Good news: You don't have to skip bread or wine on this heart-friendly diet!

Karla Walsh
July 01, 2021
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You probably could have guessed that a buttery bacon, egg and cheese biscuit isn't exactly the best breakfast for heart health. But we now have scientific proof about which common American eating style is likely most detrimental for our cardiovascular system.

For the new study published in the Journal of the American Heart Association (JAHA), scientists dissected self-reported diet data from more than 21,000 individuals 45 or older who signed up to participate in a long-term national study "Reasons for Geographic and Racial Differences in Stroke (REGARDS)." With information from questionnaires completed by people with and without family history for heart disease, the research team discovered that a Southern-style diet is correlated to higher risk of sudden cardiac death (AKA cardiac arrest) than people who had lower adherence to a Southern-style diet. The risk differential is so vast, in fact, that some cardiologists now consider North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas and Louisiana to be the "Stroke Belt."

Fried Chicken and soda on a table
Credit: Getty Images / LightFieldStudios /

In contrast, those who followed a Mediterranean-style diet had significantly lower risk for sudden cardiac death compared to their non-Mediterranean noshing peers.

Here's how they describe the two:

  • Southern Diet: Rich in added fats, fried foods, processed meats and sugary drinks.
  • Mediterranean Diet: Rich in vegetables, fruits, fish, whole grains and legumes; light on meat and dairy.

Participants were asked how often—and how much—of 110 different food items they consume over the course of the year, then broke down general patterns into categories based on each individual's most commonly eaten items. In addition to Southern and Mediterranean, they sorted diets by sweets-heavy, higher-alcohol, convenience/takeout-strong or plant-based.

"All participants had some level of adherence to each pattern, but usually adhered more to some patterns and less to others," says James M. Shikany, Dr.P.H., F.A.H.A., the study's lead author and professor of medicine and associate director for research in the Division of Preventive Medicine at the University of Alabama at Birmingham in the American Heart Association (AHA) study overview. "For example, it would not be unusual for an individual who adheres highly to the Southern pattern to also adhere to the plant-based pattern, but to a much lower degree."

After 10 years of follow-ups every 6 months to check for cardiovascular disease events, more than 400 sudden cardiac deaths were noted among the 21,000 individuals studied. The Southern-style diet followers had a 46% higher risk for sudden cardiac death compared to those who ate the least Southern fare, while Mediterranean-style diet devotees had 26% lower risk of sudden cardiac death than those who ate the least Mediterranean fare. (By the way, sudden cardiac death accounts for 1 in every 7.5 deaths in the United States in 2016, or almost 367,000 deaths, according to 2019 AHA data.)

All foods fit and many home cooks, recipe developers and celebrity chefs, including Carla Hall, prove that Southern fare can be remarkably nutritious too. Case in point: Our dozens of healthy Southern recipes.

"While this study was observational in nature, the results suggest that diet may be a modifiable risk factor for sudden cardiac death, and, therefore, diet is a risk factor that we have some control over," Dr. Shikany says. "Improving one's diet—by eating a diet abundant in fruits, vegetables, whole grains and fish such as the Mediterranean diet and low in fried foods, organ meats and processed meats, characteristics of the Southern-style dietary pattern, may decrease one's risk for sudden cardiac death."

For those looking for distinct guidelines, Stephen Juraschek, M.D., Ph.D., a member of the American Heart Association's Nutrition Committee of the Lifestyle and Cardiometabolic Health Council, suggests that we aim to eat at least 5 to 6 servings of fruits and vegetables per day, working up to 8 or 9 daily, if possible.

Yes, canned and frozen fruits and vegetables count! Accessibility to healthy food in any form is something the study authors admit is vital to consider: "This raises important points about health equity, food security and social determinants of health," Juraschek says in the AHA brief. "The authors describe the 'Southern Diet' based on the U.S. geography associated with this dietary pattern, yet it would be a mistake for us to assume that this is a diet of choice. I think American society needs to look more broadly at why this type of diet is more common in the South and clusters among some racial, ethnic or socioeconomic groups to devise interventions that can improve diet quality. The gap in healthy eating between people with means and those without continues to grow in the U.S., and there is an incredible need to understand the complex societal factors that have led and continue to perpetuate these disparities."

Check out our Good Food for All guide for more about this very timely and important topic, including why nutrition recommendations need to be more culturally relevant and 10 cheap and healthy foods to buy, according to a dietitian (Mediterranean diet-approved foods such as canned tomatoes, beans, tuna and frozen berries all made the list!).