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Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study

BMJ 2005; 330 doi: (Published 28 April 2005) Cite this as: BMJ 2005;330:991
  1. Antonia Trichopoulou (antonia{at}, associate professor1,
  2. Philippos Orfanos, senior biostatistician1,
  3. Teresa Norat, epidemiologist2,
  4. Bas Bueno-de-Mesquita, project director diet and chronic diseases3,
  5. Marga C Ocké, project director food consumption surveys3,
  6. Petra HM Peeters, associate professor4,
  7. Yvonne T van der Schouw, associate professor4,
  8. Heiner Boeing, chair5,
  9. Kurt Hoffmann, senior scientist5,
  10. Paolo Boffetta, chief6,
  11. Gabriele Nagel, physician6,
  12. Giovanna Masala, medical epidemiologist7,
  13. Vittorio Krogh, medical epidemiologist8,
  14. Salvatore Panico, senior researcher9,
  15. Rosario Tumino, director10,
  16. Paolo Vineis, chair11,
  17. Christina Bamia, chief biostatistician1,
  18. Androniki Naska, lecturer1,
  19. Vassiliki Benetou, medical epidemiologist1,
  20. Pietro Ferrari, statistician2,
  21. Nadia Slimani, nutritionist2,
  22. Guillem Pera, biostatistician12,
  23. Carmen Martinez-Garcia, researcher13,
  24. Carmen Navarro, head14,
  25. Miguel Rodriguez-Barranco, statistician14,
  26. Miren Dorronsoro, vice director15,
  27. Elizabeth A Spencer, nutritionist16,
  28. Timothy J Key, professor16,
  29. Sheila Bingham, deputy director17,
  30. Kay-Tee Khaw, professor18,
  31. Emmanuelle Kesse, researcher19,
  32. Francoise Clavel-Chapelon, research director19,
  33. Marie-Christine Boutron-Ruault, research director19,
  34. Goran Berglund, professor20,
  35. Elisabet Wirfalt, associate professor20,
  36. Goran Hallmans, head of unit of nutritional research21,
  37. Ingegerd Johansson, head of dental school22,
  38. Anne Tjonneland, head23,
  39. Anja Olsen, research assistant23,
  40. Kim Overvad, research director24,
  41. Heidi H Hundborg, senior biostatistician24,
  42. Elio Riboli, head2,
  43. Dimitrios Trichopoulos, professor25
  1. 1 Department of Hygiene and Epidemiology, University of Athens Medical School, Athens 11527, Greece,
  2. 2 Nutrition and Hormones Group, International Agency for Research on Cancer, Lyon, France,
  3. 3 Centre for Nutrition and Health, National Institute for Public Health and the Environment, Bilthoven, Netherlands,
  4. 4 Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Netherlands,
  5. 5 Department of Epidemiology, German Institute of Human Nutrition, Potsdam, Germany,
  6. 6 Division of Clinical Epidemiology, German Cancer Research Centre, Heidelberg, Germany,
  7. 7 Molecular and Nutritional Epidemiology Unit, CSPO-Scientific Institute of Tuscany, Florence, Italy,
  8. 8 Epidemiology Unit, National Cancer Institute, Milan, Italy,
  9. 9 Dipartimento di Medicina Clinica e Sperimentale Università Federico II, Naples, Italy,
  10. 10 Cancer Registry Azienda Ospedaliera “Civile M P Arezzo,” Ragusa, Italy,
  11. 11 Environmental Epidemiology, Imperial College London,
  12. 12 Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain,
  13. 13 Andalusian School of Public Health, Granada, Spain,
  14. 14 Department of Epidemiology, Murcia Regional Health Council, Murcia, Spain,
  15. 15 Department of Public Health of Guipuzcoa, San Sebastian, Spain,
  16. 16 Cancer Research UK Epidemiology Unit, University of Oxford,
  17. 17 Medical Research Council Dunn Nutrition Unit, Cambridge,
  18. 18 Clinical Gerontology, University of Cambridge,
  19. 19 Equipe E3N-EPIC, Institut National de la Sante et de la Recherche Medicale, Institut Gustave Roussy, France,
  20. 20 Malmo Diet and Cancer Study, Department of Medicine, Lund University, Sweden,
  21. 21 Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden,
  22. 22 Department of Odontology, Umea University,
  23. 23 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark,
  24. 24 Department of Clinical Epidemiology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark,
  25. 25 Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
  1. Correspondence to: A Trichopoulou
  • Accepted 3 March 2005


Objective To examine whether adherence to the modified Mediterranean diet, in which unsaturates were substituted for monounsaturates, is associated with longer life expectancy among elderly Europeans.

Design Multicentre, prospective cohort study.

Setting Nine European countries (Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, United Kingdom).

Participants 74 607 men and women, aged 60 or more, without coronary heart disease, stroke, or cancer at enrolment and with complete information about dietary intake and potentially confounding variables.

Main outcome measures Extent of adherence to a modified Mediterranean diet using a scoring system on a 10 point scale, and death from any cause by time of occurrence, modelled through Cox regression.

Results An increase in the modified Mediterranean diet score was associated with lower overall mortality, a two unit increment corresponding to a statistically significant reduction of 8% (95% confidence interval 3% to 12%). No statistically significant evidence of heterogeneity was found among countries in the association of the score with overall mortality even though the association was stronger in Greece and Spain. When dietary exposures were calibrated across countries, the reduction in mortality was 7% (1% to 12%).

Conclusion The Mediterranean diet, modified so as to apply across Europe, was associated with increased survival among older people.


  • Contributors AT is the principal investigator of the EPIC-elderly project. She is guarantor for the paper. PO is the principal biostatistician in this project. Contributors from the participating centres provided the original data, information on the respective populations, and advice on study design and analysis. Participants from the International Agency for Research on Cancer were responsible for coordination of the overall EPIC project and also contributed advice on study design and analysis.

  • Funding This study was supported by the quality of life and management of living resources programme of the European Commission (contract No QLK6-CT-2001-00241), coordinated by the Department of Hygiene and Epidemiology, University of Athens Medical School; the Europe against cancer programme of the European Commission coordinated by the International Agency for Research on Cancer; the Greek Ministry of Health and the Greek Ministry of Education; the fellowship “Vasilios and Nafsika Tricha”; Danish Cancer Society; Ligue contre le Cancer (France); Société 3M (France); Mutuelle Générale de l'Education Nationale (France); Institut National de la Santé et de la Recherche Médicale (France); Gustave Roussy Institute and several general councils in France; German Cancer Aid; German Cancer Research Centre; German Federal Ministry of Education and Research; Associazione Italiana per la Ricerca contro il Cancro; Compagnia di San Paolo (Italy); Regione Sicilia, Provincia Regionale Sicilia, Comune di Ragusa, AIRE-ONLUS and AVIS-Ragusa (Italy); national cancer registry and comprehensive cancer centres east Amsterdam and Limburg (Netherlands); Dutch Ministry of Public Health, Welfare and Sports; health research fund (FIS) of the Spanish Ministry of Health (Spain); the Spanish Regional governments of Andalucia, Asturias, Basque country, Murcia, and Navarra (Spain); ISCIII Network RCESP (Spain); Swedish Cancer Society; Swedish Scientific Council, Malmö; regional government of Skåne (Sweden); Cancer Research UK; Medical Research Council (United Kingdom). The researchers were financed independently from the funding organisations.

  • Competing interests None declared.

  • Ethical approval This study was approved by the ethical committees at the International Agency for Research on Cancer and at participating centres.

  • Accepted 3 March 2005
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