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Adherence to the Mediterranean diet and risk of stroke and stroke subtypes

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Abstract

Several meta-analyses including a small number of cohorts showed inverse associations between the Mediterranean Diet (MedDiet) and risk of stroke. However, it remains unclear whether such a relation varies by region of the study population or by major subtypes of stroke. We searched PubMed and EMBASE databases for relevant studies and we further included unpublished results from the Singapore Chinese Health Study (N = 57,078) and the Seguimiento Universidad de Navarra (SUN) study (N = 12,670). We used a random-effects model to calculate summary relative risk (RR) with 95% confidence intervals (CI) of stroke for each 4-point increment of the MedDiet score, roughly corresponding to the difference between extreme quintiles of the MedDiet score among participants of the included studies. The final analyses included 20 prospective cohort studies involving 682,149 participants and 16,739 stroke cases. The summary RRs for each 4-point increment of the MedDiet score were 0.84 (95% CI 0.81–0.88; I2 = 11.5%) for all combined, 0.76 (95% CI 0.65–0.89) for studies in Mediterranean populations and 0.86 (95% CI 0.83–0.89) for those in non-Mediterranean populations. Lower risk of stroke associated with higher MedDiet score also was observed in the analyses stratified by study population and methodological characteristics including study risk of bias, version of the MedDiet index, and definition of moderate alcohol consumption. The MedDiet was similarly associated with lower risk of ischemic stroke (RR 0.86, 95% CI 0.81–0.91; nine studies) and hemorrhagic stroke (RR 0.83, 95% CI 0.74–0.93; eight studies). Our meta-analysis suggests that adhering to the Mediterranean diet was associated with lower risk of stroke in both Mediterranean and non-Mediterranean populations, and for both ischemic stroke and hemorrhagic stroke risk.

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Acknowledgements

We thank the authors of the included studies for kindly clarifying the information in the publications and/or providing the unpublished data.

Funding

The Singapore Chinese Health Study was supported by the National Institutes of Health, USA (NIH R01 CA144034 and UM1 CA182876). W.-P.Koh is supported by the National Medical Research Council, Singapore, (NMRC/CSA/0055/2013). M.A. Martínez-Gonzalez was funded by an ERC Advanced Grant (Long-term effects of an energy-restricted Mediterranean diet on mortality and CVD, grant No 340918, PREDIMED-Plus, PI: Martínez-González MA). G.-C.Chen received an award from the China Scholarship Council.

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Authors and Affiliations

  1. Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore

    Guo-Chong Chen, Nithya Neelakantan & Rob M. van Dam

  2. Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, China

    Guo-Chong Chen & Li-Qiang Qin

  3. Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA

    Guo-Chong Chen

  4. Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Navarra, Spain

    Nerea Martín-Calvo & Miguel A. Martínez-González

  5. IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain

    Nerea Martín-Calvo & Miguel A. Martínez-González

  6. CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Institute of Health, Madrid, Spain

    Nerea Martín-Calvo & Miguel A. Martínez-González

  7. Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore

    Woon-Puay Koh

  8. Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA

    Jian-Min Yuan

  9. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Jian-Min Yuan

  10. Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, Italy

    Marialaura Bonaccio & Licia Iacoviello

  11. Department of Medicine and Surgery, University of Insubria, Varese, Italy

    Licia Iacoviello

  12. Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Miguel A. Martínez-González & Rob M. van Dam

  13. Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, 12 Science Drive 2, Tahir Foundation Building (Block MD1) #10-01U, Singapore, 117549, Singapore

    Rob M. van Dam

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  1. Guo-Chong Chen
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Chen, GC., Neelakantan, N., Martín-Calvo, N. et al. Adherence to the Mediterranean diet and risk of stroke and stroke subtypes. Eur J Epidemiol 34, 337–349 (2019). https://doi.org/10.1007/s10654-019-00504-7

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