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The Lyon Heart Study - conclusive proof

This is a randomised, controlled trial with free-living subjects. Its goal is to test the effectiveness of a Mediterranean-type diet (that is consistent with the new American Heart Association dietary guidelines) on the rate of coronary events in people who've had a first heart attack. The results suggest that a Mediterranean-style diet may help reduce recurrent events in patients with heart disease.

A total of 302 experimental and 303 control group subjects were randomised into the study. All were patients who had survived a first heart attack. The two groups had a similar coronary risk factor profile (blood lipids and lipoproteins, systolic and diastolic blood pressure, body mass index and smoking status). Patients in the experimental group were asked to comply with a specific Mediterranean-type diet. Patients in the control group received no dietary advice from the researchers but were asked by their physicians to follow a prudent diet.

An intermediate analysis was performed after a minimum follow-up of one year for each patient. The study was stopped at that point because of significant beneficial effects noted in the original group. All patients were invited to the research unit for a final exam, where they were informed of the results. 204 of the control group and 219 of the experimental group participated in the final visit. This represented 93 percent of the patients still alive at the time.
What is a Mediterranean-style diet?

There's no one, typical "Mediterranean" diet. At least 16 countries border the Mediterranean Sea. Diets vary between these countries and also between regions within a country. Many differences in culture, ethnic background, religion, economy and agricultural production result in different diets. But the common Mediterranean dietary pattern has these characteristics:

• High in fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
• Includes olive oil as an important, monounsaturated fat source
• Dairy products, fish and poultry consumed in low to moderate amounts, little red meat
• Eggs consumed zero to four times weekly
• Wine consumed in low to moderate amounts

The Mediterranean-style diet used in the Lyon Diet Heart Study was quite comparable to the common pattern but different in a significant way. It was high in alpha-linolenic acid (ALA) a polyunsaturated omega-3 fatty acid. It included:

• More bread, more root vegetables and green vegetables, more fish.
• Less beef, lamb and pork (replaced with poultry).
• No day without fruit.
• Butter and cream were replaced with margarine high in alpha-linolenic acid.

The diet averaged 30 percent of calories from fat, 8 percent from saturated fat, 13 percent from monounsaturated fat, 5 percent from polyunsaturated fat and 203 mg/day of cholesterol. Compared to the control group, people in the experimental group consumed less linoleic acid (omega-6) and more oleic acid, alpha-linolenic acid and dietary fibre.

People in the control group consumed a diet with about 34 percent of calories from fat, 12 percent from saturated fat, 11 percent from monounsaturated fat, 6 percent polyunsaturated fat and 312 mg/day of cholesterol. This diet is comparable to what is typically consumed in the United States.

The control group's diet did not meet the diet guidelines which are recommended for people with heart disease and previous heart attacks.

After an average follow-up of 46 months (four years), patients following the Mediterranean-style diet had a 50-70% lower risk of recurrent heart disease.

The risk was measured by three combinations of outcome measures:

• Cardiac death and non-fatal heart attacks
• The above two plus major events (unstable angina, stroke, heart failure, and pulmonary or peripheral embolism)
• All of these measures plus minor events that required hospitalization

The Lyon Diet Heart Study shows the potential importance of a dietary pattern that emphasizes fruits, vegetables, breads and cereals, and fish as well as alpha-linolenic acid. The fact that omega-3 fatty acids exert cardio-protective effects in several ways suggests that their presence in the diet could have accounted for the results observed. This diet plan has not yet been evaluated as a long-term strategy for primary prevention.

Detailed Research

1. AHA Scientific Statement: AHA Dietary Guidelines: Revision 2000, #71-0193 Circulation. 2000;102:2284-2299; Stroke. 2000;31:2751-2766
2. "Coronary Heart Disease in Seven Countries," Circulation, 1970;41(Suppl I):I-1--I-211
3. Summary of the Second Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II), NIH Publication No. 93-3095, 1993 (Full Text in Circulation. 1994;89)
4. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N, "Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: Final report of the Lyon Diet Heart Study," Circulation. 1999;99:779-785
5. AHA Science Advisory: Lyon Diet Heart Study: Benefits of a Mediterranean-Style, National Cholesterol Education Program/American Heart Association Step I Dietary Pattern on Cardiovascular Disease, #71-0202 Circulation. 2001;103:1823-1825;
6. Editorial: Can a Mediterranean-Style Diet Reduce Heart Disease? #71-0202 Circulation. 2001;103:1821-1822