When someone in cardiac rehabilitation is told to follow a Mediterranean diet, they most likely picture olive oil, salmon, nuts and colourful salads. Maybe tomatoes, chickpeas and whole grains. For some Canadians, these foods are familiar, affordable and readily available. For others, they may bear little resemblance to the foods they grew up eating, the meals their families prepare or what is available at their local grocery store.
That matters.
Nutrition is a core component of cardiac rehabilitation – a comprehensive program that helps people recover and reduce their risk of future cardiovascular events. The Mediterranean diet is among the dietary patterns most consistently recommended for cardiovascular health. It emphasizes vegetables and fruits, whole grains, legumes, fish, healthy fats and minimally processed foods while limiting highly processed foods and saturated fats.
But there is a problem with the way we sometimes translate this into practice: a heart-healthy dietary pattern can become a culturally specific food prescription.
In Canada, where patients come from remarkably diverse cultural, religious and socioeconomic backgrounds, that distinction is especially important.
The health benefits associated with the Mediterranean diet do not mean that everyone needs to eat the same foods. A patient from South Asia should not have to abandon dal. A Latin American family does not need to replace beans and traditional dishes with foods perceived as more “Mediterranean.” Someone accustomed to Chinese, Middle Eastern, Caribbean or African cuisine should not receive the message that heart-healthy eating requires adopting an unfamiliar cuisine.
Instead, we can ask a different question: What are the principles that make a dietary pattern heart healthy, and how can those principles be applied to foods people already know, enjoy and can afford? That question motivated our recent research involving patients, dietitians and cardiac rehab professionals.
We began by speaking with dietitians in Canada and Brazil and with people participating in cardiac rehabilitation in Toronto. Their conversations repeatedly returned to seven issues: food quality, regional availability, cultural relevance, socioeconomic circumstances, nutrition counselling, practical strategies and the social dimensions of eating.
We then took the recommendations generated from these discussions to an international panel. More than 100 patients and health professionals from 31 countries across all six World Health Organization regions participated in the first round of a structured consensus process.
The message that emerged was remarkably consistent: keep the heart-healthy principles but make their application flexible.
Too often, culture is framed as something health professionals must “work around.”
We should instead recognize it as part of the solution.
Traditional diets around the world already contain many foods consistent with cardiovascular health. Rather than asking patients to exchange these foods for an idealized Mediterranean menu, health professionals can work with them to identify what is already beneficial and where realistic changes could be made.
Our participants emphasized precisely this approach. They supported adapting traditional dishes rather than replacing them and tailoring recommendations to religious practices, family circumstances, cooking skills and individual preferences.
One dietitian captured the principle simply: “We bring Mediterranean principles into foods people are already eating.”
This seemingly small change in approach can transform a nutrition consultation. Instead of asking how to get a patient to follow the Mediterranean diet, we should ask how we can make this patient’s existing way of eating more heart healthy?
Culture is only part of the equation.
Telling someone to buy extra-virgin olive oil, fresh fish, nuts and abundant fresh produce is of little value if those foods do not fit the household budget or are difficult to obtain.
Patients in our study spoke directly about these realities. Dietitians did too. Cost, food access, time and competing financial demands shaped what people could realistically eat.
This is particularly important at a time when many Canadian households are struggling with food costs.
Heart-healthy counselling therefore needs to distinguish between nutritional principles and specific products. Frozen and canned vegetables can be appropriate alternatives to fresh produce. Beans and lentils can provide affordable plant-based protein. Healthy fats do not necessarily have to come from expensive imported olive oil.
Our international panel ultimately prioritized recommendations that explicitly considered financial and environmental circumstances, budgeting, meal planning and cost-conscious strategies.
Advice that a patient cannot afford is not patient-centred advice.
There is another reason a one-size-fits-all prescription falls short: people do not eat nutrients. They eat meals.
And meals carry history, identity, family traditions and social meaning.
Patients told us about eating with family, maintaining traditional foods and navigating dietary changes after a cardiac event. Dietitians similarly emphasized that successful counselling depends on listening to patients and understanding their lived realities.
This matters because dietary recommendations are unlikely to be sustained if they require someone to give up the foods that connect them with family and culture.
Cardiac rehabilitation should therefore move beyond simply handing patients lists of foods to eat and avoid. Nutrition counselling can instead become a conversation: What does your family normally eat? Who buys and prepares the food? Which foods are important to you? What can you afford? What changes feel realistic?
Those questions may be as important as explaining which foods contain healthy fats.
For Canadian rehab programs, that means making culturally responsive nutrition counselling part of routine care rather than an optional accommodation.
Dietitians and other rehabilitation professionals can begin with the patient’s existing diet, identify its strengths and collaboratively make small changes. Programs can ensure educational materials depict foods and meals from multiple cultures. Recommendations can account explicitly for affordability and food access. Family members can be involved when patients want them to be.
The final recommendation in our study is particularly important: prioritize heart-healthy habits and overall well-being rather than weight loss alone. In the international Delphi, 99 per cent of respondents rated this recommendation as highly important.
These are not simply matters of cultural sensitivity. They are questions of quality, feasibility and equity in health care.
Canada’s population will not become less diverse. Our dietary counselling therefore needs to become better at recognizing that there are many ways to eat well.
The goal should not be to make every Canadian patient’s plate look Mediterranean.
It should be to ensure that every patient – regardless of culture, income, religion or the foods they grew up eating – has a realistic opportunity to make their own plate healthier.
