Skip to main content

Dietary patterns and survival of older Europeans: The EPIC-Elderly Study (European Prospective Investigation into Cancer and Nutrition)

  • Christina Bamia (a1), Dimitrios Trichopoulos (a2), Pietro Ferrari (a3), Kim Overvad (a4), Lone Bjerregaard (a5), Anne Tjønneland (a6), Jytte Halkjær (a6), Françoise Clavel-Chapelon (a7), Emmanuelle Kesse (a8), Marie-Christine Boutron-Ruault (a7), Paolo Boffetta (a9), Gabriele Nagel (a10), Jacob Linseisen (a11), Heiner Boeing (a12), Kurt Hoffmann (a12), Christina Kasapa (a1), Anastasia Orfanou (a1), Chrysoula Travezea (a1), Nadia Slimani (a3), Teresa Norat (a13), Domenico Palli (a14), Valeria Pala (a15), Salvatore Panico (a16), Rosario Tumino (a17), Carlotta Sacerdote (a18), H Bas Bueno-de-Mesquita (a19), Patricia MCM Waijers (a19), Petra HM Peeters (a20), Yvonne T van der Schouw (a20), Antonio Berenguer (a21), Carmen Martinez-Garcia (a22), Carmen Navarro (a23), Aurelio Barricarte (a24), Miren Dorronsoro (a25), Göran Berglund (a26), Elisabet Wirfält (a26), Ingegerd Johansson (a27), Gerd Johansson (a28), Sheila Bingham (a29), Kay-Tee Khaw (a30), Elizabeth A Spencer (a31), Tim Key (a31), Elio Riboli (a3) and Antonia Trichopoulou (a1)...

To investigate the association of a posteriori dietary patterns with overall survival of older Europeans.

Design and setting

This is a multi-centre cohort study. Cox regression analysis was used to investigate the association of the prevailing, a posteriori-derived, plant-based dietary pattern with all-cause mortality in a population of subjects who were 60 years or older at recruitment to the European Prospective Investigation into Cancer and Nutrition (EPIC-Elderly cohort). Analyses controlled for all known potential risk factors.


In total, 74 607 men and women, 60 years or older at enrolment and without previous coronary heart disease, stroke or cancer, with complete information about dietary intakes and potentially confounding variables, and with known survival status as of December 2003, were included in the analysis.


An increase in the score which measures the adherence to the plant-based diet was associated with a lower overall mortality, a one standard deviation increment corresponding to a statistically significant reduction of 14% (95% confidence interval 5–23%). In country-specific analyses the apparent association was stronger in Greece, Spain, Denmark and The Netherlands, and absent in the UK and Germany.


Greater adherence to the plant-based diet that was defined a posteriori in this population of European elders is associated with lower all-cause mortality. This dietary score is moderately positively correlated with the Modified Mediterranean Diet Score that has been constructed a priori and was also shown to be beneficial for the survival of the same EPIC-Elderly cohort.

Corresponding author
*Corresponding author: Email
Hide All
1Carlson JJ, Monti V. The role of inclusive dietary patterns for achieving secondary prevention cardiovascular nutrition guidelines and optimal cardiovascular health. Journal of Cardiopulmonary Rehabilitation 2003; 23: 322–33.
2Kant AK. Dietary patterns and health outcomes. Journal of the American Dietetic Association 2004; 104: 615–35.
3Gordon T, Fisher M, Rifkind BM. Some difficulties inherent in the interpretation of dietary data from free-living populations. American Journal of Clinical Nutrition 1984; 39: 152–6.
4Jacques PF, Tucker KL. Are dietary patterns useful for understanding the role of diet in chronic disease? American Journal of Clinical Nutrition 2001; 73: 12.
5Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis C, Lagiou P, Polychronopoulos E, et al. . Diet and overall survival in elderly people. British Medical Journal 1995; 311: 1457–60.
6Huijbregts P, Feskens E, Rasanen L, Fidanza F, Nissinen A, Menotti A, et al. . Dietary pattern and 20 year mortality in elderly men in Finland, Italy, and the Netherlands: longitudinal cohort study. British Medical Journal 1997; 315: 13–7.
7Osler M, Schroll M. Diet and mortality in a cohort of elderly people in a north European Community. International Journal of Epidemiology 1997; 26: 155–9.
8Kumagai S, Shibata H, Watanabe S, Suzuki T, Haga H. Effect of food intake pattern on all-cause mortality in the community elderly: a 7-year longitudinal study. Journal of Nutrition, Health & Aging 1999; 3: 2933.
9Kouris-Blazos A, Gnardellis C, Wahlqvist ML, Trichopoulos D, Lukito W, Trichopoulou A. Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia. British Journal of Nutrition 1999; 82: 5761.
10Lasheras C, Fernandez S, Patterson AM. Mediterranean diet and age with respect to overall survival in institutionalised, nonsmoking elderly people. American Journal of Clinical Nutrition 2000; 71: 987–92.
11Shimizu K, Takeda S, Noji H, Hirose N, Ebihara Y, Arai Y, et al. . Dietary patterns and further survival in Japanese centenarians. Journal of Nutritional Science and Vitaminology 2003; 49: 133–8.
12Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, et al. . Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. Journal of the American Medical Association 2004; 92: 1433–9.
13Trichopoulou A, Orfanos P, Norat T, Bueno-de-Mesquita B, Ocke MC, Peeters PH, et al. . Modified Mediterranean diet and survival: The EPIC-Elderly study. British Medical Journal 2005; 330: 991.
14Trichopoulos D, Lagiou P. Dietary patterns and mortality. British Journal of Nutrition 2001; 85: 133–4.
15Patterson RE, Haines PS, Popkin BM. Diet quality index: capturing a multidimensional behavior. Journal of the American Dietetic Association 1994; 94: 57–64.
16Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. Journal of the American Dietetic Association 1995; 95: 1103–8.
17Haines PS, Siega-Riz AM, Popkin BM. The Diet Quality Index revised: a measurement instrument for populations. Journal of the American Dietetic Association 1999; 99: 697–704.
18McCullough ML, Feskanich D, Stampfer MJ, Giovannucci EL, Rimm EB, Hu FB, et al. . Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. American Journal of Clinical Nutrition 2002; 76: 1261–71.
19Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to Mediterranean diet and survival in a Greek population. New England Journal of Medicine 2003; 348: 2599S–608S.
20Schulze MB, Hoffmann K, Kroke A, Boeing H. Risk of hypertension among women in the EPIC-Potsdam Study: comparison of relative risk estimates for exploratory and hypothesis-oriented dietary patterns. American Journal of Epidemiology 2003; 158: 365–73.
21Trichopoulou A, Bamia C, Trichopoulos D. Mediterranean diet and survival among patients with coronary heart disease in Greece. Archives of Internal Medicine 2005; 165: 929–35.
22Prevost AT, Whichelow MJ, Cox BD. Longitudinal dietary changes between 1984–5 and 1991–2 in British adults: association with socio-demographic, lifestyle and health factors. British Journal of Nutrition 1997; 78: 873–88.
23Schulze MB, Hoffmann K, Kroke A, Boeing H. Dietary patterns and their association with food and nutrient intake in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Postdam Study. British Journal of Nutrition 2001; 85: 363–73.
24McCann SE, Weiner J, Graham S, Freudenheim JL. Is principal components analysis necessary to characterise dietary behaviour in studies of diet and disease? Public Health Nutrition 2001; 4: 903–8.
25Balder HF, Virtanen M, Brants HA, Krogh V, Dixon LB, Tan F, et al. . Common and country-specific dietary patterns in four European cohort studies. Journal of Nutrition 2003; 133: 4246–51.
26Costacou T, Bamia C, Ferrari P, Riboli E, Trichopoulos D, Trichopoulou A. Tracing the Mediterranean diet through principal components and cluster analyses in the Greek population. European Journal of Clinical Nutrition 2003; 57: 1378–85.
27Bamia C, Orfanos P, Ferrari P, Overvad K, Hundborg HH, Tjonneland A, et al. . Dietary patterns among older Europeans: the EPIC-Elderly study. British Journal of Nutrition 2005; 94: 100–13.
28Pala V, Sieri S, Masala G, Palli D, Panico S, Vineis P, et al. . Associations between dietary pattern and lifestyle, anthropometry and other health indicators in the elderly participants of the EPIC-Italy cohort. Nutrition, Metabolism, and Cardiovascular Diseases 2006; 16: 186201.
29Whichelow MJ, Prevost AT. Dietary patterns and their associations with demographic, lifestyle and health variables in a random sample of British adults. British Journal of Nutrition 1996; 76: 17–30.
30Slattery ML, Boucher KM, Caan BJ, Potter JD, Ma KN. Eating patterns and risk of colon cancer. American Journal of Epidemiology 1998; 148: 4–16.
31Menotti A, Kromhout D, Blackburn H, Fidanza F, Buzina R, Nissinen A. Food intake patterns and 25-year mortality from coronary heart disease: cross-cultural correlations in the Seven Countries Study. The Seven Countries Study Research Group. European Journal of Epidemiology 1999; 15: 507–15.
32Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC. Prospective study of major dietary patterns and risk of coronary heart disease in men. American Journal of Clinical Nutrition 2000; 72: 912–21.
33Osler M, Heitmann BL, Gerdes LU, Jørgensen LM, Schroll M. Dietary patterns and mortality in Danish men and women: a prospective observational study. British Journal of Nutrition 2001; 85: 219–25.
34Osler M, Helms Andreasen A, Heitmann B, Hoidrup S, Gerdes U, Morch Jorgensen L, et al. . Food intake patterns and risk of coronary heart disease: a prospective cohort study examining the use of traditional scoring techniques. European Journal of Clinical Nutrition 2002; 56: 568–74.
35Terry P, Hu FB, Hansen H, Wolk A. Prospective study of major dietary patterns and colorectal cancer risk in women. American Journal of Epidemiology 2001; 154: 1143–9.
36Fung TT, Willett WC, Stampfer MJ, Manson JE, Hu FB. Dietary patterns and the risk of coronary heart disease in women. Archives of Internal Medicine 2001; 161: 1857–62.
37van Dam RM, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Dietary patterns and risk for type 2 diabetes mellitus in US men. Annals of Internal Medicine 2002; 136: 201–9.
38Martinez ME, Marshall JR, Sechrest L. Invited commentary: Factor analysis and the search for objectivity. American Journal of Epidemiology 1998; 148: 17–9.
39Riboli E, Hunt KJ, Slimani N, Ferrari P, Norat T, Fahey M, et al. . European Prospective Investigation into Cancer and Nutrition (EPIC): study populations and data collection. Public Health Nutrition 2002; 5: 1113–24.
40Slimani N, Kaaks R, Ferrari P, Casagrande C, Clavel-Chapelon F, Lotze G, et al. . European Prospective Investigation into Cancer and Nutrition (EPIC) calibration study: rationale, design and population characteristics. Public Health Nutrition 2002; 5: 1125–45.
41Margetts BM, Pietinen P. European Prospective Investigation into Cancer and Nutrition: validity studies on dietary assessment methods. International Journal of Epidemiology 1997; 26(Suppl. 1): S1–5.
42Willett WC. Diet and coronary heart disease. In: Willett WC, ed. Nutritional Epidemiology. 2nd ed. New York: Oxford University Press, 1998; 414–66.
43James WPT, Schofield EC. Human Energy Requirements: A Manual for Planners and Nutritionists. Oxford: Oxford University Press, 1990.
44Marmot MG. Alcohol and coronary heart disease. International Journal of Epidemiology 2001; 30: 724–9.
45Britton A, Marmot M. Different measures of alcohol consumption and risk of coronary heart disease and all-cause mortality: 11-year follow-up of the Whitehall II Cohort Study. Addiction 2004; 99: 109–16.
46World Cancer Research Fund (WCRF)/American Institute for Cancer Prevention (AICR). Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC: WCFR/AICR, 1997.
47Singh PN, Sabate J, Fraser GE. Does low meat consumption increase life expectancy in humans? American Journal of Clinical Nutrition 2003; 78(3 Suppl.): 526S–32S.
48Kelemen LE, Kushi LH, Jacobs DR Jr, Cerhan JR. Associations of dietary protein with disease and mortality in a prospective study of postmenopausal women. American Journal of Epidemiology 2005; 161: 239–49.
49Trichopoulou A, Naska A, Orfanos P, Trichopoulos D. Mediterranean diet in relation to body mass index and waist-to-hip ratio: the Greek European Prospective Investigation into Cancer and Nutrition Study. American Journal of Clinical Nutrition 2005; 82: 935–40.
50Panagiotakos DB, Arapi S, Pitsavos C, Antonoulas A, Mantas Y, Zombolos S, et al. . The relationship between adherence to the Mediterranean diet and the severity and short-term prognosis of acute coronary syndromes (ACS): The Greek Study of ACS (The GREECS). Nutrition 2006; 22: 722–30.
51Huijbregts PP, Feskens EJ, Kromhout D. Dietary patterns and cardiovascular risk factors in elderly men: the Zutphen Elderly Study. International Journal of Epidemiology 1995; 24: 313–20.
52Tucker KL, Chen H, Hannan MT, Cupples LA, Wilson PW, Felson D, et al. . Bone mineral density and dietary patterns in older adults: the Framingham Osteoporosis Study. American Journal of Clinical Nutrition 2002; 76: 245–52.
53Diehr P, Beresford SA. The relation of dietary patterns to future survival, health, and cardiovascular events in older adults. Journal of Clinical Epidemiology 2003; 56: 1224–35.
54Williams DE, Prevost AT, Whichelow MJ, Cox BD, Day NE, Wareham NJ. A cross-sectional study of dietary patterns with glucose intolerance and other features of the metabolic syndrome. British Journal of Nutrition 2000; 83: 257–66.
Recommend this journal

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

Public Health Nutrition
  • ISSN: 1368-9800
  • EISSN: 1475-2727
  • URL: /core/journals/public-health-nutrition
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 27
Total number of PDF views: 230 *
Loading metrics...

Abstract views

Total abstract views: 393 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 20th November 2017. This data will be updated every 24 hours.