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Dietary habits and compliance with dietary guidelines in patients with established cardiovascular disease



Unhealthy dietary habits are an important risk factor for cardiovascular disease (CVD) and adopting a healthy diet is a central recommendation in CVD prevention. This study assessed the dietary habits of patients with established CVD, their compliance to dietary guidelines, and the relationship between guideline-compliance and recurrent cardiovascular event risk.


2656 patients with established CVD from the Utrecht Cardiovascular Cohort-Secondary Manifestations of ARTerial disease (UCC-SMART) prospective cohort study, were included between 1996 and 2022. Data on dietary intake was retrospectively collected for all participants in December 2022 using a 160-item food frequency questionnaire. Compliance with dietary guidelines was quantified using an amended version of the Dutch Healthy Diet 2015 (DHD-15) index (range: 0–135). Cox proportional hazard models were used to quantify the relationship with cardiovascular events (stroke and myocardial infarction).


Among 2656 CVD patients (77% male, mean age 59 ± 9 years), median energy intake was 1922 [IQR: 1536–2351] kcal/day. The median DHD-15 index was 81.7 [IQR 71.2–92.0], with high compliance scores for recommendations on legumes and fish, and low scores for recommendations on whole grains, red meat, processed meat, and dairy. A higher DHD-15 score was associated with lower stroke risk (HR 0.78, 95% CI 0.66–0.92 per 10-point increase) but not with myocardial infarction.


Compliance with dietary guidelines was suboptimal in patients with established CVD. High compliance was associated with a clinically significant reduction in stroke risk in patients with established CVD, emphasizing the importance of dietary counseling.

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Fig. 1: Flowchart of patient selection and dietary data collection.
Fig. 2: Compliance with the Dutch dietary guidelines (DHD-15 score).
Fig. 3: Continuous relationship between compliance with the Dutch dietary guidelines and risk of cardiovascular events.

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Data availability

Data and statistical code will be made available upon reasonable request to the corresponding author.


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We would like to thank Angela Vandersteen, Rosanne Eertman, Rutger van Petersen, Baukje van Dinther, Marjolein Harbers and the UCC-SMART research nurses for their efforts in making the collection of dietary information in the UCC-SMART cohort possible. We gratefully acknowledge the contribution of the participants, the research nurses, and the members of the UCC-SMART Study group: M.J. Cramer, H.M. Nathoe and M.G. van de Meer (co-PI), Department of Cardiology; G.J. de Borst and M. Teraa (co-PI), Department of Vascular Surgery; M.L. Bots and M. van Smeden, Julius Center for Health Sciences and Primary Care; M.H. Emmelot-Vonk, Department of Geriatrics; P.A. de Jong, Department of Radiology; A.T. Lely, Department of Gynecology and Obstetrics; N.P. van der Kaaij, Department of Cardiothoracic Surgery; L.J. Kappelle and Y.M. Ruigrok, Department of Neurology; M.C. Verhaar, Department of Nephrology & Hypertension; J.A.N. Dorresteijn (co-PI), F.L.J. Visseren (PI), Department of Vascular Medicine, UMC Utrecht.


The UCC-SMART study was financially supported by a grant of the University Medical Center Utrecht, the Netherlands. The research presented in this paper was supported by a grant from the Regio Deal FoodValley (grant number 162135). The supporting sources had no involvement in study design, analysis, interpretation, writing of the results, or the decision to submit for publication. This project was supported by Regio Deal Foodvalley (grant nr 162135). The sponsor was not involved in the study design, data collection and analysis, interpretation of the results, writing of the manuscript and decision to submit the manuscript for publication.

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NEB: Conceived and designed the research, collected the data, analysed the data, and wrote the paper. MJG: Conceived and designed the research, critically revised the paper and provided supervision. YtvdS: Collected the data and critically revised the paper. JAND: Critally revised the paper. MGvdM: Critally revised the paper. YMR: Critally revised the paper. MT: Critally revised the paper. FLV: Conceived and designed the research, analysed the data, critically revised the paper and provided supervision. CK: Conceived and designed the research, analysed the data, critically revised the paper and provided supervision.

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Correspondence to Frank L. J. Visseren.

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Bonekamp, N.E., Geleijnse, J.M., van der Schouw, Y.T. et al. Dietary habits and compliance with dietary guidelines in patients with established cardiovascular disease. Eur J Clin Nutr (2024).

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