Abstract
BackgroundDespite convincing evidence in the Mediterranean region, the cardiovascular benefit of the Mediterranean diet is not well established in non-Mediterranean countries and the optimal criteria for defining adherence are unclear. The population attributable fraction (PAF) of adherence to this diet is also unknown.MethodsIn the UK-based EPIC-Norfolk prospective cohort, we evaluated habitual diets assessed at baseline (1993–1997) and during follow-up (1998–2000) using food-frequency questionnaires (n = 23,902). We estimated a Mediterranean diet score (MDS) using cut-points projected from the Mediterranean dietary pyramid, and also three other pre-existing MDSs. Using multivariable-adjusted Cox regression with repeated measures of MDS and covariates, we examined prospective associations between each MDS with incident cardiovascular diseases (CVD) by 2009 and mortality by 2013, and estimated PAF for each outcome attributable to low MDS.ResultsWe observed 7606 incident CVD events (2818/100,000 person-years) and 1714 CVD deaths (448/100,000). The MDS based on the Mediterranean dietary pyramid was significantly associated with lower incidence of the cardiovascular outcomes, with hazard ratios (95 % confidence intervals) of 0.95 (0.92–0.97) per one standard deviation for incident CVD and 0.91 (0.87–0.96) for CVD mortality. Associations were similar for composite incident ischaemic heart disease and all-cause mortality. Other pre-existing MDSs showed similar, but more modest associations. PAF due to low dietary pyramid based MDS (<95th percentile) was 3.9 % (1.3–6.5 %) for total incident CVD and 12.5 % (4.5–20.6 %) for CVD mortality.ConclusionsGreater adherence to the Mediterranean diet was associated with lower CVD incidence and mortality in the UK. This diet has an important population health impact for the prevention of CVD.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0677-4) contains supplementary material, which is available to authorized users.
Highlights
Despite convincing evidence in the Mediterranean region, the cardiovascular benefit of the Mediterranean diet is not well established in non-Mediterranean countries and the optimal criteria for defining adherence are unclear
A total of 5660 participants died over 382,765 person-years (17.0 years of follow-up on average), among whom 1714 deaths were due to cardiovascular diseases (CVD)
Similar trends were observed when we examined the hazard ratio (HR) for quintiles of each Mediterranean diet score (MDS) (Additional file 1: Table S4)
Summary
Despite convincing evidence in the Mediterranean region, the cardiovascular benefit of the Mediterranean diet is not well established in non-Mediterranean countries and the optimal criteria for defining adherence are unclear. An Eastern European study showed that high adherence to a Mediterranean diet was associated with lower all cause and CVD mortality, but not with ischaemic heart disease (IHD) or stroke mortality [14]. In assessing adherence to the Mediterranean diet, published studies evaluated different Mediterranean diet scores (MDSs) [16,17,18,19,20,21], but there is sparse evidence on whether or not each algorithm would be useful in non-Mediterranean countries. The population impact of a cardiovascular benefit from adhering to the Mediterranean diet at the general population level remains unknown, partly because the previous trials may have limited generalisability by recruiting highly selected adults only
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