American Heart Association Ranks Keto Diet Last for Heart Health. What About Vegan?

Heart disease is the leading killer of people worldwide, and a healthy diet is key to reducing your risk, according to the American Heart Association (AHA). But which diet is considered heart healthy? 

A scientific report recently published by the AHA in its journal Circulation found that very low carb or ketogenic diets ranked last for heart health. Plant-based diets, on the other hand, ranked at the top for heart-healthy eating guidelines. 

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The report evaluated how well each of 10 popular diets or eating patterns aligns with the features of AHA’s dietary guidance for heart-healthy eating, including: 

• consuming a wide variety of fruits and vegetables 
• choosing mostly whole grains instead of refined grains
• using liquid plant oils rather than tropical oils
• eating healthy sources of protein
• minimizing added sugars and salt
• limiting alcohol
• choosing minimally processed foods instead of ultra-processed foods 
• following this guidance wherever food is prepared or consumed

The one feature not included in scoring was the energy balance needed to maintain a healthy weight, because it is influenced by factors other than dietary choices, such as physical activity levels.

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The AHA hopes this ranking helps clear up the confusion regarding various popular diets. “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,” lead author Christopher D. Gardner, a research professor of medicine at the Stanford Prevention Research Center in California, said in a statement. 

“We hope this statement serves as a tool for clinicians and the public to understand which diets promote good cardiometabolic health.”

Keto diet worst for heart health

For the analysis, the diets were rated on a scale of 1 to 100 for how well they adhered to AHA’s guidance and then divided into four tiers based on their scores. Very low-carb and keto diets were only 31 percent aligned and the paleolithic diet was 53 percent aligned to the AHA guidelines, falling into the bottom tier of the scoring system. 

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The report noted that these diets have not been shown to be any more effective for weight loss than less restrictive diets over the long term, and both diets are high in fat without limiting saturated fats.

“[The tier four diets] are highly restrictive and difficult for most people to stick with long-term. While there will likely be short-term benefits and substantial weight loss, it isn’t sustainable,” Gardner said. “A diet that’s effective at helping an individual maintain weight-loss goals, from a practical perspective, needs to be sustainable.”

Low carb diets, which are 64 percent aligned, and very low-fat, which is 72 percent aligned, fall into the third tier. The report notes that these diets restrict foods that are emphasized in the AHA’s dietary guidance. For example, very low-fat diets restrict nuts and healthy plant oils, and low-carb diets restrict consumption of fruits, grains, and legumes, which can lead to eating less fiber and higher amounts of saturated fats.

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Falling in the second tier, a vegan diet that incorporates more than 10 percent fat as well as low-fat diets both met 78 percent of the AHA dietary guidelines, according to the report. 

While they emphasize fruits, vegetables, whole grains, legumes and nuts, while limiting alcohol and added sugars, the report says the vegan diet could be challenging to follow long-term or when eating out because it is restrictive, and it may increase the risk of vitamin B-12 deficiency, which can lead to anemia.

Plant-forward diets best for heart health

The plant-forward Mediterranean diet eating pattern had a slightly higher score (89 percent) because it allows for moderate alcohol consumption and does not address added salt. The pescetarian diet (92 percent) and vegetarian diet (86 percent) also were in the top tier. 

But all of these diets share so much in common they can really be grouped together as a top tier of plant-forward eating patterns, and they are easier to follow than the vegan diet, Gardner said. “If implemented as intended, the top-tier dietary patterns align best with the American Heart Association’s guidance and may be adapted to respect cultural practices, food preferences, and budgets to enable people to always eat this way, for the long term,” Gardner said.

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The winner? The Dietary Approaches to Stop Hypertension (DASH) diet, which was 100 percent aligned with AHA goals for heart-healthy eating. This eating pattern is low in salt, added sugar, tropical oil, alcohol and processed foods and high in non-starchy vegetables, fruits, whole grains, and legumes. Proteins mostly come from plant sources, such as legumes, beans or nuts, with some seafood, meat and low-fat or fat-free dairy products also consumed.

The authors noted that more research and education are needed to show people how to follow eating patterns in ways that are culturally relevant to ensure their effectiveness. 

Efforts also need to be made to include historically marginalized groups in the research to reduce the impact of structural racism on diet-related diseases, and policies are needed to dismantle unjust practices that limit access to healthy foods in some communities, according to the report.