The health benefits of nuts and seeds

By Isabelle Sadler, PBHP UK Research Assistant and MSc Nutrition Student

Nuts and seeds are a fundamental part of a plant-based diet, providing a rich source of protein, unsaturated fats and several micronutrients. They’re also a great way to increase fibre intake, which is associated with a decreased incidence in mortality from several common chronic diseases.

There is growing evidence for the beneficial and protective effects of consuming nuts and seeds regularly, especially for cardiovascular health. Studies have demonstrated that eating a handful of nuts at least 5 days a week can increase lifespan by around 2 years. However, there is a global underconsumption of nuts, and this food group represents one of the largest gaps between recommended intake and current consumption levels. Not eating enough nuts and seeds is also one of the leading dietary risk factors for disease burden globally.

Nuts and seeds in healthy dietary patterns

Various dietary patterns have been developed to promote good health, such as the Planetary Health, Mediterranean, Portfolio, Dietary Approaches to Stop Hypertension (DASH), and Whole-Food Plant-Based (WFPB) dietary patterns. These diets share several core, healthy components, one of these being nuts and seeds!

The Portfolio diet is a plant-based eating pattern that is designed to lower cholesterol. It includes nuts and seeds as one of several cholesterol lowering foods, alongside plant protein, viscous fibre sources, phytosterols, and plant unsaturated fat sources. A higher plant-based Portfolio Diet Score has been associated with a 14% lower risk of cardiovascular disease, coronary heart disease, and stroke in 3 prospective cohort studies, as well as a more favourable blood lipid and inflammatory profile.

Similarly, regular nut consumption is a key component of the Mediterranean-style dietary pattern. In a randomised trial in people with raised cardiovascular disease risk, a Mediterranean diet with added nuts, compared to control diet, reduced the risk of cardiovascular disease, type 2 diabetes, cognitive decline, and other adverse health outcomes.

The EAT-Lancet Commission Planetary Health Diet also recommends consuming 50g of nuts per day (tree nuts and peanuts). In a systematic review and meta analysis including a total of over 2.21 million participants, this dietary pattern was associated with a significantly reduced odds of diabetes, CVD, cancer and mortality.

Cardiovascular health

Some of the strongest evidence for the health benefits of nuts and seeds is related to a reduced risk of cardiovascular disease and its risk factors.

In a systematic review and meta-analysis, consuming the high versus lowest quantity of nuts and seeds was associated with a reduced risk of cardiovascular disease, cardiovascular mortality, coronary heart disease, and coronary heart disease mortality. A smaller, but still relevant, risk reduction was also seen for stroke.

The reduction in risk of cardiovascular disease could, in part, be due to the impact that consuming nuts and seeds can have on blood lipids. In the same meta-analysis as above, intake of nuts (median ~50 g/day) lowered total cholesterol by 0.15 mmol/L and LDL-cholesterol by 0.13 mmol/L. These findings are supported by a comprehensive review of the literature, which studied 19 systematic reviews and meta-analyses of randomised controlled trials. Across the trials, there was a consistent beneficial effect of total nuts and tree nuts, including walnuts, almonds, cashews, peanuts, and pistachios, for decreasing total cholesterol by 0.09 to 0.28 mmol/L, LDL-cholesterol by 0.09 to 0.26 mmol/L, and triglycerides by 0.05 to 0.17 mmol/L. One of the included reviews also examined the effect of nuts on apolipoproteins and found a significant reduction in apolipoprotein B of 0.042 g/L, across 13 trials.

Nuts and seeds can also lower the risk of high blood pressure, a leading driver of cardiovascular disease. Flaxseeds are particularly notable for their blood pressure lowering effect, with an effect size worthy of use in people with hypertension.

Why are nuts and seeds so good for us?

Nuts and seeds are a rich source of monounsaturated and polyunsaturated fats, as well as plant protein, dietary fibre, phytosterols and polyphenols. Individually, these nutrients are beneficial for health and may, for example, have modest cholesterol-lowering effects. However, when they are combined within the natural matrix of a nut or seed, their effects appear to be even greater, contributing to the reductions in LDL-cholesterol observed in studies of regular nut consumption.

We know that the favourable fatty acid profile of nuts contributes to improvements in blood lipids, particularly when nuts replace foods high in saturated fat. Evidence has also demonstrated that phytosterols contribute to the cholesterol-lowering effects of nuts and seeds. Phytosterols interfere with cholesterol absorption in the intestinal lumen, helping to lower blood cholesterol levels. The phytosterol content of nuts varies, with pistachios, almonds, and walnuts containing some of the highest amounts.

Nuts and seeds also provide important micronutrients, including magnesium, zinc, iron, calcium, copper, phosphorus, potassium, selenium, vitamin E, and B vitamins. Together, these nutrients support several aspects of health, including cardiovascular function, immune health, bone health, and protection against oxidative stress. Nuts also contain a relatively high amount of L-arginine, which has cardiovascular health benefits.

The array of healthy nutrients in nuts together with the fact that they are likely to be replacing less healthy foods in the diet results in reduced mortality from all causes and from cardiovascular diseases, cancer, respiratory diseases and infectious diseases.

Are nuts associated with weight gain?

Despite the mounting evidence for the health benefits of nuts, concerns persist that they may contribute to weight gain due to their high energy density. Nuts are known to have a high fat content, making up at least 40% of their total energy content, ranging from around 44% in pistachios and cashews to 76% in macadamia nuts.

This may be a barrier for increasing the consumption levels of nuts in line with healthy eating recommendations, as they are seen as more energy dense and more likely to contribute to weight gain compared to other healthy foods.

Despite this concern, robust evidence from a systematic review and meta-analysis suggests that the opposite might even be true. Across six cohort studies, nuts were associated with lower incidence of overweight/obesity and across 86 randomised controlled trials, researchers found no adverse effect of nuts on body weight.

There are a number of reasons why nuts are not associated with weight gain. The high protein and fibre content and the need for prolonged chewing may contribute to an increased feeling of fullness. Not all of the fat in nuts is absorbed and unsaturated fats may result in a greater thermogenic effect (the increase in the metabolic rate that occurs after eating a meal/food) than saturated fats.

Best nuts and seeds to include in a plant-based diet

All nuts and seeds can contribute to a healthy dietary pattern and provide a wide range of beneficial nutrients. Including a variety is likely to provide the greatest nutritional benefit, as different nuts and seeds contain different combinations of unsaturated fats, fibre, vitamins, minerals, and phytochemicals.

For individuals following a plant-based diet, flaxseeds, chia seeds, hemp seeds, and walnuts are particularly valuable additions due to their content of alpha-linolenic acid (ALA), an essential omega-3 fatty acid. ALA is essential because we must obtain it from our diet. Daily requirements of ALA can be met by eating a tablespoon of chia seeds or ground flaxseeds (linseeds), two tablespoons of hemp seeds or six walnut halves.

Sesame seeds and tahini provide a useful source of calcium and zinc, while pumpkin seeds are rich in iron and zinc. Brazil nuts are notable for their selenium content, with just two nuts often providing enough selenium to meet daily requirements, though content can vary depending on where they’re grown. Almonds and hazelnuts are rich in vitamin E, and pistachios and walnuts provide particularly high levels of phytosterols, which may contribute to cholesterol lowering.

Nut and sesame allergy

Tree nut and peanut allergies are among the most common food allergies and can range from mild to severe. Individuals with a diagnosed allergy should continue to avoid the foods they are allergic to and seek guidance from their healthcare professionals regarding safe food choices.

For information on introducing peanuts safely to infants and children, please refer to the factsheet on our website.

Allergy to sesame is also increasing and is one of the 14 allergens that are mandated to be listed on food products when present.

Top tips for incorporating nuts and seeds into the diet

• Enjoy a handful of your favourite nuts as a quick and delicious snack, choosing mostly unsalted and minimally processed nuts and seeds is recommended where possible.
• Making your own homemade trail mix using unsalted nuts, seeds, and dried fruit can be a simple way to have a ready-to-go snack
• Sprinkle nuts and seeds on top of soups, salads, stir-fries, oatmeal and cereal. For example, sesame seeds on stir fries and curries, pumpkin seeds on salads.
• Blend seeds such as flax, chia, or hemp into smoothies
• Use nut butters to top off a snack, such as peanut butter with apple slices, almond butter on whole grain toast, or a tahini sauce drizzled over roasted vegetables
• Incorporate nuts into savoury meals. For example, walnuts can be added to lentil bolognese, cashews can create creamy sauces, and mixed nuts can be used in nut roasts or veggie burgers.
• Use nuts and seeds such as pistachios and pine nuts to make homemade pestos, dips, and salad dressings
• Add nuts and seeds to home baking, such as breads, muffins, flapjacks, and granola, or experiment with nut flours in baking recipes

Benefits of a Plant-Based Diet

By Dr Shireen Kassam, Director of Plant-Based Health Professionals UK

A plant-based diet is one that focuses on the consumption of fruit, vegetables, whole grains, beans, nuts and seeds, whilst minimising or avoiding animal-derived and processed foods. There is no precise medical definition of a ‘plant-based diet’, and it includes vegan (100% plant-based), vegetarian and flexitarian diet patterns. Most people consider a plant-based diet one where at least 85% of calories are derived from plant foods. There are numerous benefits to this way of eating and it is healthy and safe to do so at all stages of life.

So, what are some of the expected benefits?

Maintaining a healthy weight

A healthy diet is the main way to maintain a healthy weight. A plant-based diet consists predominantly of foods which are lower in energy density, yet packed full of essential nutrients. People following a 100% plant-based or vegan diet tend to have an overall lower body mass index when compared to people following non-vegan dietary patterns.

One of the most important nutrients for maintaining a healthy weight is fibre and this is only found in plant foods. Fibre not only keeps you feeling full for longer, but it also promotes a healthy gut microbiome, which in turn positively impacts body weight.

On a plant-based diet, you can usually eat to fullness without overly worrying about portion control or calorie counting. You are also less likely to gain weight over time. This is certainly true when you concentrate on eating minimally processed plant foods, as close to nature as possible.

Reducing the risk of high blood pressure

High blood pressure or hypertension is a leading cause of illness, especially heart disease, a major cause of death in the UK. Yet for most people it is possible to maintain a normal blood pressure throughout life by adopting healthy lifestyle habits. These include regular physical activity, avoiding tobacco smoking and alcohol consumption, sleeping well and managing stress.

When it comes to diet, plant-based diets are best for maintaining a healthy blood pressure and can have a similar blood pressure lowering effect to medications. A vegan diet may have the greatest beneficial impact on blood pressure, in part due to the association with lower body weight.

There are certain foods and nutrients within a plant-based diet that stand out in their ability to reduce blood pressure. These include whole grains, legumes and nuts and seeds. Nitrate-rich vegetables, such as leafy greens and beetroot, including beetroot juice, dilate the blood vessels and reduce blood pressure. Flaxseed and hibiscus tea are also useful additions.

Minimising salt / sodium consumption is essential for maintaining a healthy blood pressure although it is worth noting that most salt in the diet comes from ultra-processed foods rather than the salt used in cooking or for flavouring. Increasing the intake of potassium by eating more fruit and vegetables benefits blood pressure control. For those trying to cut down on salt (sodium chloride), switching to potassium chloride salt, may be beneficial, although caution is required for people with chronic kidney disease and those taking medications that elevate blood potassium levels.

Reducing the risk of high cholesterol

As animal-sourced foods are progressively removed from the diet, blood cholesterol levels fall. People who eat a vegan or 100% plant-based diet, tend to have the lowest cholesterol levels of all diet patterns. This is because a plant-based diet avoids or minimises ‘nutrients’ that increase blood cholesterol, namely saturated fat, and to a lesser extent dietary cholesterol. It also emphasises nutrients that naturally keep blood cholesterol low, such as fibre and unsaturated fatty acids.

Some standout foods for lowering cholesterol that are part of the Portfolio diet are nuts and seeds, plant protein (chickpeas, soya, beans), foods high in viscous fibre, plant sterols and oils high in monounsaturated fatty acids, such as extra virgin olive oil.

Reducing the risk of type 2 diabetes

Type 2 diabetes is driven by insulin resistance, a condition caused by the abnormal accumulation of fat inside the muscle, liver and pancreatic cells. This fat accumulation inhibits the action of insulin and thus leads to elevated blood glucose levels.

Plant-based diets, including vegetarian and vegan diets, are associated with a significantly lower risk of type 2 diabetes, in part, but not exclusively due to the beneficial impact on body weight. Plant-based diets are also central to the treatment of type 2 diabetes, and in some can induce remission.

Reducing the risk of heart disease

The main risk factors for heart disease are being an unhealthy weight, high blood pressure, high cholesterol and type 2 diabetes. Avoiding these conditions significantly reduces the risk of heart disease. So it is not surprising that plant-based diets, including vegetarian and vegan diets, are associated with lower rates of heart disease.

It is worth noting that not all plant-based diets are created equal. To optimise health outcomes, a plant-based diet needs to be composed mainly of minimally processed, whole foods. A plant-based diet that is high in refined grains, free sugar and ultra-processed foods can be as bad as a meat-heavy diet and does not benefit health.

Reducing the risk of cancer

The causes of cancer are varied and complex. Eating a plant-based diet is one of several healthy habits that is associated with a lower risk of cancer. This is because you avoid foods associated with a higher risk of cancer, such as processed and red meat, and instead focus on foods and nutrients that reduce cancer risk. These include fibre, whole grains, fruit and vegetables and soya foods.

In general, meat-free diets, both vegetarian and vegan, have been associated with a lower overall risk of cancer of around 15%. In part, because of the association with a healthier body weight, but also because of the associations with lower inflammation and a healthier gut microbiome.

Surprising benefits

There is a long list of health benefits of plant-based eating that may surprise you. Some are listed below:

• Lower risk of urinary tract infections, as most infections are derived from bacteria carried in meat.
• Improvements in menstrual pain in women.
• Improvements in menopausal symptoms, especially when emphasising soya foods.
• Lower risk of fatty liver disease because it is naturally low in saturated fat and high in fibre-rich foods.
• Lower use of insulin in people with type 1 diabetes.
• Lower in cost by a third, compared to the typical Western diet.
• Lower medical costs and lower use of prescribed medications.

Best for planetary health

Without a healthy planet there are no healthy people.

The climate and ecological crises are now directly affecting human health globally. One of the main drivers is our food system. Animal agriculture is a major cause of greenhouse gas emissions, biodiversity loss, land, water and air pollution, land use change and more. The most impactful action we can take as individuals is to remove animal-sourced foods from the diet and instead eat a plant-based diet. Without exception, the production of all plant foods has significantly less impact on the environment than animal-sourced foods. There is now international consensus that if we want to meet our climate and nature goals, we need a global transition to a plant-based food system.

The Planetary Health Diet, devised by the Eat-Lancet Commission, provides a global framework for a healthy diet that will keep the food system within planetary boundaries. It is a diet that is composed of more than 85% plant-based foods, with animal-sourced foods greatly limited and not considered essential.

Concluding remarks

The positive impacts of a plant-based diet far outweigh any perceived downsides. There are additional huge benefits to our animal kin who find themselves living their entire lives in factory farms. Like with all diet patterns, a plant-based diet needs to be appropriately planned. If adopting a vegetarian or vegan diet, supplementation with vitamin B12 is essential.

Plant-based diets are full of abundance and flavour, can be adapted to all traditional and cultural diet patterns, and are a joy to adopt.

Resources

Plant-Based Eatwell Guide

Plant-Based on a Budget

Plant-based diets for the prevention and treatment of cardiovascular diseases

By Michael Metoudi, RD

What is cardiovascular disease?

Cardiovascular disease (CVD) defines a group of disorders affecting the heart and blood vessels. The most common type is coronary heart disease (CHD), characterised by the narrowing of blood vessels and reduced blood flow to the heart. If left untreated, it develops into other serious types of CVDs such as arrhythmias (irregular heartbeats), angina (chest pain), and eventually leading to myocardial infarction (heart attack) and heart failure. Other major types of CVDs include hypertension and cerebrovascular disease, such as stroke, both of which have significantly increased in the UK during the past two decades.

CVDs remain the commonest cause of illness and death worldwide. Alarmingly, the overall rates of heart disease have dramatically increased in younger people, suggesting that it is not just a disease confined to old age.

Risk factors for cardiovascular diseases

 The main drivers of CVD are lifestyle-related and are mostly modifiable. These include:

 1) Behaviour or lifestyle risks: such as poor dietary patterns, high in salt and low in whole plant foods; smoking; physical inactivity; and alcohol use.

 2) Metabolic risks: such as high systolic blood pressure, obesity, high LDL-cholesterol and fasting blood glucose and diabetes.

 3) Environmental risk: including air pollution.

Other emerging modifiable lifestyle factors include high stress levels, poor sleep and social isolation and loneliness.  Genetics appear to be responsible for 40-60% of the risk for CVD. However, diet and lifestyle interventions can offset genetic risk for CVD by almost one half in susceptible individuals.

Cardiovascular disease risk factors

The evidence for whole-food plant-based diets in cardiovascular diseases

Prevention and Treatment

Poor diet quality represents the number one lifestyle risk factor for CVD, responsible for up to half of all cardiometabolic disease-related deaths.

Some of the strongest evidence supporting a whole food plant-based diet (WFPBD) for CVD relates to the prevention and treatment of CHD. Studies as far back as the 1950s have shown that predominantly and exclusively plant-based diets reduce CVD risk.

Two landmark cohort studies include the Framingham Heart study and the Seven Countries study, first linking diet quality (plant vs. animal fat) to CHD risk. Fast forward and we have over 75 years of data from meta-analyses of large prospective cohort studies consistently showing a reduced risk of CHD, overall CVD, their primary risk factors and CVD mortality in those following a plant-based diet. These studies include data from participants that follow vegetarian or vegan diets such as the EPIC-Oxford and Adventist Health studies showing just under 30% reduction for CHD.

For Intervention studies involving the primary prevention of CVD, the PREDIMED study showed that a Mediterranean diet pattern, supplemented with olive oil or nuts in those at high risk, reduced stroke and overall CVD events by at least one third. The more recent OMNIVEG study showed even greater benefits for heart disease risk factors for those following a vegan Mediterranean-style diet compared to the traditional Mediterranean diet.

When it comes to the treatment of established heart disease (secondary prevention), there are consistent and significant improvements in CVD risk factors including reduced blood lipids levels, blood pressure and markers of glycaemic control in people following a vegan or vegetarian diet.

The Lifestyle Heart Study, a randomised lifestyle intervention trial involved 48 patients with established CAD. This study showed that a predominantly WFPBD, low in fat, together with other lifestyle interventions (exercise, smoking cessation and stress management) resulted in 82% of patients showing regression of their arterial CHD in the intervention arm of the study, after 5 years of follow-up.

Importance of diet quality

Studies that consider diet quality, using the plant-based diet index, such as the Nurses’ Health Study and the Health Professionals Follow-up study, also find a similar risk reduction in CVD in those eating the highest portions of whole plant foods.

High adherence to a healthy plant-based diet is associated with a 14% reduction in CHD and a 10% reduction in overall CVD risk. Conversely, following an unhealthy plant-based diet, high in ultra-processed foods, refined grains, free sugars, unhealthy fats, and salt, can increase the risk of CVD and CVD Mortality.

When substituting animal foods for plant foods, such as nuts, legumes or whole grains, there is a significant reduction in CVD risk by as much as 30%. Fish consumption has also shown to reduce CVD risk up to 8%, but only in types with a high omega-3 fat content, suggesting this to be the primary cardioprotective factor. Adequate sources of omega-3 can be obtained in whole plant foods such as flaxseeds, chia seeds, walnuts, hemp hearts and soya.

Mechanisms that drive cardiovascular diseases

 At the core (or heart!) of CVD is the development of atherosclerosis, the build up of plaque inside the arteries. These plaques are made up of predominantly fat, cholesterol, calcium and debris of cells from the immune system. Over time, these plaques harden, narrow the arteries, limit blood flow to the heart and organs and give rise to the collective symptoms of CVD. Plaque rupture leads to the formation of a blood clot, resulting in a myocardial infarction and/or stroke.

Atherosclerosis begins when specific lipoproteins, that transport lipids in the circulation (e.g cholesterol), become trapped beneath the endothelium that lines the blood vessels. Lipoproteins linked to this process include ApoB-containing lipoproteins, particularly LDL-cholesterol. Their retention within the arterial wall leads to an inflammatory reaction which drives the formation and growth of atherosclerotic plaques.

It is of great concern that the development of these plaques does not just occur later in life but appears to form even from early childhood.

Atherosclerosis development in Cardiovascular Disease

How whole-food plant-based diets reduce cardiovascular diseases

Lowering blood pressure

High blood pressure, or hypertension, is the biggest risk factor for CVD. Several studies demonstrate the benefits of plant-predominant diets in reducing hypertension, with the DASH diet (Dietary Approaches to Stop Hypertension) most extensively studied. The core components of the DASH diet are fibre-rich plant foods and thus following a vegan or 100% plant-based diet has well-established benefits for lowering blood pressure. As the intake of animal-sourced foods are lowered and plant-based foods are increased, the greater the benefits for blood pressure lowering. Specific beneficial foods include  whole grains foods, fruit and vegetables, and legumes.

WFPBDs are beneficial because of the abundance of dietary potassium, a mineral that is necessary for maintaining muscle function but also relaxing blood vessels, thereby reducing blood pressure. WFPBDs are naturally lower in salt, a major risk factor for hypertension. They are also higher in fibre, a nutrient consistently associated with blood-pressure lowering effects

Reducing blood and dietary lipids

Elevated blood lipids, especially LDL cholesterol, Lipoprotein (a)(LP(a)), a genetically-determined lipoprotein, and triglycerides are major risk factors for CVD. In general, the lower the levels of these lipids, the better for prevention and managing CVD. Saturated fat intake is the main determinant of LDL-cholesterol levels, with dietary cholesterol having a smaller, but still an important impact.

Vegetarians and vegans consistently have lower LDL-cholesterol levels than omnivores. There is a great deal of evidence based on the Portfolio diet, a combination of five plant-based food groups designed to lower cholesterol. These include plant sources of protein, nuts and seeds, sources of soluble fibre (oats, barley, psyllium), plant sterols and oils high in monounsaturated fats, such as extra virgin olive oil. (see our factsheet here). Despite  Lp(a) being genetically determined, plant-based diets have also shown to reduce levels by as much as 16% in 4 weeks.

WFPBDs have a variable impact on blood triglycerides. However, fibre-rich plant foods have shown to significantly reduce levels, particularly nuts (rich in omega-3 fats) and whole grains. Minimising intake of free sugars and refined grains is also important.

Reducing inflammation and improving endothelial function

Plant-based diets lower the risk of CVD by reducing inflammation.  Vegan and vegetarian diets as well as the Mediterranean diet were ranked highest for reducing C-reactive protein (hsCRP), a primary marker of inflammation that is linked to CVD by promoting atherosclerosis and endothelial dysfunction. Vegan and vegetarian diets appear to reduce other important circulating biomarkers of inflammation linked to CVD.

Whole plant foods have also directly been shown to improve endothelial function, especially through foods such as fruits, vegetables, soya, nuts and seeds, cocoa, and tea.

Blood glucose control and diabetes

Elevated blood glucose and type 2 diabetes almost doubles the risk of CVD, especially heart failure, heart attack and stroke. WFPBDs have shown to significantly reduce the risk of type 2 diabetes as well as having a role in the clinical treatment of type 2 diabetes. Emerging evidence also shows their role in the management of type 1 diabetes.

Modulating the microbiome

The gut microbiome is linked to a host of different diseases, with CVD being no exception. Specific species of gut bacteria appear to be responsible for an increased or decreased risk of CVD. Certain bacteria that metabolize compounds from carnitine, found in red meat and eggs produce trimethylamine (TMA), a molecule which gets converted to trimethylamine N-oxide (TMAO) within the liver. TMAO is linked to CVD risk. It can alter how cholesterol is metabolised by the body by disrupting reverse cholesterol transport and reducing its excretion, promoting lipid deposition, which accelerates atherosclerosis. Predominantly plant-based diets have shown to directly shift populations of gut bacteria from TMAO producers to beneficial bacteria that metabolise fibre and produce short chain fatty acids (SCFAs) that regulate blood pressure and reduce inflammation. Vegan diets in particular have gut microbiome signatures that are associated with improved cardiometabolic health.

Consensus Guidelines for reducing Cardiovascular disease

Conclusion

There is an abundance of high quality evidence supporting a WFPBD  for the prevention and treatment of CVDs. It addresses the root causes, whilst simultaneously providing the core nutrients that not only protect the heart and blood vessels, but do not contain the dietary components from animal foods that are directly linked to CVD risk, development and progression.

Dietary and lifestyle approaches for achieving remission of type 2 diabetes

Dr Shireen Kassam, Director of Plant-Based Health Professionals UK

For too long the medical profession has considered type 2 diabetes (T2D) a chronic, progressive and life-long condition. Now we know better. Prediabetes and T2D are not only preventable but remission can be achieved in most people through diet and lifestyle interventions. The strength of evidence is such that the American College of Lifestyle Medicine have created a ‘Bill of Rights’ for people with T2D, outlining their right to be offered diet and lifestyle support, with the aim of achieving remission.

Remission is when a person achieves a HbA1C level less than 6.5% (48 mmol/mol) measured at least 3 months after stopping glucose-lowering medication.

How it all began – delaying the onset of type 2 diabetes

It has long been recognised that weight loss is the key to preventing T2D in people at high risk. The seminal study demonstrating the efficacy of lifestyle interventions was published in 2002. It compared usual care with metformin (a diabetes medication) or lifestyle interventions, aiming for 7% weight loss and at least 150 minutes of physical activity per week. Although both interventions were effective, the lifestyle intervention was more effective than metformin, reducing the development of T2D over a 3 year period by 58% compared to the control group. Metformin reduced the risk by 31%.

Longer follow-up of this study has confirmed the ability of lifestyle interventions to significantly prevent or delay the development of T2D.

This knowledge is now embedded into the NHS, and everyone with a diagnosis of pre-diabetes or at high risk of developing T2D can be referred to their local Diabetes Prevention Programme. The dietary approach is generally consistent with recommendations from the Eatwell Guide, the UK dietary guideline. The programme is effective and cost effective.

It is worth noting that recent research has shown that prevention of progression to T2D can be achieved without weight loss. The key is altering body composition and fat distribution leading to improved insulin sensitivity, β-cell function and increments in β-cell-GLP-1 sensitivity. Liver and pancreatic fat can be reduced by improving diet quality, without necessarily achieving weight loss.

How to achieve diabetes remission

There are several approaches for achieving diabetes remission, with weight loss being the key objective. In general, the more intensive the lifestyle intervention, the greater the weight loss and the higher the chances of achieving remission.

Although all pillars of lifestyle medicine are important, the most important remains the dietary intervention. Any diet that achieves weight loss will be effective. The important questions are how acceptable and sustainable the dietary changes are and whether the diet supports long-term health goals, such as preventing cardiovascular diseases, cancer and kidney disease.

Remission is achieved through reduction in liver and pancreatic fat, which then restores pancreatic beta-cell function. This requires around 15% weight loss to reduce weight below the ‘personal fat threshold’ (the amount of fat that is stored safely subcutaneously before it ‘spills over’ into the organs i.e. liver, pancreas and muscle cells). Duration of diabetes is also important, with remission more difficult in those who have had the disease for longer than 8 years.

Low calorie, meal replacements

Professor Roy Taylor is the pioneer behind the low calorie, meal replacement approach. The DIRECT study was practice changing as it showed that T2D remission was achievable in a primary care setting. The intervention involved withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal/day formula diet for 3-5 months), stepped food reintroduction (2-8 weeks), and structured support for long-term weight loss maintenance. At 12 months, 46% of participants had achieved remission. The chance of remission was directly related to the amount of weight loss achieved, with 83% of those losing 15kg or more being successful.

The effectiveness of this approach diminishes over time. At 2 year follow up, 36% of participants remained in remission and at 5 years, 27%. This highlights that long term success requires a sustainable dietary approach, otherwise weight gain is inevitable.

The NHS has now adopted this approach with the NHS Type 2 Diabetes Path to Remission Programme.

Low carbohydrate diets

Low-carb diets have become popular and are being championed in the UK. The approach makes sense to some extent. Carbohydrates are converted by the body into glucose. If the supply of carbs in the diet is limited, blood glucose levels will fall. And so it does. But this approach addresses the symptom (high blood glucose) and not the underlying cause (insulin resistance caused by intracellular fat accumulation) of T2D.

Low-carb diets can support weight loss, mainly due to the fact that the diet is naturally restrictive and also results in the elimination of many commonly consumed ultra-processed, carbohydrate-rich foods; white bread, cakes, pastries, and sugar-sweetened beverages.

Side-effects of a low-carb diet

Concerns arise when carbs are replaced by animal sources of protein and fat, whilst restricting healthy fibre-rich foods such as certain fruit, starchy vegetables, whole grains and legumes. This way of eating results in elevated LDL-cholesterol levels, increasing the long-term risk of atherosclerotic cardiovascular disease. Animal-based diets also increase the risk of cancer and all-cause mortality.

Dr Kevin Hall, an internationally renowned, former researcher at the National Institute of Health is famous for conducting metabolic ward studies. His work has demonstrated that a low-carb, high fat diet elevates markers of inflammation, LDL-cholesterol levels and promotes insulin resistance. When he compared an animal-based, low-carb diet to a plant-based diet, both led to improvements in fasting glucose and insulin levels, but the plant-based diet resulted in greater weight and body fat loss and improvements in cholesterol levels. The animal-based, low-carb group lost mainly water weight and muscle mass, developed a degree of insulin resistance and a rise in LDL-cholesterol levels. The animal-based low-carb diet improved triglyceride levels, which worsened on the plant-based diet.

International consensus on low-carb diets

The National Lipid Association in the US and Scientific Advisory Committee on Nutrition in the UK have reviewed the evidence for low-carb diets. They have both concluded that although there may be some benefits for short-term weight loss, there is no evidence that low-carb diets are superior to other dietary approaches for weight loss. However, there are concerns that an animal-based, low-carb diet that restricts healthy carbohydrate-rich foods will result in elevated LDL-cholesterol levels, worsen cardiovascular health and negatively impact the health of the gut microbiome. Both reviews make it clear that healthy diet patterns are centred around fruits, vegetables, whole grain, beans, nuts and seeds.

Whole food plant-based diet

There are a number of studies demonstrating the effectiveness of a healthy vegan or whole food plant-based diet for the treatment of type 2 diabetes. This is in part due to the fact that a plant-based diet is effective at supporting weight loss, because the diet is naturally high in fibre and lower in energy density compared to animal-based diets. Having said that, a high fibre diet may be effective at improving insulin resistance even without weight loss.

A randomised study of a low-fat vegan diet, without portion or calorie control, resulted in better glycaemic control, with reduction in the need for medication and insulin, when compared to the American Diabetes Association diet. The mechanisms explaining the benefits include reduction in visceral fat, hence restoration of insulin sensitively, along with a reduction in oxidative stress. A plant-based meal results in increased post-prandial incretin and insulin secretion when compared to a meat-based meal, suggesting that plant-based diets may be able to improve beta cell pancreatic function in patients with T2D. Incretin hormones are a group of gut hormones (including glucagon-like peptide-1) that are released after eating and stimulate the release of insulin, thus decreasing blood glucose levels. In people with type 2 diabetes, this incretin effect is reduced or absent.

Another randomised study using a whole food plant-based diet and physical activity intervention was conducted in the Marshall Islands, where the prevalence of T2D is particularly high. Compared to standard medical care, the results demonstrated that the intervention was able to improve glycaemic control, body weight, waist circumference and inflammation. It also reduced the need for glucose-lowering and cardiovascular medications and induced T2D remission in some participants.

There is now international consensus that a whole food, plant-predominant eating plan is a core component of lifestyle medicine interventions for preventing, treatment and achieving remission of T2D.

What about fruit?

Fruit is demonised in some circles since it is high in sugar/fructose and can elevate blood sugar levels. This can be a problem for people with insulin resistance but healthy individuals, who are insulin sensitive can easily handle this sugar load. However, even in people with T2D, evidence shows that eating fruit can improve glucose control and therefore should continue to be included in the diet. Berries are a particularly useful addition and even dried fruit can benefit glucose regulation. Of note, it’s generally best to limit fruit juice in the diet.

Low-carb, plant-based diet

Diet quality is more important than macronutrient ratios. Nonetheless, some people may favour a low-carb diet, which can support cardiometabolic health when centred around plant sources of protein and fat.

Low-carb plant-based diets have been studied in clinical trials. Dr David Jenkins is the creator of the so-called ‘Eco-Atkins’ diet. This low-carb plant-based diet, emphasising protein and fat from gluten and soya products, nuts and vegetable oils, was found to be more effective in lowering blood lipid levels compared to a higher carb, low-fat vegetarian diet. In people with T2D, a low-carb plant-based diet and higher carb vegetarian diet were equally effective for weight loss and blood pressure reduction.

Plant-based diets support overall health

An important aspect of diabetes care is prevention of other chronic conditions. Diabetes is a leading cause of chronic kidney disease, while cardiovascular disease remains the leading cause of death in people with diabetes. Plant-based diets have been shown to be effective at managing cardiovascular risk factors, including hypertension and elevated blood lipids.  Plant-based diets are also effective at reducing the incidence and progression of chronic kidney disease and maintaining a healthy gut microbiome. A systematic review found that plant-based diets were not only able to improve weight and glycaemic control, but were associated with improved psychological health and quality of life.

Physical activity

Regular physical activity meeting international recommendations is hugely beneficial for people with pre-diabetes and T2D. A variety of exercises can be useful, so finding one that is enjoyable and sustainable is key. Resistance training that leads to improvements in muscle strength is also important for improving insulin sensitivity and regulating glucose.

Top tips for achieving diabetes remission

1. If you have a diagnosis of pre-diabetes or T2D, speak to your doctor about lifestyle interventions to help achieve remission.
2. Make sure to get professional advice before changing your diet or altering your medications.
3. Eat a diet centred around fruit, vegetables, whole grains, beans, nuts and seeds. If eating a meat-free diet you need to supplement with vitamin B12, and vitamin D if sunlight exposure is inadequate.
4. Limit consumption of foods high in saturated fat, salt and sugar.
5. Do not fear eating fruit – they are a very healthy food group.
6. Take part in regular physical activity, including strength exercises. Do a variety of different exercises, but importantly, ones that you enjoy.

Resources

Read the PBHP UK factsheet on type 2 diabetes.

NICE guidelines – Type 2 diabetes management.

American College of Endocrinology consensus statement on the management of diabetes.

Canadian Diabetes Association review of plant-based diets for diabetes.

American College of Lifestyle Medicine consensus statement on type 2 diabetes remission.

Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults: A Clinical Practice Guideline From the American College of Lifestyle Medicine

Preventing type 2 diabetes

Dr Shireen Kassam, Director of Plant-Based Health Professionals UK

How does type 2 diabetes develop?

T2D is characterised by insulin resistance, when the body can no longer respond to increasing levels of insulin secreted by the pancreas. Cells become resistant to insulin when they accumulate abnormal amounts of fat, usually as a consequence of being overweight or obese. This results in elevation of blood glucose. Persistently high levels of blood glucose damage cells and organs. It should be remembered that high blood glucose is the symptom and not the cause of type 2 diabetes.

It is interesting to note the concept of a ‘personal fat threshold’. That is, each person has a different capacity to store fat under the skin. When this storage has reached capacity, it spills over and leads to accumulation of fat inside the cells of the liver, pancreas and muscle, making them resistant to the effects of insulin. This is why people of seemingly normal body weight can still develop T2D, because they have exceeded their personal fat threshold.

Insulin resistance is implicated in a number of other chronic diseases, including atherosclerosis and cardiovascular disease, dementia, polycystic ovary syndrome and even cancer.

What are the risk factors for type 2 diabetes?

Type 2 diabetes is predominantly caused by modifiable lifestyle behaviours, with 70% of this risk linked to dietary factors. A Western-style diet pattern, high in animal-sourced and highly processed foods, is the leading risk factor. Other risk factors include obesity, lack of physical activity, smoking and alcohol consumption. Emerging risks include sleep disturbance and psychological stress. These risk factors usually drive increases in body weight, which in term promotes the development of T2D.

It’s worth noting that being of South Asian origin is a distinct risk factor, with T2D occurring more frequently and around a decade earlier than in White populations. This is thought to be due to the lower ‘personal fat threshold’ due to a genetic propensity to lay down visceral fat at lower body weights.

Preventing of type 2 diabetes

Healthy diets

The key to preventing diabetes is to maintain a healthy body weight by addressing dietary and lifestyle risk factors. The consensus supports a fibre-rich plant-rich or fully plant-based diet for lowering the risk of T2D. In the Adventist Health Study-2, vegans had a 49% decreased risk of T2D compared to non-vegetarians and this represented the lowest risk of all the diet patterns compared. In the EPIC-Oxford study, those avoiding meat had around a 50% reduced risk of T2D when compared with regular meat eaters. However, the effect was reduced once results were adjusted for body weight. The fish eaters had the lowest incidence of T2D, but it should be noted that this group was small and results in the literature have been inconsistent. In the Tzu Chi Health Study from Taiwan, vegetarians had a 35% reduction in the risk of developing T2D, and converting from a non-vegetarian to vegetarian diet during the follow-up was associated with a 53% reduction in risk.

Combined results from the Nurses’ Health Study and the Health Professionals follow-up study have shown that those eating a healthy plant-based diet (not necessarily vegan or vegetarian) composed of predominantly whole grain, fruits, vegetables, nuts, seeds and unsaturated fats, have a significantly reduced risk of T2D. A diet that emphasised plant foods and was low in animal foods was associated with a 20% reduction in the risk of T2D. Consumption of a plant-based diet that included specifically healthy whole plant foods was associated with a larger decrease (34%) in risk, while consumption of a plant-based diet high in less healthy plant foods (processed foods and refined grains, potatoes and fruit juice) was associated with a 16% increased risk of T2D. There was a dose relationship between the consumption of healthy whole plant foods and the reduction in risk of diabetes – the more plant foods consumed the lower the risk. The study suggests that increasing intake of healthy plant foods while moderately reducing intake of some animal foods, especially red and processed meats, could be beneficial for diabetes prevention.

Encouragingly, a further updated analysis from the same study cohort showed that improvement in diet quality over time can reduce the risk of developing T2D.  Every 10% increase in adherence to a healthy plant-based diet reduces subsequent risk of diabetes by 7-9%. The converse was also true with a 10% decrease in plant-based diet quality resulting in a subsequent 12–23% higher risk of diabetes. This provides hope that diet change is beneficial regardless of age.

It is also worth noting that healthy plant-based diets can reduce the risk of gestational diabetes, which is also a significant risk factor for future development of T2D.

How plant-based diets prevent T2D

Plant-based diets are well known for supporting a healthier body weight. Interestingly, an analysis from the UK Biobank cohort showed that reductions in body mass index was only partly responsible for the reduction in risk of T2D, with additional benefits of a healthy plant-based diet coming from lower levels of inflammation and improved kidney and liver function.

The benefits of plant-based foods for diabetes prevention are the high fibre content, the low glycaemic index of certain plant-based foods, high levels of phytonutrients and antioxidants and low levels of saturated fat.

Antioxidants such as polyphenols may inhibit glucose absorption, stimulate insulin secretion, reduce hepatic glucose output, and enhance glucose uptake. Fibre maintains a more consistent blood sugar level and is fermented by intestinal bacteria to produce short-chain fatty acids, which also improves the glucose response, insulin signalling, and insulin sensitivity. Fibre reduces the energy density of foods, promotes satiety, and has been associated with maintaining a more healthy weight, which in turn promotes insulin sensitivity.

Can you eat too much fruit?

People often worry about consuming ‘too much fruit’ when it comes to diabetes prevention. The confusion arises with the fact that fruit contains fructose and fructose consumption is associated with an increased risk of chronic disease.

However, when fructose is present in whole fruit, combined with fibre and micronutrients, there is no detrimental effect on health outcomes. Quite the opposite. An analysis from the EPIC study analysed fruit and vegetable consumption in 9754 participants with and 13, 662 participants without type 2 diabetes. The novel aspect of this study was that plasma biomarkers of fruit and vegetable consumption were measured, such as vitamin C and carotenoids, to give a more accurate indication of consumption. The results showed that fruit and vegetable consumption was associated with a significantly reduced risk of T2D, in the order of 20-30%, and that even small to moderate increases in consumption were beneficial. Numerous other studies have confirmed the benefits of fruit consumption for multiple health outcomes, including T2D. Even dried fruit can provide benefits.

Meat consumption and type 2 diabetes

Consuming protein from animal sources has consistently been associated with an increased risk of T2D. Red meat, processed meat and poultry consumption is associated with a 8-15% increased risk. In the EPIC study, a dose-response was demonstrated with every 5% of calories derived from animal protein being associated with a 30% increased risk of developing T2D..

In contrast, when food substitutions were examined in the Nurses Health Study and Health Professionals Follow-up Study, one serving of nuts, low-fat dairy, and whole grains per day substituted for one serving of red meat per day was associated with a 16–35% lower risk of T2D.

How does meat increase the risk of type 2 diabetes?

Ultra-processed foods and type 2 diabetes

High intakes of ultra-processed foods (UPFs) are contributing to the burden of chronic disease, including increasing the risk of T2D. However, not all UPFs are equally harmful and some, such as whole grain bread and cereals, are associated with good health outcomes. The most harmful subtypes are processed meat, sugar-sweetened beverages and foods and snacks high in saturated fat, salt and free sugars. UPFs increase the risk of T2D when they contribute to excess calorie intake, thus driving overweight and obesity. In addition, consumption of fructose, in the form of table sugar and high fructose corn syrup, when in excess of calorie requirements, increases the production of triglycerides, contributing to obesity and also the accumulation of fat in the  liver and muscle cells, promoting insulin resistance.

Physical activity

Meeting international recommendations for physical activity, 150 minutes of moderate intensity activity and strengthening activity at least twice per week, is associated with a lower risk of T2D. Studies show that any level of physical activity is better than none, the more the better, with benefits throughout the lifespan. In a large UK-based cohort study, the equivalent of a daily 20-min brisk walk was associated with an almost 20% reduction in risk of T2D. In addition, sedentary lifestyles, such as long periods of time sitting watching TV, at the computer or driving, are also increase the risk of T2D.

Physical activity helps to maintain a healthy weight, reduces the accumulation of fat in the organs such as the liver and muscles, promotes insulin sensitivity, reduces inflammation and supports the health of the gut microbiome.

Other healthy habits

Avoiding cigarette smoking or quitting if you are a smoker is associated with a lower risk of T2D. Although the data on alcohol consumption and diabetes risk is mixed, for overall health, including for cardiovascular health and cancer prevention, it is best not to drink alcohol.

Regular and sufficient sleep aiming for 7-9 hours a day is important, with less and more hours of sleep impacting the risk of T2D. Managing stress, time in nature, and fostering healthy relationships and reducing loneliness all contribute to overall health and may reduce diabetes risk.

Top tips of preventing diabetes

• Eat a diet centred around fruit, vegetables, whole grains, beans, nuts and seeds. If eating a meat-free diet you need to supplement with vitamin B12, and vitamin D if sunlight exposure is inadequate.
• Limit consumption of foods high in saturated fat, salt and sugar.
• Take part in regular physical activity, including strength exercises. Do a variety of different exercises, but importantly, ones that you enjoy.
• Reduce time sitting by taking regular movement breaks.
• Aim to sleep 7-9 hours a day, keeping your sleep routine as regular as you can.
• Avoid cigarette smoking and drinking alcohol.
• Prioritise time in nature and spending time with friends, family and your companion animals.

Diet, lifestyle and immune health

Dr Shireen Kassam, Director of Plant-Based Health Professionals UK

The role of the gut microbiome

Seventy percent of our immune system resides in our gut. It’s pretty incredible to think that the trillions of bacteria and other organisms in the intestine play such an important role in maintaining health. We understand the most about the bacteria in the large intestine and these bacteria are involved in regulating and educating the immune system. When provided with the right nourishment, healthy bacteria can flourish and are able to make compounds such as short chain fatty acids that are essential to the functioning of the immune system. These signalling molecules can activate cells of the immune system and communicate with other organs such as the brain and lungs, thus regulating their immune systems too. In addition, gut bacteria are involved in making vitamins and hormones that are required for good health.

What factors affect our immune system?

There are a number of factors that impact the health of the gut microbiome and the immune system in general. Some we have control over and others we don’t. For example, ageing results in a decline in the functioning of immune cells. At the same time, ageing immune cells release inflammatory compounds, resulting in chronic low level inflammation, known as ‘inflammaging’. Together, these changes increase the risk of severe infections and chronic conditions associated with inflammation, such as cardiovascular diseases, cancer and degenerative diseases of the brain. 

However, there are a number of modifiable risk factors that can positively impact the immune system and can be addressed by adopting healthy habits. These include all six pillars of lifestyle medicine.

Nutrition and immune health

The main foods associated with a healthy immune system are fruit, vegetables, whole grains, beans, nuts and seeds. This is because they contain important nutrients that have been shown to support the health of the gut microbiome and the functioning of immune cells.

Eat the rainbow 

Fruit and vegetables are packed full of antioxidants, anti-inflammatory compounds and an array of phytonutrients, which all act to support immune health. Making sure your diet is varied and includes foods with an array of different colours will ensure you are consuming a wide range of beneficial nutrients.

Vitamin C is an essential component of the diet and only found in fruits and vegetables. An adequate intake is required for optimal functioning of the immune system, and we should aim for around 100mg per day. Top food sources of vitamin C include red and green peppers, oranges, kiwi fruit and broccoli.

Vitamin D, more a hormone than a vitamin, plays an important role in maintaining a healthy immune system. The main source of vitamin D is from the action of sunlight on the skin. If sun exposure is inadequate, like in the winter months in the UK, then supplementation is recommended.  

Micronutrients such as selenium and zinc are important for immune health. Two brazil nuts a day will take care of your selenium needs and it is also found in whole grains, beans and seeds. Foods rich in zinc include whole grains, beans and nuts. Soaking grains and beans before cooking can increase the bioavailability of zinc and other nutrients in the food.

Herbs and spices in various forms have some of the highest concentrations of antioxidant compounds and also contain a number of beneficial compounds that support the immune system. Many show anti-infective properties, at least in the laboratory. So use a variety of herbs and spices liberally in cooking every day. Turmeric and its active component, Curcumin, has an array of health promoting effects. This includes anti-inflammatory, antioxidant and anti-infective properties. A number of studies have shown that curcumin has activity against different viruses.

Fibre

Fibre, only found in plant-based foods, is crucial for maintaining the health of the gut microbiome, which in turn helps maintain a functional immune system. Fibre is a type of carbohydrate that is not fully digested by the body and makes its way down to the large intestine and is used as fuel by the resident bacteria. A plant-based diet, especially a vegan diet, has been shown to be associated with better gut health and a greater abundance of bacteria that produce short chain fatty acids.

Changing your diet to being more plant-based can have beneficial effects on the gut microbiome in a matter of days to weeks. Adults should be aiming to consume 30g of fibre per day. 

What about prebiotics and probiotics?

Prebiotics are food for your gut bacteria. They are generally foods that are high in non-digestible fibre such as whole grains, bananas, greens, onions, garlic, soya beans and artichokes.

Probiotics are foods that contain live bacteria or yeast, usually because they have been fermented. This includes foods such as sauerkraut, kimchi, tempeh, miso, water and coconut kefir. Some plant-based yogurts also contain live cultures.

Most people in good health do not benefit from taking a probiotic supplement but including plenty of prebiotic and probiotic foods can improve the health of the gut microbiome and hence support immune health.

Good quality sleep

Sleep is essential for maintaining immune health. Inadequate sleep results in low-grade inflammation and adversely affects metabolic health and increases the risk of degenerative diseases. We should aim to get between 7–9 hours of sleep per night. To help ensure good quality sleep, the following can help:-

• maintain a regular sleep schedule;
• avoid daytime naps and if you do nap keep this to less than 30 minutes;
• make sure your bedroom is at a cool temperature, around 15–19 degrees Celsius;
• ensure a dark room without noise;
• avoid bright lights in the evening and expose yourself to sunlight in the morning;
• avoid heavy, carbohydrate-loaded meals 2–3 hours before bedtime;
• minimise screen-time/use of electronic devices in the evenings and avoid after 9pm;
• avoid caffeinated drinks after 2pm and eliminate alcohol.

Physical activity

There are so many benefits to being physically active and meeting international recommendations for both aerobic and strength-building exercises. Physical activity enhances the function of immune cells, reduces inflammation and amplifies the immune response to infections.

Any additional movement you can add to your daily routine is beneficial, even everyday household activities such as cleaning and gardening counts. Combining physical activity with time in nature may be even more beneficial as being in nature has been shown to enhance immune cell function.

Managing stress

Experiencing stress is a normal part of life and an acute stress response can temporarily strengthen the immune system. However, chronic stress and the persistent elevation of the stress hormone cortisol leads to immune dysregulation, immune suppression and promotes inflammation. This leads to increased susceptibility to infections, an increased risk of autoimmune conditions and may even increase the risk of developing cancer.

Having tools at hand to manage stress is really useful. This can include regular physical activity, spending time in nature, mindfulness activities such as meditation or yoga, and prioritising time with loved ones.

Avoid alcohol and cigarette smoking

Both alcohol and smoking impair the function of the immune system. There is no safe limit of alcohol to consume, so it’s best not to drink. Similarly, it is well established that smoking tobacco adversely affects all aspects of our health and significantly reduces life expectancy by an average of 10 years. It is never too late to quit alcohol or smoking and there is free support available from the NHS.

Lifestyle habits and autoimmune conditions

Dysfunction of the immune system can lead to autoimmune conditions. That is when the immune system ‘attacks’ normal cells. This manifests in different ways depending on where in the body this takes place. For example, the immune system can attack joints leading to rheumatoid arthritis, or the central nervous system causing multiple sclerosis.

The good news is that even if you have an autoimmune condition, there is emerging evidence that adopting a plant-based diet and other healthy habits can have a hugely positive impact on symptom severity and reducing the reliance on medication. This has been demonstrated in the Plants for Joints study in people with rheumatoid arthritis and observed in people living with multiple sclerosis.

1. Eat a diet high in fibre-rich foods, including fruit, vegetables, whole grains, beans, nuts and seeds.
2. Aim to get nutrients from food rather than supplements. The exceptions are Vitamin D if you are not getting sufficient sunlight and vitamin B12 if you are eating a meat-free diet.
3. Prioritise sleep, aiming for 7-9 hours per night.
4. Add movement to your day, aiming for 150 minutes of moderately vigorous activity per week and at least two sessions of strength-building exercises.
5. Avoid smoking and alcohol. Drink mainly water for thirst. Tea and coffee are both healthy additions to the diet.
6. Incorporate stress-relieving activities into your daily routine.
7. Prioritise time in nature and time with loved ones.
8. It is never too late. Even if you have a health condition related to the immune system, healthy habits can make a big difference.

The power of healthy habits for people living with multiple sclerosis

Multiple Sclerosis (MS) is an autoimmune condition affecting the brain and the spinal cord. Conventional pharmaceutical treatments slow the progression but rarely reverse and cannot cure the disease. People living with MS often explore diet and lifestyle interventions as a means of managing their symptoms and reducing reliance on medication and increasingly, lifestyle interventions are recognised as beneficial by medical professionals.

The impact of diet on multiple sclerosis 

We know that people living with MS can benefit from increasing the proportion and variety of healthy plant foods in the diet i.e. fruit, vegetables, whole grains, beans, nuts and seeds, whilst limiting or avoiding animal-derived and processed foods. 

Dr Roy Swank, a pioneer of dietary approaches in MS, used a diet low in saturated fat that limited meat consumption and emphasised fruit and vegetable consumption. His observational study is the longest ever reported on diet and MS, following his patients for up to 34 years. The results suggested that patients adhering to his dietary protocol had significantly less neurological disability and longer lives. 

Subsequent studies have shown that these positive results are likely to be explained by the fact that a plant-based diet is rich in nutrients that reduce inflammation and thus leading to improvements in symptoms. In contrast diets high in meat and saturated fats promote inflammation and in general worsen symptoms and quality of life. Dairy may also have a negative impact on symptoms.

The impact of the gut microbiome

Growing evidence suggests that the health of the gut microbiome is a key factor in the development and progression of MS, especially given its importance in maintaining a healthy immune system. Diet is the main determinant of gut health, with a fibre and polyphenol-rich plant-based diet being essential. Meat heavy diets reduce the number of healthy bacterial species in the gut and thus adversely affect the immune system. In contrast plant-based diets support the growth of a variety of healthy gut bacteria, which are associated with better immune health and lower levels of inflammation. 

A randomised study demonstrated that the adoption of a plant-rich, anti-inflammatory diet led to reduced levels of inflammation in the gut of people with MS and that this was also associated with improvements in visual symptoms.

Specific nutrients to emphasise

People living with MS may benefit from higher blood levels of vitamin D, aiming for 100-150nmol/l. This will usually require supplementation, along with judicious exposure to the sun.

Long-chain omega-3 fatty acid supplementation in some, but not all, studies has been shown to reduce fatigue, relapse rate and disability. This can be in the form of high potency fish oil or cold pressed flaxseed oil (20-40mls daily). 

Healthy lifestyle habits

Alongside a healthy, fibre-rich diet, all aspects of lifestyle are important for reducing symptom burden and disability and improving quality of life in people with MS. Regular physical activity, managing stress using mindfulness and meditation techniques, adequate sleep and avoiding tobacco and other toxins all support better health and wellbeing in people with MS. 

Programs such as ‘Overcoming MS’, which support people to adopt healthy lifestyle habits have been hugely valuable. They provide community and purpose along with essential information.

Inspiring hope

To raise awareness of the power of healthy habits, we published two case histories highlighting the remarkable potential of lifestyle changes, including a whole food plant-based diet, to improve symptoms and quality of life, allowing for the discontinuation of medication. This is not the first report of such successes. Dr Saray Stancic, a US-based physician has also previously charted her experience of reversing severe disability from MS using a whole food plant-based diet and lifestyle approach. 

We fully appreciate that not all people living with MS can expect to have such positive results, but these same lifestyle habits are key for reducing the longer term risk of cardiovascular disease and certain cancers, conditions with a higher incidence in people living with MS.

Resources

PBHP UK factsheet on multiple sclerosis

Healing from the Inside Out: Managing autoimmune disease with a whole-food plant-based diet by Karen Lee

Everything you need to know about ultra-processed foods on a plant-based diet

By Isabelle Sadler, PBHP UK Research Assistant, MSc Nutrition Student

Navigating the world of UPFs can be confusing. What foods should we avoid and in what quantities? Much of the food available in supermarkets is processed in some way, and convenience foods can play a role in busy lives. Plus, some commonly used foods, such as plant milks or meat alternatives, are classified as ultra-processed.

Below we answer some of the most common questions we receive.

What is an ultra-processed food?

Different classification systems have been developed to describe foods by their degree of processing. The NOVA system is most commonly used, developed by researchers at the University of São Paulo, Brazil.

NOVA categorises food into four groups based on processing (see Figure 1 below). Ultra-processed foods make up group 4; these are industrial formulations, characterised by extensive processing, made from cheap industrial ingredients, and combined with additives. Flavours, colours, emulsifiers, and other additives are used to make the food look, smell, and taste good, often hyper-palatable, as well as to extend shelf-life. Examples include carbonated soft drinks, flavoured yoghurt, hot dogs, sausages, desserts, and ready-to-eat meals. Infant formulas, plant-based dairy and meat alternatives, breakfast cereals, and breads are also considered ultra-processed foods under NOVA.

While NOVA is widely used in research and public health policy work, it does receive criticism. Classification is based on the degree of processing, and not nutritional quality, which means the categorisation of foods can seem inconsistent. This can make the system confusing, and it’s not always easy to apply in practice.

Are all ultra-processed foods unhealthy?

Diets high in UPFs are generally associated with an increased risk of several chronic diseases, including cardiovascular disease (CVD), type 2 diabetes and some cancers. However, when we break this down by type of ultra-processed food, the health impacts can be strikingly different.

In 2023, a cohort study found that processed animal meats and sugar-sweetened beverages were most strongly associated with increased risk of developing cancer and cardiometabolic diseases. In contrast, plant-based meat alternatives were not associated with increased risk, and even showed a trend toward a lower risk.

More recent research has also shown that the health effects of ultra-processed foods vary depending on the type of food. A 2024 analysis of three large U.S. cohort studies, involving more than 206,000 participants followed for nearly 30 years, found that higher overall UPF intake was associated with an 11% higher risk of CVD. However, the associations differed by food category: sugar-sweetened beverages and processed meats showed consistent increased risk, while breads, breakfast cereals, yoghurts, and some savoury snacks were associated with lower CVD risk.

Similarly, a 2024 study of over 311,000 participants in Europe found that each 10% increase in UPF intake was associated with a 17% higher risk of type 2 diabetes overall. Yet again, the results varied by food type: processed animal products, savoury snacks and sweetened beverages were associated with higher risk, whereas breads, breakfast cereals and plant-based alternatives were linked with lower risk.

These foods differ greatly in their nutritional quality and ingredients, and those that are linked to lower risk of chronic diseases, such as breakfast cereals and whole-grain breads, can add valuable nutrients, including fibre, iron and B vitamins. Therefore, simply classifying them as unhealthy because of their level of processing can be misleading.

Are plant-based meat alternatives ultra-processed and unhealthy?

Based on the NOVA classification system, most plant-based meat alternatives (PBMAs) are considered ultra-processed foods. However, current evidence suggests that consuming these products may not be associated with an increased risk of chronic diseases. They may also offer health benefits over the consumption of red or processed meat.

Read our full article for more evidence on plant-based meat alternatives here.

Can I drink processed plant-based dairy alternatives?

Plant-based drinks are often classified as ultra-processed because they undergo industrial processing and may contain ingredients such as emulsifiers or stabilisers. However, they do not share many of the characteristics of ultra-processed foods that are typically linked with poorer health outcomes. For example, most are not high in salt or saturated fat, and they are not designed to be hyper-palatable or easy to overconsume. Choosing unsweetened varieties can also help avoid added sugars. Additionally, some of their processing is beneficial, such as the addition of vitamin D, calcium, and iodine.

Evidence also suggests they can support good cardiometabolic health. A systematic review and meta-analysis of 17 trials found that replacing cow’s milk with soya milk, regardless of the presence of added sugars, led to reductions in non-HDL cholesterol, systolic and diastolic blood pressure, and small reductions in LDL cholesterol and C-reactive protein. This is despite soya milk being classified as an ultra-processed food, and dairy milk being classified as minimally processed.

Consumers often perceive organic or less processed products as healthier. However, in the UK organic plant milks are typically not fortified, meaning they may lack nutrients such as calcium and iodine.

Should I be worried about emulsifiers in plant-based drinks?

Some plant-based drinks contain small amounts of emulsifiers, such as gellan gum, to improve texture and prevent separation.

There has been growing interest in how certain food additives might influence health, particularly gut health. However, at present there is not enough evidence to suggest that people without specific gastrointestinal conditions, such as irritable bowel syndrome, need to avoid emulsifiers altogether. Gellan gum, one of the most common emulsifiers used in plant drinks, is considered safe by food safety authorities and is used in small amounts.

For people living with inflammatory bowel disease, avoiding emulsifiers may be beneficial. A recent randomised controlled trial in people with mild to moderately active Crohn’s disease found that those following a low-emulsifier diet were more likely to achieve symptom improvement and remission over eight weeks compared with a control group. However, much of the existing evidence on how emulsifiers may affect the gut microbiome and intestinal barrier comes from laboratory and animal studies, and more human research is needed.

It is also important to consider overall dietary patterns. Diets high in ultra-processed foods may contain much larger amounts of emulsifiers overall. In contrast, a diet based largely on whole plant foods, with occasional foods containing small amounts of emulsifiers (such as plant drinks), is less likely to have the same impact.

For those who prefer to avoid emulsifiers, various plant milks are available without them. However, these products are not always fortified, so it is important to ensure nutrients such as calcium, iodine and vitamin D are obtained from other sources.

Read our complete guide to plant-based milks here.

What about plant-based cheese alternatives?

Plant-based cheese is also classified as ultra-processed. However, like many foods in this category, its nutritional value varies widely depending on the ingredients used.

Many commercial plant-based cheeses are made primarily from coconut oil and starches. These products can be relatively high in saturated fat and salt, typically contain little protein or fibre, and may contain a range of additives, so they fit better with the accepted definition of UPF.

However, other varieties are based on whole plant foods, such as cashews or tofu. These options tend to offer a more favourable nutritional profile. For example, cashew-based cheeses may contain more protein and unsaturated fats, and tofu-based cheeses can provide a useful source of plant protein.

Some plant-based cheeses are also fortified with important nutrients such as vitamin B12, calcium and iodine.

Do plant-based diets contain more ultra-processed foods than other diets?

Not necessarily. In fact, several studies show that consumption of ultra-processed food tends to be very similar, sometimes identical, across plant-based diets and diets that include animals.

Some studies have shown a higher intake of UPF in vegans and vegetarians, which is likely related to the fact that plant-based dairy and meat alternatives are categorised as ultra-processed. These often replace animal-based meat and dairy in the diet, many of which are considered minimally processed foods spanning NOVA groups 1-3.

A plant-based diet can be very high or very low in ultra-processed foods, depending on the choices someone makes, just like any dietary pattern. For example, a minimally processed plant-based diet may include foods such as vegetables and fruits, whole grains, beans and lentils, tofu and tempeh, and nuts and seeds. Whereas a plant-based diet high in UPFs might rely heavily on vegan ready meals, plant-based burgers or sausages, confectionery and snack foods, and sugary drinks.

What should I look out for on food labels?

Rather than focusing solely on whether a food is ultra-processed, it can be more helpful to consider its nutritional quality.

Some things to look out for include:

• High levels of added sugar
• High salt content
• High saturated fat
• Very low fibre
• High in calories

Foods that combine high sugar, salt or fat with low fibre are more likely to contribute to poorer health outcomes. This aligns with the conclusions of an evidence review by the UK Scientific Advisory Committee on Nutrition, that states most of the negative health impacts of UPFs are related to higher calorie, salt, sugar and fat intake.

You can also look at the ingredient list. Very long lists with many unfamiliar ingredients may suggest a highly processed product, although lots of ingredients does not automatically mean it is unhealthy.

Should I try to avoid ultra-processed foods completely?

For most people, the goal does not need to be complete avoidance, but rather building a diet that is mostly made up of minimally processed plant foods. Small amounts of processed foods can still fit within a healthy dietary pattern.

Recommended reading

Ultra-Processed or Ultra-Confused? A Data Sheet for Evidence-Based Choices on UPFs | ProVeg International

Are all ultra-processed foods bad? A critical review of the NOVA classification system by Jimmy Chun Yu Louie

Unpacking the Evidence on Ultra-Processed Foods & Plant-Based Meat: A Summary for Healthcare Professionals by PAN International

Ultra-processed food and cancer | World Cancer Research Fund

Rethinking Easter: choosing lentils instead of lamb

By Shireen Kassam, Founder and Director of Plant-Based Health Professionals UK

Health Benefits of Lentils

Lentils are edible seeds of the legume family that grow in pods. They are nutritional powerhouses that provide an excellent source of plant-based protein, fibre, and essential vitamins and minerals such as iron, magnesium, B vitamins, zinc, and folate. Higher intakes of lentils and other legumes have been associated with better cardiometabolic health, lower risk of cancer and a reduction in premature mortality. Lentils have a low glycaemic index, helping to stabilise blood sugar levels, reducing the risk of type 2 diabetes and improving glucose control in people with diabetes. Lentils have also been shown to have anti-inflammatory and anti-microbial properties, while promoting gut health and immune function.

Health Concerns around Lamb

In contrast, consumption of red meat such as lamb has been consistently associated with adverse health outcomes, including an increased risk of cardiovascular diseases, type 2 diabetes and cancer. In fact, the World Health Organisation has classified red meat as a group 2a carcinogen – a probable cause of cancer. These negative impacts on health are due, in part, to the presence of saturated fat and haem iron in lamb, plus the generation of cancer-causing chemicals when cooking red meat at high heat. In addition, lamb lacks beneficial nutrients such as fibre and other anti-inflammatory and antioxidant compounds present in plant foods that support gut health and immune function.

The Environmental Impact of Lamb

The environmental consequences of raising ruminant animals, such as lamb, for food is staggering. Not only is there the issue of carbon emissions, but methane emissions from burps and manure have a greater warming potential and will prevent us from meeting our climate commitments. In the UK, more than 60% of greenhouse gas emissions from farming arise from the production of red meat and dairy. The production of meat from lamb is hugely inefficient. In the UK around 20% of farmland is dedicated to raising sheep but these roughly 32 million sheep provide only 1% of our energy intake. The conversion of feed for the animals into energy for people is a ratio of 5 to 1. The UK is the sixth largest producer and third largest exporter of lamb, a food we do not need for maintaining good health. This vast amount of land dedicated to raising sheep is leading to the degradation of soil, habitat destruction, water and land pollution and biodiversity loss.

It is often stated that the uplands of the UK (hills, dales, moors and mountains) are not suitable for anything other than grazing animals. This is far from true. These areas could instead be used to grow tree crops (fruit and nuts), rewilded to restore natural habitats, and provide other ecosystem services such as natural flood barriers in watershed management.

Lentils: A Climate-Friendly Protein

Lentils, on the other hand, have an exceptionally low environmental footprint. They require minimal water and land compared to farming animals and can even improve soil health by fixing nitrogen and thus reducing the need for synthetic fertilisers. The production of lentils generates far fewer greenhouse gas emissions than meat production, making them a climate-friendly food choice. By shifting to consuming plant-sources of protein we would free up 75% of farmland in the UK, that is land mass the size of Scotland, which could be used to restore nature and capture carbon.

For food security and sovereignty, we need to vastly increase our domestic production of fruit, vegetables, whole grains and legumes, which this land could also be used for and thus further supporting rural livelihoods. Currently we only dedicate 15% of farmland to growing fruit, vegetables and legumes with the UK relying heavily on imported fruit and vegetables. Even then there is insufficient availability of these foods for people to consume the recommended five portions a day. By opting for lentils this Easter, we take a small but meaningful step toward reducing our ecological impact, preserving the planet for future generations and ensuring our food security.

Ethical Considerations: Compassion Over Tradition

Easter is a celebration of renewal and life, yet the tradition of eating lamb contradicts this message. Millions of lambs are slaughtered for Easter worldwide with more than 2 million killed in the UK at the mere age of six months. Contrast this with the natural lifespan of sheep of around 12 years. These young animals we love to observe in fields around the UK are removed from their mothers and rendered unconscious by firing a metal bolt into their heads or electrically stunned before being killed in a slaughterhouse.

By choosing lentils over lamb, we embrace a more compassionate approach to food. Lentils provide all the nourishment we need without the suffering that comes with meat production. In an age where plant-based alternatives are more accessible and delicious than ever, there is no need to take an animal’s life for our celebrations. Instead, we can honour Easter’s themes of renewal and kindness by embracing plant-based meals that are nourishing for both body and soul.

A Delicious Easter Alternative

Lentils are incredibly versatile and can be used in a variety of Easter dishes. From hearty lentil stews, lentil loaf,  shepherd’s pie to lentil-based curries, there are countless ways to create a festive, flavourful meal without relying on meat. Lentils absorb seasonings beautifully, allowing for a range of culinary possibilities that can delight even the most devoted meat eaters. You can add flavour to meals with onion, garlic, bay leaves, herbs, and vegetable stock during cooking. Puy lentils also add a wonderful texture and boost fibre and protein in salads.

Why not try our 21-day plant-based challenge to receive free tips, email support and recipes for delicious and nourishing plant-based meals?

Eid after Ramadan: a time to celebrate with compassion, health and stewardship

By Dr Shireen Kassam, Founder and Director, Plant-Based Health Professionals UK

Eid al-Fitr follows the most sacred month in the muslim calendar and is a moment of happiness and joy. The word Eid means celebration or festival and Eid al-Fitr is the festival of the breaking of the fast. After a month of fasting, reflection and spiritual renewal, we gather with family and our communities to give thanks, share food and express gratitude for our blessings. It is a celebration rooted in compassion, self-discipline and generosity.

But as we prepare our festive tables, it is worth asking: how do our food choices reflect the very values Ramadan has strengthened within us?

As a Muslim and a physician, I believe that choosing a more plant-based way to celebrate Eid is not only consistent with Islamic ethics, it is a powerful expression of them.

Islamic ethics: moderation, mercy and stewardship

The Qur’an and the Sunnah provide a framework for living that prioritises balance (mīzān), moderation and compassion. The Prophet Muhammad did not eat meat daily; in fact, historical accounts suggest it was consumed occasionally and in moderation. Excess was discouraged. Ramadan itself trains us in restraint and self-control, qualities that should not disappear once the fast ends.

A recent qualitative study of British Muslims explored attitudes to meat consumption and plant-based diets. The researchers found that while meat is often perceived as a “God-given blessing”, participants also recognised the prophetic tradition of moderation and the Islamic duty of stewardship over the Earth. Importantly, environmental responsibility, being “custodians of the earth”, emerged as a core Islamic value, even if not always translated into daily dietary practice.

Health as an Islamic obligation

Islam teaches that our bodies are an amanah – a trust. We are responsible for preserving our health. Yet we know that in the UK, high meat consumption is associated with increased risks of cardiovascular disease, type 2 diabetes and certain cancers. The same study highlights that British Muslims face disproportionate rates of diet-related disease and often consume more meat than the national average. The participants also identified health as a key motivator for reducing meat intake. This aligns with the scientific evidence: well-planned plant-based diets are associated with lower risks of heart disease, diabetes, obesity and some cancers. They are also rich in fibre, phytonutrients and antioxidants, nutrients notably absent in animal products.

Rethinking meat as a “blessing”

The study describes how meat is often framed as a blessing, particularly in the context of Eid. Yet a blessing is not something to be exploited without limit. A blessing calls for gratitude, humility and responsibility.

In today’s world of industrial animal agriculture, the scale and conditions of meat production sit uneasily alongside Islamic teachings on mercy towards animals and environmental care. With 85% of farm animals in the UK raised in industrial factory farms, which are known to disregard the rights of animals, eating their flesh can no longer be regarded as desirable.

Eid as an opportunity for leadership

Food is central to Eid celebrations. Hospitality is a cherished part of our culture. But generosity does not require excess meat. A beautifully prepared plant-based feast – fragrant lentil dishes, spiced chickpeas, vegetable biryanis, stuffed vine leaves, fresh salads, dates and desserts – honours our culinary heritage while aligning with our ethics.

The study also highlights the powerful role of community norms and religious leaders in shaping dietary habits. Imagine if our faith leaders spoke more openly about compassion towards animals, environmental stewardship and health as religious responsibilities.

A compassionate celebration

Ramadan and Eid is an opportunity to align our faith with our ethics. As we break our fast for the final time and celebrate Eid, we can extend compassion beyond ourselves, to our communities, to animals and to the planet.

Resources

Vegan Islam

Animal Welfare in World Religion: Teaching and Practice, by Joyce D’Silva

Mulla Z, Coupe N. Halal and healthy: A qualitative study of British Muslim perspectives on meat consumption and plant-based diets. Appetite. 2026 Feb 6;221:108496. doi: 10.1016/j.appet.2026.108496