Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men
and women. The HALE project.
Knoops KTB, et al
JAMA 2004;292:1433-1439
Quality of Relevance for Relevance for
Science
Originality Application
South Africa Practitioner Group
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Rationale: The number of elderly people (>60years) is increasing worldwide. In industrialized
countries the majority of deaths in these elderly individuals are from cardiovascular diseases and
cancer. Diet and lifestyle influence mortality and morbidity aside from predisposing factors.
Furthermore these factors have an accumulative effect throughout life. Dietary patterns and lifestyle
factors have been shown to be associated with mortality from all causes, coronary heart disease
(CHD), cardiovascular diseases (CVD) and cancer; however few studies have investigated the effects
of these factors in combination. The aim of this study was to investigate the single and combined
effect of Mediterranean diet, being physical active, moderate alcohol use and nonsmoking on all-
cause and cause-specific mortality in European elderly individuals.
Methods: The Healthy Ageing: a Longitudinal study in Europe (HALE) population comprised of 1507
apparently healthy men and 832 women aged 70 to 90 years recruited from 11 European countries
(Belgium, Denmark, Finland, France, Greece, Hungary, Italy, the Netherlands, Portugal, Spain and
Switzerland). This cohort of individuals was recruited by means of two studies (SENECA and FINE)
between 1988 and 1991 and the follow-up period was 10 years. Importantly participants who had
CHD, CVD, cancer or diabetes mellitus were excluded at baseline.
Food consumption data were collected by trained dietitians using a dietary history method which
provides information about the usual food consumption of the participants over a 2 to 4 week period.
Information on smoking status; physical activity level; educational achievement (number of years); the
prevalence of CHD, stroke, diabetes mellitus and cancer; the use of antihypertensive medication and
occupation was collected using questionnaires. The prevalence of chronic diseases was confirmed by
general practitioners and hospital registrars. Information on habitual physical activity was obtained by
questionnaires developed for retired individuals, which focus on leisure-time activities such as walking,
cycling and gardening.
Weight, height and waist circumference measurements were obtained and body mass index (BMI)
calculated.
To assess the association of diet and lifestyle factors with mortality, a low risk group was defined. For
dietary intake the low risk group were those individuals who had a score of at least 4 on a modified
version of the Mediterranean diet score (0=low-quality diet and 8=high-quality diet). For alcohol intake
the low risk group were those individuals who consumed more than 0g of alcohol per day. (Kaplan-
Meier survival curves showed no differences in survival between participants who consumed between
1g and 29g of alcohol per day and those who consumed 30g or more per day). For smoking
individuals were considered as not at risk if they had never smoked or had stopped at least 15 years
prior to the start of the study. For physical activity, individuals in the intermediate to highest tertile of
the physical activity questionnaire were considered the low risk group.
A lifestyle score was calculated by adding the individual scores for diet, physical activity level, smoking
status, and alcohol intake.
The effects of individual and combined dietary patterns and lifestyle factors on ten year mortality from
all causes, CHD, CVD and cancer were assessed using Cox proportional hazards models adjusted for
sex, age, years of education, and BMI.
Summary of Findings: For the whole population the median of the diet score was 4; the mean
alcohol intake was 21g/d (men) and 6g/d (women); the lowest percentile for activity was 200min/week
(~30min/day). Mediterranean diet, moderate alcohol consumption, moderate to high level physical
activity levels and nonsmoking were associated with lower mortality rates from all causes, CHD, CVD,
cancer as well as other causes during the 10 years of follow-up. Individuals with 2, 3 or 4 low risk
factors had lower risk of all-cause and cause-specific mortality compared with individuals with 0 or 1
low risk factor. 60% of all deaths were associated with failure to adhere to the low risk pattern. For
cause-specific mortality 64% of deaths were due to CHD, 61% due to CVD, 60% due to cancer and
61% due to other causes.
The cause-specific hazard ratios (HR) for single effects of dietary and lifestyle factors were similar to
those for all-cause mortality (namely 0.77 for adhering to a Mediterranean diet; 0.83 for moderate
alcohol consumption; 0.65 for engaging in physical activity; 0.67 for non- smoking). The HR for
combined effects declined with increasing number of low risk factors. The HR for 4 low risk factors
were 0.35 for all-cause; 0.27 for CHD; 0.33 for CVD; 0.31 for cancer and 0.33 for other causes com
pared to a HR of 1.00 for the presence of 0-1 low risk factor.
Interpretation: The results of this study support the hypothesis that individuals that adhere to a
Mediterranean diet (rich in plant foods) and maintain a healthy lifestyle (non-smoking, moderate
alcohol consumption and at least 30mins of physical activity per day) are less likely to die from all-
cause and cause-specific mortality even in the elderly.
Prof Angela Woodiwiss