BACKGROUND & AIMS: The Mediterranean diet (MedDiet) is recognised to reduce risk of coronary heart disease (CHD), in part, via its anti-inflammatory and antioxidant properties, which may be mediated via effects on body fat distribution. Diet efficacy via these mechanisms is however unclear in patients with diagnosed CHD. This study aimed to determine: (1) the effect of ad libitum MedDiet versus low-fat diet intervention on adiposity, anti-inflammatory marker adiponectin, oxidative stress marker malondialdehyde (MDA) and traditional CVD risk markers, and (2) whether improvement in MedDiet adherence score in the pooled cohort was associated with these risk markers, in a pilot cohort of Australian patients post coronary event. METHODS: Participants (62 ± 9 years, 83% male) were randomised to 6-month ad libitum MedDiet (n = 34) or low-fat diet (n = 31). Pre- and post-intervention, dietary adherence, anthropometry, body composition (Dual-energy X-ray Absorptiometry) and venepuncture measures were conducted. RESULTS: The MedDiet group reduced subcutaneous adipose tissue (SAT) area compared to the low-fat diet group (12.5 cm CONCLUSIONS: Adherence to 6-month ad libitum MedDiet reduced subcutaneous fat and waist circumference which discounts the misconception that this healthy but high fat diet leads to body fat gain. The effect of MedDiet on body fat distribution and consequent anti-inflammatory and antioxidant effects, as well as need for medications, in patients with CHD warrants exploration in larger studies. Clinically significant effects on these markers may require adjunct exercise and/or caloric restriction. TRIAL REGISTRATION: ACTRN12616000156482.