To update the clinical practice guidelines for nutrition therapy of the European Association for the Study of Diabetes, we conducted a systematic review and meta-analysis of prospective cohort studies and randomized clinical trials (RCTs) to evaluate the effect of the Mediterranean diet (MedDiet) on the prevention of cardiovascular disease (CVD) incidence and mortality. We searched Medline, EMBASE (through April 20, 2018) and Cochrane (through May 7, 2018) databases. Pooled relative risks (RRs) and 95% confidence interval (CI) were calculated by the generic inverse variance method. A total of 41 reports (3 RCTs and 38 cohorts) were included. Meta-analyses of RCTs revealed a beneficial effect of the MedDiet on total CVD incidence (RR: 0.62; 95% CI: 0.50, 0.78) and total myocardial infarction (MI) incidence (RR: 0.65; 95% CI: 0.49, 0.88). Meta-analyses of prospective cohort studies, which compared the highest versus lowest categories of MedDiet adherence, revealed an inverse association with total CVD mortality (RR: 0.79; 95% CI: 0.77, 0.82), coronary heart disease (CHD) incidence (RR: 0.73; 95% CI: 0.62, 0.86), CHD mortality (RR: 0.83; 95% CI: 0.75, 0.92), stroke incidence (RR: 0.80; 95% CI: 0.71, 0.90), stroke mortality (RR: 0.87; 95% CI: 0.80, 0.96) and MI incidence (RR: 0.73; 95% CI: 0.61, 0.88). The present study suggests that MedDiet has a beneficial role on CVD prevention in populations inclusive of individuals with diabetes.

Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y la Nutrición Institute of Health Carlos 3 Madrid Spain

College of Pharmacy and Nutrition University of Saskatchewan Saskatoon Saskatchewan Canada

Department of Endocrinology Diabetes and Clinical Pharmacology Dubrava University Hospital Zagreb Croatia

Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto Ontario Canada

Institut d'Investigació Sanitària Pere Virgili Reus Spain

Institute for Clinical and Experimental Medicine Prague Czech Republic

Li Ka Shing Knowledge Institute St Michael's Hospital Toronto Ontario Canada

Nutrition Unit University Hospital of Sant Joan de Reus Reus Spain

Physicians Committee for Responsible Medicine Washington DC USA

School of Medicine University of Zagreb Zagreb Croatia

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada

Unitat de Nutrició Departament de Bioquímica i Biotecnologia Universitat Rovira i Virgili Reus Spain

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