Does recommending healthy diets in general practice benefit secondary prevention of cardiovascular disease? A systematic review and meta-analysis.
Clinical Snapshot
PICO Framework
| P — Population | Patients with established cardiovascular disease (CVD) in primary care settings |
| I — Intervention | Healthy dietary recommendations (Mediterranean diet, low-fat, low-sodium, high-fibre, fat-replacement diets) |
| C — Comparator | Minimal or no dietary advice/usual care |
| O — Outcomes | All-cause mortality, CVD mortality, and CVD recurrence |
Bottom Line
This systematic review suggests that Mediterranean diet recommendations in general practice may benefit CVD secondary prevention, with RCT evidence showing 60% reduction in CVD mortality and observational data indicating 29% reduction in all-cause mortality. However, the evidence quality is limited by substantial heterogeneity between studies and bias concerns in most included trials. While the Mediterranean diet shows the most consistent benefits across both RCTs and cohort studies, GPs should interpret these findings cautiously given the methodological limitations. The authors appropriately conclude that more rigorous studies with clearly defined dietary interventions are needed. Current evidence supports discussing Mediterranean diet principles with CVD patients as part of comprehensive secondary prevention, but expectations should be managed regarding the certainty of benefits.
Key Findings
P Value: Not explicitly reported
Effect Size: Mediterranean diet: CVD mortality RR 0.40 (RCTs), all-cause mortality RR 0.71 (cohorts)
Primary Outcome: Mediterranean diet showed significant reduction in CVD mortality in RCTs
Nnt Or Sensitivity: 29% reduction in all-cause mortality, 25% reduction in CVD mortality, 17% reduction in CVD recurrence for highest vs lowest dietary adherence
Confidence Interval: CVD mortality: 95% CI 0.19-0.83; All-cause mortality: 95% CI 0.65-0.78
Clinical Application
Mediterranean diet recommendations are practical in primary care but require clear definition and patient education resources Relevant to Australian general practice under RACGP guidelines for CVD management; Mediterranean diet components align with Australian Dietary Guidelines; potential PBS implications for dietitian referrals Patients with established CVD in general practice settings requiring secondary prevention
Abstract
BACKGROUND: Suboptimal diet is the main preventable risk factor globally for cardiovascular disease (CVD), posing major burden for primary care. However, healthy dietary recommendations' evidence in patients with established CVD is unclear. AIM: Systematically review and meta-analyse dietary patterns' effect on CVD patients' all-cause and CVD mortality, and CVD recurrence. METHOD: Publication databases were searched for randomised controlled trials (RCTs) (≥6 months follow-up) and prospective cohort studies. Random-effects meta-analysis calculated relative-risks (RR) and 95% confidence-intervals (95% CI). Cochrane bias risk tools assessed study quality. RESULTS: Screening 28 291 abstracts identified 41 articles meeting inclusion criteria. Nineteen articles from 14 unique RCTs conducted 1956-2020, enrolling 14 065 CVD patients, compared fat-replacement, Mediterranean, low-fat, low-sodium, and high-fibre diets with minimal/no dietary advice. Pooled results showed no diet intervention significantly impacted mortality/CVD outcomes. However, stratified meta-analysis revealed a Mediterranean-diet significantly reduced CVD mortality (RR: 0.40; 95% CI: 0.19, 0.83). Twenty-two cohort studies, conducted 1976-2017 for 104 386 CVD patients, predominantly assessed a Mediterranean diet (60%), showing greatest healthy dietary pattern adherence significantly reduced all-cause mortality by 29% (0.71; 0.65, 0.78), CVD mortality by 25% (0.75; 0.66, 0.84), and CVD recurrence by 17% (0.83; 0.75, 0.92). Overall, there was considerable between-study heterogeneity (RCTs: I2 = 34-60%, cohorts: I2 = 49-76%) partly explained by disparate geographical locations, and studies were mainly classified as of some concerns (65% RCTs) or high bias risk (52% cohorts). CONCLUSION: GPs providing healthy dietary advice, particularly the Mediterranean diet, likely enhances CVD secondary prevention. However, cogent studies with clearly defined diets are required to bolster the evidence.
References
- 1.Goldberg, A., Sajjad, W., Griep, L. O., & Cruijsen, E. (2026). Does recommending healthy diets in general practice benefit secondary prevention of cardiovascular disease? A systematic review and meta-analysis. British Journal of General Practice. https://doi.org/10.3399/bjgp26X745221
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