Sugar substitutes don’t raise your blood sugar or cause tooth decay the way sugar (sucrose) does, but that may be the extent of their health benefits.

Health Impact.

Sugar substitutes are typically used to replace sucrose in processed foods. “The consumption of sugar-sweetened foods (and beverages in particular) has been consistently linked with increased risk for a number of disorders,” says Alice H. Lichtenstein, DSc, Gershoff Professor at the Friedman School and editor-in-chief of this newsletter, “including type 2 diabetes, coronary heart disease, hypertension, excess body weight, and possibly even frailty. Use of beverages and foods made with sugar substitutes, if successful in reducing the intake of added sugars, could result in health benefits. However, the jury is still out on how successful their use is in accomplishing this goal and what the health impact will be.”

Dental Health: It is generally accepted that replacing sucrose with sugar substitutes reduces the risk of developing cavities. Some data even indicate that the sugar alcohol xylitol in chewing gum may play an active role in cavity prevention.

Weight Loss: It’s difficult to determine if sugar substitutes help with weight loss. Long-term studies are lacking, but short term randomized controlled trials (which can establish cause and effect) have shown that providing beverages sweetened with sugar substitutes in place of those sweetened with sucrose has a beneficial effect on body weight. But in one trial, a beverage sweetened with the artificial sweetener sucralose was reported to increase food cravings more than a sugar-sweetened beverage, especially in women and people with obesity.

Some observational studies (in which researchers compared people’s reported food intake to their weight) have suggested that consumption of foods made with sugar substitutes may actually be associated with higher body weight. “However, these studies cannot determine whether the sugar substitutes themselves lead to excess weight gain or if individuals with overweight or obesity are just more likely to choose products containing sugar substitutes,” says Lichtenstein. “Additionally, if low-sugar or sugar-free products are added to a high calorie diet, rather than replacing sugar-containing products, weight loss will not occur.”

Diabetes: If cutting calories by using sugar substitutes does lead to weight loss, it could help treat or decrease the risk of developing type 2 diabetes. Additionally, sugar substitutes raise blood sugar levels much less than sucrose—if at all. The American Diabetes Association cautions that some research indicates even sugar substitutes may be associated with some rise in blood sugar. “Foods and beverages made with sugar substitutes are a better option than those with added sugar for people with diabetes,” says Richard Siegel, MD, co-director of the Diabetes and Lipid Center at Tufts Medical Center, “but I encourage my patients to focus on nutrient-dense foods, like fruits, vegetables, and nuts instead of low-calorie or low-sugar versions of cookies and candy.”

Even if foods made with sugar substitutes do have some health benefits when used in place of sugar-sweetened foods, Lichtenstein says it’s best to limit their intake anyway. “Foods containing these compounds are almost always ultraprocessed,” she says, “and we know dietary patterns high in ultraprocessed foods are associated with negative health outcomes.”

Safety Concerns.

There is a large body of research looking at potential health hazards from consuming sugar substitutes, but there has yet to be any conclusive proof of danger from any products currently on the market.

Plant-derived noncaloric sweeteners (sugar alcohols, stevia, monk fruit extracts, and allulose) fall under the U.S. Food and Drug Administration (FDA) category “Generally Recognized as Safe,” or GRAS. This means experts have concluded that the substance is safe under the conditions of its intended use in the quantities typically consumed.

Artificial sweeteners (synthetic, or man-made, compounds) are regulated as food additivies and must meet a higher standard of proof of safety. The FDA establishes an acceptable daily intake (ADI) level for all artificial sweetners. An ADI is the amount of a substance that is considered safe to consume each day over the course of a person’s lifetime. Artificial sweeteners are 200 to 20,000 times sweeter than sucrose, so very little is needed to make foods taste sweet. Even people who consume a lot of these man-made sweeteners are unlikely to exceed the ADIs.

Cardiovascular Disease: Recent studies involving participants in the U.S. and Europe found that high blood levels of the sugar alcohols erythritol and xylitol were associated with increased risk of heart attack and stroke, but these findings need confirmation. At this time, there are no established links between sugar substitutes and cardiovascular disease.

Cancer: Federal legislation prohibits the approval of any compound established to cause cancer. Overall, the results of the large number of studies looking for a link between sugar substitutes and cancer have been inconsistent. A 2023 review that looked at all available data concluded that evidence associating artificially sweetened beverage intake with cancer was weak. An observational study published in 2022 found the highest reported intake of artificial sweeteners was associated with a small increase in cancer risk compared to the lowest reported intake. While there is limited evidence (not convincing) that aspartame may increase cancer risk, experts agree this artificial sweetener is likely safe at the levels at which it is typically consumed.

Looking at the body of research to date, sugar substitutes (in reasonable quantities) appear to be a safe alternative to added sugars, and may reduce tooth decay and help manage blood sugar levels—but the truly healthy choice is to cut back on ultraprocessed sweet foods. Drinking mostly water and getting one’s sweet fix from nutrient packed fruits is truly a “sweet” choice.

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Troubling Shortfall

The research, led by a team from the University of Michigan Health Frankel Cardiovascular Center, tracked nearly 150,000 people who were seen at hospitals for serious heart conditions (including heart attack and heart failure) between late 2015 and early 2020. The analysis (Journal of the Academy of Nutrition and Dietetics, July) showed that clinicians documented providing dietary counseling in just 23 percent of cases within 90 days of hospitalization. Women, adults ages 65 and older, and people with chronic kidney disease were least likely to receive counseling.

Getting Help

Nutrition counseling is included in cardiac rehabilitation programs, and also can be obtained via a separate kind of care called medical nutrition therapy. “Cardiac rehabilitation programs counsel participants on diet, exercise and behavior modifications, with the aim of improving health outcomes in people with cardiovascular disease,” Dr. Darrow says. “These programs have been shown to boost physical function and reduce the risk of hospitalization and death for older adults with heart failure.” Medicare Part B covers cardiac rehabilitation for enrollees who have had a heart attack in the previous 12 months and those who have stable angina (chest pain caused by blocked heart arteries) or chronic heart failure. People who have undergone cerain heart procedures also are covered—the Medicare website has details (www.cms.gov). “Medical nutrition therapy involves working with a registered dietitian to build an eating plan tailored to your individual health needs,” Dr. Darrow says. The therapy is covered by Medicare Part B for certain individuals (check at the Medicare website). You need a doctor’s referral to utilize the program.

Eating to Support Heart Health

Dr. Darrow provides nutrition guidance to his patients just in case they are not able to attend a cardiac rehabilitation program or get medical nutrition therapy. He recommends people who have cardiovascular disease or have suffered a heart-related event follow an eating plan that is low in sodium and fat, such as the Mediterranean diet (see our chart) or DASH (Dietary Approaches to Stop Hypertension) diet. “Both diets are high in fruits, vegetables, whole grains and healthy fats, and limit the saturated fats that can contribute to elevated blood pressure and cholesterol,” he says. “They also permit enough of what you enjoy that it doesn’t feel like you are depriving yourself at every meal.”

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Common Shortfall Nutrients. The U.S. Dietary Guidelines identify several nutrients that are often lacking in the average diet. These include:

Calcium: Vital for bone health and muscle function, calcium is often underconsumed, which can lead to osteoporosis and higher fracture risk.

Vitamin D: Essential for calcium absorption and bone health, vitamin D deficiency is widespread due to limited dietary sources and insufficient sunlight exposure. It plays a crucial role in immune function and inflammation reduction.

Potassium: This mineral helps regulate blood pressure and fluid balance. Most people do not consume enough potassium which can contribute to hypertension and cardiovascular issues.

Fiber: Dietary fiber is often lacking in diets dominated by processed foods. Adequate fiber intake supports healthy bowel movements and can help manage cholesterol and blood sugar levels.

Iron: Essential for producing hemoglobin and red blood cells, iron deficiency can lead to anemia, fatigue, and impaired cognitive function.

Next Steps. To help meet the recommended intake of these nutrients, consider the following ideas:

Diversify Your Diet: Consume a variety of fruits, vegetables, whole grains, lean proteins, and dairy or alternatives to ensure a broad intake of nutrients.

Focus on Nutrient-Rich Foods: Choose foods that are naturally high in shortfall nutrients. For example, opt for leafy greens, nuts, and seeds for calcium and vitamin D, and include bananas or potatoes for potassium.

Consider Supplements: Supplements may help meet nutritional needs. Consult with a healthcare professional before starting any new supplement.

The Bottom Line. Understanding and addressing shortfall nutrients is key to preventing deficiencies and supporting long-term health. Aim for a balanced and varied diet to help ensure that your body gets the nutrients it needs.

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What is a Low Carbon Diet? A low carbon diet focuses on reducing the carbon dioxide (CO2) emissions associated with the production, transportation, and consumption of food. Food production is a significant contributor to greenhouse gas emissions, with agriculture alone accounting for about 10 percent of total emissions in the U.S. A low carbon diet aims to lower these emissions by choosing foods that have a smaller environmental impact.

Key Components of a Low Carbon Diet:

Plant-Based Foods. These are generally less resource-intensive to produce than animal-based foods. Fruits, vegetables, grains, nuts, and seeds typically have lower carbon footprints.

Local and Seasonal Foods. Foods grown locally and in season require less transportation and energy for storage, thus reducing emissions.

Minimized Food Waste. Reducing food waste can significantly decrease the carbon footprint associated with food disposal and production.

Sustainable Farming Practices. Supporting organic and sustainably farmed products can lower the environmental impact of food production.

Benefits of a Low Carbon Diet

Environmental Impact. Adopting a low carbon diet can substantially reduce your personal carbon footprint. According to a study published in Environmental Research Letters, shifting to a plant-based diet can reduce food-related greenhouse gas emissions by up to 73 percent per person. This reduction helps mitigate climate change and its associated impacts.

Health Benefits. A low carbon diet often aligns with dietary recommendations for health. Plant-based diets are linked to lower risks of heart disease, hypertension, diabetes, and certain cancers. Emphasizing fruits, vegetables, and whole grains can improve overall health and longevity.

Economic Savings. By focusing on seasonal and locally produced foods, you can often save on grocery bills. Additionally, reducing food waste means you get more value, as less food ends up in the trash.

Supporting Biodiversity. Choosing foods from sustainable sources helps protect ecosystems and supports biodiversity. Sustainable farming practices preserve soil health and protect natural habitats, supporting a healthier planet.

How to Follow a Low Carbon Diet

1.Increase Plant-Based Meals. One of the most effective ways to reduce your carbon footprint is by eating more plant-based meals. This doesn’t mean you have to become vegetarian or vegan overnight. Start by incorporating a few meatless meals each week, focusing on legumes, grains, and vegetables.

Try it! Prepare a vegetable stir-fry with tofu or a hearty lentil soup as alternatives to meat-based dishes.

2. Choose Local and Seasonal Foods. Shopping at local farmers’ markets or joining a community-supported agriculture (CSA) program ensures that you’re consuming foods with a lower carbon footprint. These options reduce the distance food travels and support local farmers.

Try it! In the summer, enjoy fresh tomatoes, cucumbers, and berries from nearby farms instead of imported produce.

3.Minimize Food Waste. Plan your meals to use all the ingredients you purchase. Store foods properly to extend their shelf life, and consider composting food scraps to reduce waste.

Try it! Keep a list of meals for the week to avoid overbuying and use leftovers creatively, like turning roasted vegetables into a soup.

4.Opt for Sustainable Seafood. If you consume seafood, choose options that are sustainably sourced. Look for certifications like the Marine Stewardship Council (MSC) label, which ensures that the fish was caught responsibly.

Try it! Enjoy sardines or mussels, which generally have lower carbon footprints than larger fish or shrimp.

5. Reduce Processed Foods. Processed and packaged foods often require more energy for production and packaging, leading to higher emissions. Focus on whole foods that require minimal processing.

Try it! Choose whole oats over instant oatmeal packets and fresh fruit over fruit-flavored snacks.

6. Grow Your Own Food. If possible, consider growing your own vegetables and herbs. This not only reduces your carbon footprint but also provides fresh produce at your fingertips.

Try it! Start with easy-to-grow plants like tomatoes, herbs, and leafy greens in your backyard or on a balcony.

7. Be Mindful of Packaging. Reduce your use of single-use plastics and packaging by buying in bulk and using reusable bags and containers.

Try it! Bring your own bags to the grocery store and choose bulk bins for grains and nuts.

The Bottom Line. A low carbon diet offers a simple way to support a healthier environment while also reaping personal health benefits. By focusing on plant-based foods, choosing local and seasonal produce, minimizing food waste, and supporting sustainable practices, you can make a significant impact. Small changes in eating habits can lead to a healthier planet and a healthier you. Adopting a low carbon diet is not only a personal choice but also a step toward global responsibility.

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According to the American Heart Association, women should have no more than six teaspoons of added sugar a day and men no more than nine teaspoons (which is equal to about 100 calories for women, or 150 calories for men). Many people are blowing past these numbers, and that is concerning. A 2023 review of 73 meta-analyses, published in The BMJ, found that a diet high in added sugar was linked to 45 poor health outcomes, including diabetes, cancer, gout, hypertension, cardiovascular disease, asthma, and depression. “In essence, added sugar contributes “empty energy” or calories without the benefits of key nutrients like fiber, protein, or vitamins,” says Debbie Petitpain, MBA, RDN, spokesperson for the Academy of Nutrition and Dietetics.

The good news is you can make a few simple changes to the way you eat to decrease (not eliminate!) your added sugar intake. Here’s how to cut back on the sweet stuff without feeling deprived.

Read the Fine Print. Now that the Nutrition Facts panel on packaged foods requires producers to list the grams of added sugar in their products, it is easier than ever to spot how much is being steathfully added to everything from granola to ketchup to jerky. Petitpain says this lets you compare the nutrition numbers on products so you can choose those with fewer grams of added sugar. Another good move is to look for labels such as “no added sugar” or “unsweetened” on items like almond milk and applesauce.

Natural Selection. To help quell a sweet tooth, try eating more foods that are naturally sweet. Sugars in vegetables, like beets or sweet potatoes, and fruit, such as apples don’t count as added sugars, and research is bereft of any data linking natural occurring sugars with health woes. “Naturally occurring sugars in vegetables, fruits, and dairy are part of a complex food matrix which alters how the body digests, breaks down, and uses these sugars, which changes the effects on the body,” notes Petitpain. “There also tends to be a lot less sugar, bite for bite, compared to foods with added sugars.” So buy plain versions of items like yogurt and oatmeal and sweeten them with naturally sweet foods such as berries.

Make the Cut. If you are keen on baking, keep in mind that many recipes including those for muffins and cakes call for more sugar than what is necessary. So, you can try reducing the amount of sweetener called for by about 25 percent. Petitpain suggests including sweet tasting items like mashed banana, dates, and applesauce in your baking in place of some of the added sugar.

Embrace Other Tastes. Sweet is one of the five main tastes, with others being salty, sour, bitter, and umami. To reboot your taste buds, gradually increase your intake of unsweetened sour (such as plain yogurt or tart cherries), bitter (like arugula and radicchio), and umami (such as parmesan and mushrooms) foods. As a payoff, you’ll net more nutrients.

Be Wary of Free. Be especially skeptical of products like peanut butter, frozen yogurt, and salad dressings advertised as “reduced-fat” or “fat-free,” “When fat is removed from a product, sugar is usually added as a replacement to improve mouthfeel and flavor” Petitpain says. A serving of fat-free, fruit-flavored yogurt typically has three times as much sugar as a serving of two percent plain yogurt.

Spice it Up. Research suggests amping up the flavor of your cuisine with spices may allow you to cut back on the amount of sugar added to foods while still preserving acceptable overall liking. So, go bigger on spices like cinnamon and nutmeg in items like baked goods, oatmeal, and hot chocolate.

Don’t Fall for Health Halos. Sugar now comes in many guises, some of which, such as honey and maple syrup, are marketed as being better-for-you “more natural” ways to get your sweet fix. But for the most part, they don’t live up to their hype. “While they may offer extremely minimal nutritional benefits over refined sugar, they should still be consumed in moderation,” says Petitpain. No matter how virtuous it might sound, “organic sugar” is still sugar.

Walk Away from Cravings. The next time you’re about to give into candy bar temptation, lace up your running shoes. Research shows the simple act of taking a 15-minute brisk walk is enough to tame cravings for sugary snack foods. “Exercise releases endorphins and can improve mood and reduce stress, which are common triggers for sugar cravings,” notes Petitpain.

Order Water. Soft drinks, even the smallest sized ones, sold at top-earning restaurant chains in the U.S., have greater amounts of added sugar than the suggested daily limit, according to a report from the Center for Science in the Public Interest. When dining out, look for unsweetened beverage options. Many chain restaurants now have added sugar numbers for their foods and drinks listed on their websites, making it easier to tailor your order so it’s less sweet.

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In this Q&A, Dana Hunnes, RD, MPH, PhD, Senior Dietitian Supervisor, UCLA Medical Center, provides insights on dietary choices that can help us potentially live longer and also live better.

What does the phrase “food is medicine” mean?

“This phrase means that what we eat has the ability to protect our health, as medicine can,” explains Hunnes. “When we use food to protect our health, we are eating in a way that lowers our risk for chronic conditions. Or if we already have chronic conditions, eating healthfully may help manage them or control them better. If we are fortunate, a heathy diet can possibly reverse them.”

For example, research published in the Journal of Clinical Endocrinology & Metabolism found that study participants who followed an intermittent fasting regimen achieved complete diabetes remission, defined as maintaining an HbA1c level of less than 6.5% for at least a year without diabetes medication.

Why is eating whole foods so beneficial?

“There are many nutrients in whole foods that work synergistically with each other that make the “whole” greater than the sum of its parts,” says Hunnes. “By that I mean, we reap so many more benefits from eating a whole raspberry with all of its fiber and seeds. We gain more antioxidants, anthocyanins, micronutrients, and other anti-inflammatory compounds than we can ever get from eating one isolated nutrient extracted from said raspberry. When we eat ultra-processed foods or isolated nutrients, we are not getting that synergy. We are only getting single nutrients that likely don’t have the same effects.”

A good example of this is taking fish oil supplements for heart health. Numerous studies have shown that fish oil supplementation makes little to no difference in reducing the risk for heart attacks and stroke. But eating fish high in omega-3 fats may reduce risk of heart disease.

Why the  buzz around adhering to a mostly plant-based diet?

“Whole plant foods are filling, lower in calories, nutrient dense, and are associated with lower risk for disease and disability. That doesn’t mean no risk. It just means reduced risk,” she explains. “Plants have naturally occurring compounds that protect them against disease and pests which are also healthful to humans. For example, there are bitter compounds in sulphorphane vegetables (e.g., broccoli, Brussels sprouts, cauliflower) that protect them against pests, but are extremely anti-inflammatory and healthful to humans. Fiber also helps clean out the toxins from our digestive tracts, which is good. We don’t want to keep too much waste in our digestive tracts for long periods of time.”

Though eating these veggies raw provides the most nutrients, not everyone enjoys them raw. Steaming for a minute or two, lightly sautéing or even blanching helps maintain nutrients. Definitely avoid boiling because that method destroys valuable nutrients.

Can foods replace medicines and even cure diseases?

“While I’ve heard of these so-called miracles, they are relatively few and far between,” says Hunnes. “Certain chronic conditions such as diabetes or heart disease can be relieved, reduced, and possibly even reversed (sort-of like cured) by an extremely healthy diet. Other diseases, such as certain types of cancer, far less so, though (again) not impossible. With that said, it’s much easier to decrease the risk of ever developing these diseases, which are food/diet associated, than it is to try to correct/treat them after you have them. Healthy diet is always to our benefit.”

What are some simple ways to incorporate heathy foods daily?

“For easy snacks, keep sliced jicama, carrots, bell peppers, or other favorite veggies with hummus or pureed beans in the fridge,” she suggests. “For sweet treats, make your own trail mix of dried fruits and nuts, or enjoy fresh fruit such as blueberries, raspberries, or other blackberries with walnuts or almonds.”

Another strategy Hunnes suggests is to have a variety of whole and minimally processed foods in your kitchen. Also, be sure to stock canned and frozen healthy foods to ensure that you always have nutrient-rich foods available, regardless of the season. Leave the ultra-processed foods at the store and make rich desserts something you go out for as a special treat. 

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Among those who don’t have their high blood pressure (hyperten­sion) under control, many simply don’t know they have hypertension or, if they do, aren’t getting treat­ment or taking any steps on their own to bring their blood pressure into a healthy range.

Then there are individuals who have a condition known as treat­ment-resistant hypertension. Research suggests that about 20 per­cent of people with high blood pres­sure have treatment-resistant hyper­tension, which means their blood pressure is higher than normal even though they are taking at least three different antihypertensive medica­tions (taken at the maximum recom­mended doses), one of which is a diuretic. Other commonly pre­scribed blood pressure-lowering drugs that may be used include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and cal­cium channel blockers. Another class of medications, known as aldos­terone antagonists—typically spironolactone (Adactone) or eplerenone (Inspire)—are also often among medications used to treat resistant hypertension.

In March 2024, the Food and Drug Administration (FDA) approved aprocitentan (Tryvio), the first endothelial-receptor agonist specifically meant for people with treatment-resistant hypertension. “It’s a completely new class of drug, so it offers us an opportunity that we haven’t had until very recently,” says Randy Zusman, MD, director of the Division of Hypertension at Massa­chusetts General Hospital.

He adds that the options for physi­cians and their patients with treat­ment-resistant hypertension continue to grow. In 2023, the FDA approved a procedure called renal denervation for treatment-resistant hypertension. The procedure involves the use of radiofrequency (heat) energy or ultra­sound to destroy certain nerves in the kidneys that affect the function of the renal arteries, which deliver blood to the kidneys. The reduced nerve activ­ity can help lower blood pressure.

Dr. Zusman adds that an experi­mental antihypertensive drug that is injected once or twice a year is show­ing promise, though much more research is needed to determine who would be best served by the drug and how to deal with safety concerns, such as a sudden drop in blood pressure.

Medication Management

While it’s certainly helpful to have additional options to help people get their high blood pressure under con­trol, Dr. Zusman notes that managing treatment-resistant hypertension is much more than finding the right mix of meds. He says that a big prob­lem is non-compliance—individuals who don’t take their medications as recommended or stop taking their medications because they finally got a good blood pressure reading or they don’t like the side effects. Of course, stopping the medications that helped lower your blood pressure—without first consulting your health­care provider—means your blood pressure is likely to rise again.

For others who have been diag­nosed with treatment-resistant hypertension, the problem may be that they aren’t yet taking the right combination of medications at the right doses and at the right times during the day.

He also explains that many indi­viduals, especially older adults, may have other health conditions that make it more difficult to get their blood pressure under control. For example, they may take other medi­cations that drive up blood pressure. Over-the-counter drugs, such as cer­tain cold medications and nons­teroidal anti-inflammatory drugs, such as ibuprofen (Advil) and naproxen (Aleve), may interfere with antihypertensive medications.

You may find that taking an alter­native painkiller or cold medicine, for example, will provide symptom relief without interfering with your antihypertensive regimen. It’s impor­tant to talk with your health-care provider about all the medications you take—over-the-counter and pre­scription drugs—as well as any sup­plements. Don’t assume that dietary or herbal supplements labeled “natu­ral” are necessarily harmless or even especially helpful.

Diet, Exercise, and Much More Even the most effective medication management can only go so far. Dr. Zusman explains that obesity, a high­salt diet, a sedentary lifestyle, smoking, and other unhealthy behaviors can conspire to keep your blood pressure elevated along with your risk for stroke, cardiovascular disease, and other health problems.

“Controlling treatment-resistant hypertension involves lifestyle mod­ifications and medications,” Dr. Zusman says, acknowledging that breaking long-held eating habits can be difficult for some people. Like­wise, getting up and moving more can be a challenge for individuals who have settled into a fairly seden­tary lifestyle.

Research suggests that even small changes can make a big difference. The AHA recommends 150 minutes a week of moderate-intensity aero­bic activity, such as brisk walking, swimming, cycling, or tennis. That works out to about 30 to 40 minutes a day, most days of the week. You can even break those daily workouts into shorter bursts of exercise if that helps.

The AHA also suggests that losing just 10 pounds can lead to notice­able improvements in your blood pressure. Some studies have found that some people may see a drop of 1 millimeter of mercury (mm Hg) in their systolic blood pressure (the top number in a blood pressure reading) for every two pounds of lost weight.

What You Can Do

Dr. Zusman recommends getting reliable blood pressure checks peri­odically to know whether your treat­ment is working and to spot con­cerning changes in your blood pres­sure as early as possible. “This is especially important for people with a family history of hypertension or cardiovascular disease,” he says.

Talk with your doctor about using a home blood pressure monitor. The

more proactive you can be and con­sistently follow your doctor’s advice about medications and lifestyle changes, the more likely you may be to move from treatment-resistant hypertension to well-managed hypertension.

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Plant-Based.

A plant-based dietary pattern can avoid all animal products—or not. Here are some common terms:

➧ Flexitarian: includes eggs, dairy foods, and occasionally meat, poultry, fish, and seafood.

➧ Pescetarian: includes eggs, dairy foods, fish, and shellfish, but no meat or poultry.

➧ Vegetarian: (sometimes referred to as lacto-ovo vegetarian) includes eggs and dairy foods, but no meat, poultry, fish, or seafood.

➧ Vegan: excludes all animal products, including dairy, eggs, and honey. If you plan to follow a strict vegan diet, let your healthcare provider know. You may need to be checked periodically to make sure you’re getting enough iron and vitamin B12.

Research clearly associates vegetarian and vegan dietary patterns with multiple health benefits. For example, a review of research found that long term consumption of these dietary patterns was significantly associated with better blood sugar control, more desirable body weight, lower levels of inflammation, and more favorable levels of cholesterol and triglycerides, which likely contributed to lower risk for ischemic heart disease (hardening of the arteries) and cancer.

If a plant-only diet is not for you, try thinking in terms of “plant-forward” eating: focus on foods from plants first, and animal products second. Nonfat and low-fat dairy, fish and shellfish, and eggs are excellent options to bring to the table. Small portions of poultry and lean, unprocessed meat can fit into plant-forward eating as well.

There’s a lot of research supporting the association between plant-forward dietary patterns and better health. In fact, the two most-studied diets for cardiovascular health—the Mediterranean-style dietary pattern and Dietary Approaches to Stop Hypertension (DASH)—are both plant forward diets that are not animal food-free, as is the EAT-Lancet Planetary Health Diet (see NewsBites).

Be aware that plant-based and plant forward dietary patterns are only good for health if they don’t include a lot of ultraprocessed plant-based foods. A study that analyzed the reported dietary intake of over 126,000 participants found that consuming a plant-based dietary pattern built on whole or minimally processed plant foods (whole grains, fruits, vegetables, nuts, legumes, tea, and coffee) was associated with lower risk of death, cancer, and cardiovascular disease (CVD), but, an unhealthy plant based dietary pattern built on ultraprocessed foods (including refined grains, potato products, sugary drinks, fruit juices, sweets, and desserts) was associated with higher risk. Plant-based “meats,” “cheeses,” and many “milks” are ultraprocessed, as are protein bars and powders.

Introducing…Plants.

If you’d like to increase your intake of plant foods but aren’t too familiar with plant-based cooking, it’s fine to start slowly. Consider if any of these ideas might work for you:

• Make one day a week plant-only. Work up to one meal a day. (If you already eat one plant-only meal, move up to two.)

• Think of meat as a side or garnish, rather than the main event. (Instead of “I have this animal protein, which starch and veggie sides should I have with it,” think, “I have these veggies and whole grains, what healthy protein (animal or plant) should I have with them?”

• Eat beans and lentils in place of some of the animal protein on your plate more often (see Make Room for Legumes for suggestions). If you typically eat large portions of meat or poultry (larger than a deck of cards), you can replace some of that protein with vegetables and/or whole grains.

• Try one new plant-based recipe a week until you have a set of recipes you like.

• Make simple swaps that increase fruit and veggie intake, like a piece of fruit for a bag of chips; plain popcorn in place of pretzels; nuts and seeds instead of croutons; barley instead of white rice; or fresh fruit with plain yogurt instead of sweetened, colored yogurt options.

• For a month or two, bring home one new veggie or fruit to try each time you shop. The internet is a great source for ways to tell when an unfamiliar type of produce is ripe and how to use it.

• Sample different whole grains. Move away from white rice, potatoes, and refined pasta. Brown rice and whole wheat pasta are a start, but the whole grains listed in “Great Grains” are also excellent options, and they’re just as easy to cook as rice (see “Cooking Grains”).

• Check out vegetarian or vegan recipe books or look for online ideas, recipes, blogs, and “how to” videos.

• Cook with tofu and tempeh in place of meat or cheese.

• Switch from butter and other animal fats to non-tropical plant-based oils.

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As health and nutrition experts have been saying all along, it’s always best to stick with whole foods (like vegetables, nuts, fruits, etc.) and eschew most items with lengthy, hard-to-pronounce ingredient lists. “We’ve shown that increased intake over time of ultra-processed foods can impact the two most common and significant causes of neurologi­cal disability—stroke and cognitive impairment. The good news is that even modest cutbacks in consump­tion of UPFs are associated with meaningful brain health benefits,” says the study’s senior author, W. Taylor Kimberly, MD, PhD, chief of the Division of Neurocritical Care at Massachusetts General Hospital (MGH).

Processed vs. Ultra-Processed

Processed foods have long been considered dietary no-no’s, items that may be tasty and convenient, but shouldn’t be taking the place of healthier whole foods at mealtime or snack time. But in recent years, nutrition experts have been sounding the alarm regarding ultra­processed foods, which may have you asking: “What’s the difference?”

In simple terms, processed foods are those that have undergone some type of change from their natural state. The change could be minimal, leaving the food’s nutritional value intact. Think frozen vegetables. But processed foods also may contain other ingredients that may raise some health concerns. Think canned vegetables preserved with hundreds of milligrams of sodium.

Ultra-processed foods, as you might imagine, include products that are a long way from their natural state. Ultra­processed foods are often made up of substances extracted from whole foods or derived from food constituents, leaving little actual whole food intact. Examples of ultra-processed foods include soda, hot dogs, cookies, and most boxed or bagged snack foods and sweets.

“It’s important for individuals to pay attention to not just what foods they eat, but how those foods are processedbefore they eat them,” Dr. Kimberly says. Ultra-processed foods often contain fats, starches, sugars, salts, and hydrogenated oils to boost their flavor and extend their shelf-life. Over time, however, these added ingredients may not be doing the same for your own life. In many cases, the more ingredients a product has, especially if those ingredi­ents are chemicals and preservatives, the more likely it is to fall into the ultra-­processed category.

PFs and the Brain

Numerous studies in recent years have established a strong associa­tion between the consumption of ultra-processed foods and increased risks of conditions such as cardiovascular disease, diabetes, obesity, and even cancer.

In the MGH study, researchers analyzed 10 years worth of data from REGARDS, a stroke research project based at the University of Alabama Birmingham (UAB) School of Public Health and involving more than 30,000 adults. Researchers found that increased consumption of UPFs was associ­ated with a 9 percent increased risk of stroke and a 12 percent increased risk of accelerated cogni­tive decline. The study findings, published recently in the journal Neurology, also suggest that the association between UPFs and stroke is stronger among Black adults, possibly because of the higher incidence of hypertension in that population.

Researchers also looked at how specific diets, such as the Mediterranean, DASH (Dietary Approaches to Stop Hypertension) and MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) might affect stroke and cognitive decline risk. Those diets emphasize vegetables, fresh fruits, whole grains, lean proteins, and healthy fats (such as olive oil), while minimizing red and processed meats, and foods with added sugars and unhealthy fats.

Study authors found those diets were independently associated with reduced risk of stroke and cognitive decline. The findings also suggest that the degree of food pro­cessing plays a key role in overall brain health and function. They also underscore the degree to which other dietary patterns doc­tors often recommend, such as Mediterranean, DASH and MIND eschew ultra-processed foods and include only processed foods that are still rich in health benefits.

Next Steps

Researchers at MGH and UAB say it’s now important to learn more about the biological mechanisms that link UPFs to poorer brain health and to better understand the role of the gut microbiome in metabolizing the foods we eat. Dr. Kimberly explains that such research could lead to the discovery of biomarkers in the blood that measure UPF intake, which could then be used to develop personalized medicine plans to help individuals decide ifmchanging their diet could help them improve their brain health or at least reduce the risk of cognitive decline or stroke.

“While our study clearly sounds a warning, it also provides hope that there are things we can do as individuals and which policymakers can do on a national scale to reduce UPFs from our daily diets,” Dr. Kimberly says. “As we found, even incremental changes are associated with a significant difference in improving our brain health, along with lowering our risk for stroke and cognitive decline.”

Health experts often recommend making slow, small dietary changes in order to establish a healthy eating pattern that will stick. To that end, opt for a small bowl of berries for dessert instead of cookies or other sweets. Try sparkling water instead of soda and raw vegetables with hummus instead of chips or crackers. Aim for making one or two changes a week, rather than trying to overhaul your diet in a day.

The next time you go shopping, take a moment before buying ultra­processed products and think about healthier alternatives. And if the idea of making major dietary changes seems overwhelming on your own, talk with your doctor about prescribing the services of a registered dietitian to help you plan meals and snacks.

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