Beyond One-Size-Fits-All: A MODIFIED, TWO-ROUND DELPHI CONSENSUS STUDY TO IDENTIFY KEY PRIORITIES FOR ADAPTING THE MEDITERRANEAN DIET IN MULTICULTURAL CARDIAC REHABILITATION SETTINGS.

Abstract

Purpose To identify and prioritize key considerations for culturally adapting the Mediterranean diet for diverse populations participating in cardiac rehabilitation (CR) programs outside the Mediterranean region. Methods This modified, 2-round Delphi consensus study (September to December 2025) included 3 phases. Phase 1 involved online focus groups with dietitians from Canada and Brazil. Phase 2 comprised in-person and virtual focus groups with adults enrolled in a Canadian CR program. Data from Phases 1 and 2 were analyzed using thematic analysis to generate candidate recommendations. Phase 3 consisted of a 2-round Delphi process with CR health care professionals and patients from 31 countries across all 6 World Health Organization regions, who rated recommendation importance using a 5-point Likert scale. Consensus was assessed using descriptive statistics. Results Focus groups with dietitians (n = 27) and CR participants (n = 15) generated 26 recommendations across 7 thematic categories. In the 2-round Delphi process (N = 102), 15 recommendations reached consensus in round 1 and were refined, while 11 were excluded or merged. Twelve recommendations progressed to round 2, yielding a final set of 11 consensus-based recommendations. Key priorities included flexibility, cultural and religious relevance, affordability, local food availability, individualized counseling, and emphasis on heart-healthy behaviors over weight loss. Alcohol was considered nonessential, with support for excluding it from educational materials. Conclusions This international, stakeholder-informed study established 11 consensus recommendations to guide culturally responsive adaptation of the Mediterranean diet in CR. Findings support flexible, patient-centered dietary approaches that maintain cardioprotective principles while enhancing feasibility and relevance across diverse global settings.