Beyond One-Size-Fits-All

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.