CATEGORY: EATING FOR HEART HEALTH
Of three eating patterns compared over 20 years, the low-fat one came last. Among more than 12,000 American adults at raised risk of heart disease, those who consistently ate a Mediterranean-style pattern had an estimated 21% lower risk of heart attack, stroke or death from heart disease than those following the low-fat approach.1 The analysis appeared in August 2026 in the American Journal of Clinical Nutrition. The American Heart Association’s 2020 food-based goals landed in between, about 13% below the low-fat pattern.
Both Patterns That Beat It Are Rich in Fat
The low-fat pattern discouraged cooking oils and spreads, nuts, fatty fish, fried snacks and pastries. The Mediterranean pattern, in a version adapted to American eating habits, leaned on olive oil, nuts, fish, vegetables, legumes such as beans, lentils and peas, and whole grains. The AHA-2020 pattern centered on fruits, vegetables, fish and whole grains while limiting sugary drinks and processed meat. Both of the patterns that came out ahead are rich in fat. What sets them apart from the low-fat approach is the kind of fat and the foods that carry it.1
Replaying the Same 20 Years With a Different Menu
Researchers drew on the Nurses’ Health Study and the Health Professionals Follow-up Study, two long-running American cohorts, narrowing to 12,197 adults aged 55 to 80 who had diabetes or at least three major heart-disease risk factors. Nobody was handed a diet to follow. Participants simply reported what they ate every four years on detailed food questionnaires. Over 20 years, 3,469 developed cardiovascular disease: a non-fatal heart attack, a procedure to reopen blocked heart arteries, a stroke, or death from heart disease, each confirmed against medical records. To compare diets nobody was assigned, the team used a method called target trial emulation, modeling what would have happened had everyone stuck with each pattern the whole time. Think of it as replaying the same 20 years three times with a different menu each time.1
Eight Fewer Cases per 100 People
Estimated 20-year risk of cardiovascular disease came to 35.9% under the low-fat diet, 31.2% under the AHA-2020 goals and 28.2% under the Mediterranean pattern. That last gap works out to roughly eight fewer cases for every 100 people. The advantage showed up for coronary heart disease and for cardiovascular death. For stroke on its own, it did not. In a broader group not selected for high risk, the gaps narrowed to about 10% and 6%.1
This is observational work modeled from self-reported diet. It can show that the patterns and the outcomes travel together, not that food caused the difference. Participants were also mostly white health professionals. The direction does match the Spanish PREDIMED randomized trial, in which a Mediterranean diet with extra-virgin olive oil or nuts reduced major heart events by roughly 30%.2
Key Takeaways
- Consistently following a Mediterranean-style pattern tracked with a 21% lower 20-year risk of cardiovascular disease than a low-fat diet among 12,197 American adults with diabetes or multiple heart risk factors, while the AHA-2020 goals came out about 13% below the low-fat pattern.
- Estimated 20-year risk was about 28% under Mediterranean eating against 36% under low-fat eating, roughly eight fewer cases per 100 people.
- The study is observational and modeled from self-reported diet, and the benefit was clear for coronary disease and heart-related death but not for stroke alone.
References
- Li Y, Stern D, Martínez-González MA, et al. Cardiovascular disease risk under low-fat, Mediterranean, and American Heart Association diets: a target trial emulation in United States adults. The American Journal of Clinical Nutrition. 2026;124(2):101404. link
- Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. The New England Journal of Medicine. 2018;378(25):e34. link