"The Mediterranean diet has been used in many studies because several of its components have been related to common chronic diseases, ecological evidence suggests that such a diet may be beneficial to health, and variants of this diet have improved the prognosis of patients with coronary heart disease," write Antonia Trichopoulou, MD, and colleagues from the European Prospective Investigation into Cancer and nutrition study (EPIC). "The Mediterranean diet is characterized by a high intake of vegetables, legumes, fruits, and cereals (in the past largely unrefined); a moderate to high intake of fish; a low intake of saturated lipids but high intake of unsaturated lipids, particularly olive oil; a low to moderate intake of dairy products, mostly cheese and yogurt; a low intake of meat; and a modest intake of ethanol, mostly as wine."

Because intake of monounsaturates from olive oil is minimal in non-Mediterranean populations, the investigators determined adherence to a modified Mediterranean diet by substituting monounsaturated lipids with the sum of monounsaturated and polyunsaturated lipids in the numerator of the lipid ratio used to calculate the adherence score.

This multicenter study enrolled 74,607 men and women from Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, and the U.K. Subjects were aged 60 years or older, without coronary heart disease, stroke, or cancer at enrollment and with complete information about dietary intake and potentially confounding variables.

Primary outcomes were the extent of adherence to the modified Mediterranean diet based on a 10-point scoring system and death from any cause by time of occurrence analyzed with Cox regression.

Increased modified Mediterranean diet score was associated with lower overall mortality, with a two-unit increment corresponding to a statistically significant reduction of 8% (95% confidence interval, 3% - 12%). Although the association was stronger in Greece and Spain, there was no significant heterogeneity among countries in the association of the score with overall mortality. When dietary exposures were calibrated across countries, mortality was reduced by 7% (1% - 12%).

"The Mediterranean diet, modified so as to apply across Europe, was associated with increased survival among older people," the authors write. "Because the study is observational, it is possible for residual confounding from suboptimally measured factors."

The European Commission and various other public and private agencies supported this study. The authors report no competing interests.

BMJ. Posted online April 8, 2005.

Learning Objectives for This Educational Activity

• Identify the main components of the Mediterranean and the modified Mediterranean diet.
• Describe the association between the Mediterranean and the modified Mediterranean diet to the overall mortality in elderly European populations.

Clinical Context

The Mediterranean diet is characterized by a high intake of vegetables, legumes, fruits, and cereals; a moderate to high intake of fish; a low intake of saturated fats, with a high intake of unsaturated fats such as olive oil; a low intake of dairy products (mainly cheese and yogurt) and meat; and a modest intake of alcohol, mostly as wine. The modified Mediterranean diet relies on plant foods and unsaturated fats. Studies have demonstrated a protective effect of this diet on mortality, but no large international study with comparability of the diet using standardized calibration has yet been conducted, according to the current authors. Adherence to this diet has been measured by a 10-unit score (higher value indicating greater adherence), which was adapted by the authors of the current study who substituted monounsaturated fats with the sum of monounsaturated and polyunsaturated fats in the numerator of the lipid ratio. The current authors chose this calculation process because in Northern Europe a principal source of monounsaturated fat is meat.

The current authors conducted a study of prognosis and investigated the relation of the modified Mediterranean diet adherence score to overall mortality in a prospective cohort of elderly Europeans from nine countries already participating in the EPIC study. The EPIC study examined the relationship between nutrition and cancer and chronic diseases. The nine countries included France, U.K., Norway, Denmark, Greece, Italy, Spain, Germany, and Netherlands.

Study Highlights

• 74,607 participants aged 60 years or older from the EPIC study who completed dietary assessments and for whom vital status was available were included.
• At baseline, participants completed 24-hour food recalls or records of intake for 7 or 14 days. Nutrient intakes were calculated using food composition tables for 14 food groups and nonalcoholic beverages. Intake of each of those groups and total energy were estimated.
• Lifestyle and health history were documented and anthropometric measurements were taken. At 3 centers, self-reported anthropometric measurements were used.
• The degree of adherence to the modified Mediterranean diet was assessed by the modified Trichopoulou, scale with 0 representing minimal adherence and 9 representing maximal adherence.
• Vital status was obtained from mortality registries and by active follow-up with participants classified as alive at last follow-up, dead, emigrated, refused participation, or unknown.
• Cox proportional hazards regression was used for analysis with adjustment for age, sex, self-reported diabetes mellitus at enrollment, educational level, body mass index, and total energy intake.
• Follow-up was for a median of 89 months for a total of 541,872 person-years. During follow-up, 4,047 participants died, with most deaths in the Swedish, Danish, and U.K. cohorts.
• There was an inverse association between overall mortality and higher intake of vegetables, fruits and cereals, and ratio of unsaturated to saturated fats.
• There was a positive association between overall mortality and higher saturated fat intake.
• An increase in the adherence score was associated with reduced overall mortality, with a 2-unit increment corresponding to a statistically significant 8% reduction in both fixed effects and random effects models.
• The effect was stronger in Greece and Spain and absent in the Netherlands and Germany.
• After excluding the Greece data, the reduction in overall mortality associated with a higher adherence score remained statistically significant.
• A 3- to 4-point increase in adherence to the modified Mediterranean diet was associated with reduction in total mortality of 11% to 14%.

Pearls for Practice

• The Mediterranean diet is characterized by a high intake of vegetables, legumes, fruits and cereals; a moderate to high intake of fish; a low intake of saturated fats, with a high intake of unsaturated fats such as olive oil; a low intake of dairy products (mainly cheese and yogurt) and meat; and a modest intake of alcohol, mostly as wine.
• Adherence to a diet relying on plant foods and unsaturated fats that resembles the Mediterranean diet is associated with reduction in overall mortality in elderly Europeans.

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