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It is time to stop counting calories, and time instead to promote dietary changes that substantially and rapidly reduce cardiovascular morbidity and mortality
  1. Aseem Malhotra1,2,
  2. James J DiNicolantonio3 and
  3. Simon Capewell4
  1. 1Department of Cardiology, Frimley Park Hospital, Surrey, UK
  2. 2Consultant Clinical Associate to the Academy of Medical Royal Colleges, London, UK
  3. 3Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
  4. 4Professor of Clinical Epidemiology, University of Liverpool, Liverpool, UK
  1. Correspondence to Dr Aseem Malhotra; aseem_malhotra{at}

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Most heart attacks and ischaemic strokes are caused by complicated atheroma usually compounded by thrombosis suddenly reducing blood flow in a critical artery. Extensive evidence suggests that this atheroma silently builds up over many decades. However, arterial stiffening can be seen even in children who are obese, and aortic fatty streaks are visible in some teenagers and young adults.1 Yet, most cardiovascular events do not manifest until after the age of 60 years. The general perception is thus of a slow process that will therefore only reverse slowly, if at all. However, this perception is wrong. Extensive empirical and trial evidence reveals that substantial reductions in mortality can occur within months of quitting smoking, or making healthy dietary changes. These reductions apply to both individuals and to entire populations. In one American hospital, admissions for acute coronary syndromes decreased by 40% within 6 months of the introduction of local smoke free legislation.2 When the law was rescinded, coronary admissions rapidly returned to previous levels. The introduction of smoke-free legislation in Scotland in 2006 was soon followed by a 6% decrease in out of hospital cardiac deaths and a 17% decrease in hospital admissions within a year.3 Even 30 min of secondhand smoke exposure has been proven to increase platelet activity and hence elevate cardiovascular risk.4

Similarly, changes in diet can rapidly improve outcomes of cardiovascular disease (CVD), as demonstrated by several randomised trials. In the DART trial, 2033 survivors of myocardial infarction who were advised to eat fatty fish had a significant 29% reduction in all-cause mortality compared with control patients, with survival curves separating within months. Likewise, in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarcto Miocardico (GISSI)-Prevention trial, 1 g of Ω-3 fatty acids significantly reduced all-cause mortality and cardiovascular mortality in 11 324 myocardial infarction survivors. Moreover, …

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  • Twitter Follow Aseem Malhotra at @DrAseemMalhotra

  • Contributors AM and SC wrote the initial draft and JJD helped revise the arguments, wrote parts of the paper and included several additional references.

  • Funding JJD works for a company that sells nutriceuticals, but he is not involved in the selling or marketing of these products. SC is a non-trustee for the UK Faculty of Public Health, The UK Health Forum and Heart of Mersey.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.