Across 87 studies encompassing over 1.4 million participants, higher Mediterranean diet (MD) adherence delivered statistically significant reductions across every major cardiovascular endpoint examined. The effect was most dramatic for peripheral artery disease (HR 0.34–0.54), followed by atrial fibrillation (HR 0.65), with more modest but still significant reductions in coronary heart disease (HR 0.95), cerebrovascular disease (HR 0.97), hypertension (HR 0.97), and CVD mortality (HR 0.97). Crucially, even a single one-point increment in MD adherence score produced measurable benefit.
The peripheral artery disease signal deserves particular attention — a 46–66% risk reduction dwarfs the more widely cited cardiac effects, yet PAD remains underemphasized in dietary guidance. This disparity likely reflects vascular inflammation pathways where olive oil polyphenols and omega-3-rich fish exert outsized anti-atherogenic effects in peripheral versus coronary beds.
As a systematic review and meta-analysis of predominantly observational data, this work inherits the classic confounding vulnerability: healthier, wealthier, or more health-conscious individuals self-select toward MD adherence. The PREDIMED RCT anchor partially addresses causality, but its supplemented-olive-oil design limits generalizability to unsupplemented dietary patterns. The dose-response finding — benefit from every additional adherence point — strengthens the causal argument and has immediate clinical utility: partial adoption is not futile. For adults at cardiovascular risk, this is confirmatory but unusually well-powered evidence. The backing of Italian national guidelines lends institutional weight. Incremental in mechanism but paradigm-reinforcing in scale.