European Journal of Epidemiology

, Volume 34, Issue 4, pp 337–349 | Cite as

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

  • Guo-Chong ChenEmail author
  • Nithya Neelakantan
  • Nerea Martín-Calvo
  • Woon-Puay Koh
  • Jian-Min Yuan
  • Marialaura Bonaccio
  • Licia Iacoviello
  • Miguel A. Martínez-González
  • Li-Qiang Qin
  • Rob M. van DamEmail author


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 We searched PubMed and EMBASE databases for relevant studies and we further included unpublished results from the Singapore Chinese Health Study (N = 57,078) and the Seguimiento Universidad de Navarra (SUN) study (N = 12,670).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.


Mediterranean diet Ischemic stroke Hemorrhagic stroke Cohort studies Meta-analysis 



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the authors of the included studies for kindly clarifying the information in the publications and/or providing the unpublished data.


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.

Compliance with ethical standards

Conflict of interest

No conflict of interest existed for any of the authors.

Supplementary material

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Supplementary material 1 (PDF 1110 kb)


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Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Guo-Chong Chen
    • 1
    • 2
    • 3
    Email author
  • Nithya Neelakantan
    • 1
  • Nerea Martín-Calvo
    • 4
    • 5
    • 6
  • Woon-Puay Koh
    • 7
  • Jian-Min Yuan
    • 8
    • 9
  • Marialaura Bonaccio
    • 10
  • Licia Iacoviello
    • 10
    • 11
  • Miguel A. Martínez-González
    • 4
    • 5
    • 6
    • 12
  • Li-Qiang Qin
    • 2
  • Rob M. van Dam
    • 1
    • 12
    • 13
    Email author
  1. 1.Saw Swee Hock School of Public HealthNational University of Singapore and National University Health SystemSingaporeSingapore
  2. 2.Department of Nutrition and Food Hygiene, School of Public HealthSoochow UniversitySuzhouChina
  3. 3.Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxUSA
  4. 4.Department of Preventive Medicine and Public HealthUniversity of NavarraPamplonaSpain
  5. 5.IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
  6. 6.CIBER Physiopathology of Obesity and Nutrition (CIBERobn)Carlos III Institute of HealthMadridSpain
  7. 7.Health Services and Systems ResearchDuke-NUS Medical SchoolSingaporeSingapore
  8. 8.Division of Cancer Control and Population Sciences, UPMC Hillman Cancer CenterUniversity of PittsburghPittsburghUSA
  9. 9.Department of Epidemiology, Graduate School of Public HealthUniversity of PittsburghPittsburghUSA
  10. 10.Department of Epidemiology and PreventionIRCCS NEUROMEDPozzilliItaly
  11. 11.Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
  12. 12.Department of NutritionHarvard T.H. Chan School of Public HealthBostonUSA
  13. 13.Department of Medicine, Yong Loo Lin School of MedicineNational University of Singapore and National University Health SystemSingaporeSingapore

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