Physicians' Academy for Cardiovascular Education

Following Mediterranean diet may confer more CV benefit than avoiding less healthy foods

Literature - Stewart et al., Eur Heart J. 2016

Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease

Stewart RAH, Wallentin L, Benatar J, et al.
Eur Heart J 2016; published online ahead of print


European and American guidelines recommend a healthy diet, including lots of fruit, vegetables, and fish, and avoiding sodium, saturated fats, and refined carbohydrates [1,2]. The Mediterranean dietary pattern is such a healthy diet, and has been associated with reduced CV and total mortality [3-6]. However, there are limited data regarding the relationship between a healthy dietary pattern and outcomes, in patients with stable CHD [7].
This study evaluated whether a ‘Mediterranean’ (assigning points for increased consumption (0 lowest to 4 highest frequency) of whole grains, vegetables, legumes, fruits and fish, and for less consumption of meat, and alcohol consumption (0 points for none or potentially hazardous drinking, 2 or 4 points for some or moderate consumption) or a ‘Western’ (assigning points for increased consumption of refined grains, sweets and deserts, sugared drinks, and deep fried foods (0 lowest to 4 highest frequency) diet score (MDS, WDS) predicts MACE in a global population of 15 482 high-risk patients with stable CHD who participated in the STABILITY trial, with the use of a simple self-administered food frequency questionnaire (FFQ) [8]. MACE was defined as non-fatal myocardial infarction, non-fatal stroke, or death from a CV cause.

Main results

  • After a median follow-up of 3.7 years MACE occurred in 7.3% of 2885 subjects with an MDS ≥15, 10.5% of 4018 subjects with an MDS of 13–14, and 10.8% of 8579 subjects with an MDS ≤12
  • There was no association between WDS and MACE (adjusted model +1 category HR: 0.99; 95% CI: 0.97-1.01).
  • There was a non-linear association between MDS and MACE, such that for MDS ≤12 (n = 8579, 56% of subjects), there was no significant association between increase in MDS and MACE, but for MDS scores >12, a one unit increase in MDS was associated with a lower risk of MACE (HR for +1 increase in MDS 0.93; 95% CI: 0.90-0.96; P < 0.0001), and this association remained statistically significant after stepwise adjustment for covariates
  • A simple MDS based on daily consumption of fruit and vegetables, and weekly consumption of alcohol and fish was also associated with a lower risk of MACE. The HR for each one point increase in the simple MDS was adjusted for treatment only: 0.90; 95% CI: 0.87–0.94; P = 0.0001, and in the fully adjusted model: 0.94; 95% CI: 0.90–0.98; P = 0.002


In a large cohort of high-risk patients with stable CHD, a Mediterranean diet was associated with a lower risk of MACE and all-cause death, while a less healthy Western diet was not associated with MACE. These findings suggest that the consumption of healthy foods may be more important for CAD secondary prevention than the avoidance of less healthy foods. 
Find this article online at Eur Heart J


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8. White HD, Held C, Stewart RA, et al, on behalf of the STABILITY Steering Committee. Study design and rationale for the clinical outcomes of the STABILITY Trial (STabilisation of Atherosclerotic plaque By Initiation of darapLadIb TherapY) comparing darapladib versus placebo in patients with clinical coronary heart disease). Am Heart J 2010;160:655–661.

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