[127] Medication adherence is a complex, multifactorial issue that involves the entire healthcare system. Patient factors negatively impacting adherence may include inadequate understanding of their medical condition, lack of perceived benefit, adverse effects, pill burden, and time lag to benefit. The patient focus group emphasized the need for stronger provider-patient communication and additional education to improve their understanding of treatment. As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence related to this recommendation.[121] The Work Group s confidence in the quality of the evidence was low. The body of evidence had some limitations, including lack of blinding given the nature of the interventions, significant heterogeneity for short-term adherence, and outcome assessment. There were no harms identified in the systematic review, and there is a significant benefit of improved adherence. Other considerations regarding this recommendation are the cost and availability of resources, such as labor and time commitment. Patient values and preferences were somewhat varied. Because there were no harms identified and given the potential benefits of medication adherence, the Work Group decided upon a Weak for recommendation. C. Lifestyle Interventions Recommendation 25. For primary and secondary prevention of cardiovascular disease, we suggest a dietitian-led Mediterranean diet. (Weak for | Reviewed, New-replaced) Discussion A systematic review by Hooper et al. (2015) reviewed 15 RCTs that reduced dietary saturated fat and replaced it with carbohydrate, monounsaturated, or polyunsaturated fat to determine the effect on CVD morbidity and mortality.[128] In eight RCTs, reducing saturated fat did not reduce CVD mortality. A systematic review by Rees et al. (2019) found that a Mediterranean diet reduced composite CV events, stroke, incidence of Type 2 DM, MI, and CV and all-cause mortality and improved the management of dyslipidemia.[129] Wu et al. 