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Long-term dietary adherence and changes in dietary intake in coronary patients after intervention with a Mediterranean diet or a low-fat diet: the CORDIOPREV randomized trial

European Journal of Nutrition volume 59, pages 2099–2110 (2020)Cite this article

Abstract

Purpose

Adherence to a healthy dietary pattern positively influences clinical outcomes in cardiovascular prevention, but long-term adherence is difficult to maintain. We evaluated 5-year changes in dietary habits, adherence achieved, and its maintenance in a cohort of coronary patients from the CORDIOPREV study.

Methods

1002 coronary patients were randomized to a Mediterranean diet (n = 502) or a low-fat diet (n = 500) and received individual-group-telephone visits and personalized dietary advice. A validated food-frequency questionnaire, a 14-point Mediterranean diet adherence screener, and a 9-point low-fat diet adherence score were used. Dietary adherence was categorized into Low, Medium, and High Adherence. Changes in nutrient intake, food consumption, and adherence were analyzed on a yearly basis. The maintenance of long-term dietary adherence was evaluated using data after the first year and fifth year.

Results

From baseline to 5 years, significant increases were observed in overall dietary adherence (Mediterranean diet from 8.9 to 11.4; low-fat diet from 3.9 to 7.1) and in the percentage of patients considered High Adherence (Mediterranean diet from 41 to 89%; low-fat diet from 4 to 67%). When we evaluated the maintenance of adherence, patients considered Low and Medium Adherence at 1 year increased their adherence at the 5 years with both diets and patients considered High Adherence maintained their adherence with a Mediterranean diet, but decreased their adherence with a low-fat diet.

Conclusions

A comprehensive dietary intervention results in an overall long-term improvement and maintenance of adherence to the Mediterranean and low-fat diets. In our population, the Mediterranean diet group achieved a high level of adherence in the short term which was maintained in the long term.

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References

  1. World Health Organization (Website). Press center. Accessed Dec 18

  2. Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, Gomez-Gracia E, Ruiz-Gutierrez V, Fiol M, Lapetra J, Lamuela-Raventos RM, Serra-Majem L, Pinto X, Basora J, Munoz MA, Sorli JV, Martinez JA, Martinez-Gonzalez MA (2018) Retraction and republication: primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–90. N Engl J Med 378(25):2441–2442. https://doi.org/10.1056/nejmc1806491

    Article  PubMed  Google Scholar 

  3. Delgado-Lista J, Perez-Martinez P, Garcia-Rios A, Alcala-Diaz JF, Perez-Caballero AI, Gomez-Delgado F, Fuentes F, Quintana-Navarro G, Lopez-Segura F, Ortiz-Morales AM, Delgado-Casado N, Yubero-Serrano EM, Camargo A, Marin C, Rodriguez-Cantalejo F, Gomez-Luna P, Ordovas JM, Lopez-Miranda J, Perez-Jimenez F (2016) CORonary Diet Intervention with Olive oil and cardiovascular PREVention study (the CORDIOPREV study): rationale, methods, and baseline characteristics: a clinical trial comparing the efficacy of a Mediterranean diet rich in olive oil versus a low-fat diet on cardiovascular disease in coronary patients. Am Heart J 177:42–50. https://doi.org/10.1016/j.ahj.2016.04.011

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. National Cholesterol Education Program Expert Panel on Detection E, Treatment of High Blood Cholesterol in A (2002) Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) final report. Circulation 106(25):3143–3421

    Article  Google Scholar 

  5. Barzi F, Woodward M, Marfisi RM, Tavazzi L, Valagussa F, Marchioli R, Investigators GI-P (2003) Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI-Prevenzione trial. Eur J Clin Nutr 57(4):604–611. https://doi.org/10.1038/sj.ejcn.1601575

    CAS  Article  PubMed  Google Scholar 

  6. Trichopoulou A, Bamia C, Trichopoulos D (2005) Mediterranean diet and survival among patients with coronary heart disease in Greece. Arch Intern Med 165(8):929–935. https://doi.org/10.1001/archinte.165.8.929

    Article  PubMed  Google Scholar 

  7. Sofi F, Abbate R, Gensini GF, Casini A (2010) Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 92(5):1189–1196. https://doi.org/10.3945/ajcn.2010.29673

    CAS  Article  PubMed  Google Scholar 

  8. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A (2014) Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 17(12):2769–2782. https://doi.org/10.1017/S1368980013003169

    Article  PubMed  Google Scholar 

  9. Grosso G, Marventano S, Yang J, Micek A, Pajak A, Scalfi L, Galvano F, Kales SN (2017) A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: are individual components equal? Crit Rev Food Sci Nutr 57(15):3218–3232. https://doi.org/10.1080/10408398.2015.1107021

    Article  PubMed  Google Scholar 

  10. Crichton GE, Howe PR, Buckley JD, Coates AM, Murphy KJ, Bryan J (2012) Long-term dietary intervention trials: critical issues and challenges. Trials 13:111. https://doi.org/10.1186/1745-6215-13-111

    Article  PubMed  PubMed Central  Google Scholar 

  11. Desroches S, Lapointe A, Ratte S, Gravel K, Legare F, Turcotte S (2013) Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults. Cochrane Database Syst Rev 2:CD008722. https://doi.org/10.1002/14651858.cd008722.pub2

    Article  Google Scholar 

  12. De Geest S, Sabate E (2003) Adherence to long-term therapies: evidence for action. Eur J Cardiovasc Nurs 2(4):323. https://doi.org/10.1016/S1474-5151(03)00091-4

    Article  PubMed  Google Scholar 

  13. Women’s Health Initiative Study G (2004) Dietary adherence in the Women’s Health Initiative Dietary Modification Trial. J Am Diet Assoc 104(4):654–658. https://doi.org/10.1016/j.jada.2004.01.014

    Article  Google Scholar 

  14. Downer MK, Gea A, Stampfer M, Sanchez-Tainta A, Corella D, Salas-Salvado J, Ros E, Estruch R, Fito M, Gomez-Gracia E, Aros F, Fiol M, De-la-Corte FJ, Serra-Majem L, Pinto X, Basora J, Sorli JV, Vinyoles E, Zazpe I, Martinez-Gonzalez MA (2016) Predictors of short- and long-term adherence with a Mediterranean-type diet intervention: the PREDIMED randomized trial. Int J Behav Nutr Phys Act 13:67. https://doi.org/10.1186/s12966-016-0394-6

    Article  PubMed  PubMed Central  Google Scholar 

  15. Vilaro MJ, Staub D, Xu C, Mathews AE (2016) Theory-based interventions for long-term adherence to improvements in diet quality: an in-depth review. Am J Lifestyle Med 10(6):369–376. https://doi.org/10.1177/1559827616661690

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lemstra M, Bird Y, Nwankwo C, Rogers M, Moraros J (2016) Weight loss intervention adherence and factors promoting adherence: a meta-analysis. Patient Prefer Adher 10:1547–1559. https://doi.org/10.2147/PPA.S103649

    Article  Google Scholar 

  17. Lara J, Evans EH, O’Brien N, Moynihan PJ, Meyer TD, Adamson AJ, Errington L, Sniehotta FF, White M, Mathers JC (2014) Association of behaviour change techniques with effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomised controlled trials. BMC Med 12:177. https://doi.org/10.1186/s12916-014-0177-3

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wibisono C, Probst Y, Neale E, Tapsell L (2016) Impact of food supplementation on weight loss in randomised-controlled dietary intervention trials: a systematic review and meta-analysis. Br J Nutr 115(8):1406–1414. https://doi.org/10.1017/S0007114516000337

    CAS  Article  PubMed  Google Scholar 

  19. Zazpe I, Sanchez-Tainta A, Estruch R, Lamuela-Raventos RM, Schroder H, Salas-Salvado J, Corella D, Fiol M, Gomez-Gracia E, Aros F, Ros E, Ruiz-Gutierrez V, Iglesias P, Conde-Herrera M, Martinez-Gonzalez MA (2008) A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc 108(7):1134–1144. https://doi.org/10.1016/j.jada.2008.04.011

    CAS  Article  PubMed  Google Scholar 

  20. Martin-Moreno JM, Boyle P, Gorgojo L, Maisonneuve P, Fernandez-Rodriguez JC, Salvini S, Willett WC (1993) Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 22(3):512–519

    CAS  Article  Google Scholar 

  21. Fernandez-Ballart JD, Pinol JL, Zazpe I, Corella D, Carrasco P, Toledo E, Perez-Bauer M, Martinez-Gonzalez MA, Salas-Salvado J, Martin-Moreno JM (2010) Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain. Br J Nutr 103(12):1808–1816. https://doi.org/10.1017/S0007114509993837

    CAS  Article  PubMed  Google Scholar 

  22. Moreiras O, Carbajal A, Cabrera L, Cuadrado C (2013) Tablas de composición de alimentos y guía de prácticas, 16ª edn. Ediciones Pirámide (Grupo Anaya, SA), Madrid

    Google Scholar 

  23. Mataix Verdu J, Garcia Diz L, Mañas Almendros M, Martinez de Vitoria E, Llopis Gonzalez J (2009) Tabla de composición de alimentos españoles, 5ª edn. Editorial Universidad de Granada, Granada

    Google Scholar 

  24. Schroder H, Fito M, Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Lamuela-Raventos R, Ros E, Salaverria I, Fiol M, Lapetra J, Vinyoles E, Gomez-Gracia E, Lahoz C, Serra-Majem L, Pinto X, Ruiz-Gutierrez V, Covas MI (2011) A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J Nutr 141(6):1140–1145. https://doi.org/10.3945/jn.110.135566

    CAS  Article  PubMed  Google Scholar 

  25. Martinez-Gonzalez MA, Garcia-Arellano A, Toledo E, Salas-Salvado J, Buil-Cosiales P, Corella D, Covas MI, Schroder H, Aros F, Gomez-Gracia E, Fiol M, Ruiz-Gutierrez V, Lapetra J, Lamuela-Raventos RM, Serra-Majem L, Pinto X, Munoz MA, Warnberg J, Ros E, Estruch R, Investigators PS (2012) A 14-item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial. PLoS One 7(8):e43134. https://doi.org/10.1371/journal.pone.0043134

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  26. Elosua R, Marrugat J, Molina L, Pons S, Pujol E (1994) Validation of the Minnesota leisure time physical activity questionnaire in Spanish men. The MARATHOM Investigators. Am J Epidemiol 139(12):1197–1209. https://doi.org/10.1093/oxfordjournals.aje.a116966

    CAS  Article  PubMed  Google Scholar 

  27. Elosua R, Garcia M, Aguilar A, Molina L, Covas MI, Marrugat J (2000) Validation of the Minnesota Leisure Time Physical Activity Questionnaire In Spanish Women. Investigators of the MARATDON Group. Med Sci Sports Exerc 32(8):1431–1437

    CAS  Article  Google Scholar 

  28. Willett W (1998) Nutritional epidemiology, 2nd edn. Oxford University Press, New York

    Book  Google Scholar 

  29. Rosato V, Temple NJ, La Vecchia C, Castellan G, Tavani A, Guercio V (2017) Mediterranean diet and cardiovascular disease: a systematic review and meta-analysis of observational studies. Eur J Nutr. https://doi.org/10.1007/s00394-017-1582-0

    Article  PubMed  Google Scholar 

  30. Lara J, Hobbs N, Moynihan PJ, Meyer TD, Adamson AJ, Errington L, Rochester L, Sniehotta FF, White M, Mathers JC (2014) Effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomized controlled trials. BMC Med 12:60. https://doi.org/10.1186/1741-7015-12-60

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  31. Zazpe I, Estruch R, Toledo E, Sanchez-Tainta A, Corella D, Bullo M, Fiol M, Iglesias P, Gomez-Gracia E, Aros F, Ros E, Schroder H, Serra-Majem L, Pinto X, Lamuela-Raventos R, Ruiz-Gutierrez V, Martinez-Gonzalez MA (2010) Predictors of adherence to a Mediterranean-type diet in the PREDIMED trial. Eur J Nutr 49(2):91–99. https://doi.org/10.1007/s00394-009-0053-7

    CAS  Article  PubMed  Google Scholar 

  32. Satija A, Yu E, Willett WC, Hu FB (2015) Understanding nutritional epidemiology and its role in policy. Adv Nutr 6(1):5–18. https://doi.org/10.3945/an.114.007492

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to thank the team at the EASP (Escuela Andaluza de Salud Publica), Granada, Spain, who performed the randomization process for this study, and also the volunteers who participated in the study.

Funding

The CORDIOPREV study is supported by the Fundacion Patrimonio Comunal Olivarero. We also received additional funding from Centro Tecnologico del Olivar y del Aceite (CITOLIVA), Centro de Excelencia en Investigacion sobre Aceite de Oliva y Salud (CEAS), Junta de Andalucia (Consejeria de Salud, Consejeria de Agricultura y Pesca, Consejeria de Innovacion, Ciencia y Empresa), Diputaciones de Jaen y Cordoba and Ministerio de Medio Ambiente, Medio Rural y Marino, Spanish Government. It was also partly supported by research grants from the Ministerio de Ciencia e Innovacion (FIS PI13/00185 to PP-M, FIS PI13/00023 to J D-L); Ministerio de Economia, Industria y Competitividad (AGL2012/39615 to J Lopez-Miranda and AGL2015-67896-P to J Lopez-Miranda); Instituto de Salud Carlos III (PIE14/00005, PIE14/00031); Proyecto de Excelencia, Consejería de Economía, Innovación, Ciencia y Empleo (CVI-7450 to J Lopez-Miranda); and by a Research Grant from the European Community (NUTRITECH European Integrated Project-289511) and Fondo Europeo de Desarrollo Regional (FEDER). Ana Leon-Acuña is supported by an Instituto de Salud Carlos III research contract (Programa Rio-Hortega). Antonio Camargo is supported by an Instituto de Salud Carlos III research contract (Programa Miguel-Servet CP14/00114). This material is partially based on work supported by the U.S. Department of Agriculture-Agricultural Research Service (ARS), under Agreement No. 58-1950-4-003. The Centro de Investigacion Biomedica en Red Fisiopatologia de la Obesidad y Nutricion (CIBEROBN) is an initiative of the Instituto de Salud Carlos III, Madrid, Spain. The sponsors had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Author notes

  1. Gracia Maria Quintana-Navarro and Juan Francisco Alcala-Diaz have contributed equally to this work.

  2. Jose Lopez-Miranda and Javier Delgado-Lista are joint senior authors.

Affiliations

  1. Lipids and Atherosclerosis Unit, Department of Internal Medicine, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Av. Menendez Pidal s/n, 14004, Cordoba, Spain

    Gracia Maria Quintana-Navarro, Juan Francisco Alcala-Diaz, Javier Lopez-Moreno, Isabel Perez-Corral, Ana Leon-Acuña, Jose David Torres-Peña, Oriol Alberto Rangel-Zuñiga, Antonio Pablo Arenas de Larriva, Andreea Corina, Antonio Camargo, Elena Maria Yubero-Serrano, Antonio Garcia-Rios, Pablo Perez-Martinez, Jose Lopez-Miranda & Javier Delgado-Lista

  2. Department of Cell Biology, Physiology, and Immunology, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain

    Raul Miguel Luque

  3. CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain

    Gracia Maria Quintana-Navarro, Juan Francisco Alcala-Diaz, Javier Lopez-Moreno, Isabel Perez-Corral, Ana Leon-Acuña, Jose David Torres-Peña, Oriol Alberto Rangel-Zuñiga, Antonio Pablo Arenas de Larriva, Andreea Corina, Antonio Camargo, Elena Maria Yubero-Serrano, Antonio Garcia-Rios, Raul Miguel Luque, Pablo Perez-Martinez, Jose Lopez-Miranda & Javier Delgado-Lista

  4. Biochemical Laboratory, Reina Sofia University Hospital, Cordoba, Spain

    Fernando Rodriguez-Cantalejo

  5. Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA

    Jose Maria Ordovas

  6. IMDEA Food Institute, CEI UAM-CSIC, Madrid, Spain

    Jose Maria Ordovas

Authors
  1. Gracia Maria Quintana-Navarro
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  2. Juan Francisco Alcala-Diaz
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  3. Javier Lopez-Moreno
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  4. Isabel Perez-Corral
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  5. Ana Leon-Acuña
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  6. Jose David Torres-Peña
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  7. Oriol Alberto Rangel-Zuñiga
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  8. Antonio Pablo Arenas de Larriva
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  9. Andreea Corina
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  10. Antonio Camargo
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  11. Elena Maria Yubero-Serrano
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  12. Fernando Rodriguez-Cantalejo
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  13. Antonio Garcia-Rios
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  14. Raul Miguel Luque
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  15. Jose Maria Ordovas
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  16. Pablo Perez-Martinez
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  17. Jose Lopez-Miranda
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  18. Javier Delgado-Lista
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Contributions

J Lopez-Miranda, PP-M, and JD-L conceived and designed the research. JFA-D, J Lopez-Moreno, AL-A, JDT-P, APAL, AG-R, PP-M, J Lopez-Miranda, and JD-L participated in the recruitment and carried out the clinical control of the volunteers. GMQ-N, IP-C, and A Corina carried out the nutritional control of the volunteers and GMQ-N drafted the nutritional approach for this paper. OAR-Z, A Camargo, EMY-S, and FR-C performed the lab tests. GMQ-N, JFA-D, and JD-L analyzed and interpreted the data. GMQ-N drafted the manuscript. RML, JMO, PP-M, J Lopez-Miranda, and JD-L provided critical revision of the paper for important intellectual content and edited the content of the draft. PP-M, J Lopez-Miranda, and JD-L had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All the authors revised the manuscript, and read and approved the final manuscript.

Corresponding author

Correspondence to Javier Delgado-Lista.

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Conflict of interest

None of the authors has any conflict of interest that could affect the performance of the work or the interpretation of the data.

Ethical approval

The study protocol was approved by the Human Investigation Review Committee of the Reina Sofia University Hospital, according to institutional and Good Clinical Practice guidelines.

Informed consent

All participants provided written informed consent.

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Quintana-Navarro, G.M., Alcala-Diaz, J.F., Lopez-Moreno, J. et al. Long-term dietary adherence and changes in dietary intake in coronary patients after intervention with a Mediterranean diet or a low-fat diet: the CORDIOPREV randomized trial. Eur J Nutr 59, 2099–2110 (2020). https://doi.org/10.1007/s00394-019-02059-5

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Keywords

  • Dietary adherence
  • Long-term dietary adherence
  • Mediterranean diet
  • Low-fat diet
  • Secondary cardiovascular prevention
  • Dietary intervention