Skip to main content


Log in

Dietary fat intakes and cardiovascular disease risk in adults with type 2 diabetes: a systematic review and meta-analysis

  • Original Contribution
  • Published:
European Journal of Nutrition Aims and scope Submit manuscript



Advice regarding the intake of dietary fats is particularly relevant to those with type 2 diabetes, given their increased risk of cardiovascular disease.


We have undertaken a systematic review of fat intakes and cardiovascular disease risk in adults with type 2 diabetes using an online search strategy to 24 April 2020, augmented with hand searching. Searches, extraction, and risk of bias assessments were undertaken by two researchers. The quality of evidence was assessed with GRADE protocols.


We identified five eligible prospective studies of 22,591 participants followed for on average 9.8 years, and one trial of 14 participants with type 2 diabetes. Limited data were available; however, replacement analyses of saturated fat with polyunsaturated fat (RR for 2% energy replacement 0.87 95% CI: 0.77–0.99) or carbohydrate (RR for 5% energy replacement 0.82 95% CI: 0.67–1.00) was associated with reduced cardiovascular disease occurrence. Higher polyunsaturated: saturated fat intake was also associated with reduced cardiovascular disease occurrence (RR 0.75 95% CI: 0.57–0.98). The quality of evidence was low to very-low.


Although only limited data were available, replacement of saturated fats with other macronutrients, such as polyunsaturated fats, was associated with reduced cardiovascular disease occurrence. Supporting evidence from research in the general population increases confidence in these findings. Until more data are available to better comment on dietary fat intakes in cardiovascular disease risk of those with type 2 diabetes, it appears appropriate that saturated fats be replaced in the diet with other macronutrients, such as polyunsaturated fats.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others


  1. De Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, Uleryk E, Budylowski P, Schünemann H, Beyene J (2015) Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ 351:h3978

    Article  Google Scholar 

  2. Hooper L, Martin N, Jimoh OF, Kirk C, Foster E, Abdelhamid AS (2020) Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev.

    Article  PubMed  PubMed Central  Google Scholar 

  3. DuBroff R, de Lorgeril M (2019) Fat or fiction: the diet-heart hypothesis. BMJ EBM.

    Article  Google Scholar 

  4. Astrup A, Bertram HC, Bonjour J-P, de Groot LC, de Oliveira Otto MC, Feeney EL, Garg ML, Givens I, Kok FJ, Krauss RM, Lamarche B, Lecerf J-M, Legrand P, McKinley M, Micha R, Michalski M-C, Mozaffarian D, Soedamah-Muthu SS (2019) WHO draft guidelines on dietary saturated and trans fatty acids: time for a new approach? BMJ 366:l4137.

    Article  PubMed  Google Scholar 

  5. Ricci C, Baumgartner J, Zec M, Kruger HS, Smuts CM (2018) Type of dietary fat intakes in relation to all-cause and cause-specific mortality in US adults: an iso-energetic substitution analysis from the american national health and nutrition examination survey LINKED to the US mortality registry. Br J Nutr 119(4):456–463

    Article  CAS  Google Scholar 

  6. Chiu S, Williams PT, Krauss RM (2017) Effects of a very high saturated fat diet on LDL particles in adults with atherogenic dyslipidemia: a randomized controlled trial. PLoS ONE 12(2):e0170664

    Article  Google Scholar 

  7. Hornstra G, Kester AD (1997) Effect of the dietary fat type on arterial thrombosis tendency: systematic studies with a rat model. Atherosclerosis 131(1):25–33

    Article  CAS  Google Scholar 

  8. World Health Organization (2018) Draft guidelines on saturated fatty acid and trans-fatty acid intake for adults and children. World Health Organization, Geneva, Switzerland, p 103

    Google Scholar 

  9. Vitolins MZ, Anderson AM, Delahanty L, Raynor H, Miller GD, Mobley C, Reeves R, Yamamoto M, Champagne C, Wing RR (2009) Action for health in diabetes (Look AHEAD) trial: baseline evaluation of selected nutrients and food group intake. J Am Diet Assoc 109(8):1367–1375

    Article  Google Scholar 

  10. Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera SF, Aboyans V, Adetokunboh O, Afshin A, Agrawal A (2017) Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet 390(10100):1151–1210

    Article  Google Scholar 

  11. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD (2018) Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation 137(12):e67–e492

    Article  Google Scholar 

  12. Cavender MA, Steg PG, Smith SC Jr, Eagle K, Ohman EM, Goto S, Kuder J, Im K, Wilson PW, Bhatt DL (2015) Impact of diabetes mellitus on hospitalization for heart failure, cardiovascular events, and death: outcomes at 4 years from the reduction of atherothrombosis for continued health (REACH) registry. Circulation 132(10):923–931

    Article  Google Scholar 

  13. Rawshani A, Rawshani A, Franzén S, Eliasson B, Svensson A-M, Miftaraj M, McGuire DK, Sattar N, Rosengren A, Gudbjörnsdottir S (2017) Mortality and cardiovascular disease in type 1 and type 2 diabetes. N Engl J Med 376(15):1407–1418.

    Article  PubMed  Google Scholar 

  14. Ray KK, Colhoun HM, Szarek M, Baccara-Dinet M, Bhatt DL, Bittner VA, Budaj AJ, Diaz R, Goodman SG, Hanotin C, Harrington RA, Jukema JW, Loizeau V, Lopes RD, Moryusef A, Murin J, Pordy R, Ristic AD, Roe MT, Tuñón J, White HD, Zeiher AM, Schwartz GG, Steg PG (2019) Effects of alirocumab on cardiovascular and metabolic outcomes after acute coronary syndrome in patients with or without diabetes: a prespecified analysis of the ODYSSEY OUTCOMES randomised controlled trial. Lancet Diabetes Endocrinol 7(8):618–628.

    Article  CAS  PubMed  Google Scholar 

  15. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS med 6(7):e1000097

    Article  Google Scholar 

  16. Mann J, De Leeuw I, Hermansen K, Karamanos B, Karlström B, Katsilambros N, Riccardi G, Rivellese A, Rizkalla S, Slama G (2004) Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr Metab Cardiovasc Dis 14(6):373–394

    Article  CAS  Google Scholar 

  17. World Health Organization (2018) WHO plans to eliminate industrially-produced trans-fatty acids from global food supply. Accessed 7 Jul 2020

  18. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, Welch V (eds) (2020) Cochrane Handbook for systematic reviews of interventions version 6.1 (updated September 2020). Cochrane, 2020. Available from

  19. Reynolds AN, Akerman AP, Mann J (2020) Dietary fibre and whole grains in diabetes management: systematic review and meta-analyses. PLoS medicine 17(3):e1003053

    Article  Google Scholar 

  20. Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, Tugwell P, (2011) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. oxford. asp, Ottawa

    Google Scholar 

  21. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JA (2011) The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  Google Scholar 

  22. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188

    Article  CAS  Google Scholar 

  23. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557

    Article  Google Scholar 

  24. StataCorp, (2017) Stata statistical software: release 15. College Station, StataCorp LP, TX

    Google Scholar 

  25. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336(7650):924

    Article  Google Scholar 

  26. Soinio M, Laakso M, Lehto S, Hakala P, Rönnemaa T (2003) Dietary fat predicts coronary heart disease events in subjects with type 2 diabetes. Diabetes Care 26(3):619–624

    Article  Google Scholar 

  27. Trichopoulou A, Psaltopoulou T, Orfanos P, Trichopoulos D (2006) Diet and physical activity in relation to overall mortality amongst adult diabetics in a general population cohort. J Intern Med 259(6):583–591

    Article  CAS  Google Scholar 

  28. Campmans-Kuijpers MJ, Sluijs I, Nöthlings U, Freisling H, Overvad K, Boeing H, Masala G, Panico S, Tumino R, Sieri S, Johansson I, Winkvist A, Katzke VA, Kuehn T, Nilsson PM, Halkjær J, Tjønneland A, Spijkerman AM, Arriola L, Sacerdote C, Barricarte A, May AM, Beulens JW (2016) The association of substituting carbohydrates with total fat and different types of fatty acids with mortality and weight change among diabetes patients. Clin Nutr 35(5):1096–1102.

    Article  CAS  PubMed  Google Scholar 

  29. Tanasescu M, Cho E, Manson JE, Hu FB (2004) Dietary fat and cholesterol and the risk of cardiovascular disease among women with type 2 diabetes. Am j clin nutr 79(6):999–1005

    Article  CAS  Google Scholar 

  30. Jiao J, Liu G, Shin HJ, Hu FB, Rimm EB, Rexrode KM, Manson JE, Zong G, Sun Q (2019) Dietary fats and mortality among patients with type 2 diabetes: analysis in two population based cohort studies. BMJ 366:l4009.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Heine R, Mulder C, Popp-Snijders C, Van Der Meer J, Van Der Veen E (1989) Linoleic-acid-enriched diet: long-term effects on serum lipoprotein and apolipoprotein concentrations and insulin sensitivity in noninsulin-dependent diabetic patients. Am j clin nutr 49(3):448–456

    Article  CAS  Google Scholar 

  32. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM (2010) Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am j clin nutr 91(3):535–546

    Article  CAS  Google Scholar 

  33. Mozaffarian D, Micha R, Wallace S (2010) Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS medicine 7(3):e1000252

    Article  Google Scholar 

  34. Hirahatake KM, Jiang L, Wong ND, Shikany JM, Eaton CB, Allison MA, Martin L, Garcia L, Zaslavsky O, Odegaard AO (2019) Diet quality and cardiovascular disease risk in postmenopausal women with type 2 diabetes mellitus: the women’s health initiative. J Am Heart Assoc 8(19):e013249

    Article  Google Scholar 

  35. Sacks FM, Lichtenstein AH, Wu JH, Appel LJ, Creager MA, Kris-Etherton PM, Miller M, Rimm EB, Rudel LL, Robinson JG (2017) Dietary fats and cardiovascular disease: a presidential advisory from the american heart association. Circulation 136(3):e1–e23

    Article  Google Scholar 

  36. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA (2020) 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: the task force for the management of dyslipidaemias of the european society of cardiology (ESC) and european atherosclerosis society (EAS). Eur Heart J 41(1):111–188

    Article  Google Scholar 

  37. Mensink RP, Zock PL, Kester AD, Katan MB (2003) Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am j clin nutr 77(5):1146–1155

    Article  CAS  Google Scholar 

  38. Reiner Ž, Catapano AL, De Backer G, Graham I, Taskinen M-R, Wiklund O et al (2011) ESC/EAS Guidelines for the management of dyslipidaemias: the task force for the management of dyslipidaemias of the european society of cardiology (ESC) and the european atherosclerosis society (EAS). Eur Heart J 32(14):1769–1818.

    Article  PubMed  Google Scholar 

  39. Mensink RP, World Health Organization (2016) Effects of saturated fatty acids on serum lipids and lipoproteins: a systematic review and regression analysis.

  40. Imamura F, Micha R, Wu JH, de Oliveira Otto MC, Otite FO, Abioye AI, Mozaffarian D (2016) Effects of saturated fat, polyunsaturated fat, monounsaturated fat, and carbohydrate on glucose-insulin homeostasis: a systematic review and meta-analysis of randomised controlled feeding trials. PLoS medicine 13(7):e1002087

    Article  Google Scholar 

  41. Schulze MBMA, Saleh RNM, Risérus U (2020) Intake and metabolism of n-3 and n-6 PUFA (review): nutritional implications for cardiometabolic diseases. Lancet Diabetes Endocrinol 8(11):915–930.

    Article  CAS  PubMed  Google Scholar 

  42. Silverman MG, Ference BA, Im K, Wiviott SD, Giugliano RP, Grundy SM, Braunwald E, Sabatine MS (2016) Association between lowering LDL-C and cardiovascular risk reduction among different therapeutic interventions: a systematic review and meta-analysis. JAMA 316(12):1289–1297.

    Article  CAS  PubMed  Google Scholar 

  43. US Department of Health and Human Services; US Department of Agriculture (2015) 2015–2020 Dietary guidelines for americans, 8th edn. US Dept of Health and Human Services, Washington DC

    Google Scholar 

Download references


Thank you to Heikki Laitinen, for developing the search terms and conducting the searches.


This research received no external funding. ANR was supported by a National Heart Foundation of New Zealand Fellowship.

Author information

Authors and Affiliations



USS designed the research, conducted searches and data extraction, contributed to interpretation of results; ANR collated and analysed the results, wrote the manuscript draft, contributed to interpretation of results; TS conducted searches and data extraction, contributed to interpretation of results; AAR involved with study design, conducting the review, and contributed to interpretation of results; UR involved with study design, conducting the review, and contributed to interpretation of results.

Corresponding author

Correspondence to Andrew N. Reynolds.

Ethics declarations

Conflicts of interest

The authors declare no conflict of interest.

Availability of data and material

Available within the original articles.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 27 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schwab, U., Reynolds, A.N., Sallinen, T. et al. Dietary fat intakes and cardiovascular disease risk in adults with type 2 diabetes: a systematic review and meta-analysis. Eur J Nutr 60, 3355–3363 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: