma lipids and lipoproteins in vegetarians and controls.
      United States, 1975American population73 (63%)/43 (47%)16–62126 ± 30184 ± 37<0.00173 ± 24118 ± 34<0.001
       Fisher et al
      • Fisher M.
      • Levine P.
      • Weiner B.
      • Ockene I.
      • Johnson B.
      • Johnson M.H.
      • Natale A.M.
      • Vaudreuil C.H.
      • Hoogasian J.
      The effect of vegetarian diets on plasma lipids and platelet levels.
      United States, 1986American population22 (44%)/28 (56%)20–47140 ± 28173 ± 270.02596 ± 22115 ± 23NS
       Harman et al
      • Harman S.
      • Parnell W.
      The nutritional health of New Zealand vegetarian and non-vegetarian Seventh-Day Adventists: selected vitamin mineral and lipid levels.
      New Zealand, 1998Seventh-Day Adventists23 (49%)/24 (51%)20–65 (43)193 ± 31
      Results for men.
      , 186 ± 43
      Results for women.
      201 ± 39
      Results for men.
      , 205 ± 39
      Results for women.
      NS124 ± 27
      Results for men.
      , 116 ± 39
      Results for women.
      135 ± 39
      Results for men.
      , 135 ± 35
      Results for women.
      NS
      Data are expressed as mean ± SD, range (mean ± SD), mean (range), or number (percentage).
      LDL-C = LDL cholesterol.
      low asterisk To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Results for men aged 20 to 30 years.
      Results for women aged 20 to 30 years.
      § Results for men.
      Results for women.
      Of the 10 cross-sectional studies, 9 demonstrated significant differences between the cholesterol levels of subjects eating plant-based diets and those of the general population.
      • Burslem J.
      • Schonfeld G.
      • Howald M.
      • Weidman S.
      • Miller J.P.
      Plasma apoprotein and lipoprotein lipid levels in vegetarians.
      • Thorogood M.
      • Carter R.
      • Benfield L.
      • McPherson K.
      • Mann J.I.
      Plasma lipids and lipoprotein cholesterol concentrations in people with different diets in Britain.
      • Melby C.
      • Toohey M.L.
      • Cebrick J.
      Blood pressure and blood lipids among vegetarian, semivegetarian, and nonvegetarian African Americans.
      • Toohey M.L.
      • Harris M.A.
      • DeWitt W.
      • Foster G.
      • Schmidt W.D.
      • Melby C.L.
      Cardiovascular disease risk factors are lower in African-American vegans compared to lacto-ovo-vegetarians.
      • Alexander H.
      • Lockwood L.P.
      • Harris M.A.
      • Melby C.L.
      Risk factors for cardiovascular disease in two groups of Hispanic Americans with differing dietary habits.
      • Li D.
      • Sinclair A.
      • Mann N.
      • Turner A.
      • Ball M.
      • Kelly F.
      • Abedin L.
      • Wilson A.
      The association of diet and thrombotic risk factors is healthy male vegetarians and meat-eaters.
      • Fu C.H.
      • Yang C.C.H.
      • Lin C.L.
      • Kuo T.B.J.
      Effects of long-term vegetarian diets on cardiovascular autonomic functions in healthy postmenopausal women.
      • De Biase S.G.
      • Fernandes S.F.
      • Gianini R.J.
      • Duarte J.L.
      Vegetarian diet and cholesterol and triglyceride levels.
      • Teixeira Rde C.
      • Molina Mdel C.
      • Zandonade E.
      • Mill J.G.
      Cardiovascular risk in vegetarians and omnivores: a comparative study.
      In studies that evaluated the effects of different plant-based diets (i.e., ovolactovegetarian, lactovegetarian, and vegan), populations following vegan diets had the lowest cholesterol concentrations.
      • Thorogood M.
      • Carter R.
      • Benfield L.
      • McPherson K.
      • Mann J.I.
      Plasma lipids and lipoprotein cholesterol concentrations in people with different diets in Britain.
      • Melby C.
      • Toohey M.L.
      • Cebrick J.
      Blood pressure and blood lipids among vegetarian, semivegetarian, and nonvegetarian African Americans.
      • Toohey M.L.
      • Harris M.A.
      • DeWitt W.
      • Foster G.
      • Schmidt W.D.
      • Melby C.L.
      Cardiovascular disease risk factors are lower in African-American vegans compared to lacto-ovo-vegetarians.
      • Li D.
      • Sinclair A.
      • Mann N.
      • Turner A.
      • Ball M.
      • Kelly F.
      • Abedin L.
      • Wilson A.
      The association of diet and thrombotic risk factors is healthy male vegetarians and meat-eaters.
      • De Biase S.G.
      • Fernandes S.F.
      • Gianini R.J.
      • Duarte J.L.
      Vegetarian diet and cholesterol and triglyceride levels.
      The only cross-sectional study that did not show an association between lower cholesterol and a plant-based diet used participants maximally treated with lipid-lowering medications before study onset.
      • Hoffmann I.
      • Groeneveld M.J.
      • Boeing H.
      • Koebnick C.
      • Golf S.
      • Katz N.
      • Leitzmann C.
      Giessen Wholesome Nutrition Study: relation between a health-conscious diet and blood lipids.
      Of the 3 case-control studies, 2 demonstrated significantly lower TC and LDL cholesterol values in populations consuming plant-based diets.
      • Sacks F.M.
      • Castelli W.P.
      • Donner A.
      • Kaas E.H.
      Plasma lipids and lipoproteins in vegetarians and controls.
      • Fisher M.
      • Levine P.
      • Weiner B.
      • Ockene I.
      • Johnson B.
      • Johnson M.H.
      • Natale A.M.
      • Vaudreuil C.H.
      • Hoogasian J.
      The effect of vegetarian diets on plasma lipids and platelet levels.
      The 1 study that examined the effects of different plant-based diets showed the lowest lipid levels in vegans.
      • Fisher M.
      • Levine P.
      • Weiner B.
      • Ockene I.
      • Johnson B.
      • Johnson M.H.
      • Natale A.M.
      • Vaudreuil C.H.
      • Hoogasian J.
      The effect of vegetarian diets on plasma lipids and platelet levels.
      Harman et al
      • Harman S.
      • Parnell W.
      The nutritional health of New Zealand vegetarian and non-vegetarian Seventh-Day Adventists: selected vitamin mineral and lipid levels.
      studied Seventh-Day Adventist vegetarians and nonvegetarians in New Zealand and reported significant differences in saturated fat (15.4% vs 10.4% of energy) and cholesterol intake (279 vs 133 mg/day) but found no significant differences in lipid parameters.

      Randomized controlled trials

      Fourteen randomized controlled trials met the inclusion criteria. These included 2 studies evaluating primary-plant diets, 5 studies evaluating vegetarian diets, 3 studies evaluating vegan diets, and 4 studies evaluating combination diets. Summarized in Figure 3, Figure 4, Figure 5 and listed in Table 2, these trials included 1,939 participants from 6 different countries.
      Figure thumbnail gr4
      Figure 4Effects of plant-based diets in subjects with normal lipid levels: randomized controlled trials. HDL-C = HDL cholesterol; LDL-C = LDL cholesterol.
      Figure thumbnail gr5
      Figure 5Effects of plant-based diets on cholesterol in subjects with hyperlipidemia: randomized controlled trials. HDL-C = HDL cholesterol; LDL-C = LDL cholesterol.
      Table 2Randomized controlled trials evaluating the effects of diet on lipids
      StudyCountry, YearType of StudyNo. of Participants: Men/WomenAge (years)TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Intervention, Baseline (mg/dl)
      TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Intervention (% Change)
      TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control, Baseline (mg/dl)
      TC
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control (% Change)
      p Value (Between Groups)LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Intervention, Baseline (mg/dl)
      LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Intervention (% Change)
      LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control, Baseline (mg/dl)
      LDL-C
      To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      Control (% Change)
      p Value (Between Groups)Study Duration
      Primary plant
       Gardner et al
      • Gardner C.D.
      • Coulston A.
      • Chatterjee L.
      • Rigby A.
      • Spiller G.
      • Farquhar J.W.
      The effect of a plant-based diet on plasma lipids in hypercholesterolemic men.
      United States, 2005Prospective randomized60 (50%)/60 (50%)30–65 (48)222 ± 22−18 (7.9%)223 ± 30−9 (4.1%)0.014148 ± 50−14 (9.5%)150 ± 23−7 (4.6%)0.0164 wk
       OmniHeart
      • Appel L.J.
      • Sacks F.M.
      • Carey V.J.
      • Obarzanek E.
      • Swain J.F.
      • Miller 3rd, E.R.
      • Conlin P.R.
      • Erlinger T.P.
      • Rosner B.A.
      • Laranjo N.M.
      • Charleston J.
      • McCarron P.
      • Bishop L.M.
      OmniHeart Collaborative Research Group
      Effect of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial.
      United States, 2005Prospective crossover91 (55%)/73 (45%)(54 ± 11)204 ± 36−20 (9.8%)
      Protein diet.
      , −15 (7.6%)
      Monounsaturated fat diet.
      204 ± 36−12 (6.1%)<0.05
      Protein diet.
      , NS
      Monounsaturated fat diet.
      129 ± 32−14 (11.0%)
      Protein diet.
      , −13 (10.1%)
      Monounsaturated fat diet.
      129 ± 32−12 (9.0%)0.01
      Protein diet.
      , NS
      Monounsaturated fat diet.
      3 6-wk periods
      Vegetarian
       Cooper et al
      • Cooper R.
      • Goldber R.
      • Trevisan M.
      • Tsong Y.
      • Liu K.
      • Stamler J.
      • Rubenstein A.
      • Scanu A.M.
      The selective lipids-lowering effect of vegetarianism on low density lipoproteins in a cross-over experiment.
      United States, 1982Prospective crossover10 (67%)/5 (33%)21–34 (28)160 ± 22−20 (11.9%)160 ± 220 (0%)<0.01109 ± 23−16 (14.7%)109 ± 230 (0%)<0.0252 3-wk periods
       Kestin et al
      • Kestin M.
      • Rouse I.L.
      • Correll R.A.
      • Nestel P.J.
      Cardiovascular disease risk factors in free living men: comparison of two prudent diets, one based on lactoovovegetarianism and the other allowing lean meat.
      Australia, 1989Prospective crossover26 (100%)/0 (0%)28–64 (44)234 (228–237)−24 (10.1%)234 (228–237)−11 (4.6%)<0.01155 (149–161)−24 (15.2%)155 (149–161)−10 (6.7%)<0.012 6-wk periods
       Lifestyle Heart Trial
      • Ornish D.
      • Brown S.E.
      • Scherwitz L.W.
      • Billings J.H.
      • Armstrong W.T.
      • Ports T.A.
      • McLanahan S.M.
      • Kirkeeide R.L.
      • Brand R.J.
      • Gould K.L.
      Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.
      United States, 1990Prospective randomized36 (88%)/5 (12%)35–75 (58)227 ± 50−55 (24.3%)245 ± 39−13 (5.3%)0.019152 ± 48−57 (37.4%)167 ± 30−10 (6.0%)0.00712 mo
       Lifestyle Heart Trial
      • Ornish D.
      • Scherwitz L.W.
      • Billings J.H.
      • Brown S.E.
      • Gould K.L.
      • Merritt T.A.
      • Sparler S.
      • Armstrong W.T.
      • Ports T.A.
      • Kirkeeide R.L.
      • Hogeboom C.
      • Brand R.J.
      Intensive lifestyle changes for reversal of coronary heart disease.
      United States, 1998Prospective randomized32 (91%)/3 (9%)39–79225 ± 12−37 (16.5%)248 ± 9−31 (12.5%)0.60144 ± 11−29 (20.1%)144 ± 11−10 (6.9%)0.765 yrs
       Hunt et al
      • Hunt J.
      • Matthys L.
      • Johnson L.K.
      Zinc absorption, mineral balance, and blood lipids in women consuming controlled lactoovovegetarian and omnivorous diets for 8 wk.
      ,
      No SD or confidence intervals given.
      United States, 1997Prospective crossover0 (0%)/21 (100%)20–42 (33 ± 7)172−14 (8.3%)1720 (0%)0.001106−10 (9.2%)1060 (0%)0.0012 8-wk periods
      Vegan
       Jenkins et al
      • Jenkins D.J.
      • Popovich D.G.
      • Kendall C.W.
      • Vidgen E.
      • Tariq N.
      • Ransom T.P.
      • Wolever T.M.
      • Vuksan V.
      • Mehling C.C.
      • Boctor D.L.
      • Bolognesi C.
      • Huang J.
      • Patten R.
      Effect of a diet high in vegetables, fruit, and nuts on serum lipids.
      Canada, 1997Prospective crossover7 (70%)/3 (30%)(33 ± 4)182 ± 9−39 (21.3%)179 ± 10+10 (5.8%)<0.001107 ± 10−32 (29.3%)106 ± 9+5 (4.4)<0.0012 2-wk periods
       Barnard et al
      • Barnard N.D.
      • Scialli A.R.
      • Bertron P.
      • Hurlock D.
      • Edmonds K.
      • Talev L.
      Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women.
      United States, 2000Prospective crossover0 (0%)/35 (100%)22–48 (36)163 ± 30−22 (13.2%)163 ± 30−1 (1.0%)<0.00197 ± 24−17 (16.9%)97 ± 24−3 (3.1%)<0.0018–10 wk
       Barnard et al
      • Barnard N.D.
      • Cohen J.
      • Jenkins D.J.
      • Turner-McGrievy G.
      • Gloede L.
      • Jaster B.
      • Seidl K.
      • Green A.A.
      • Talpers S.
      A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a random clinical trial in individuals with type 2 diabetes.
      United States, 2006Prospective randomized39 (39%)/60 (61%)27–82 (56)187 ± 37−28 (14.8%)199 ± 44−24 (12.2%)NS104 ± 33−16 (15.7%)119 ± 42−15 (13.0%)NS22 wk
      Subanalysis
      Subset of participants without changes in lipid or diabetes medications.
      80191 ± 37−34 (17.8%)195 ± 41−19 (9.7%)0.01107 ± 34−23 (21.4%)115 ± 40−11 (10.5%)0.0222 wk
      Combination
       Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.
      • Vidgen E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Parker T.L.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
      Canada, 2003Prospective randomized16 (64%)/9 (36%)36–85 (60 ± 10)251 ± 10−68 (26.6%)258 ± 6−26 (9.9%)<0.001170 ± 10−61 (35.0%)179 ± 6−22 (12.1%)<0.0014 wk
       Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vigden E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein.
      ,
      No SD or confidence intervals given.
      Canada, 2003Prospective randomized25 (54%)/21 (46%)36–85 (59 ± 1)268−59 (22.0%)246−15 (6.2%)<0.001179−53 (28.6%)166−14 (8.4%)<0.0011 mo
       Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants.
      ,
      No SD or confidence intervals given.
      Canada, 2005Prospective crossover20 (59%)/14 (41%)36–71 (58 ± 9)261−58 (22.3%)263−22 (8.2%)0.001174−51 (29.6%)177−17 (8.5%)0.0013 1-mo periods
       Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Faulkner D.A.
      • Nguyen T.
      • Kemp T.
      • Marchie A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Holmes C.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      • Singer W.
      Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia.
      Canada, 2006Prospective55
      The initial numbers of men and women were 31 and 35, but no final numbers were given.
      32–86 (59 ± 1)261 ± 4−27 (10.4%)<0.001173 ± 3−23 (14.6%)<0.00112 mo
      Data are expressed as mean ± SD, range (mean ± SD), mean (range), or number (percentage).
      low asterisk To convert TC and LDL-C to millimoles per liter, divide by 38.67.
      No SD or confidence intervals given.
      Protein diet.
      § Monounsaturated fat diet.
      Subset of participants without changes in lipid or diabetes medications.
      The initial numbers of men and women were 31 and 35, but no final numbers were given.

      Primary-Plant Diets

      In 2005, Gardner et al
      • Gardner C.D.
      • Coulston A.
      • Chatterjee L.
      • Rigby A.
      • Spiller G.
      • Farquhar J.W.
      The effect of a plant-based diet on plasma lipids in hypercholesterolemic men.
      compared a low-fat NCEP Step I diet and a “low-fat plus” diet in adults with hypercholesterolemia recruited from newspaper advertisements and brochures mailed to previous study participants and Stanford University employees. The diets were identical in total fat, saturated fat, protein, carbohydrate, and cholesterol contents, but the low-fat plus diet included “considerably more vegetables, legumes, and whole grains” and <1 serving of meat or eggs per week. All food was provided except for 1 “free-choice” meal per week. Lipid concentrations of participants assigned to the 2 groups decreased significantly, although the results were more dramatic in those in the low-fat plus arm.
      The OmniHeart trial
      • Appel L.J.
      • Sacks F.M.
      • Carey V.J.
      • Obarzanek E.
      • Swain J.F.
      • Miller 3rd, E.R.
      • Conlin P.R.
      • Erlinger T.P.
      • Rosner B.A.
      • Laranjo N.M.
      • Charleston J.
      • McCarron P.
      • Bishop L.M.
      OmniHeart Collaborative Research Group
      Effect of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial.
      tested the effects of macronutrient content in a racially diverse group of participants with hypertension and prehypertension who were not taking medications that affected lipids or blood pressure. Participants were primarily recruited through mass mailings and advertisements in Baltimore, Maryland, and Boston, Massachusetts. In an attempt to determine the best macronutrient combination, the investigators substituted either protein or monounsaturated fat for carbohydrate in a diet patterned after that used in the Dietary Approaches to Stop Hypertension (DASH) study. Protein (of which 2/3 came from plants) accounted for 25% of energy in the high-protein diet, and fat (55% monounsaturated) accounted for 37% of energy of the high-fat diet. Participants were provided with all food. Compared to participants assigned to the low-fat diet, participants assigned to the high-protein diet experienced significant decreases in TC, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and non-HDL cholesterol. Participants assigned to the monounsaturated fat diet experienced decreases in TC, triglycerides, and non-HDL cholesterol and increases in HDL cholesterol compared to participants assigned to the low-fat diet.

      Vegetarian Diets

      Of 19 randomized controlled studies, 8 tested the effect of vegetarian diets on plasma lipids. Of these, 5 used ovolactovegetarian diets and 3 used low-fat vegan diets.
      Cooper et al
      • Cooper R.
      • Goldber R.
      • Trevisan M.
      • Tsong Y.
      • Liu K.
      • Stamler J.
      • Rubenstein A.
      • Scanu A.M.
      The selective lipids-lowering effect of vegetarianism on low density lipoproteins in a cross-over experiment.
      tested the lipid-lowering effects of a lactovegetarian diet in healthy, nonsmoking physicians and medical students recruited from the Chicago area. Participants were randomly assigned to a low–saturated fat vegetarian diet or a “typical American diet.” While consuming the vegetarian diet, participants reported consuming 30% fewer calories, with 11% of energy from protein, 20% from fat, and 69% from carbohydrate. Participants consuming the vegetarian diet experienced significant decreases in TC and LDL cholesterol.
      Kestin et al
      • Kestin M.
      • Rouse I.L.
      • Correll R.A.
      • Nestel P.J.
      Cardiovascular disease risk factors in free living men: comparison of two prudent diets, one based on lactoovovegetarianism and the other allowing lean meat.
      studied the effects of an ovolactovegetarian diet, a lean-meat diet, and a typical Australian diet in participants with moderate cholesterol levels recruited from a “non-profit fitness institute” in the Adelaide, Australia, area. Participants eating the lean-meat and ovolactovegetarian diets reduced TC and LDL cholesterol concentrations and increased triglycerides, with no change in HDL cholesterol. While consuming the ovolactovegetarian diet, participants' TC and LDL cholesterol concentrations decreased significantly more than while consuming the lean-meat or Australian diet.
      In the Lifestyle Heart Trial, Ornish et al
      • Ornish D.
      • Brown S.E.
      • Scherwitz L.W.
      • Billings J.H.
      • Armstrong W.T.
      • Ports T.A.
      • McLanahan S.M.
      • Kirkeeide R.L.
      • Brand R.J.
      • Gould K.L.
      Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.
      evaluated whether a low-fat vegetarian diet, in addition to lifestyle modification (smoking cessation, exercise, and stress management), could improve plasma cholesterol concentrations and reverse atherosclerosis. Participants with diagnosed coronary artery disease and not taking lipid-lowering drugs were recruited from 2 San Francisco–area hospitals. After 1 year, the intervention group had lower TC and LDL cholesterol concentrations compared to controls. Triglycerides and HDL cholesterol concentrations remained unchanged in the 2 groups. Lipid values did not change significantly in the control group. Atherosclerotic stenosis decreased by 2.2% in mean diameter in the intervention group, while lesions worsened by 3.4% in the control group.
      After an additional 4 years, with 35 of the original participants,
      • Ornish D.
      • Scherwitz L.W.
      • Billings J.H.
      • Brown S.E.
      • Gould K.L.
      • Merritt T.A.
      • Sparler S.
      • Armstrong W.T.
      • Ports T.A.
      • Kirkeeide R.L.
      • Hogeboom C.
      • Brand R.J.
      Intensive lifestyle changes for reversal of coronary heart disease.
      the intervention group continued to maintain decreased TC and LDL cholesterol values without medication. The investigators noted the addition of statins in 9 of the control subjects (60%), compared to none in the intervention group. Atherosclerotic stenosis decreased by 3.1% in mean diameter in the intervention group, whereas lesions worsened by 11.8% in the control group (p = 0.001). Control-group participants experienced twice as many cardiac events compared to intervention-group participants.
      Assessing mineral absorption and lipids, Hunt et al
      • Hunt J.
      • Matthys L.
      • Johnson L.K.
      Zinc absorption, mineral balance, and blood lipids in women consuming controlled lactoovovegetarian and omnivorous diets for 8 wk.
      recruited premenopausal women with no apparent underlying diseases through public advertisements in North Dakota. Participants were assigned, in random order, to a nonvegetarian or an ovolactovegetarian diet. All foods were provided. The ovolactovegetarian diet included more whole grains, legumes, fruits, vegetables, nuts, and seeds, with 25% less protein, 12% less fat, and 16% more carbohydrate, as well as 96 mg/day less cholesterol and 24 g/day more fiber. While consuming the intervention diet, the women experienced decreased TC, LDL cholesterol, and HDL cholesterol. Apolipoprotein (apo) A-1, apo B, and lipoprotein(a) were also significantly decreased.

      Vegan Diets

      Jenkins et al
      • Jenkins D.J.
      • Popovich D.G.
      • Kendall C.W.
      • Vidgen E.
      • Tariq N.
      • Ransom T.P.
      • Wolever T.M.
      • Vuksan V.
      • Mehling C.C.
      • Boctor D.L.
      • Bolognesi C.
      • Huang J.
      • Patten R.
      Effect of a diet high in vegetables, fruit, and nuts on serum lipids.
      evaluated the effects a very high fiber vegan diet compared to a control diet (usual diet) on plasma lipid concentrations in healthy volunteers recruited from the University of Toronto graduate student population and the university and hospital staff population. While following the vegan diet, participants had decreases in TC, LDL cholesterol, and triglyceride concentrations. Significant reductions were also noted in the TC/HDL cholesterol ratio, the LDL cholesterol/HDL cholesterol ratio, and the apo B/apo A-1 ratio. Reductions in TC were 34% to 49% greater than expected by differences in dietary fat and cholesterol alone.
      Barnard et al
      • Barnard N.D.
      • Scialli A.R.
      • Bertron P.
      • Hurlock D.
      • Edmonds K.
      • Talev L.
      Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women.
      studied the effects of a vegan diet consisting of grains, vegetables, legumes, and fruits in a population of premenopausal women with normal plasma lipid concentrations. Participants were recruited by newspaper advertisements and brochures mailed to physicians in the Washington, District of Columbia, area. Participants were asked either to continue their customary diets and to take a placebo pill or to begin a low-fat (10% of energy from fat) vegan diet, each for 2 menstrual cycles, in random order. Food was not provided, but participants received weekly group nutrition instruction. While consuming the vegan diet, participants' TC, LDL cholesterol, and HDL cholesterol concentrations decreased and their triglycerides increased significantly more than while consuming the control diet.
      Barnard et al
      • Barnard N.D.
      • Cohen J.
      • Jenkins D.J.
      • Turner-McGrievy G.
      • Gloede L.
      • Jaster B.
      • Seidl K.
      • Green A.A.
      • Talpers S.
      A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a random clinical trial in individuals with type 2 diabetes.
      evaluated the effects of diet in 99 volunteers with type 2 diabetes recruited by advertisements in Washington-area newspapers. Participants were randomized to a low-fat, low–glycemic index vegan diet, or control diet based on 2003 American Diabetes Association guidelines.
      American Diabetes Association
      Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (position statement).
      At the end of the trial, more participants following the vegan diet decreased their cholesterol and diabetes medications, compared to participants following American Diabetes Association guidelines. After controlling for changes in lipid-lowering medications, participants assigned to the vegan diet experienced greater decreases in TC and LDL cholesterol values compared to participants assigned to the American Diabetes Association diet.

      Combination Diets

      Certain foods appear to have specific lipid-lowering properties: plant sterols, viscous fibers, soy proteins, and almonds may all contribute to lowering cholesterol. Accordingly, Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.
      • Vidgen E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Parker T.L.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
      evaluated the effects of a vegan dietary “portfolio” including plant sterols 1.2 g/1,000 kcal, soy protein 16.2 g/1,000 kcal, viscous fiber 8.3 g/1,000 kcal, and almonds 16.6 g/1,000 kcal. Participants were recruited from patients attending the Risk Factor Modification Center at St. Michael's Hospital in Toronto, Ontario, Canada, and from newspaper advertisements and asked to follow a low-fat diet for 1 month. Participants were then randomized to either the portfolio diet or an NCEP Step II ovolactovegetarian diet. Participants assigned to the portfolio diet experienced greater decreases in TC, LDL cholesterol, apo B, TC/HDL cholesterol ratio, LDL cholesterol/HDL cholesterol ratio, and apo B/apo A-1 ratio compared to participants assigned to the control diet.
      In a population similar to the previous study, Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vigden E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein.
      directly compared a vegetarian portfolio diet (plant sterols 1.0 g/1,000 kcal, soy protein 21.4 g/1,000 kcal, viscous fiber 9.8 g/1,000 kcal, and almonds 14 g/1,000 kcal) to a low-fat diet plus placebo (control group) and a low-fat diet plus lovastatin. Compared to controls, participants assigned to the lovastatin and portfolio groups significantly reduced TC and LDL cholesterol concentrations. The lovastatin and portfolio diet groups significantly reduced C-reactive protein levels, TC/HDL cholesterol ratios, HDL cholesterol/LDL cholesterol ratios, apo B values, and apo B/apo A-1 ratios. There were no differences between the lovastatin and portfolio diet groups in any changes in plasma lipid concentrations.
      Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants.
      compared 3 dietary interventions: a low-fat NCEP Step II diet, lovastatin 20 mg plus a low-fat NCEP Step II diet, and the portfolio diet (plant sterols 1.0 g/1,000 kcal, soy protein 21.4 g/1,000 kcal, viscous fiber 10.0 g/1,000 kcal, and almonds 14 g/1,000 kcal) in a crossover trial. Participants, recruited as in previous studies, were assigned in random order to all 3 groups. TC and LDL cholesterol concentrations decreased significantly in participants in the lovastatin and portfolio groups. However, subjects taking lovastatin lowered TC and LDL cholesterol to a significantly greater extent than those following the portfolio diet (p = 0.013).
      Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Faulkner D.A.
      • Nguyen T.
      • Kemp T.
      • Marchie A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Holmes C.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      • Singer W.
      Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia.
      tested the portfolio diet in a less restrictive, “real-world” environment. Participants, recruited from 2 sets of newspaper advertisements in the Toronto area and from an earlier study, were instructed to consume a low–saturated fat (<7% of calories) and low-cholesterol (<200 mg/day) diet for 2 months before study onset. All participants were then instructed to follow a portfolio diet. Food was not provided. After 1 year, participants experienced significant reductions in plasma lipid concentrations. This study did not include a control group, relying on baseline values and previous control measures in about 1/2 of the studied subjects. The investigators reported that a significant correlation was found between dietary adherence and change in LDL cholesterol (r = −0.42, p <0.001).

      Discussion

      Our review demonstrates that individuals following plant-based diets experience significantly lower blood lipid concentrations compared to those following diets that include animal products. In observational studies, vegetarians also appear to have fewer and smaller age-related increases in lipids compared to nonvegetarians.
      Although it is difficult to directly compare the effects of dietary interventions from various studies, the reviewed studies suggest that a greater reduction in dietary animal products yields greater reductions in lipid levels. In randomized controlled trials, compared to baseline values, primary plant-based and ovolactovegetarian dietary interventions were associated with decreases of TC and LDL cholesterol of about 10% to 15%, vegan dietary interventions were associated with decreases of approximately 15% to 25%, and combination dietary interventions (vegetarian diets with additional fiber, soy, and nuts) were associated with decreases of approximately 20% to 35%. The studies were not subjected to a meta-analysis. Although the combination dietary interventions prescribed by Jenkins et al
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.
      • Vidgen E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Parker T.L.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vigden E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein.
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants.
      • Jenkins D.J.
      • Kendall C.W.
      • Faulkner D.A.
      • Nguyen T.
      • Kemp T.
      • Marchie A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Vidgen E.
      • Trautwein E.A.
      • Lapsley K.G.
      • Holmes C.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      • Singer W.
      Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia.
      contained varying amounts of plant sterols, soy protein and isoflavins, viscous fibers, and nuts, other plant-based diets in the reviewed trials contained some or all of these components in unknown amounts, making direct comparisons difficult.
      Like all cholesterol subfractions, HDL cholesterol is typically lower in vegetarians compared to nonvegetarians. Trials of low-fat vegetarian diets, in which carbohydrates replace fats, have demonstrated decreases in HDL cholesterol. The mechanism for the effect of diet on HDL cholesterol is unclear, but lower apo A-1 production rates have been suggested as a contributing factor.
      • Desroches S.
      • Paradis M.E.
      • Pérusse M.
      • Archer W.R.
      • Bergeron J.
      • Couture P.
      • Bergeron N.
      • Lamarche B.
      Apolipoprotein A-I, A-II, and VLDL-B-100 metabolism in men: comparison of a low-fat diet and a high-monounsaturated fatty acid diet.
      Observational mortality studies in subjects who consume low-fat vegetarian diets, such as American Seventh-Day Adventists
      • Fraser G.E.
      • Shavlik D.J.
      Ten years of life: is it a matter of choice?.
      and individuals living in Asia,
      • Campbell T.C.
      • Parpia B.
      • Chen J.
      Diet, lifestyle, and the etiology of coronary artery disease: The Cornell China Study.
      suggest that decreased HDL cholesterol associated with low-fat vegetarian diets is not associated with poor cardiovascular health. In a randomized controlled trial, Ornish et al
      • Ornish D.
      • Brown S.E.
      • Scherwitz L.W.
      • Billings J.H.
      • Armstrong W.T.
      • Ports T.A.
      • McLanahan S.M.
      • Kirkeeide R.L.
      • Brand R.J.
      • Gould K.L.
      Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.
      • Ornish D.
      • Scherwitz L.W.
      • Billings J.H.
      • Brown S.E.
      • Gould K.L.
      • Merritt T.A.
      • Sparler S.
      • Armstrong W.T.
      • Ports T.A.
      • Kirkeeide R.L.
      • Hogeboom C.
      • Brand R.J.
      Intensive lifestyle changes for reversal of coronary heart disease.
      showed decreases in atherosclerotic lesions and cardiac events in subjects following an intervention including a low-fat vegetarian diet and moderate exercise, even in those with decreased HDL cholesterol. Also, although long-term adherence to a vegetarian diet is consistently associated with lower plasma triglyceride concentrations, randomized trials have demonstrated varied effects on triglycerides. Although diets high in refined carbohydrates may increase triglyceride concentrations, high-fiber and low–glycemic index foods appear to have the opposite result.
      • Jenkins D.J.
      • Wolever T.M.
      • Kalmusky J.
      • Guidici S.
      • Giordano C.
      • Patten R.
      • Wong G.S.
      • Bird J.N.
      • Hall M.
      • Buckley G.
      • Csima A.
      • Little J.A.
      Low-glycemic index diet in hyperlipidemia: use of traditional starchy foods.
      Plant-based diets reduce plasma cholesterol concentrations through several mechanisms. Reduced dietary intake of total fat, saturated fat, and cholesterol leads to less absorption and conversion to blood cholesterol.
      • Hu F.B.
      • Stampfer M.J.
      • Manson J.E.
      • Rimm E.
      • Colditz G.A.
      • Rosner B.A.
      • Hennekens C.H.
      • Willett W.C.
      Dietary fat intake and the risk of coronary heart disease in women.
      • Dreon D.M.
      • Fernstrom H.A.
      • Miller B.
      • Krauss R.M.
      Low-density lipoprotein subclass patterns and lipoprotein response to a reduced-fat diet in men.
      • Mensink R.P.
      • Katan M.B.
      Effect of dietary fatty acids on serum lipids and lipoproteins: a meta-analysis of 27 trials.
      • Keys A.
      • Anderson J.T.
      • Grande F.
      Serum cholesterol response to changes in the diet IV. Particularly saturated fatty acids in the diet.
      Most plant-based diets are low in saturated fat and cholesterol. However, the reductions in these macronutrients account for only a portion of the decrease in TC.
      • Burslem J.
      • Schonfeld G.
      • Howald M.
      • Weidman S.
      • Miller J.P.
      Plasma apoprotein and lipoprotein lipid levels in vegetarians.
      • Appel L.J.
      • Sacks F.M.
      • Carey V.J.
      • Obarzanek E.
      • Swain J.F.
      • Miller 3rd, E.R.
      • Conlin P.R.
      • Erlinger T.P.
      • Rosner B.A.
      • Laranjo N.M.
      • Charleston J.
      • McCarron P.
      • Bishop L.M.
      OmniHeart Collaborative Research Group
      Effect of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial.
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.
      • Vidgen E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Parker T.L.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.A.
      • Wong J.M.
      • de Souza R.
      • Emam A.
      • Parker T.L.
      • Vigden E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Lapsley K.G.
      • Josse R.G.
      • Leiter L.A.
      • Singer W.
      • Connelly P.W.
      Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein.
      Plant-based diets include compounds such as dietary fiber, phytosterols, phenolics, carotenoids, flavonoids, and saponins, derived primarily from whole grains, fruits and vegetables, and legumes.
      • De Lorgeril M.
      • Salen P.
      • Martin J.L.
      • Mamelle N.
      • Monjaud I.
      • Touboul P.
      • Delaye J.
      Effect of a Mediterranean type of diet on the rate of cardiovascular complications in patients with coronary artery disease Insights into the cardioprotective effect of certain nutriments.
      These compounds appear to affect cholesterol through multiple mechanisms. Viscous fiber intake can increase cholesterol removal through binding of bile acids and cholesterol.
      • Brown L.
      • Rosner B.
      • Willett W.W.
      • Sacks F.M.
      Cholesterol-lowering effects of dietary fiber: a meta-analysis.
      • Cara L.
      • Dubois C.
      • Borel P.
      • Armand M.
      • Senft M.
      • Portugal H.
      • Pauli A.M.
      • Bernard P.M.
      • Lairon D.
      Effects of oat bran, rice bran, wheat fiber, and wheat germ on postprandial lipemia in healthy adults.
      Plant sterol intake reduces cholesterol absorption through binding of cholesterol and bile acids.
      • Tilvis R.S.
      • Miettinen T.A.
      Serum plant sterols and their relation to cholesterol absorption.
      • Lichtenstein A.H.
      • Deckelbaum R.J.
      AHA Science Advisory Stanol/sterol ester-containing foods and blood cholesterol levels. A statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association.
      Increases in dietary soy may slightly decrease cholesterol synthesis with soy protein intake.
      • Anderson J.W.
      • Johnstone B.M.
      • Cook-Newel M.E.
      Meta-analysis of the effects of soy protein intake on serum lipids.
      • Sacks F.M.
      • Lichtenstein A.
      • Van Horn L.
      • Harris W.
      • Kris-Etherton P.
      • Winston M.
      American Heart Association Committee
      Soy protein, isoflavones, and cardiovascular health: an American Heart Association advisory for professionals from the Nutrition Committee.
      Soy intake may also improve cardiovascular health by increasing LDL cholesterol oxidation resistance
      • Damasceno N.R.T.
      • Apolinário E.
      • Flauzino F.D.
      • Fernandes I.
      • Abdalla D.S.P.
      Soy isoflavones reduce electronegative low-density lipoprotein (LDL) and anti-LDL autoantibodies in experimental atherosclerosis.
      and inhibiting thrombus formation
      • Rimbach G.
      • Boesch-Saadatmandi C.
      • Frank J.
      • Fuchs D.
      • Wenzel U.
      • Daniel H.
      • Hall W.L.
      • Weinberg P.D.
      Dietary isoflavones in the prevention of cardiovascular disease—a molecular perspective.
      due to isoflavin (genistein and daidzein) effects. Markers of cardiovascular health, such as decreased C-reactive protein, LDL cholesterol particle size, and increased resistance to oxidation of LDL cholesterol, have been associated with the intake of monounsaturated fats, nuts, and fruit and vegetables.
      • Reaven P.
      • Parthasarathy S.
      • Grasse B.J.
      • Miller E.
      • Steinberg D.
      • Witztum J.L.
      Effects of oleate-rich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects.
      • Lu S.C.
      • Wu W.H.
      • Lee C.A.
      • Chou H.F.
      • Lee H.R.
      • Huang P.C.
      LDL of Taiwanese vegetarians are less oxidizable than those of omnivores.
      • Zambon D.
      • Sabate J.
      • Munoz S.
      • Campero B.
      • Casals E.
      • Merlos M.
      • Laguna J.C.
      • Ros E.
      Substituting walnuts for monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women A randomized crossover trial.
      • Nagyova A.
      • Krajcovicova-Kudlackova M.
      • Kivanova J.
      LDL and HDL oxidation and fatty acid composition in vegetarians.
      • Lahteenmaki T.A.
      • Seppo L.
      • Laakso J.
      • Korpela R.
      • Vanhanen H.
      • Tikkanen M.J.
      Vapaatalo
      Oxidized LDL from subjects with different dietary habits modifies atherogenic processes in endothelial and smooth muscle cells.
      • Mori T.A.
      • Burke V.
      • Puddey I.B.
      • Watts G.F.
      • O'Neal D.N.
      • Best J.D.
      • Beilin L.J.
      Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men.
      Observational studies have demonstrated that populations following plant-based diets have lower overall and ischemic heart disease mortality.
      • Fu C.H.
      • Yang C.C.H.
      • Lin C.L.
      • Kuo T.B.J.
      Effects of long-term vegetarian diets on cardiovascular autonomic functions in healthy postmenopausal women.
      • Chang-Claude J.
      • Frentzel-Beyme R.
      Dietary and lifestyle determinants of mortality among German vegetarians.
      • Thorogood M.
      • Mann J.
      • Appleby F.
      • McPherson K.
      Risk of death from cancer and ischaemic heart disease in meat and non-meat eaters.
      Vegetarian diets have been associated with lower blood pressure,
      • Fu C.H.
      • Yang C.C.H.
      • Lin C.L.
      • Kuo T.B.J.
      Effects of long-term vegetarian diets on cardiovascular autonomic functions in healthy postmenopausal women.
      • McDougall J.
      • Litzau K.
      • Haver I.
      • Saunders V.
      • Spiller G.A.
      Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet.
      lower body weight and body mass index,
      • Ornish D.
      • Scherwitz L.W.
      • Billings J.H.
      • Brown S.E.
      • Gould K.L.
      • Merritt T.A.
      • Sparler S.
      • Armstrong W.T.
      • Ports T.A.
      • Kirkeeide R.L.
      • Hogeboom C.
      • Brand R.J.
      Intensive lifestyle changes for reversal of coronary heart disease.
      • Barnard N.D.
      • Cohen J.
      • Jenkins D.J.
      • Turner-McGrievy G.
      • Gloede L.
      • Jaster B.
      • Seidl K.
      • Green A.A.
      • Talpers S.
      A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a random clinical trial in individuals with type 2 diabetes.
      • McDougall J.
      • Litzau K.
      • Haver I.
      • Saunders V.
      • Spiller G.A.
      Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet.
      • Nicholson A.S.
      • Sklar M.
      • Barnard N.D.
      • Gore S.
      • Sullivan R.
      • Browning S.
      Toward improved management of NIDDM: a randomized, controlled, pilot intervention using a low-fat, vegetarian diet.
      lower C-reactive protein levels,
      • Jenkins D.J.
      • Kendall C.W.
      • Marchie A.
      • Faulkner D.
      • Vidgen E.
      • Lapsley K.G.
      • Trautwein E.A.
      • Parker T.L.
      • Josse R.G.
      • Leiter L.A.
      • Connelly P.W.
      The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
      • Krajcovicova-Kudlackova M.
      • Blazicek P.
      C-reactive protein and nutrition.
      lower blood concentrations of inflammatory markers,
      • Hostmark A.T.
      • Lystad E.
      • Vellar O.D.
      • Hovi K.
      • Berg J.E.
      Reduced plasma fibrinogen, serum peroxidases, lipids, and apolipoproteins after 3-week vegetarian diet.
      improved insulin sensitivity,
      • Mori T.A.
      • Burke V.
      • Puddey I.B.
      • Watts G.F.
      • O'Neal D.N.
      • Best J.D.
      • Beilin L.J.
      Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men.
      and better glycemic control in patients with diabetes.
      • Barnard N.D.
      • Cohen J.
      • Jenkins D.J.
      • Turner-McGrievy G.
      • Gloede L.
      • Jaster B.
      • Seidl K.
      • Green A.A.
      • Talpers S.
      A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a random clinical trial in individuals with type 2 diabetes.
      • Lahteenmaki T.A.
      • Seppo L.
      • Laakso J.
      • Korpela R.
      • Vanhanen H.
      • Tikkanen M.J.
      Vapaatalo
      Oxidized LDL from subjects with different dietary habits modifies atherogenic processes in endothelial and smooth muscle cells.
      • Nicholson A.S.
      • Sklar M.
      • Barnard N.D.
      • Gore S.
      • Sullivan R.
      • Browning S.
      Toward improved management of NIDDM: a randomized, controlled, pilot intervention using a low-fat, vegetarian diet.
      Multiple studies investigating the acceptability of plant-based diets have found the acceptability of these diets to be similar to that of other therapeutic diets across racially diverse populations.
      • Jenkins D.J.
      • Popovich D.G.
      • Kendall C.W.
      • Vidgen E.
      • Tariq N.
      • Ransom T.P.
      • Wolever T.M.
      • Vuksan V.
      • Mehling C.C.
      • Boctor D.L.
      • Bolognesi C.
      • Huang J.
      • Patten R.
      Effect of a diet high in vegetables, fruit, and nuts on serum lipids.
      • Barnard N.D.
      • Scialli A.R.
      • Bertron P.
      • Hurlock D.
      • Edmonds K.
      • Talev L.
      Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women.
      • Barnard N.D.
      • Scialli A.R.
      • Turner-McGrievy G.
      • Lanou A.J.
      Acceptability of a low-fat vegan diet compares favorably to a Step II diet in a randomized controlled trial.
      • Smith C.F.
      • Burke L.E.
      • Wing R.R.
      Young adults remain on vegetarian diet longer than weight loss diets.
      • White R.F.
      • Seymour J.
      • Frank E.
      Vegetarianism among U.S. women physicians.
      Compared with other therapeutic diets, plant-based diets have the advantage of not requiring macronutrient content calculations or portion-size control. Plant-based diets are also high in fiber, improving satiety, which sets them apart from calorie-restricted weight-loss diets. With adequate planning, vegetarian diets meet all nutritional needs.
      American Dietetic Association
      Position of the American Dietetic Association: vegetarian diets.
      Dietary trials have certain limitations. Dietary intervention studies typically cannot be double blinded. Study interventions (type of dietary intervention, degree of fat restriction, and duration) and end points vary, making direct comparisons and meta-analyses difficult. Most of the studies reviewed were observational studies or randomized controlled trials with relatively small sample sizes and brief intervention periods. Confounding factors such as different baseline cholesterol levels, baseline diets, glucose homeostasis, insulin sensitivity, and body fat composition and distribution can affect the effectiveness of dietary interventions. Few studies have examined the effect of diet on morbidity or mortality. Long-term, large prospective studies, with consistent diets and outcomes, may clarify questions surrounding the effects of plant-based diets on cardiac and total mortality, effects in patients already treated with lipid-lowering medications and associated direct and indirect costs.
      Hypercholesterolemia and associated coronary artery disease, peripheral vascular disease, and stroke are major contributors to morbidity, mortality, and health care costs. The treatment of dyslipidemia accounts for significant costs and potentially adverse effects. Dietary changes are recommended as first-line therapy for dyslipidemia because they are safe and cost effective. However, to date, studies have shown NCEP diets and similar regimens to be only modestly effective, reducing TC and LDL cholesterol concentrations by 5% to 10%. However, plant-based diets, which follow the current recommendations of the Third Adult Treatment Panel and the American Heart Association, have demonstrated greater cholesterol reductions and are a preferable option for cholesterol reduction.

      References

        • Pekkanen J.
        • Linn S.
        • Heiss G.
        • Suchindran C.M.
        • Leon A.
        • Rifkind B.M.
        • Tyroler H.A.
        Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease.
        N Engl J Med. 1990; 322: 1700-1707
        • Rosengren A.
        • Hagman M.
        • Wedel H.
        • Wilhelmsen L.
        Serum cholesterol and long-term prognosis in middle-aged men with myocardial infarction and angina pectoris.
        Eur Heart J. 1997; 18: 754-761
        • Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
        Third report of the National Cholesterol Education Program (NCEP) (Adult Treatment Panel III).
        Circulation. 2002; 106: 3143-3421
      1. Heart disease and stroke statistics 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Committee.
        Circulation. 2008; 117: e25-e146
        • Austin M.A.
        • Hutter C.M.
        • Zimmern R.L.
        • Humphries S.E.
        Genetic causes of monogenic heterozygous familial hypercholesterolemia: a HuGE prevalence review.
        Am J Epidemiol. 2004; 160: 408-420
        • Carroll M.D.
        • Lacher D.A.
        • Sorlie P.D.
        • Cleeman J.I.
        • Gordon D.J.
        • Wolz M.
        • Grundy S.M.
        • Johnson C.L.
        Trends in serum lipids and lipoproteins of adults, 1960–2002.
        JAMA. 2005; 294: 1773-1781
        • Key T.J.
        • Fraser G.E.
        • Thorogood M.
        • Appleby P.N.
        • Beral V.
        • Reeves G.
        • Burr M.L.
        • Chang-Claude J.
        • Frentzel-Beyme R.
        • Kuzma J.W.
        • Mann J.
        • McPherson K.
        Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies.
        Am J Clin Nutr. 1999; 70: 516S-524S
        • Burslem J.
        • Schonfeld G.
        • Howald M.
        • Weidman S.
        • Miller J.P.
        Plasma apoprotein and lipoprotein lipid levels in vegetarians.
        Metabolism. 1978; 27: 711-719
        • Thorogood M.
        • Carter R.
        • Benfield L.
        • McPherson K.
        • Mann J.I.
        Plasma lipids and lipoprotein cholesterol concentrations in people with different diets in Britain.
        Br Med J. 1987; 295: 351-353
        • Melby C.
        • Toohey M.L.
        • Cebrick J.
        Blood pressure and blood lipids among vegetarian, semivegetarian, and nonvegetarian African Americans.
        Am J Clin Nutr. 1994; 59: 103-109
        • Toohey M.L.
        • Harris M.A.
        • DeWitt W.
        • Foster G.
        • Schmidt W.D.
        • Melby C.L.
        Cardiovascular disease risk factors are lower in African-American vegans compared to lacto-ovo-vegetarians.
        J Am Coll Nutr. 1998; 17: 425-434
        • Alexander H.
        • Lockwood L.P.
        • Harris M.A.
        • Melby C.L.
        Risk factors for cardiovascular disease in two groups of Hispanic Americans with differing dietary habits.
        J Am Coll Nutr. 1999; 18: 127-136
        • Li D.
        • Sinclair A.
        • Mann N.
        • Turner A.
        • Ball M.
        • Kelly F.
        • Abedin L.
        • Wilson A.
        The association of diet and thrombotic risk factors is healthy male vegetarians and meat-eaters.
        Eur J Clin Nutr. 1999; 53: 612-619
        • Fu C.H.
        • Yang C.C.H.
        • Lin C.L.
        • Kuo T.B.J.
        Effects of long-term vegetarian diets on cardiovascular autonomic functions in healthy postmenopausal women.
        Am J Cardiol. 2006; 97: 380-383
        • De Biase S.G.
        • Fernandes S.F.
        • Gianini R.J.
        • Duarte J.L.
        Vegetarian diet and cholesterol and triglyceride levels.
        Arq Bras Cardiol. 2007; 88: 35-39
        • Teixeira Rde C.
        • Molina Mdel C.
        • Zandonade E.
        • Mill J.G.
        Cardiovascular risk in vegetarians and omnivores: a comparative study.
        Arq Bras Cardiol. 2007; 89: 237-244
        • Hoffmann I.
        • Groeneveld M.J.
        • Boeing H.
        • Koebnick C.
        • Golf S.
        • Katz N.
        • Leitzmann C.
        Giessen Wholesome Nutrition Study: relation between a health-conscious diet and blood lipids.
        Eur J Clin Nutr. 2001; 55: 887-895
        • Sacks F.M.
        • Castelli W.P.
        • Donner A.
        • Kaas E.H.
        Plasma lipids and lipoproteins in vegetarians and controls.
        N Engl J Med. 1975; 292: 1148-1151
        • Fisher M.
        • Levine P.
        • Weiner B.
        • Ockene I.
        • Johnson B.
        • Johnson M.H.
        • Natale A.M.
        • Vaudreuil C.H.
        • Hoogasian J.
        The effect of vegetarian diets on plasma lipids and platelet levels.
        Arch Int Med. 1986; 146: 1193-1197
        • Harman S.
        • Parnell W.
        The nutritional health of New Zealand vegetarian and non-vegetarian Seventh-Day Adventists: selected vitamin mineral and lipid levels.
        N Z Med J. 1998; 111: 91-94
        • Gardner C.D.
        • Coulston A.
        • Chatterjee L.
        • Rigby A.
        • Spiller G.
        • Farquhar J.W.
        The effect of a plant-based diet on plasma lipids in hypercholesterolemic men.
        Ann Intern Med. 2005; 142: 725-733
        • Appel L.J.
        • Sacks F.M.
        • Carey V.J.
        • Obarzanek E.
        • Swain J.F.
        • Miller 3rd, E.R.
        • Conlin P.R.
        • Erlinger T.P.
        • Rosner B.A.
        • Laranjo N.M.
        • Charleston J.
        • McCarron P.
        • Bishop L.M.
        • OmniHeart Collaborative Research Group
        Effect of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial.
        JAMA. 2005; 294: 2455-2464
        • Cooper R.
        • Goldber R.
        • Trevisan M.
        • Tsong Y.
        • Liu K.
        • Stamler J.
        • Rubenstein A.
        • Scanu A.M.
        The selective lipids-lowering effect of vegetarianism on low density lipoproteins in a cross-over experiment.
        Atherosclerosis. 1982; 44: 293-305
        • Kestin M.
        • Rouse I.L.
        • Correll R.A.
        • Nestel P.J.
        Cardiovascular disease risk factors in free living men: comparison of two prudent diets, one based on lactoovovegetarianism and the other allowing lean meat.
        Am J Clin Nutr. 1989; 50: 280-287
        • Ornish D.
        • Brown S.E.
        • Scherwitz L.W.
        • Billings J.H.
        • Armstrong W.T.
        • Ports T.A.
        • McLanahan S.M.
        • Kirkeeide R.L.
        • Brand R.J.
        • Gould K.L.
        Can lifestyle changes reverse coronary heart disease?.
        Lancet. 1990; 336: 129-133
        • Ornish D.
        • Scherwitz L.W.
        • Billings J.H.
        • Brown S.E.
        • Gould K.L.
        • Merritt T.A.
        • Sparler S.
        • Armstrong W.T.
        • Ports T.A.
        • Kirkeeide R.L.
        • Hogeboom C.
        • Brand R.J.
        Intensive lifestyle changes for reversal of coronary heart disease.
        JAMA. 1998; 280: 2001-2007
        • Hunt J.
        • Matthys L.
        • Johnson L.K.
        Zinc absorption, mineral balance, and blood lipids in women consuming controlled lactoovovegetarian and omnivorous diets for 8 wk.
        Am J Clin Nutr. 1998; 67: 421-430
        • Jenkins D.J.
        • Popovich D.G.
        • Kendall C.W.
        • Vidgen E.
        • Tariq N.
        • Ransom T.P.
        • Wolever T.M.
        • Vuksan V.
        • Mehling C.C.
        • Boctor D.L.
        • Bolognesi C.
        • Huang J.
        • Patten R.
        Effect of a diet high in vegetables, fruit, and nuts on serum lipids.
        Metabolism. 1997; 46: 530-537
        • Barnard N.D.
        • Scialli A.R.
        • Bertron P.
        • Hurlock D.
        • Edmonds K.
        • Talev L.
        Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women.
        Am J Cardiol. 2000; 85: 969-972
        • Barnard N.D.
        • Cohen J.
        • Jenkins D.J.
        • Turner-McGrievy G.
        • Gloede L.
        • Jaster B.
        • Seidl K.
        • Green A.A.
        • Talpers S.
        A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a random clinical trial in individuals with type 2 diabetes.
        Diabetes Care. 2006; 29 (1777–1183)
        • American Diabetes Association
        Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (position statement).
        Diabetes Care. 2003; 26: S51-S61
        • Jenkins D.J.
        • Kendall C.W.
        • Marchie A.
        • Faulkner D.
        • Vidgen E.
        • Lapsley K.G.
        • Trautwein E.A.
        • Parker T.L.
        • Josse R.G.
        • Leiter L.A.
        • Connelly P.W.
        The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.
        Metabolism. 2003; 52: 1478-1483
        • Jenkins D.J.
        • Kendall C.W.
        • Marchie A.
        • Faulkner D.A.
        • Wong J.M.
        • de Souza R.
        • Emam A.
        • Parker T.L.
        • Vigden E.
        • Lapsley K.G.
        • Trautwein E.A.
        • Lapsley K.G.
        • Josse R.G.
        • Leiter L.A.
        • Singer W.
        • Connelly P.W.
        Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein.
        JAMA. 2003; 290: 502-510
        • Jenkins D.J.
        • Kendall C.W.
        • Marchie A.
        • Faulkner D.A.
        • Wong J.M.
        • de Souza R.
        • Emam A.
        • Parker T.L.
        • Vidgen E.
        • Trautwein E.A.
        • Lapsley K.G.
        • Josse R.G.
        • Leiter L.A.
        • Singer W.
        • Connelly P.W.
        Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants.
        Am J Clin Nutr. 2005; 81: 380-387
        • Jenkins D.J.
        • Kendall C.W.
        • Faulkner D.A.
        • Nguyen T.
        • Kemp T.
        • Marchie A.
        • Wong J.M.
        • de Souza R.
        • Emam A.
        • Vidgen E.
        • Trautwein E.A.
        • Lapsley K.G.
        • Holmes C.
        • Josse R.G.
        • Leiter L.A.
        • Connelly P.W.
        • Singer W.
        Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia.
        Am J Clin Nutr. 2006; 83: 582-591
        • Desroches S.
        • Paradis M.E.
        • Pérusse M.
        • Archer W.R.
        • Bergeron J.
        • Couture P.
        • Bergeron N.
        • Lamarche B.
        Apolipoprotein A-I, A-II, and VLDL-B-100 metabolism in men: comparison of a low-fat diet and a high-monounsaturated fatty acid diet.
        J Lipid Res. 2004; 45: 2331-2338
        • Fraser G.E.
        • Shavlik D.J.
        Ten years of life: is it a matter of choice?.
        Arch Intern Med. 2001; 161: 1645-1652
        • Campbell T.C.
        • Parpia B.
        • Chen J.
        Diet, lifestyle, and the etiology of coronary artery disease: The Cornell China Study.
        Am J Cardiol. 1998; 82: 18T-21T
        • Jenkins D.J.
        • Wolever T.M.
        • Kalmusky J.
        • Guidici S.
        • Giordano C.
        • Patten R.
        • Wong G.S.
        • Bird J.N.
        • Hall M.
        • Buckley G.
        • Csima A.
        • Little J.A.
        Low-glycemic index diet in hyperlipidemia: use of traditional starchy foods.
        Am J Clin Nutr. 1987; 46: 66-71
        • Hu F.B.
        • Stampfer M.J.
        • Manson J.E.
        • Rimm E.
        • Colditz G.A.
        • Rosner B.A.
        • Hennekens C.H.
        • Willett W.C.
        Dietary fat intake and the risk of coronary heart disease in women.
        N Engl J Med. 1997; 337: 1491-1499
        • Dreon D.M.
        • Fernstrom H.A.
        • Miller B.
        • Krauss R.M.
        Low-density lipoprotein subclass patterns and lipoprotein response to a reduced-fat diet in men.
        FASEB J. 1994; 8: 121-126
        • Mensink R.P.
        • Katan M.B.
        Effect of dietary fatty acids on serum lipids and lipoproteins: a meta-analysis of 27 trials.
        Arterioscler Thromb. 1992; 12: 911-919
        • Keys A.
        • Anderson J.T.
        • Grande F.
        Serum cholesterol response to changes in the diet.
        Metabolism. 1996; 14: 776-787
        • De Lorgeril M.
        • Salen P.
        • Martin J.L.
        • Mamelle N.
        • Monjaud I.
        • Touboul P.
        • Delaye J.
        Effect of a Mediterranean type of diet on the rate of cardiovascular complications in patients with coronary artery disease.
        J Am Coll Cardiol. 1996; 28: 1103-1108
        • Brown L.
        • Rosner B.
        • Willett W.W.
        • Sacks F.M.
        Cholesterol-lowering effects of dietary fiber: a meta-analysis.
        Am J Clin Nutr. 1999; 69: 30-42
        • Cara L.
        • Dubois C.
        • Borel P.
        • Armand M.
        • Senft M.
        • Portugal H.
        • Pauli A.M.
        • Bernard P.M.
        • Lairon D.
        Effects of oat bran, rice bran, wheat fiber, and wheat germ on postprandial lipemia in healthy adults.
        Am J Clin Nutr. 1992; 55: 81-88
        • Tilvis R.S.
        • Miettinen T.A.
        Serum plant sterols and their relation to cholesterol absorption.
        Am J Clin Nutr. 1986; 43: 92-97
        • Lichtenstein A.H.
        • Deckelbaum R.J.
        AHA Science Advisory.
        Circulation. 2001; 103: 1177-1179
        • Anderson J.W.
        • Johnstone B.M.
        • Cook-Newel M.E.
        Meta-analysis of the effects of soy protein intake on serum lipids.
        N Engl J Med. 1995; 333: 376-382
        • Sacks F.M.
        • Lichtenstein A.
        • Van Horn L.
        • Harris W.
        • Kris-Etherton P.
        • Winston M.
        • American Heart Association Committee
        Soy protein, isoflavones, and cardiovascular health: an American Heart Association advisory for professionals from the Nutrition Committee.
        Circulation. 2006; 113: 1034-1044
        • Damasceno N.R.T.
        • Apolinário E.
        • Flauzino F.D.
        • Fernandes I.
        • Abdalla D.S.P.
        Soy isoflavones reduce electronegative low-density lipoprotein (LDL) and anti-LDL autoantibodies in experimental atherosclerosis.
        Eur J Nutr. 2007; 46: 125-132
        • Rimbach G.
        • Boesch-Saadatmandi C.
        • Frank J.
        • Fuchs D.
        • Wenzel U.
        • Daniel H.
        • Hall W.L.
        • Weinberg P.D.
        Dietary isoflavones in the prevention of cardiovascular disease—a molecular perspective.
        Food Chem Toxicol. 2008; 46: 1308-1319
        • Reaven P.
        • Parthasarathy S.
        • Grasse B.J.
        • Miller E.
        • Steinberg D.
        • Witztum J.L.
        Effects of oleate-rich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects.
        J Clin Invest. 1993; 91: 668-676
        • Lu S.C.
        • Wu W.H.
        • Lee C.A.
        • Chou H.F.
        • Lee H.R.
        • Huang P.C.
        LDL of Taiwanese vegetarians are less oxidizable than those of omnivores.
        J Nutr. 2000; 130: 1591-1596
        • Zambon D.
        • Sabate J.
        • Munoz S.
        • Campero B.
        • Casals E.
        • Merlos M.
        • Laguna J.C.
        • Ros E.
        Substituting walnuts for monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women.
        Ann Intern Med. 2000; 132: 538-546
        • Nagyova A.
        • Krajcovicova-Kudlackova M.
        • Kivanova J.
        LDL and HDL oxidation and fatty acid composition in vegetarians.
        Ann Nutr Metab. 2001; 45: 148-151
        • Lahteenmaki T.A.
        • Seppo L.
        • Laakso J.
        • Korpela R.
        • Vanhanen H.
        • Tikkanen M.J.
        • Vapaatalo
        Oxidized LDL from subjects with different dietary habits modifies atherogenic processes in endothelial and smooth muscle cells.
        Life Sci. 2000; 66: 455-465
        • Mori T.A.
        • Burke V.
        • Puddey I.B.
        • Watts G.F.
        • O'Neal D.N.
        • Best J.D.
        • Beilin L.J.
        Purified eicosapentaenoic and docosahexaenoic acids have differential effects on serum lipids and lipoproteins, LDL particle size, glucose, and insulin in mildly hyperlipidemic men.
        Am J Clin Nutr. 2000; 71: 1085-1094
        • Chang-Claude J.
        • Frentzel-Beyme R.
        Dietary and lifestyle determinants of mortality among German vegetarians.
        Int J Epidemiol. 1993; 22: 228-236
        • Thorogood M.
        • Mann J.
        • Appleby F.
        • McPherson K.
        Risk of death from cancer and ischaemic heart disease in meat and non-meat eaters.
        Br Med J. 1994; 308: 1667-1671
        • McDougall J.
        • Litzau K.
        • Haver I.
        • Saunders V.
        • Spiller G.A.
        Rapid reduction of serum cholesterol and blood pressure by a twelve-day, very low fat, strictly vegetarian diet.
        J Am Coll Nutr. 1995; 14: 461-466
        • Nicholson A.S.
        • Sklar M.
        • Barnard N.D.
        • Gore S.
        • Sullivan R.
        • Browning S.
        Toward improved management of NIDDM: a randomized, controlled, pilot intervention using a low-fat, vegetarian diet.
        Prev Med. 1999; 29: 87-91
        • Krajcovicova-Kudlackova M.
        • Blazicek P.
        C-reactive protein and nutrition.
        Bratisl Lek Listy. 2005; 106: 345-347
        • Hostmark A.T.
        • Lystad E.
        • Vellar O.D.
        • Hovi K.
        • Berg J.E.
        Reduced plasma fibrinogen, serum peroxidases, lipids, and apolipoproteins after 3-week vegetarian diet.
        Plant Foods Hum Nutr. 1993; 43: 55-61
        • Barnard N.D.
        • Scialli A.R.
        • Turner-McGrievy G.
        • Lanou A.J.
        Acceptability of a low-fat vegan diet compares favorably to a Step II diet in a randomized controlled trial.
        J Cardiopulm Rehabil. 2004; 24: 229-235
        • Smith C.F.
        • Burke L.E.
        • Wing R.R.
        Young adults remain on vegetarian diet longer than weight loss diets.
        Ann Behav Med. 1999; 21: S090
        • White R.F.
        • Seymour J.
        • Frank E.
        Vegetarianism among U.S. women physicians.
        J Am Diet Assoc. 1999; 99: 595-598
        • American Dietetic Association
        Position of the American Dietetic Association: vegetarian diets.
        J Am Diet Assoc. 1997; 97: 1317-1321

      Linked Article

      • Vegetarians from Latin America
        American Journal of CardiologyVol. 105Issue 6
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          Ferdowsian and Barnard1 have presented important information about populations following plant-based diets, particularly vegetarian (VEG) and vegan, suggesting that they are at lower risk for ischemic heart disease mortality.
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