Mediterranean and Low-Fat Diet for Long-Term Secondary Prevention of Cardiovascular Disease
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- The authors of this study conducted a single-center, randomised clinical trial to compare the effect of a Mediterranean versus low-fat diet for secondary prevention in 1002 patients with established coronary heart disease. Multivariable hazard ratios for a composite of major cardiovascular events (myocardial infarction, revascularisation, ischaemic stroke, peripheral artery disease, and cardiovascular death) favored the Mediterranean diet in two different models (HR, 0.72; HR, 0.75). Beneficial effects appeared to be restricted to men (HR, 0.67; P = .02) versus women, in whom there was no difference between diet groups.
- These findings suggest that the Mediterranean diet may be more effective in preventing secondary cardiovascular events in patients with established coronary disease compared with low-fat diets. Dietary reduction remains a critical element of primary and secondary prevention of atherosclerotic cardiovascular disease, and these data highlight the effectiveness of the Mediterranean diet in risk reduction for patients with established coronary disease.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND
Mediterranean and low-fat diets are effective in the primary prevention of cardiovascular disease. We did a long-term randomised trial to compare the effects of these two diets in secondary prevention of cardiovascular disease.
METHODS
The CORDIOPREV study was a single-centre, randomised clinical trial done at the Reina Sofia University Hospital in Córdoba, Spain. Patients with established coronary heart disease (aged 20-75 years) were randomly assigned in a 1:1 ratio by the Andalusian School of Public Health to receive a Mediterranean diet or a low-fat diet intervention, with a follow-up of 7 years. Clinical investigators (physicians, investigators, and clinical endpoint committee members) were masked to treatment assignment; participants were not. A team of dietitians did the dietary interventions. The primary outcome (assessed by intention to treat) was a composite of major cardiovascular events, including myocardial infarction, revascularisation, ischaemic stroke, peripheral artery disease, and cardiovascular death. This study is registered with ClinicalTrials.gov, NCT00924937.
FINDINGS
From Oct 1, 2009, to Feb 28, 2012, a total of 1002 patients were enrolled, 500 (49·9%) in the low-fat diet group and 502 (50·1%) in the Mediterranean diet group. The mean age was 59·5 years (SD 8·7) and 827 (82·5%) of 1002 patients were men. The primary endpoint occurred in 198 participants: 87 in the Mediterranean diet group and 111 in the low-fat group (crude rate per 1000 person-years: 28·1 [95% CI 27·9-28·3] in the Mediterranean diet group vs 37·7 [37·5-37·9] in the low-fat group, log-rank p=0·039). Multivariable-adjusted hazard ratios (HRs) of the different models ranged from 0·719 (95% CI 0·541-0·957) to 0·753 (0·568-0·998) in favour of the Mediterranean diet. These effects were more evident in men, with primary endpoints occurring in 67 (16·2%) of 414 men in the Mediterranean diet group versus 94 (22·8%) of 413 men in the low-fat diet group (multiadjusted HR 0·669 [95% CI 0·489-0·915], log-rank p=0·013), than in 175 women for whom no difference was found between groups.
INTERPRETATION
In secondary prevention, the Mediterranean diet was superior to the low-fat diet in preventing major cardiovascular events. Our results are relevant to clinical practice, supporting the use of the Mediterranean diet in secondary prevention.
FUNDING
Fundacion Patrimonio Comunal Olivarero; Fundacion Centro para la Excelencia en Investigacion sobre Aceite de Oliva y Salud; local, regional, and national Spanish Governments; European Union.
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Additional Info
Disclosure statements are available on the authors' profiles:
Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV): a randomised controlled trial
Lancet 2022 May 04;[EPub Ahead of Print], J Delgado-Lista, JF Alcala-Diaz, JD Torres-Peña, GM Quintana-Navarro, F Fuentes, A Garcia-Rios, AM Ortiz-Morales, AI Gonzalez-Requero, AI Perez-Caballero, EM Yubero-Serrano, OA Rangel-Zuñiga, A Camargo, F Rodriguez-Cantalejo, F Lopez-Segura, L Badimon, JM Ordovas, F Perez-Jimenez, P Perez-Martinez, J Lopez-MirandaFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Low-fat or Mediterranean diet? What should we recommend for our secondary prevention patients?
In the 1950s, Ancel Keys noticed that poor people in the small towns of southern Italy were healthier than their relatives who immigrated to the United States. He concluded that the food must be the difference. The diet in the Mediterranean basin, which historians call “the cradle of society,” consisted of a high proportion of fruits, vegetables, legumes, and cereals, with white meat and fish as the main protein source and olive oil as the main fat source.
Our current recommendation for patients with adverse cardiovascular (CV) events is to limit fat intake. However, should we be more prescriptive as to what they should be eating to prevent future events?
This study conducted in Spain evaluated 1002 patients aged between 20 and 75 years with established coronary heart disease and randomly assigned them to either a Mediterranean diet or a low-fat diet. The follow-up period was 7 years. The participants had to be stable, with no events in the previous 6 months, and they could not have conditions that would affect their longevity. This means that a healthier group of patients were selected for this study.
Dieticians worked with the patients to get them onto their proper diets. The dieticians and patients knew which group the patients were assigned to. However, the physicians and outcomes adjudicators were blinded to the randomisation. To ensure that cost was not a barrier, extra-virgin olive oil was provided free of charge to the Mediterranean group (1 L per week per household), and free healthy food packs rich in complex carbohydrates were given to the low-fat group.
The primary outcome was a composite of major CV events, myocardial infarction, revascularization, ischemic stroke, peripheral artery disease, and CV death. There were 111 events in the low-fat group and 87 events in the Mediterranean group, representing a 25% reduction in events in favor of the Mediterranean diet (HR, 0.745; P = ·040).
For men, the reduction was 33% (HR, 0.669; P = ·013). For women, there was no difference between the groups. However, there were only 175 women in the trial, so the lack of effect may be just due to the small number.
The participants who had high dietary adherence during the study, meaning adherence ≥80%, did even better. The adherent participants in the Mediterranean group had a 40% reduction in events (HR, 0.602; P = ·026). Also, patients who did not have a family history of coronary heart disease, did not have hypertension, had LDL cholesterol <100 mg/dL, and were <70 years of age all did better on the Mediterranean diet.
The lipid profile and glucose levels of the participants did not change significantly during the study. Looking at the two diets side by side, the differences I noted between the Mediterranean and low-fat diets were that the Mediterranean diet had more olive oil, nuts, white meat, and sofrito (a homemade sauce with garlic, onion, aromatic herbs, and tomato cooked slowly in olive oil), and wine was allowed. Overall, the Mediterranean diet is very doable and it can help reduce CV events. Therefore, we should recommend it to patients with CV diseases.
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