Cardiovascular nutrition in 2026: consolidation, controversy and therapeutic convergence

As the BDA Cardiovascular Specialist Group celebrates its first year – and ahead of World Heart Day on 29 September – members of the group look back on some of the hot topics of 2026. 

The past year has delivered a not dramatic rewrite of cardiovascular dietary advice so much as a slow tightening of consensus around it. Guidance from NICE, the European Society of Cardiology (ESC), European Atherosclerosis Society (EAS) and the American Heart Association (AHA) continues to converge on food-based, pattern-level thinking, even as controversies test how confidently that consensus can be communicated. 

In this short article we look at the major guideline updates, the ongoing dispute over dietary supplements, the latest twist in the lean mass hyper-responder (LMHR) debate, emerging plaque-imaging evidence for vitamin K, aged garlic extract and purified EPA, the 2026 AHA/ACC/ADA/ASN cardiovascular-kidney-metabolic (CKM) guideline and England’s new NHS CVD Modern Service Framework. So, what’s happened over the last year, and where do we go from here? 

Guideline convergence: NICE, ESC/EAS and AHA move towards pattern-level thinking 

Recent guidance from NICE, ESC/EAS and the AHA reinforces a message that has been building for some time: diet quality, weight trajectory, lipid exposure, blood pressure, glycaemia, kidney function and social determinants cannot sensibly be treated as separate problems.^1–4 What is new is the growing insistence, across three continents’ worth of guideline bodies, that isolated nutrient targets are no longer an adequate frame for cardiovascular prevention – saturated fat, fibre, sodium, alcohol and food processing are now consistently presented as components of a pattern rather than standalone levers. 

NICE guideline NG238 asks clinicians to systematically identify people at elevated cardiovascular risk, use QRISK3 in primary prevention, engage in shared decision making and address modifiable factors including diet, physical activity, smoking, alcohol intake and weight¹ and places dietary intervention within a preventive pathway rather than as an alternative to lipid-lowering therapy. The 2025 ESC/EAS-focused dyslipidaemia update maintains the long-standing emphasis on low saturated fat intake and higher consumption of wholegrains, vegetables, fruit and fish, while updating pharmacotherapy recommendations, including bempedoic acid and treatment intensification after acute coronary syndromes.² The AHA’s 2026 dietary guidance restates cardiovascular nutrition as food-based, lifelong and implementation-focused, prioritising vegetables, fruits, wholegrains, legumes, nuts, fish and unsaturated oils, while limiting saturated fat, sodium, added sugars, alcohol and highly processed foods,³ aligning with the 2025–2030 US Dietary Guidelines’ plant-forward emphasis.⁵ ‘Cardiovascular nutrition’ remains not one diet but a reproducible set of principles operationalised through Mediterranean, DASH, portfolio-style or other minimally processed patterns. 

A 2025 network meta-analysis reported favourable effects of Mediterranean-style patterns on several cardiovascular risk markers, while ketogenic diets performed better on short-term weight and triglyceride outcomes but worse on LDL and total cholesterol,⁶ a finding echoed by a 2025 systematic review of carbohydrate-restricted diets, which favoured moderate carbohydrate approaches for overall risk-factor balance.⁷ Weight-loss efficacy and atherogenic lipoprotein safety are not the same outcome: weight reduction can improve blood pressure, glycaemia and triglycerides without offsetting a substantial rise in LDL-C or ApoB. 

The LMHR retraction saga: what KETO-CTA showed – and didn’t show 

The lean mass hyper-responder (LMHR) phenotype (characterised by markedly elevated LDL-C with high HDL-C and low triglycerides in lean [noting an absence in absolute definition], physically active people on ketogenic diets) dominated discussion on social media this year. The KETO-CTA study reported that in 100 such individuals, ApoB and LDL-C exposure were not associated with coronary plaque progression over one year⁸ but was retracted due to methodological concerns that could not be resolved by corrigendum.⁹ Short-term observational imaging in a selective, non-randomised cohort cannot easily overturn decades of evidence linking cumulative ApoB exposure to atherosclerosis. In January 2026, the same investigators posted a new preprint reanalysis of the cohort using the originally prespecified endpoint, reporting plaque progression that looks less severe than the retracted paper’s headline implied.¹⁰ This is worth stating plainly: it is a preprint, not yet peer-reviewed, from a group with one retraction on this exact dataset already. This data is informative but not definitive, and the causal weight of evidence for LDL-C and ApoB has not changed. However, this paper has accelerated the importance of plaque imaging when considering how diets can modify cardiovascular risk, and dietitians in this area should be familiar with vascular imaging techniques to ensure currency. 

Supplements under scrutiny: the EAS/ESC recommendation vs Heart UK’s rebuttal 

In 2025, the EAS/ESC updated their guidelines2 to reflect “new” evidence. However, this publication was plagued by issues around the evidence used to support points made. The new recommendation from the EAS/ESC was that supplements or vitamins without documented safety and significant LDL-C lowering are not recommended to lower the risk of ASCVD. The references used to support this point included a trial of omega-3 in elderly post-MI patients, which showed a negative effect on the primary outcome of clinical events with no change in LDL-C,¹⁴ and a study comparing various supplements (including fish oil, cinnamon, garlic, turmeric, plant sterols or red yeast rice) to low-dose rosuvasatin.¹⁵ In the context of stanols and sterols, they reliably lower LDL-C through doses of 1.5–2.4g/day, backed by over 100 RCTs; red yeast rice can lower LDL-C via monacolin K but carries quality-control and drug interaction risks; and prescription EPA has outcome evidence in hypertriglyceridaemia, while over-the-counter fish oil does not. 

Heart UK’s position statement pushed back, noting the guideline’s own conclusions apply to supplements, not diet generally, and that fortified-food sterols and stanols – tested across 100+ RCTs with an EFSA health claim – are not the same product as an unregulated capsule at an uncertain dose.¹⁶ Critics have also noted SPORT was powered to compare statin against supplement, not placebo against supplement, so its null result for sterols should be read with appropriate caution rather than treated as the final word. This also shows the importance of not just blindly following guideline recommendations but rather reading the supporting evidence and challenging decisions. 

Beyond LDL-C: plaque imaging and vitamin K, aged garlic extract and purified EPA Evidence is also moving beyond LDL-C (and even ApoB) to now look directly at coronary plaque via serial CT imaging. In the context of nutrition, there are several areas that are growing in interest. Vitamin K supplementation has received interest as a means of slowing coronary calcification. A 2026 paper published in JAMA found that in 85 adults receiving menaquinone-7, coronary artery calcification in noncalcified plaques was significantly attenuated when compared with placebo.¹⁷ The authors themselves framed this as hypothesis-generating rather than practice-changing, especially as there is a credible school of thought that suggests that calcification of plaque can lead to stabilisation, but this highlights the shift from LDL-C to now direct measures of vascular health and a need to see if the changes in vascular health translate to hard endpoints. 

Aged garlic extract, tested mainly by one research group using serial CT angiography, has repeatedly slowed low-attenuation plaque accumulation at around 2,400mg/day.¹⁸ These are real imaging endpoints, but from small, largely single-centre trials which have not yet been independently replicated. Yet head over to any Facebook high cholesterol support group and you will see these results being discussed. 

Purified EPA has the strongest backing: the EVAPORATE trial found icosapent ethyl reduced low-attenuation plaque volume by 17% over 18 months, while placebo plaque more than doubled,¹⁹ plausibly explaining the roughly 25% reduction in major cardiovascular events seen with icosapent ethyl in REDUCE-IT.20 This is a prescription-only, high-dose, purified formulation of EPA in a specific hypertriglyceridaemic population – not a licence to recommend generic fish oil for plaque stabilisation. Indeed, ethyl-ester preparations such as those used in REDUCE-IT have been shown to be rapidly incorporated into arterial plaques, in contrast to other preparations such as free fatty acids, which are more readily oxidised, and these may explain why the evidence regarding EPA and CV outcomes has been so mixed. 

The 2026 CKM guideline: retiring single-condition frameworks 

The 2026 AHA/ACC/ADA/ASN CKM guideline formalises the overlapping biology of adiposity, insulin resistance, hypertension, dyslipidaemia, chronic kidney disease and atherosclerotic CVD,⁴ retiring and replacing the 2013 AHA/ACC/TOS obesity guideline entirely. It defines CKM syndrome across four stages, from risk-factor presence through subclinical organ damage to established cardiovascular disease, and for patients with type 2 diabetes and CKM stage 2 or 3, it explicitly recommends dietary and behavioural modification alongside pharmacological or surgical intervention, not instead of it. Nutritional assessment should now routinely include food insecurity, weight history, sarcopenic risk, renal considerations, lipid phenotype, glycaemic status and capacity to sustain change. 

England’s Modern Service Framework: ABCDE and neighbourhood CKM teams 

England’s own health system has moved in the same direction. NHS England and the Department of Health and Social Care’s July 2026 Cardiovascular Disease Modern Service Framework explicitly adopts “a cardiovascular-kidney-metabolic approach”, replacing isolated CVD risk management with joined-up assessment of the ABCDE risk cluster: atrial fibrillation, albuminuria, blood pressure, cholesterol, diabetes, excess weight and reduced kidney function.²¹ For dietetics, the practical implication is a shift away from single-condition clinics towards neighbourhood-based cardiovascular renal-metabolic teams handling weight, lipid, glycaemic and renal nutrition together, with systematic referral to weight management services built into the framework’s core priorities rather than left to opportunistic contact. Undertaking this change requires significant modification to various care pathways and will likely be challenging. 

GLP-1RAs and cardiovascular risk: new priorities for dietetic care 

There has been huge interest in GLP-1RAs and cardiovascular health. For example, SELECT demonstrated that semaglutide 2.4mg reduced major adverse cardiovascular events in people with established CVD and overweight or obesity without diabetes,^₁₁ and subsequent meta-analyses have strengthened the case for cardiovascular and kidney benefit across obesity, diabetes, CKD and established CVD.¹² NICE has authorised semaglutide 2.4mg, alongside diet and activity, for this purpose.¹³ GLP-1 therapy does not replace dietetic care; it creates new priorities such as protecting protein and micronutrient intake, preserving lean mass, managing gastrointestinal symptoms and planning for weight regain if treatment stops, alongside genuine equity concerns over access and cost. This is going to have a huge impact on nutritional considerations in cardiovascular rehabilitation programmes, and it is imperative that dietitians are involved in shaping pathways to support those cardiac patients taking these medications. 

Where this leaves practice 

The past year has strengthened, rather than overturned, the case for plant-forward, high-fibre, minimally processed dietary patterns low in saturated fat and sodium. The LMHR saga and the SPORT/sterols dispute both illustrate the same lesson: mechanistic plausibility, single-trial headlines and social media narratives can pull against the totality of evidence, and nutrition professionals are best placed to hold that line. Both the AHA’s CKM guideline and the NHS’s own Modern Service Framework confirm where the system is heading structurally: away from siloed diet, kidney and diabetes clinics and towards joined-up cardiovascular-renal-metabolic teams. The field’s future looks less like a story about diet alone and more like one of integrated cardiometabolic care. How this is delivered remains to be seen. 

One year of impact 

Although the BDA Cardiovascular Specialist Group is only one year old, our first year has demonstrated what can be achieved through collaboration, enthusiasm and a shared commitment to improving cardiovascular health. From establishing a brand new specialist group to building a thriving professional community, the past year has been one of growth, collaboration and impact. Since its launch on 1 July 2025, the group has established itself as a supportive professional network for dietitians with an interest in cardiovascular nutrition, creating opportunities to share knowledge, influence practice and raise the profile of our profession. 

Membership has grown from zero to 106 active members, reflecting the increasing interest in cardiovascular nutrition. Committee representation has also expanded from three to seven active members, strengthening our capacity to deliver meaningful work. We have also embraced social media and digital platforms to extend our reach, building engaged communities of 318 LinkedIn followers and 315 Instagram followers within our first year. 

A major highlight was receiving the BDA Specialist Group of the Year: Campaigning and Influencing Award. This national recognition reflects the committee’s commitment to championing the role of dietitians in cardiovascular disease prevention and management and demonstrates the impact an engaged specialist group can achieve in a relatively short time. For a newly established specialist group, this recognition reinforced that our collective efforts are already making a meaningful contribution to the profession. 

Throughout the year, we have supported students, dietitians, researchers and other healthcare professionals through webinars, journal clubs and newsletters. We have also contributed to developing the BACPR Dietetic Competency Framework, collaborated on the BDA GLP-1 incretin partnership with the Obesity Specialist Group and engaged in cardiovascular nutrition advocacy through organisations including the European Atherosclerosis Society (EAS) and the European Commission consultation on cardiovascular health checks. Together, these initiatives have promoted learning, networking and professional development while supporting evidence-based practice. 

As we begin our second year, we aim to build on these strong foundations by strengthening collaborations with partners across the NHS, NIHR, universities, industry and the voluntary sector. Our first anniversary webinar provides an opportunity to celebrate what has been achieved, reflect on the group’s journey so far and showcase future opportunities for members. We also hope to encourage more students, early-career dietitians and experienced practitioners to contribute through webinars, projects, writing opportunities and committee activities.  

Cardiovascular disease remains one of the UK’s leading public health challenges, and dietitians have a vital role in its prevention, treatment and longterm management. As  specialist group, we remain committed to supporting our members, influencing policy and practice and ensuring dietetic expertise continues to shape the future of cardiovascular care. We are incredibly proud of what has been achieved during our first year and look forward to continuing this journey together. 

References

1. National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline NG238. London: NICE; 2023. 
2. Mach F, Koskinas KC, Roeters van Lennep JE, et al. 2025 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias. Eur Heart J. 2025;46(42):4359–4378. 
3. Lichtenstein AH, Khera A, Anderson CAM, Appel LJ, DeSilva AM, Gardner CD, et al. 2026 dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2026. 
4. Ndumele CE, Rodriguez F, Dixon DL, et al. 2026 AHA/ACC/ADA/ASN guideline for the prevention, detection, evaluation, and management of cardiovascular-kidney metabolic syndrome: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026;153:e00–e00. doi:10.1161/CIR.0000000000001453. 
5. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans, 2025–2030. Washington, DC: HHS/USDA; 2025. 
6. Sun Y, Wang X, Li J, et al. Comparative effect of dietary patterns on selected cardiovascular risk factors: a network meta-analysis. Sci Rep. 2025. 
7. Feng S, et al. Effects of carbohydrate-restricted diets and macronutrient composition on cardiometabolic risk factors: systematic review and meta-analysis. Am J Clin Nutr. 2025. 
8. Soto-Mota A, et al. Retraction: Longitudinal data from the KETOCTA study: plaque progression in coronary computed tomography angiography. JACC Adv. 2025. 
9. JACC: Advances Editors. Retraction notice: Longitudinal data from the KETO-CTA study. JACC Adv. 2026. 
10. Budoff MJ, Kinninger A, Manubolu VS, Norwitz NG, Feldman D, Soto-Mota A. The impact of sustained LDL-C elevation on plaque changes: primary coronary plaque progression results from the Keto CTA study [preprint]. medRxiv. Posted 2026 Jan 16. doi:10.64898/2026.01.15.26343955. 
11. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389:2221–32. 
12. Badve SV, et al. Effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes: a meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol. 2025. 
13. National Institute for Health and Care Excellence. Semaglutide for reducing the risk of major adverse cardiovascular events in adults with established cardiovascular disease and overweight or obesity. Technology appraisal guidance. London: NICE; 2026. 
14. Kalstad, A.A., Myhre, P.L., Laake, K. Effects of n-3 fatty acid supplements in elderly patients after myocardial infarction: a randomized, controlled trial. Circulation. 2021;143:528-539. 
15. Laffin LJ, Bruemmer D, Garcia M, et al. Comparative effects of low-dose rosuvastatin, placebo, and dietary supplements on lipids and inflammatory biomarkers. J Am Coll Cardiol. 2023;81(1):1–12. 
16. HEART UK. Position statement on ESC/EAS focused update on dietary supplements. London: HEART UK; 2025. 
17. Vossen LM, de Leeuw PW, Schurgers LJ, Heuts S, Adriaans BP, de Haan C, van Varik BJ, Kroon AA. Two years of menaquinone-7 supplementation and coronary artery calcification: a randomized clinical trial. JAMA cardiology. 2026 Jun 10. 
18. Matsumoto S, Nakanishi R, Alani A, et al. The effects of aged garlic extract on the regression of coronary plaque in patients with metabolic syndrome: a prospective randomized double-blind study. J Nutr. 2016. 
19. Budoff MJ, Muhlestein JB, Le VT, May HT, Roy S, Nelson JR. Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: final results of the EVAPORATE trial. Eur Heart J. 2020;41(40):3925–3932. 
20. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380(1):11–22. 
21. Department of Health and Social Care, NHS England. Cardiovascular disease (CVD) modern service framework (MSF): a cardiovascular-kidney-metabolic approach - the strategic vision and delivery model. London: DHSC; 2026 Jul 7.