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



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.

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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.

Author information




GMC and HS conceived the project; MAM, JS-S, DC, RE, MF, EGG, MF, JL, FA, LS-M, JAT, XP, ER, OC, AD-L, and MR-C conducted the research; CMG, IS, and HS analysed the data; CMG wrote the manuscript: CMG and HS had primary responsibility for the final content of the manuscript; all authors read and approved the final manuscript.

Corresponding author

Correspondence to Helmut Schröder.

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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.

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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).

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  • Exercise
  • Physical activity
  • Mediterranean diet
  • Mortality
  • Aged
  • Older adults