Relationship between healthy diet and risk of cardiovascular disease among patients on drug therapies for secondary prevention: a prospective cohort study of 31 546 high-risk individuals from 40 countries

Circulation. 2012 Dec 4;126(23):2705-12. doi: 10.1161/CIRCULATIONAHA.112.103234.


Background: Diet quality is strongly related to cardiovascular disease (CVD) incidence, but little is known about its impact on CVD events in older people at high risk of CVD and receiving effective drugs for secondary prevention. This study assessed the association between diet quality and CVD events in a large population of subjects from 40 countries with CVD or diabetes mellitus with end-organ damage receiving proven medications.

Methods and results: Overall, 31 546 women and men 66.5±6.2 years of age enrolled in 2 randomized trials, the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET) and the Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects With Cardiovascular Disease (TRANSCEND), were studied. We used 2 dietary indexes: the modified Alternative Healthy Eating Index and the Diet Risk Score. The association between diet quality and the primary composite outcome of CV death, myocardial infarction, stroke, or congestive heart failure was assessed with Cox proportional hazard regression with adjustment for age, sex, trial enrollment allocation, region, and other known confounders. During the 56-month follow-up, there were 5190 events. Patients in the healthier quintiles of modified Alternative Healthy Eating Index scores had a significantly lower risk of CVD (hazard ratio, 0.78; 95% confidence interval, 0.71-0.87, top versus lowest quintile of modified Alternative Healthy Eating Index). The reductions in risk for CV death, myocardial infarction, and stroke were 35%, 14%, and 19%, respectively. The protective association was consistent regardless of whether patients were receiving proven drugs.

Conclusions: A higher-quality diet was associated with a lower risk of recurrent CVD events among people ≥55 years of age with CVD or diabetes mellitus. Highlighting the importance of healthy eating by health professionals would substantially reduce CVD recurrence and save lives globally.

Trial registration: NCT00153101.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Benzimidazoles / therapeutic use
  • Benzoates / therapeutic use
  • Cardiovascular Agents / therapeutic use*
  • Cardiovascular Diseases / diet therapy*
  • Cardiovascular Diseases / drug therapy*
  • Cardiovascular Diseases / epidemiology
  • Cohort Studies
  • Diabetes Mellitus / diet therapy
  • Diabetes Mellitus / drug therapy
  • Diabetes Mellitus / epidemiology
  • Diet* / methods
  • Double-Blind Method
  • Female
  • Follow-Up Studies
  • Humans
  • Internationality
  • Male
  • Middle Aged
  • Prospective Studies
  • Risk Factors
  • Risk Reduction Behavior*
  • Secondary Prevention / methods*
  • Surveys and Questionnaires
  • Telmisartan


  • Benzimidazoles
  • Benzoates
  • Cardiovascular Agents
  • Telmisartan

Associated data