Although evidence indicates that both physical activity and adherence to the Mediterranean diet (MedDiet) reduce the risk of all-cause mortality, a little is known about optimal intensities of physical activity and their combined effect with MedDiet in older adults. We assessed the separate and combined associations of leisure-time physical activity (LTPA) and MedDiet adherence with all-cause mortality.
We prospectively studied 7356 older adults (67 ± 6.2 years) at high vascular risk from the PREvención con DIeta MEDiterránea study. At baseline and yearly thereafter, adherence to the MedDiet and LTPA were measured using validated questionnaires.
After 6.8 years of follow-up, we documented 498 deaths. Adherence to the MedDiet and total, light, and moderate-to-vigorous LTPA were inversely associated with all-cause mortality (p < 0.01 for all) in multiple adjusted Cox regression models. The adjusted hazard of all-cause mortality was 73% lower (hazard ratio 0.27, 95% confidence interval 0.19–0.38, p < 0.001) for the combined category of highest adherence to the MedDiet (3rd tertile) and highest total LTPA (3rd tertile) compared to lowest adherence to the MedDiet (1st tertile) and lowest total LTPA (1st tertile). Reductions in mortality risk did not meaningfully differ between total, light intensity, and moderate-to-vigorous LTPA.
We found that higher levels of LTPA, regardless of intensity (total, light and moderate-to-vigorous), and greater adherence to the MedDiet were associated separately and jointly with lower all-cause mortality. The finding that light LTPA was inversely associated with mortality is relevant because this level of intensity is a feasible option for older adults.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Kontis V, Bennett JE, Mathers CD et al (2017) Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble. Lancet 6736:1–13. https://doi.org/10.1016/S0140-6736(16)32381-9
World Health Organization (2015) World report on ageing and health. https://doi.org/10.1017/CBO9781107415324.004
Kelly P, Kahlmeier S, Götschi T et al (2014) Systematic review and meta-analysis of reduction in all-cause mortality from walking and cycling and shape of dose response relationship. Int J Behav Nutr Phys Act 11:132. https://doi.org/10.1186/s12966-014-0132-x
Ekelund U, Steene-Johannessen J, Brown WJ et al (2016) Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet 388:1302–1310. https://doi.org/10.1016/S0140-6736(16)30370-1
Li F, Hou L, Chen W et al (2015) Associations of dietary patterns with the risk of all-cause, CVD and stroke mortality: a meta-analysis of prospective cohort studies. Br J Nutr 113:16–24. https://doi.org/10.1017/S000711451400289X
Onvani S, Haghighatdoost F, Surkan PJ et al (2017) Adherence to the Healthy Eating Index and Alternative Healthy Eating Index dietary patterns and mortality from all causes, cardiovascular disease and cancer: a meta-analysis of observational studies. J Hum Nutr Diet 30:216–226. https://doi.org/10.1111/jhn.12415
Araceta-Bartrina J, Arija Val V, Maiz Aldalur E et al (2016) Guías alimentarias para la población española (SENC, diciembre 2016); la nueva pirámide de la alimentación saludable. Nutr Hosp 33:1–48. https://doi.org/10.3305/nh.2013.28.sup4.6783
(2011) French National Nutrition and Health Program 2011–2015. http://solidarites-sante.gouv.fr/IMG/pdf/PNNS_UK_INDD_V2.pdf
Agriculture USD of (2015) Dietary Guidelines for Americans 2015–2020. Dietary guidelines and MyPlate. http://www.choosemyplate.gov/dietary-guidelines
Kahlmeier S, Wijnhoven TM, Alpiger P et al (2015) National physical activity recommendations: systematic overview and analysis of the situation in European countries. BMC Public Health 15:133. https://doi.org/10.1186/s12889-015-1412-3
Hupin D, Roche F, Gremeaux V et al (2015) Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥ 60 years: a systematic review and meta-analysis. Br J Sports Med 49:1262–1267. https://doi.org/10.1136/bjsports-2014-094306
Matthews CE, Keadle SK, Troiano RP et al (2016) Accelerometer-measured dose-response for physical activity, sedentary time, and mortality in US adults. Am J Clin Nutr 104:1424–1432. https://doi.org/10.3945/ajcn.116.135129
Schröder H (2007) Protective mechanisms of the Mediterranean diet in obesity and type 2 diabetes. J Nutr Biochem 18:149–160. https://doi.org/10.1016/j.jnutbio.2006.05.006
Dinu M, Pagliai G, Casini A, So F (2017) Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomised trials. Eur J Clin Nutr 1–14. https://doi.org/10.1038/ejcn.2017.58
Liyanage T, Ninomiya T, Wang A et al (2016) Effects of the Mediterranean diet on cardiovascular outcomes—a systematic review and meta-analysis. PLoS One 11:e0159252. https://doi.org/10.1371/journal.pone.0159252
Limongi F, Noale M, Gesmundo A et al (2017) Adherence to the Mediterranean diet and all-cause mortality risk in an elderly Italian population: data from the ILSA study. J Nutr Health Aging 21:505–513. https://doi.org/10.1007/s12603-016-0808-9
Knoops KTB, de Groot LCPGM., Kromhout D et al (2004) Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 292:1433–1439. https://doi.org/10.1097/01.ieb.0000150381.96671.6b
Zaslavsky O, Zelber-Sagi S, Hebert JR et al (2017) Biomarker-calibrated nutrient intake and healthy diet index associations with mortality risks among older and frail women from the Women’s Health Initiative. Am J Clin Nutr 105:1399–1407. https://doi.org/10.3945/ajcn.116.151530
Behrens G, Fischer B, Kohler S et al (2013) Healthy lifestyle behaviors and decreased risk of mortality in a large prospective study of U.S. women and men. Eur J Epidemiol 28:361–372. https://doi.org/10.1007/s10654-013-9796-9
Estruch R, Martínez-González MA, Corella D et al (2006) Effects of a Mediterranean-style diet on cardiovascular risk factors. A randomized trial. Ann Intern Med 145:1–11. https://doi.org/10.7326/0003-4819-145-1-200607040-00004
Martínez- González M, Corella D, Salas-Salvado J et al (2012) Cohort profile: design and methods of the PREDIMED study. Int J Epidemiol 41:377–385. https://doi.org/10.1093/ije/dyq250
The PREDIMED network. http://www.predimed.es/. Accessed 27 Feb 2017
BioMed Central. ISRCTN registry. http://www.isrctn.com/. Accessed 22 March 2017
Schroder H, Fitó M, Estruch R et al (2011) A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J Nutr Nutr Epidemiol 141:1140–1145. https://doi.org/10.3945/jn.110.135566
Elosua R, Marrugat J, Molina L et al (1994) Validation of the Minnesota Leisure Time Physical Activity Questionnaire in Spanish men. The MARATHOM Investigators. Am J Epidemiol 139:1197–1209
Elosua R, Garcia M, Aguilar A et al (2000) Validation of the Minnesota Leisure Time Physical Activity Questionnaire in Spanish Women. Med Sci Sport Exerc 32:1431–1437
Taylor HL, Jacobs DR, Schucker B et al (1978) A questionnaire for the assessment of leisure time physical activities. J Chronic Dis 31:741–755. https://doi.org/10.1016/0021-9681(78)90058-9
Fernández-Ballart JD, Piñol JL, Zazpe I et al (2010) Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain. Br J Nutr 103:1808–1816. https://doi.org/10.1017/S0007114509993837
De la Fuente-Arrillaga C, Vázquez Ruiz Z, Bes-Rastrollo M et al (2010) Reproducibility of an FFQ validated in Spain. Public Health Nutr 13:1364–1372. https://doi.org/10.1017/S1368980009993065
Borgundvaag E, Janssen I (2017) Objectively measured physical activity and mortality risk among American adults. Am J Prev Med 52:e25–e31. https://doi.org/10.1016/j.amepre.2016.09.017
Ekelund U, Ward H, Norat T et al (2015) Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC). Am J Clin Nutr 101:613–621. https://doi.org/10.3945/ajcn.114.100065
Moore SC, Patel AV, Matthews CE et al (2012) Leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. PLoS Med 9:e1001335. https://doi.org/10.1371/journal.pmed.1001335
Matthews CE, Moore SC, Sampson J et al (2015) Mortality benefits for replacing sitting time with different physical activities. Med Sci Sports Exerc 47:1833–1840. https://doi.org/10.1249/MSS.0000000000000621
Ensrud KE, Blackwell TL, Cauley JA et al (2014) Objective measures of activity level and mortality in older men. J Am Geriatr Soc 62:2079–2087. https://doi.org/10.1111/jgs.13101
Fishman EI, Steeves JA, Zipunnikov V et al (2016) Association between objectively measured physical activity and mortality in NHANES. Med Sci Sports Exerc 48:1303–1311. https://doi.org/10.1249/MSS.0000000000000885
Moore SC, Lee I-M, Weiderpass E et al (2016) Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med 176:816. https://doi.org/10.1001/jamainternmed.2016.1548
Lee I-M, Shiroma EJ, Lobelo F et al (2012) Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 380:219–229. https://doi.org/10.1016/S0140-6736(12)61031-9
Murtagh EM, Nichols L, Mohammed MA et al (2014) Walking to improve cardiovascular health: a meta-analysis of randomised control trials. Lancet 384:545. https://doi.org/10.1016/S0140-6736(14)62180-2
Fortes C, Mastroeni S, Sperati A et al (2013) Walking four times weekly for at least 15 min is associated with longevity in a Cohort of very elderly people. Maturitas 74:246–251. https://doi.org/10.1016/j.maturitas.2012.12.001
PREDIMED PLUS Network. http://www.predimedplus.com. Accessed 30 March 2017
CIBERESP and CIBEROBN are initiatives of the Instituto de Salud Carlos III (ISCIII) of Spain, which are supported by FEDER funds (CB06/03). Also supported by ISCIII, the official funding agency for biomedical research of the Spanish government, through grants provided to research networks specifically developed for the trial (RTIC G03/140 and RD 06/0045) through CIBEROBN, and by grants from Centro Nacional de Investigaciones Cardiovasculares (CNIC 06/2007), Fondo de Investigación Sanitaria-Fondo Europeo de Desarrollo Regional (PI04-2239, PI05/2584, CP06/00100, PI07/0240, PI07/1138, PI07/0954, PI 07/0473, PI10/01407, PI10/02658, PI11/01647, and PI11/02505; PI13/00462), Ministerio de Ciencia e Innovación (AGL-2009-13906-C02 and AGL2010-22319-C03), Fundación Mapfre 2010, Consejería de Salud de la Junta de Andalucía (PI0105/2007), Public Health Division of the Department of Health of the Autonomous Government of Catalonia, Generalitat Valenciana (ACOMP06109, GVA-COMP2010-181, GVACOMP2011-151, CS2010-AP-111, and CS2011-AP-042), and the Navarra Regional Government (27/2011). MF was supported by a joint contract of the ISCIII and Health Department of the Catalan Government (Generalitat de Catalunya) (CP 06/00100). The Fundación Patrimonio Comunal Olivarero and Hojiblanca SA (Málaga, Spain), California Walnut Commission (Sacramento, CA), Borges SA (Reus, Spain), and Morella Nuts SA (Reus, Spain) donated the olive oil, walnuts, almonds, and hazelnuts, respectively, used in the study. We appreciate the English revision by Elaine M. Lilly, Ph.D.
Conflict of interest
The authors declare that they have no competing interests related to the study.
Ethics and consent
The Institutional Review Board of all participating centres approved the study protocol and the trial was conducted following the guidelines of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Cárdenas-Fuentes, G., Subirana, I., Martinez-Gonzalez, M.A. et al. Multiple approaches to associations of physical activity and adherence to the Mediterranean diet with all-cause mortality in older adults: the PREvención con DIeta MEDiterránea study. Eur J Nutr 58, 1569–1578 (2019). https://doi.org/10.1007/s00394-018-1689-y
- Physical activity
- Mediterranean diet
- Older adults