To evaluate in an Italian general population, the association with mortality of a traditional Mediterranean diet (MD) and non-Mediterranean dietary (non-MD) patterns, and their combined effect, and to test some biomarkers of cardiovascular (CVD) risk as potential mediators of such associations.
Longitudinal analysis on 22,849 men and women aged ≥ 35 years, recruited in the Moli-sani Study (2005–2010), followed up for 8.2 years (median). The MD was assessed by the Mediterranean diet score (MDS). The Dietary Approaches to Stop Hypertension (DASH), the Palaeolithic diet, and the Nordic diet were chosen as reportedly healthy non-MD patterns. Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated by multivariable Cox regression.
Participants reaching higher MDS or DASH diet score experienced lower risk of both all-cause (HR 0.77; 95% CI 0.66–0.90 and 0.81; 0.69–0.96, respectively, highest vs lowest quartile) and CVD (0.77; 0.59–1.00 and 0.81; 0.69–0.96, respectively) death risk; risk reduction associated with the Palaeolithic diet was limited to total and other cause death, whereas the Nordic diet did not alter risk of mortality. Increasing adherence to MD was associated with higher survival in each stratum of non-MD diets. Biomarkers of glucose metabolism accounted for 7% and 21.6% of the association between either MDS or DASH diet, respectively, with total mortality risk.
Both the traditional MD and DASH diet may reduce risk of all-cause mortality among Italians, as well as risk of dying from cardiovascular causes. The Palaeolithic diet did not appear to reduce cardiovascular risk, while the Nordic eating pattern was unlikely to be associated with any substantial health advantage.
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The Moli-sani Study research group thanks the Associazione Cuore Sano Onlus (Campobasso, Italy) for its financial and cultural support, and is grateful to the BIOMARCARE Consortium. MB conceived the study, LI and ADiC contributed to the design of the work and interpretation of data; SC, ADeC, and MP managed data collection; MB and ADiC analysed the data; MB wrote the manuscript; MBD, CC, GdG, and LI originally inspired the research and critically reviewed the manuscript. All authors have read and approved the manuscript.
Moli-sani Study Investigators: The enrolment phase of the Moli-sani Study was conducted at the Research Laboratories of the Catholic University in Campobasso (Italy), and the follow-up of the Moli-sani cohort is being conducted at the Department of Epidemiology and Prevention of the IRCCS Neuromed, Pozzilli, Italy. Steering Committee: Licia Iacoviello*°(Chairperson), Giovanni de Gaetano* and Maria Benedetta Donati*. Scientific secretariat: Licia Iacoviello*° (Coordinator), Marialaura Bonaccio*, Americo Bonanni*, Chiara Cerletti*, Simona Costanzo*, Amalia De Curtis*, Giovanni de Gaetano*, Augusto Di Castelnuovo§, Maria Benedetta Donati*, Francesco Gianfagna*°, Mariarosaria Persichillo*, Teresa Di Prospero* (Secretary). Safety and Ethical Committee: Jos Vermylen (Catholic Univesity, Leuven, Belgio) (Chairperson), Ignacio De Paula Carrasco (Accademia Pontificia Pro Vita, Roma, Italy), Simona Giampaoli (Istituto Superiore di Sanità, Roma, Italy), Antonio Spagnuolo (Catholic University, Roma, Italy). External Event adjudicating Committee: Deodato Assanelli (Brescia, Italy), Vincenzo Centritto (Campobasso, Italy). Baseline and Follow-up data management: Simona Costanzo* (Coordinator), Marco Olivieri (Università del Molise, Campobasso, Italy). Informatics: Marco Olivieri (Università del Molise, Campobasso, Italy). Data Analysis: Augusto Di Castelnuovo§ (Coordinator), Marialaura Bonaccio*, Simona Costanzo*, Alessandro Gialluisi*, Francesco Gianfagna*°, Emilia Ruggiero*. Biobank and biomedical analyses: Amalia De Curtis* (Coordinator), Sara Magnacca*. Genetic analyses: Benedetta Izzi* (Coordinator), Francesco Gianfagna*°, Annalisa Marotta*, Fabrizia Noro*. Communication and Press Office: Americo Bonanni* (Coordinator), Francesca De Lucia (Associazione Cuore Sano, Campobasso, Italy). Recruitment staff: Mariarosaria Persichillo* (Coordinator), Francesca Bracone*, Francesca De Lucia (Associazione Cuore Sano, Campobasso, Italy), Salvatore Dudiez*, Livia Rago*. Follow-up Event adjudication: Livia Rago* (Coordinator), Simona Costanzo*, Amalia De Curtis*, Licia Iacoviello*°, Teresa Panzera*, Mariarosaria Persichillo*. Regional Health Institutions: Direzione Generale per la Salute - Regione Molise; Azienda Sanitaria Regionale del Molise (ASReM, Italy); Molise Dati Spa (Campobasso, Italy); Offices of vital statistics of the Molise region. Hospitals: Presidi Ospedalieri ASReM: Ospedale A. Cardarelli—Campobasso, Ospedale F. Veneziale – Isernia, Ospedale San Timoteo - Termoli (CB), Ospedale Ss. Rosario - Venafro (IS), Ospedale Vietri—Larino (CB), Ospedale San Francesco Caracciolo - Agnone (IS); Casa di Cura Villa Maria - Campobasso; Fondazione di Ricerca e Cura Giovanni Paolo II - Campobasso; IRCCS Neuromed - Pozzilli (IS). * Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy. °Department of Medicine and Surgery, University of Insubria, Varese-Como, Italy. § Mediterranea, Cardiocentro, Napoli, Italy. Baseline Recruitment staff is available at https://www.moli-sani.org/?page_id=173.
The enrolment phase of the Moli-sani Study was supported by research grants from Pfizer Foundation (Rome, Italy), the Italian Ministry of University and Research (MIUR, Rome, Italy)-Programma Triennale di Ricerca, Decreto no.1588, and Instrumentation Laboratory, Milan, Italy. MB was supported by a Fondazione Umberto Veronesi Fellowship. SC was the recipient of a Fondazione Umberto Veronesi travel grant. The present analyses were partially supported by a grant to MB of the Italian Ministry of Health 2013 (Grant number GR-2013-02356060), a grant to LI of the Italian Association for Cancer Research (AIRC) (AIRC “5xMILLE” n. 12237), and a grant to LI as a partner of BiomarCaRE (Biomarkers for Cardiovascular Risk Assessment in Europe) by European Commission Seventh Framework Programme FP7/2007-2013 (HEALTH-F2-2011-278913). Funders had no role in study design, collection, analysis, and interpretation of data; in the writing of the manuscript and in the decision to submit the article for publication. All authors were and are independent from funders.
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None of the authors has conflicts of interest to disclose.
Moli-sani Study investigators are listed in the Acknowledgements.
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Bonaccio, M., Di Castelnuovo, A., Costanzo, S. et al. Association of a traditional Mediterranean diet and non-Mediterranean dietary scores with all-cause and cause-specific mortality: prospective findings from the Moli-sani Study. Eur J Nutr 60, 729–746 (2021). https://doi.org/10.1007/s00394-020-02272-7