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Changing diet and alcohol consumption

A cardio-protective (Mediterranean) diet is the first line dietary advice in preventing cardiovascular disease (CVD). It can be used in primary or secondary prevention and in conjunction with specific dietary advice related to individually relevant risk factors (diabetes, high cholesterol, high blood pressure, overweight). In the following section, we describe the different components of a cardio-protective diet in secondary prevention, as well as providing practical advice on how to implement it.

reviewed by Prof. Demosthenes Panagiotakos, August 2021

Mediterranean-type of diet

  • Advise people to consume a Mediterranean-type diet [1-3]. This is a cardio-protective eating plan based on all the classic foods and beverages that were consumed in the countries bordering the Mediterranean Sea in the 1960s.
  • The Mediterranean-type of diet is high in unsaturated fats (e.g. olive oil, nuts, seeds), low in saturated fats (e.g. red meat, full fat dairy) and overall contains more fresh than processed food items (e.g. fruit, vegetables, whole grains).

 Dietary Fat & Cholesterol

  • Saturated fat (e.g. found in red-meat, cheese, full fat dairy) increases the total and LDL-cholesterol, a major CVD risk factor .
  • Trans-fat (e.g. found in fried and baked goods) increases the total and LDL- cholesterol, as well as lowering the beneficial HDL cholesterol.
  • Changing the type of fat in our diet (replacing saturated fats with unsaturated fats) may reduce the risk of CVD [4]. Unsaturated fats are found in olive oil, nuts, seeds and oily fish.
  • Eating foods that naturally contain cholesterol (e.g. eggs, shellfish, organ meats) have less impact on blood cholesterol levels than eating foods that are high in saturated fat.

Dietary Fibre

  • Dietary fibre (e.g. found in fruit, vegetables, legumes, wholegrain foods) helps to reduce the risk of CVD [5]. It regulates the blood sugar levels and helps to lower total and LDL cholesterol levels.


  • Excess salt is associated with increased blood pressure levels. The recommended intake is less than 5 g of salt per day.
  • A small reduction in salt intake of 1 g per day can lead to a significant reduction in blood pressure [6].

Soft Drinks & Alcoholic Drinks

  • Regular consumption of sugar-sweetened soft drinks is associated with excess weight, the metabolic syndrome and type 2 diabetes, all of which are risk factors for CVD.
  • Excess alcohol intake is associated with increased blood pressure and body weight, major risk factors for CVD.

Plant Sterols

  • Functional foods containing sterols/stanols can be used to lower LDL cholesterol levels by 10% on average, when taken in the correct daily dose (2 g/day) [7].


  • Do not recommend nutritional supplementation (such as omega-3 fatty acids, antioxidant or folic acid supplements) to reduce the risk of CVD [8].
Tips for a Heart Healthy Diet
Replace saturated fat with unsaturated fat
  • Replace red-meat with oily fish such as mackerel, trout, sardines or salmon.
  • Replace butter with olive oil or canola oil.
  • Replace unhealthy snacks such as biscuits with a handful of unsalted nuts.
Reduce intake of trans-fats
  • Read food labels and avoid foods containing hydrogenated oils.
  • Limit intake of biscuits, pies, cakes and fried foods.
Increase fibre intake
  • Aim for a minimum of 5 servings of fruit and vegetables per day. 1 serving = 1 medium piece of fruit (e.g. apple, orange), 2 small pieces of fruit (e.g. plums, kiwis), ½ cup of cooked vegetables, a bowl of salad.
  • Base your meals on vegetables, salad and fruit. Add salad vegetables to sandwiches.
  • Choose fruit and raw vegetables as healthy snacks.
Reduce salt intake
  • Replace salt with healthier alternatives such as fresh and dried herbs, spices, black pepper, chilli and lemon.
  • Remove the salt cellar from the table.
  • Choose fresh foods instead of processed and canned foods.
Limit alcohol intake
  • Limit alcohol intake to 2 glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women.
  • Aim for at least two alcohol free days in the week.


[1] De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction. Circulation. 1999 Feb 16;99(6):779-85.

[2] Esposito K, Kastorini CM, Panagiotakos DB, Giugliano D. Mediterranean diet and metabolic syndrome: an updated systematic review. Rev Endocr Metab Disord. 2013 Sep;14(3):255-63. doi: 10.1007/s11154-013-9253-9. Review. PubMed PMID: 23982678.

[3] Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011 Mar 15;57(11):1299-313. doi: 10.1016/j.jacc.2010.09.073. PubMed PMID: 21392646.

[4] Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. The Cochrane Library. 2015 Jan 1.

[5] Threapleton DE, Greenwood DC, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, Cade JE, Gale CP, Burley VJ. Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ. 2013 Dec 19;347:f6879.

[6] He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. Journal of Human Hypertension. 2002 Nov 1;16(11):761.

[7] Ras RT, Geleijnse JM, Trautwein EA. LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. British Journal of Nutrition. 2014 Jul 28;112(02):214-9.

[8] National Institute for Health and Clinical Excellence (NICE). MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction. National Clinical Guideline Centre; 2013.

[9] Croí, West of Ireland Cardiac Foundation. Nutrition and dietary information. Galway: Croí, West of Ireland Cardiac Foundation; 2015. Available from:

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.