Skip to main content Accessibility help

Associations of evolutionary-concordance diet, Mediterranean diet and evolutionary-concordance lifestyle pattern scores with all-cause and cause-specific mortality

  • En Cheng (a1), Caroline Y. Um (a1), Anna Prizment (a2) (a3), DeAnn Lazovich (a2) (a3) and Roberd M. Bostick (a1) (a4)...


Various individual diet and lifestyle factors are associated with mortality. Investigating these factors collectively may help clarify whether dietary and lifestyle patterns contribute to life expectancy. We investigated the association of previously described evolutionary-concordance and Mediterranean diet pattern scores and a novel evolutionary-concordance lifestyle pattern score with all-cause and cause-specific mortality in the prospective Iowa Women’s Health Study (1986–2012). We created the diet pattern scores from Willett FFQ responses, and the lifestyle pattern score from self-reported physical activity, BMI and smoking status, and assessed their associations with mortality, using multivariable Cox proportional hazards regression. Of the 35 221 55- to 69-year-old cancer-free women at baseline, 18 687 died during follow-up. The adjusted hazard ratios (HR) and 95 % CI for all-cause, all CVD, and all-cancer mortality among participants in the highest relative to the lowest quintile of the evolutionary-concordance lifestyle score were, respectively, 0·52 (95 % CI 0·50, 0·55), 0·53 (95 % CI 0·49, 0·57) and 0·51 (95 % CI 0·46, 0·57). The corresponding findings for the Mediterranean diet score were HR 0·85 (95 % CI 0·82, 0·90), 0·83 (95 % CI 0·76, 0·90) and 0·93 (95 % CI 0·84, 1·03), and for the evolutionary-concordance diet score they were close to null and not statistically significant. The lowest estimated risk was among those in the highest joint quintile of the lifestyle score and either diet score (both Pinteraction <0·01). Our findings suggest that (1) a more Mediterranean-like diet pattern and (2) a more evolutionary-concordant lifestyle pattern, alone and in interaction with a more evolutionary-concordant or Mediterranean diet pattern, may be inversely associated with mortality.


Corresponding author

*Corresponding author: R. M. Bostick, fax +1 404 727 8737, email


Hide All
1. GBD 2013 Mortality and Causes of Death Collaborators (2015) Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 385, 117171.
2. Behrens, G, Fischer, B, Kohler, S, et al. (2013) Healthy lifestyle behaviors and decreased risk of mortality in a large prospective study of U.S. women and men. Eur J Epidemiol 28, 361372.
3. Ding, D, Rogers, K, van der Ploeg, H, et al. (2015) Traditional and emerging lifestyle risk behaviors and all-cause mortality in middle-aged and older adults: evidence from a large population-based Australian cohort. PLoS Med 12, e1001917.
4. Loef, M & Walach, H (2012) The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Prev Med 55, 163170.
5. Petersen, KE, Johnsen, NF, Olsen, A, et al. (2015) The combined impact of adherence to five lifestyle factors on all-cause, cancer and cardiovascular mortality: a prospective cohort study among Danish men and women. Br J Nutr 113, 849858.
6. McCullough, ML (2014) Diet patterns and mortality: common threads and consistent results. J Nutr 144, 795796.
7. Jankovic, N, Geelen, A, Streppel, MT, et al. (2014) Adherence to a healthy diet according to the World Health Organization guidelines and all-cause mortality in elderly adults from Europe and the United States. Am J Epidemiol 180, 978988.
8. Knoops, KT, de Groot, LC, Kromhout, D, et al. (2004) Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 292, 14331439.
9. McNaughton, SA, Bates, CJ & Mishra, GD (2012) Diet quality is associated with all-cause mortality in adults aged 65 years and older. J Nutr 142, 320325.
10. Mitrou, PN, Kipnis, V, Thiebaut, AC, et al. (2007) Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study. Arch Intern Med 167, 24612468.
11. Reedy, J, Krebs-Smith, SM, Miller, PE, et al. (2014) Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults. J Nutr 144, 881889.
12. Sotos-Prieto, M, Bhupathiraju, SN, Mattei, J, et al. (2017) Association of changes in diet quality with total and cause-specific mortality. N Engl J Med 377, 143153.
13. Tognon, G, Lissner, L, Saebye, D, et al. (2014) The Mediterranean diet in relation to mortality and CVD: a Danish cohort study. Br J Nutr 111, 151159.
14. Tognon, G, Nilsson, LM, Lissner, L, et al. (2012) The Mediterranean diet score and mortality are inversely associated in adults living in the subarctic region. J Nutr 142, 15471553.
15. Tong, TY, Wareham, NJ, Khaw, KT, et al. (2016) Prospective association of the Mediterranean diet with cardiovascular disease incidence and mortality and its population impact in a non-Mediterranean population: the EPIC-Norfolk study. BMC Med 14, 135.
16. Vormund, K, Braun, J, Rohrmann, S, et al. (2015) Mediterranean diet and mortality in Switzerland: an alpine paradox? Eur J Nutr 54, 139148.
17. Zazpe, I, Sanchez-Tainta, A, Toledo, E, et al. (2014) Dietary patterns and total mortality in a Mediterranean cohort: the SUN project. J Acad Nutr Diet 114, 3747.
18. Hu, FB (2002) Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 13, 39.
19. Gellert, C, Schottker, B & Brenner, H (2012) Smoking and all-cause mortality in older people: systematic review and meta-analysis. Arch Intern Med 172, 837844.
20. Jones, MR, Tellez-Plaza, M & Navas-Acien, A (2013) Smoking, menthol cigarettes and all-cause, cancer and cardiovascular mortality: evidence from the National Health and Nutrition Examination Survey (NHANES) and a meta-analysis. PLOS ONE 8, e77941.
21. Li, Y, Gu, M, Jing, F, et al. (2016) Association between physical activity and all cancer mortality: dose–response meta-analysis of cohort studies. Int J Cancer 138, 818832.
22. Lollgen, H, Bockenhoff, A & Knapp, G (2009) Physical activity and all-cause mortality: an updated meta-analysis with different intensity categories. Int J Sports Med 30, 213224.
23. McGee, DL, Diverse Populations Collaboration (2005) Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Ann Epidemiol 15, 8797.
24. Mons, U, Muezzinler, A, Gellert, C, et al. (2015) Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium. BMJ 350, h1551.
25. Nocon, M, Hiemann, T, Muller-Riemenschneider, F, et al. (2008) Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 15, 239246.
26. Ford, ES, Bergmann, MM, Boeing, H, et al. (2012) Healthy lifestyle behaviors and all-cause mortality among adults in the United States. Prev Med 55, 2327.
27. Hulsegge, G, Looman, M, Smit, HA, et al. (2016) Lifestyle changes in young adulthood and middle age and risk of cardiovascular disease and all-cause mortality: the Doetinchem Cohort Study. J Am Heart Assoc 5, e002432.
28. Prinelli, F, Yannakoulia, M, Anastasiou, CA, et al. (2015) Mediterranean diet and other lifestyle factors in relation to 20-year all-cause mortality: a cohort study in an Italian population. Br J Nutr 113, 10031011.
29. Yun, JE, Won, S, Kimm, H, et al. (2012) Effects of a combined lifestyle score on 10-year mortality in Korean men and women: a prospective cohort study. BMC Public Health 12, 673.
30. Whalen, KA, McCullough, ML, Flanders, WD, et al. (2016) Paleolithic and Mediterranean diet pattern scores are inversely associated with biomarkers of inflammation and oxidative balance in adults. J Nutr 146, 12171226.
31. Whalen, KA, McCullough, M, Flanders, WD, et al. (2014) Paleolithic and Mediterranean diet pattern scores and risk of incident, sporadic colorectal adenomas. Am J Epidemiol 180, 10881097.
32. Whalen, KA, Judd, S, McCullough, ML, et al. (2017) Paleolithic and Mediterranean diet pattern scores are inversely associated with all-cause and cause-specific mortality in adults. J Nutr 147, 612620.
33. Konner, M & Eaton, SB (2010) Paleolithic nutrition: twenty-five years later. Nutr Clin Pract 25, 594602.
34. Eaton, SB & Konner, M (1985) Paleolithic nutrition. A consideration of its nature and current implications. N Engl J Med 312, 283289.
35. Eaton, SB, Konner, M & Shostak, M (1988) Stone agers in the fast lane: chronic degenerative diseases in evolutionary perspective. Am J Med 84, 739749.
36. Trichopoulou, A (2004) Traditional Mediterranean diet and longevity in the elderly: a review. Public Health Nutr 7, 943947.
37. Garcia-Fernandez, E, Rico-Cabanas, L, Rosgaard, N, et al. (2014) Mediterranean diet and cardiodiabesity: a review. Nutrients 6, 34743500.
38. Willett, WC, Sacks, F, Trichopoulou, A, et al. (1995) Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr 61, 1402S1406S.
39. Trichopoulou, A, Costacou, T, Bamia, C, et al. (2003) Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 348, 25992608.
40. Dinu, M, Pagliai, G, Casini, A, et al. (2018) Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomised trials. Eur J Clin Nutr 72, 3043.
41. Folsom, AR, Kaye, SA, Prineas, RJ, et al. (1990) Increased incidence of carcinoma of the breast associated with abdominal adiposity in postmenopausal women. Am J Epidemiol 131, 794803.
42. Munger, RG, Folsom, AR, Kushi, LH, et al. (1992) Dietary assessment of older Iowa women with a food frequency questionnaire: nutrient intake, reproducibility, and comparison with 24-hour dietary recall interviews. Am J Epidemiol 136, 192200.
43. Willett, WC, Sampson, L, Browne, ML, et al. (1988) The use of a self-administered questionnaire to assess diet four years in the past. Am J Epidemiol 127, 188199.
44. Kushi, LH, Fee, RM, Folsom, AR, et al. (1997) Physical activity and mortality in postmenopausal women. JAMA 277, 12871292.
45. Klein, JP & Moeschberger, ML (2005) Survival Analysis: Techniques for Censored and Truncated Data. New York: Springer Science & Business Media.
46. Fung, TT, McCullough, ML, Newby, PK, et al. (2005) Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction. Am J Clin Nutr 82, 163173.
47. Reedy, J, Mitrou, PN, Krebs-Smith, SM, et al. (2008) Index-based dietary patterns and risk of colorectal cancer: the NIH-AARP Diet and Health Study. Am J Epidemiol 168, 3848.
48. Dash, C, Bostick, RM, Goodman, M, et al. (2015) Oxidative balance scores and risk of incident colorectal cancer in a US prospective cohort study. Am J Epidemiol 181, 584594.
49. Dash, C, Goodman, M, Flanders, WD, et al. (2013) Using pathway-specific comprehensive exposure scores in epidemiology: application to oxidative balance in a pooled case–control study of incident, sporadic colorectal adenomas. Am J Epidemiol 178, 610624.
50. Cheng, E, Um, CY, Prizment, AE, et al. (2018) Evolutionary-concordance lifestyle and diet and Mediterranean diet pattern scores and risk of incident colorectal cancer in Iowa women. Cancer Epidemiol Biomarkers Prev 27, 11951202.
51. Lampe, JW (1999) Health effects of vegetables and fruit: assessing mechanisms of action in human experimental studies. Am J Clin Nutr 70, 475S490S.
52. Bao, Y, Han, J, Hu, FB, et al. (2013) Association of nut consumption with total and cause-specific mortality. N Engl J Med 369, 20012011.
53. Santarelli, RL, Pierre, F & Corpet, DE (2008) Processed meat and colorectal cancer: a review of epidemiologic and experimental evidence. Nutr Cancer 60, 131144.
54. Ward, MH, Cross, AJ, Divan, H, et al. (2007) Processed meat intake, CYP2A6 activity and risk of colorectal adenoma. Carcinogenesis 28, 12101216.
55. McAfee, AJ, McSorley, EM, Cuskelly, GJ, et al. (2010) Red meat consumption: an overview of the risks and benefits. Meat Sci 84, 113.
56. Micha, R, Wallace, SK & Mozaffarian, D (2010) Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation 121, 22712283.
57. Koeth, RA, Wang, Z, Levison, BS, et al. (2013) Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 19, 576585.
58. Cross, AJ, Leitzmann, MF, Gail, MH, et al. (2007) A prospective study of red and processed meat intake in relation to cancer risk. PLoS Med 4, e325.
59. Warburton, DE, Glendhill, N & Quinney, A (2001) The effects of changes in musculoskeletal fitness on health. Can J Appl Physiol 26, 161216.
60. Barness, LA, Opitz, JM & Gilbert-Barness, E (2007) Obesity: genetic, molecular, and environmental aspects. Am J Med Genet A 143A, 30163034.
61. BMIMC, Global, Di Angelantonio, E, Bhupathiraju, Sh N, et al. (2016) Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet 388, 776786.
62. Solomon, CG & Manson, JE (1997) Obesity and mortality: a review of the epidemiologic data. Am J Clin Nutr 66, 1044S1050S.
63. Doll, R (1999) Risk from tobacco and potentials for health gain. Int J Tuberc Lung Dis 3, 9099.
64. Tsiara, S, Elisaf, M & Mikhailidis, DP (2003) Influence of smoking on predictors of vascular disease. Angiology 54, 507530.
65. Genoni, A, Lyons-Wall, P, Lo, J, et al. (2016) Cardiovascular, metabolic effects and dietary composition of ad-libitum Paleolithic v. Australian guide to healthy eating diets: a 4-week randomised trial. Nutrients 8, 314.
66. Lindeberg, S, Jonsson, T, Granfeldt, Y, et al. (2007) A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease. Diabetologia 50, 17951807.
67. Mellberg, C, Sandberg, S, Ryberg, M, et al. (2014) Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. Eur J Clin Nutr 68, 350357.
68. Osterdahl, M, Kocturk, T, Koochek, A, et al. (2008) Effects of a short-term intervention with a Paleolithic diet in healthy volunteers. Eur J Clin Nutr 62, 682685.
69. Otten, J, Stomby, A, Waling, M, et al. (2017) Benefits of a Paleolithic diet with and without supervised exercise on fat mass, insulin sensitivity, and glycemic control: a randomized controlled trial in individuals with type 2 diabetes. Diabetes Metab Res Rev 33, e2828.
70. Bligh, HF, Godsland, IF, Frost, G, et al. (2015) Plant-rich mixed meals based on Palaeolithic diet principles have a dramatic impact on incretin, peptide YY and satiety response, but show little effect on glucose and insulin homeostasis: an acute-effects randomised study. Br J Nutr 113, 574584.
71. Boers, I, Muskiet, FA, Berkelaar, E, et al. (2014) Favourable effects of consuming a Palaeolithic-type diet on characteristics of the metabolic syndrome: a randomized controlled pilot-study. Lipids Health Dis 13, 160.
72. Frassetto, LA, Schloetter, M, Mietus-Synder, M, et al. (2009) Metabolic and physiologic improvements from consuming a Paleolithic, hunter–gatherer type diet. Eur J Clin Nutr 63, 947955.
73. Jonsson, T, Granfeldt, Y, Ahren, B, et al. (2009) Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol 8, 35.
74. Masharani, U, Sherchan, P, Schloetter, M, et al. (2015) Metabolic and physiologic effects from consuming a hunter–gatherer (Paleolithic)-type diet in type 2 diabetes. Eur J Clin Nutr 69, 944948.
75. World Health Organization & World Health Organization/Tufts University Consultation on Nutritional Guidelines for the Elderly (2002) Keep Fit for Life: Meeting the Nutritional Needs of Older Persons. Geneva: World Health Organization.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

British Journal of Nutrition
  • ISSN: 0007-1145
  • EISSN: 1475-2662
  • URL: /core/journals/british-journal-of-nutrition
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Cheng et al. supplementary material
Tables S1-S6

 Word (56 KB)
56 KB


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed