Plant-based Mediterranean-style diet cuts heart disease risk by 26%

By Dr. Priyom Bose, Ph.D.Reviewed by Lauren HardakerJun 24 2026

A 20-year study of more than 3,000 Greek adults found that people whose diets most closely resembled a plant-based Mediterranean eating pattern had substantially lower cardiovascular disease risk, while calorie-dense diets low in white meat were linked to worse long-term heart health outcomes.

Study: Sustainable diets and long-term cardiovascular disease outcomes; insights from the 20-year follow-up ATTICA study (2002–2022). Image credit: YARUNIV Studio/Shutterstock.com

A recent European Journal of Nutrition study examined common dietary patterns in a Mediterranean cohort and assessed their long-term associations with cardiovascular disease (CVD) risk and outcomes. These patterns were evaluated through a sustainability lens.

Global burden of cardiovascular disease and sustainable food systems

Between 2010 and 2021, age-standardized rates of cardiovascular disease (CVD) modestly declined. However, the absolute numbers of cases, deaths, and disability-adjusted life years (DALYs) rose significantly, primarily due to demographic shifts. Projections indicate that CVD cases and related DALYs will continue to rise, intensifying pressure on healthcare systems and highlighting the urgent need for effective prevention strategies.

Poor dietary habits, especially inadequate consumption of nutrient-dense foods, remain a leading modifiable risk factor. This highlights the importance of developing food systems that ensure equitable access to healthy diets and supportive environments.

Unsustainable food production and consumption drive environmental degradation, threatening the capacity of food systems to deliver healthy diets. The global food system significantly contributes to greenhouse gas emissions, resource depletion, and pollution, while climate change undermines food security and quality. These environmental and social stressors, combined with rising demand for resource-intensive foods, may place additional pressure on food systems and challenge their long-term resilience and stability. 

Transitioning to healthy, sustainable diets centered on a diverse range of plant-based foods and reduced reliance on resource-intensive animal products offers a promising path toward improved health, reduced environmental impact, and greater equity. However, achieving population-level dietary change remains a major challenge amid persistent barriers in the food system and social inequities.

Nutritional epidemiology increasingly focuses on overall dietary patterns rather than isolated nutrients, utilizing both a priori (guideline-based) and a posteriori (data-driven) approaches to identify patterns. However, many studies have relied on a priori indices, which may not fully reflect how people actually eat in everyday life.

Health, lifestyle, and dietary patterns in the ATTICA cohort

The ATTICA Study is a 20-year prospective cohort of 3,042 healthy adults from Attica, Greece, recruited by stratified random sampling. Follow-up assessments at 5, 10, and 20 years maintained high participation, with in-person evaluations for survivors and cause of death recorded for deceased participants. At 20 years, 1,988 participants had complete cardiovascular data. Individuals lost to follow-up tended to have lower socioeconomic status.

Baseline assessments included questionnaires, physical exams, and blood tests. Primary endpoints were fatal and non-fatal cardiovascular events, with non-CVD deaths also tracked for competing risk calculations.

Medical history targeted hypertension, hypercholesterolemia, and type 2 diabetes. Standardized anthropometric measures included body weight, height, waist and hip circumference, with central obesity and body ratio calculations.

Smoking was classified as ever or never. Physical activity was measured with a validated questionnaire, with activity defined as recreational episodes of at least 10 minutes. Dietary intake was evaluated by trained dietitians using a detailed, validated questionnaire.

Sustainable, plant-based diet associated with lower long-term cardiovascular risk

Analyses of 3,042 participants revealed three distinct dietary patterns, which together explained nearly half of the variation in dietary habits. The first pattern was plant-based and sustainable, characterized by higher intakes of vegetables, fruits, plant proteins (legumes and nuts), grains, fish, seafood, and dairy. The second was a Western dietary pattern, high in red meat, potatoes, sweets, and eggs, reflecting greater reliance on animal-based and processed foods. The third pattern showed higher energy intake than metabolic needs and less white meat consumption. Participants were grouped by their level of adherence to each pattern.

Those with the highest adherence to the plant-based, sustainable pattern were generally older and led healthier lifestyles. The Western pattern was more common among younger men, who also had lower smoking exposure and cholesterol issues, likely due to age distribution. High adherence to the high-calorie, low-white-meat pattern was linked to younger age, greater overweight and obesity, and less favorable body measurements.

During 20 years of follow-up, 36% of participants experienced a cardiovascular event, with fatal events being rare. Lower adherence to the plant-based pattern or higher adherence to the high-calorie, low-white-meat pattern was associated with increased lifetime cardiovascular risk. Although the Western pattern was linked to earlier CVD onset, total CVD incidence appeared lower, possibly due to unmeasured factors. The apparent relationship between the Western dietary pattern and CVD largely disappeared after adjustment for age and other cardiovascular risk factors.

After adjusting for confounders, advanced statistical models showed that greater adherence to a plant-based, sustainable dietary pattern was associated with a significantly lower risk of CVD over 20 years. Specifically, each one-standard-deviation increase in adherence to the pattern was associated with a 26% lower hazard of developing CVD over 20 years. Participants in the highest-adherence group had a 61% lower adjusted hazard of 20-year CVD incidence than those in the lowest-adherence group, after accounting for demographic, socioeconomic, clinical, and lifestyle factors.

Further analysis confirmed that greater adherence to the high-calorie, low-white-meat dietary pattern increased lifetime CVD risk and CVD burden, as measured by disability-adjusted life years (DALYs). Physical activity reduced CVD risk, while smoking increased it. Excluding early CVD cases did not change these findings, confirming their robustness.

Mediterranean-style habits support long-term cardiovascular health

Adopting a sustainable, plant-based dietary pattern resembling the traditional Mediterranean diet may benefit both cardiovascular health and the environment. The authors interpreted this dietary pattern as more sustainable because it emphasized plant-based foods and reduced reliance on resource-intensive animal products, although environmental impacts were not measured directly. 

The findings should be interpreted in light of several limitations. Dietary intake was self-reported using a food-frequency questionnaire and may be subject to recall or measurement errors. The dietary patterns were derived using principal component analysis, which involves some degree of researcher interpretation. In addition, participants lost to follow-up tended to have lower socioeconomic status, which could introduce selection bias. As an observational study conducted in a Mediterranean population, the results cannot establish causation and may not be fully generalizable to other populations.

Looking ahead, research should assess the long-term effects of such diets across diverse settings. Strong collaboration among stakeholders and ongoing innovation in public health and food systems will be key to building a healthier, more sustainable future.

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