The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women

Background: The Mediterranean diet has been associated with reduced mortality; few studies have investigated the combined impact of the Mediterranean diet with other modifiable lifestyle factors. Objective: The objective was to investigate the association between adherence to the Mediterranean diet and total mortality and estimate the overall impact of a combined healthy lifestyle on premature death. Design: In 1986 a cohort of 120,852 men and women aged 55‐69 y provided information on dietary and other lifestyle habits. A mortality follow-up until 1996 was established by linkage to the Dutch Central Bureau of Genealogy. A combined lifestyle score was constructed by allocating one point per the following healthy lifestyle factors: adhering to the Mediterranean diet, nonsmoking, normal weight [BMI (in kg/m 2 ): 18.5 to ,25], and regular physical activity. The lifestyle score ranged from 0 to 4 points (least healthy to healthiest). The multivariate case-cohort analysis was based on 9691 deaths and 3576 subcohort members. Results: Adherence to the Mediterranean diet was significantly related to lower mortality in women but not significantly in men. The healthy lifestyle score was strongly inversely related to mortality in women and men. When the least-healthy to the healthiest lifestyle scores were compared, HRs of 4.07 (95% CI: 2.59, 6.40; P-trend ,0.001) and 2.61 (95% CI: 1.79, 3.80; P-trend ,0.001) were shown in women and men, respectively. For the same comparison, the mortality rate advancement period (“aging effect”) was 15.1 y (95% CI: 9.9, 20.2 y) in women and 8.4 y (95% CI: 5.0, 11.8 y) in men. Conclusion: This study suggests that adherence to 4 modifiable healthy lifestyle factors can substantially reduce premature mortality in women and men. Am J Clin Nutr doi: 10.3945/ajcn.110. 008250.

[1]  H Löllgen,et al.  Physical activity and all-cause mortality: an updated meta-analysis with different intensity categories. , 2009, International journal of sports medicine.

[2]  J. Manson,et al.  Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction. , 2005, The American journal of clinical nutrition.

[3]  R. Collins,et al.  Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies , 2009, Lancet.

[4]  Giske Ursin,et al.  Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: the United Kingdom health and lifestyle survey. , 2010, Archives of internal medicine.

[5]  D. Annane,et al.  Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis , 2004, BMJ : British Medical Journal.

[6]  J. Manson,et al.  Mediterranean diet and incidence and mortality of coronary heart disease and stroke in women , 2009, Circulation.

[7]  H. Adami,et al.  Mediterranean dietary pattern and mortality among young women: a cohort study in Sweden , 2006, British Journal of Nutrition.

[8]  C. Weinberg,et al.  Use and misuse of population attributable fractions. , 1998, American journal of public health.

[9]  David A. Schoenfeld,et al.  Partial residuals for the proportional hazards regression model , 1982 .

[10]  R A Goldbohm,et al.  A large-scale prospective cohort study on diet and cancer in The Netherlands. , 1990, Journal of clinical epidemiology.

[11]  W. Willett,et al.  Mediterranean diet pyramid: a cultural model for healthy eating. , 1995, The American journal of clinical nutrition.

[12]  Robert Luben,et al.  Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study , 2008, PLoS medicine.

[13]  S. Greenland,et al.  Risk and Rate Advancement Periods as Measures of Exposure Impact on the Occurrence of Chronic Diseases , 1993, Epidemiology.

[14]  Rosanna Abbate,et al.  Adherence to Mediterranean diet and health status: meta-analysis , 2008, BMJ : British Medical Journal.

[15]  R A Goldbohm,et al.  Validation of a dietary questionnaire used in a large-scale prospective cohort study on diet and cancer. , 1994, European journal of clinical nutrition.

[16]  A. Trichopoulou,et al.  Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia , 1999, British Journal of Nutrition.

[17]  A. Volovics,et al.  Methods for the Analyses of Case‐Cohort Studies , 1997 .

[18]  P. V. Rao,et al.  Applied Survival Analysis: Regression Modeling of Time to Event Data , 2000 .

[19]  Amanda J Lee,et al.  Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners' Oral Contraception Study. , 2010, The British journal of general practice : the journal of the Royal College of General Practitioners.

[20]  L. Lipworth,et al.  Diet and overall survival in elderly people , 1995, BMJ.

[21]  H. Akaike A new look at the statistical model identification , 1974 .

[22]  O. Franco,et al.  Combined impact of lifestyle factors on mortality: prospective cohort study in US women , 2008, BMJ : British Medical Journal.

[23]  A. Tamakoshi,et al.  Healthy lifestyle and preventable death: findings from the Japan Collaborative Cohort (JACC) Study. , 2009, Preventive medicine.

[24]  M. Schroll,et al.  Diet and mortality in a cohort of elderly people in a north European community. , 1997, International journal of epidemiology.

[25]  David W. Hosmer,et al.  Applied Survival Analysis: Regression Modeling of Time-to-Event Data , 2008 .

[26]  L. J. Wei,et al.  The Robust Inference for the Cox Proportional Hazards Model , 1989 .

[27]  Victor Kipnis,et al.  Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study. , 2007, Archives of internal medicine.

[28]  R. Goldbohm,et al.  Relationship between Tap Water Hardness, Magnesium, and Calcium Concentration and Mortality due to Ischemic Heart Disease or Stroke in the Netherlands , 2009, Environmental health perspectives.

[29]  Tina Costacou,et al.  Adherence to a Mediterranean diet and survival in a Greek population. , 2003, The New England journal of medicine.

[30]  R A Goldbohm,et al.  Baseline recreational physical activity, history of sports participation, and postmenopausal breast carcinoma risk in the Netherlands Cohort Study , 2001, Cancer.

[31]  R. L. Prentice,et al.  A case-cohort design for epidemiologic cohort studies and disease prevention trials , 1986 .

[32]  O S Miettinen,et al.  Proportion of disease caused or prevented by a given exposure, trait or intervention. , 1974, American journal of epidemiology.

[33]  F. Clavel-Chapelon,et al.  Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study , 2005, BMJ : British Medical Journal.

[34]  R. Shephard Combined Impact of Lifestyle-Related Factors on Total and Cause-Specific Mortality among Chinese Women: Prospective Cohort Study , 2011 .