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Cardiovascular disease (CVD) reduces survival following cardiothoracic transplantation. In a randomised trial we compared feasibility and effectiveness of Mediterranean and low-fat dietary interventions in decreasing CVD severity.Adult cardiothoracic transplant recipients were randomly allocated to a Mediterranean or low-fat diet for 12 months. Feasibility was measured by participation and retention rates, adherence and acceptability of each diet to patients and families. Weight, blood pressure (BP), blood glucose and lipids, and prednisolone dose were assessed at baseline, intervention mid-point and cessation. Similar outcomes were collected retrospectively from eligible patients who declined participation (surrogate controls).Of those approached, 21 of 56 heart transplant recipients and 20 of 60 lung recipients were recruited (45%) and randomised to Mediterranean (n=21) or low-fat (n=20) diets. All but one from each group completed the study (95%). In both groups dietary adherence was high and family members approved. No adverse events related to the intervention were reported. Respective clinical changes in the Mediterranean and low-fat diet groups were: weight (kg), –1.8, –0.2; BMI (kg/m2), –0.5, 0.0; systolic/diastolic BP (mmHg), 0.5/0.1, –4.4/–3.5, and corresponding cardiometabolic changes were: fasting glucose (mmol/L) –0.26, –0.27; total cholesterol (mmol/L) –0.56, –0.40; triglycerides (mmol/L) –0.17, –0.44. Prednisolone doses were reduced in both groups in the 12-month study period. In contrast all routinely recorded CVD risk factors increased among surrogate controls.High retention, adherence and family satisfaction indicated that both dietary interventions are feasible. Improved CVD outcomes suggest both are highly beneficial compared with no intervention.