Cardiovascular risk under low-fat, Mediterranean, and AHA diets: a target trial emulation in US adults.

Authors

Yi Li, Dalia Stern, Miguel A Martínez-González, Shuyuan Yang, Jorge E Chavarro, JoAnn E Manson, Eric B Rimm, Robert W Platt, Yu-Han Chiu

Published in

The American journal of clinical nutrition. Pages 101404. Jun 20, 2026. Epub Jun 20, 2026.

Abstract

The Mediterranean diet reduces cardiovascular disease (CVD) risk in European populations, but its long-term effectiveness in US adults, particularly relative to the American Heart Association (AHA)-2020 dietary goals, remains uncertain. We compared 20-year CVD risk in US adults under sustained adherence to a low-fat diet, a Mediterranean diet, and the food-based AHA-2020 dietary goals.
We emulated a target trial using data from the Nurses' Health Study and Health Professionals Follow-up Study among 12,197 US adults aged 55-80 years with diabetes or ≥3 major CVD risk factor. Diet was assessed every 4 years via validated food frequency questionnaires. The primary outcome was CVD, defined as nonfatal myocardial infarction, coronary revascularization, stroke, and CVD death, confirmed by medical records. We applied the parametric g-formula to estimate 20-year CVD risk under each dietary strategy.
Over 20 years, 3,469 CVD cases occurred (1,451 men and 2,018 women). Pooled absolute risks of CVD were 35.9% (95% CI, 33.1%, 38.5%) under the low-fat diet, 28.2% (95% CI: 25.8%, 31.4%) under the Mediterranean diet, and 31.2% (95% CI: 29.1%, 33.4%) under the AHA-2020 dietary goals. Compared to the low-fat diet, estimated risk ratios were 0.79 (95% CI: 0.70, 0.91) for the Mediterranean diet and 0.87 (95% CI: 0.79, 0.96) for the AHA-2020 dietary goals. In a general population not selected for age, diabetes, or CVD risk factors, the corresponding risk ratios were 0.90 (95% CI: 0.84, 0.95) and 0.94 (95% CI: 0.90, 0.99).
Sustained adherence to the Mediterranean diet and the AHA-2020 dietary goals were estimated to have a lower 20-year risk of CVD compared with a low-fat diet in US adults.

PMID:
42323165
Bibliographic data and abstract were imported from PubMed on 22 Jun 2026.

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