Skip to main content
×
×
Home

Mediterranean diet and its components in relation to all-cause mortality: meta-analysis

  • Dimitra Eleftheriou (a1) (a2), Vassiliki Benetou (a1), Antonia Trichopoulou (a1) (a3), Carlo La Vecchia (a4) and Christina Bamia (a1)...
Abstract

The beneficial association of the Mediterranean diet (MedDiet) with longevity has been consistently demonstrated, but the associations of MedDiet components have not been accordingly evaluated. We performed an updated meta-analysis of prospective cohort studies published up to 31 December 2017, to quantify the association of adherence to MedDiet, expressed as an index/score (MDS) and of its components with all-cause mortality. We estimated summary relative risks (SRR) and 95 % CI using random effects models. On the basis of thirty studies (225 600 deaths), SRR for the study-specific highest/lowest and per 1sd MDS increment were 0·79 (95 % CI 0·77, 0·81, Ι2=42 %, P-heterogeneity 0·02) and 0·92 (95 % CI 0·90, 0·94, Ι2 56 %, P-heterogeneity <0·01), respectively. Inversely, statistically significant associations were evident in stratified analyses by country, MDS range and publication year, with some evidence for heterogeneity across countries overall (P-heterogeneity 0·011), as well as across European countries (P=0·018). Regarding MDS components, relatively stronger and statistically significant inverse associations were highlighted for moderate/none-excessive alcohol consumption (0·86, 95 % CI 0·77, 0·97) and for above/below-the-median consumptions of fruit (0·88, 95 % CI 0·83, 0·94) and vegetables (0·94, 95 % CI 0·89, 0·98), whereas a positive association was apparent for above/below-the-median intake of meat (1·07, 95 % CI 1·01, 1·13). Our meta-analyses confirm the inverse association of MedDiet with mortality and highlight the dietary components that influence mostly this association. Our results are important for better understanding the role of MedDiet in health and proposing dietary changes to effectively increase adherence to this healthy dietary pattern.

Copyright
Corresponding author
*Corresponding author: Associate Professor C. Bamia, email cbamia@med.uoa.gr
References
Hide All
1. Martínez-González, MA & Bes-Rastrollo, M (2014) Dietary patterns, Mediterranean diet, and cardiovascular disease. Curr Opin Lipidol 25, 2026.
2. Schwingshackl, L & Hoffmann, G (2014) Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis 24, 929939.
3. Gay, HC, Rao, SG, Vaccarino, V, et al. (2016) Effects of different dietary interventions on blood pressure: systematic review and meta-analysis of randomized controlled trials. Hypertension 67, 733739.
4. Sofi, F, Macchi, C, Abbate, R, et al. (2014) Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 17, 27692782.
5. Schwingshackl, L, Schwedhelm, C, Galbete, C, et al. (2017) Adherence to Mediterranean diet and risk of cancer: an updated systematic review and meta-analysis. Nutrients 9, E1063.
6. 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.
7. Trichopoulou, A, Bamia, C & Trichopoulos, D (2009) Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ 338, b2337.
8. Martínez-González, MA, Guillén-Grima, F, De Irala, J, et al. (2012) The Mediterranean diet is associated with a reduction in premature mortality among middle-aged adults. J Nutr 142, 16721678.
9. 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.
10. Stefler, D, Malyutina, S, Kubinova, R, et al. (2017) Mediterranean diet score and total and cardiovascular mortality in Eastern Europe: the HAPIEE study. Eur J Nutr 56, 421429.
11. Bloomfield, HE, Koeller, E, Greer, N, et al. (2016) Effects on health outcomes of a Mediterranean diet with no restriction on fat intake: a systematic review and meta-analysis. Ann Intern Med 165, 491500.
12. 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.
13. Martínez-González, MA, Zazpe, I, Razquin, C, et al. (2015) Empirically-derived food patterns and the risk of total mortality and cardiovascular events in the PREDIMED study. Clin Nutr 34, 859867.
14. Menotti, A, Puddu, PE, Maiani, G, et al. (2016) Cardiovascular and other causes of death as a function of lifestyle habits in a quasi extinct middle-aged male population. A 50-year follow-up study. Int J Cardiol 210, 173178.
15. Kouris-Blazos, A & Itsiopoulos, C (2014) Low all-cause mortality despite high cardiovascular risk in elderly Greek-born Australians: attenuating potential of diet? Asia Pac J Clin Nutr 23, 532544.
16. Kouris-Blazos, A, Gnardellis, C, Wahlqvist, ML, et al. (1999) Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia. Br J Nutr 82, 5761.
17. 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.
18. Panagiotakos, DB, Georgousopoulou, EN, Pitsavos, C, et al. (2015) Ten-year (2002–2012) cardiovascular disease incidence and all-cause mortality, in urban Greek population: the ATTICA Study. Int J Cardiol 180, 178184.
19. Guasch-Ferré, M, Salas-Salvadó, J, Ros, E, et al. (2017) The PREDIMED trial, Mediterranean diet and health outcomes: how strong is the evidence? Nutr Metab Cardiovasc Dis 27, 624632.
20. Ebell, MH & Grad, R (2017) Top 20 research studies of 2016 for primary care physicians. Am Fam Physician 95, 572579.
21. Rautiainen, S, Gaziano, JM, Christen, WG, et al. (2017) Effect of baseline nutritional status on long-term multivitamin use and cardiovascular disease risk: a secondary analysis of the Physicians’ Health Study II randomized clinical trial. JAMA Cardiol 2, 617625.
22. Harmon, BE, Boushey, CJ, Shvetsov, YB, et al. (2015) Associations of key diet-quality indexes with mortality in the multiethnic cohort: the Dietary Patterns Methods Project. Am J Clin Nutr 101, 587597.
23. Shvetsov, YB, Harmon, BE, Ettienne, R, et al. (2016) The influence of energy standardisation on the alternate Mediterranean diet score and its association with mortality in the multiethnic cohort. Br J Nutr 116, 15921601.
24. Liese, AD, Krebs-Smith, SM, Subar, AF, et al. (2015) The Dietary Patterns Methods Project: synthesis of findings across cohorts and relevance to dietary guidance. J Nutr 145, 393402.
25. George, SM, Ballard-Barbash, R, Manson, JE, et al. (2014) Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women’s Health Initiative Observational Study: evidence to inform national dietary guidance. Am J Epidemiol 180, 616625.
26. 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.
27. Lassale, C, Gunter, MJ, Romaguera, D, et al. (2016) Diet quality scores and prediction of all-cause, cardiovascular and cancer mortality in a pan-European cohort study. PLOS ONE 11, e0159025.
28. Trichopoulou, A, Orfanos, P, Norat, T, et al. (2005) Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. BMJ 330, 991.
29. Alvarez-Alvarez, I, Zazpe, I, Pérez de Rojas, J, et al. (2018) Mediterranean diet, physical activity and their combined effect on all-cause mortality: the Seguimiento Universidad de Navarra (SUN) cohort. Prev Med 106, 4552.
30. Trichopoulou, A, Kouris-Blazos, A, Wahlqvist, ML, et al. (1995) Diet and overall premature mortality in men and women survival in elderly people. BMJ 311, 14571460.
31. Lasheras, C, Fernandez, S & Patterson, AM (2000) Mediterranean diet and age with respect to overall survival in institutionalized, nonsmoking elderly people. Am J Clin Nutr 71, 987992.
32. 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.
33. Lagiou, P, Trichopoulos, D, Sandin, S, et al. (2006) Mediterranean dietary pattern and mortality among young women: a cohort study in Sweden. Br J Nutr 96, 384392.
34. Mitrou, PN, Kipnis, V, Thiébaut, 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.
35. Sjögren, P, Becker, W, Warensjö, E, et al. (2010) Mediterranean and carbohydrate-restricted diets and mortality among elderly men: a cohort study in Sweden. Am J Clin Nutr 92, 967974.
36. Tognon, G, Rothenberg, E, Eiben, G, et al. (2011) Does the Mediterranean diet predict longevity in the elderly? A Swedish perspective. Age (Dordr) 33, 439450.
37. Buckland, G, Agudo, A, Travier, N, et al. (2011) Adherence to the Mediterranean diet reduces mortality in the Spanish cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Spain). Br J Nutr 106, 15811591.
38. van den Brandt, PA (2011) The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women. Am J Clin Nutr 94, 913920.
39. 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.
40. 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.
41. Cuenca-García, M, Artero, EG, Sui, X, et al. (2014) Dietary indices, cardiovascular risk factors and mortality in middle-aged adults: findings from the Aerobics Center Longitudinal Study. Ann Epidemiol 24, 297303.e2.
42. Tognon, G, Lissner, L, Sæbye, D, et al. (2014) The Mediterranean diet in relation to mortality and CVD: a Danish cohort study. Br J Nutr 111, 151159.
43. Vormund, K, Braun, J, Rohrmann, S, et al. (2015) Mediterranean diet and mortality in Switzerland: an alpine paradox? Eur J Nutr 54, 139148.
44. 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.
45. Bellavia, A, Tektonidis, TG, Orsini, N, et al. (2016) Quantifying the benefits of Mediterranean diet in terms of survival. Eur J Epidemiol 31, 527530.
46. Bo, S, Ponzo, V, Goitre, I, et al. (2016) Predictive role of the Mediterranean diet on mortality in individuals at low cardiovascular risk: a 12-year follow-up population-based cohort study. J Transl Med 14, 91.
47. Limongi, F, Noale, M, Gesmundo, A, et al. (2017) Adherence to the Mediterranean diet and all-cause mortality risk in an elderly Italian population: data from the ILSA study. J Nutr Health Aging 21, 505513.
48. 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.
49. Franzon, K, Byberg, L, Sjögren, P, et al. (2017) Predictors of independent aging and survival: a 16-year follow-up report in octogenarian men. J Am Geriatr Soc 65, 19531960.
50. Shah, NS, Leonard, D, Finley, CE, et al. (2018) Dietary patterns and long-term survival: a retrospective study of healthy primary care patients. Am J Med 131, 4855.
51. 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.
52. Georgousopoulou, EN, Kastorini, CM, Milionis, HJ, et al. (2014) Association between Mediterranean diet and non-fatal cardiovascular events, in the context of anxiety and depression disorders: a case/case–control study. Hellenic J Cardiol 55, 2431.
53. DerSimonian, R & Laird, N (1986) Meta-analysis in clinical trials. Control Clin Trials 7, 177188.
54. Greenland, S (1987) Quantitative methods in the review of epidemiologic literature. Epidemiol Rev 9, 130.
55. Higgins, JP & Thompson, SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21, 15391558.
56. Stuck, AE, Rubenstein, LZ & Wieland, D (1998) Bias in meta-analysis detected by a simple, graphical test. Asymmetry detected in funnel plot was probably due to true heterogeneity. BMJ 316, 469, author reply 470–471.
57. Macaskill, P, Walter, SD & Irwig, L (2001) A comparison of methods to detect publication bias in meta-analysis. Stat Med 20, 641654.
58. Sofi, F, Abbate, R, Gensini, GF, et al. (2010) Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 92, 11891196.
59. Menendez, JA & Lupu, R (2006) Mediterranean dietary traditions for the molecular treatment of human cancer: anti-oncogenic actions of the main olive oil’s monounsaturated fatty acid oleic acid (18:1n-9). Curr Pharm Biotechnol 7, 495502.
60. Dedoussis, GV, Kanoni, S, Mariani, E, et al. (2008) Mediterranean diet and plasma concentration of inflammatory markers in old and very old subjects in the ZINCAGE population study. Clin Chem Lab Med 46, 990996.
61. Pelucchi, C, Bosetti, C, Negri, E, et al. (2011) Olive oil and cancer risk: an update of epidemiological findings through 2010. Curr Pharm Des 17, 805812.
62. Di Castelnuovo, A, Costanzo, S, Bagnardi, V, et al. (2006) Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. Arch Intern Med 166, 24372445.
63. Wang, X, Ouyang, Y, Liu, J, et al. (2014) Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose–response meta-analysis of prospective cohort studies. BMJ 349, g4490.
64. Grosso, G, Yang, J, Marventano, S, et al. (2015) Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systematic review and meta-analysis of epidemiologic studies. Am J Clin Nutr 101, 783793.
65. Abete, I, Romaguera, D, Vieira, AR, et al. (2014) Association between total, processed, red and white meat consumption and all-cause, CVD and IHD mortality: a meta-analysis of cohort studies. Br J Nutr 112, 762775.
66. Wang, X, Lin, X, Ouyang, YY, et al. (2016) Red and processed meat consumption and mortality: dose–response meta-analysis of prospective cohort studies. Public Health Nutr 19, 893905.
67. Aune, D, Keum, N, Giovannucci, E, et al. (2016) Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose–response meta-analysis of prospective studies. BMJ 353, i2716.
68. Hajishafiee, M, Saneei, P, Benisi-Kohansal, S, et al. (2016) Cereal fibre intake and risk of mortality from all causes, CVD, cancer and inflammatory diseases: a systematic review and meta-analysis of prospective cohort studies. Br J Nutr 116, 343352.
69. Zhao, LG, Sun, JW, Yang, Y, et al. (2016) Fish consumption and all-cause mortality: a meta-analysis of cohort studies. Eur J Clin Nutr 70, 155161.
70. Marventano, S, Izquierdo Pulido, M, Sánchez-González, C, et al. (2017) Legume consumption and CVD risk: a systematic review and meta-analysis. Public Health Nutr 20, 245254.
71. Schwingshackl, L & Hoffmann, G (2014) Monounsaturated fatty acids, olive oil and health status: a systematic review and meta-analysis of cohort studies. Lipids Health Dis 13, 154.
72. Grosso, G, Marventano, S, Yang, J, et al. (2017) A comprehensive meta-analysis on evidence of mediterranean diet and cardiovascular disease: are individual components equal? Crit Rev Food Sci Nutr 57, 32183232.
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? *
×

Keywords

Metrics

Altmetric attention score

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