A Mediterranean diet and risk of myocardial infarction, heart failure and stroke: A population-based cohort study


      • Mediterranean diet was associated with a lower risk of MI, HF and ischemic stroke.
      • There was no association between Mediterranean diet and hemorrhagic stroke.
      • The Mediterranean diet is likely to be beneficial in primary prevention of atherosclerosis related cardiovascular disease.


      Background and aims

      The Mediterranean diet, which is palatable and easily achievable, has been associated with lower all-cause and cardiovascular disease (CVD) incidence and mortality. Data on heart failure (HF) and stroke types are lacking. The aim was to examine a Mediterranean diet in relation to incidence of myocardial infarction (MI), HF and stroke types in a Swedish prospective cohort.


      In a population-based cohort of 32,921 women, diet was assessed through a self-administered questionnaire. The modified Mediterranean diet (mMED) score was created based on high consumption of vegetables, fruits, legumes, nuts, whole grains, fermented dairy products, fish and monounsaturated fat, moderate intakes of alcohol and low consumption of red meat, on a 0–8 scale. Relative risks (RR) with 95% confidence intervals (CI), adjusted for potential confounders, were estimated by Cox proportional hazards regression models.


      During 10 y of follow-up (1998–2008), 1109 MIs, 1648 HFs, 1270 ischemic strokes and 262 total hemorrhagic strokes were ascertained. A high adherence to the mMED score (6–8), compared to low, was associated with a lower risk of MI (RR: 0.74, 95% CI: 0.61–0.90, p = 0.003), HF (RR: 0.79, 95% CI: 0.68–0.93, p = 0.004) and ischemic stroke (RR: 0.78, 95% CI: 0.65–0.93, p = 0.007), but not hemorrhagic stroke (RR: 0.88, 95% CI: 0.61–1.29, p = 0.53).


      Better adherence to a Mediterranean diet was associated with lower risk of MI, HF and ischemic stroke. The Mediterranean diet is most likely to be beneficial in primary prevention of all major types of atherosclerosis-related CVD.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Murphy S.L.
        • Xu J.
        • Kochanek K.D.
        Deaths: final data for 2010.
        Natl. Vital Stat. Rep. 2013; 61: 111-117
        • Nichols M.
        • Townsend N.
        • Luengo-Fernandez R.
        • et al.
        European Cardiovascular Disease Statistics, European Heart Network and European Society of Cardiology.
        Sophia Antipolis, Brussels2012
        • Schroeder S.A.
        Shattuck Lecture. We can do better–improving the health of the American people.
        N. Engl. J. Med. 2007; 357: 1221-1228
        • Mozaffarian D.
        • Benjamin E.J.
        • Go A.S.
        • et al.
        Heart disease and stroke statistics-2015 update: a report from the American heart association.
        Circulation. 2015; 131 (p. e29-e322)
        • da Silva R.
        • Bach-Faig A.
        • Raido Quintana B.
        • et al.
        Worldwide variation of adherence to the Mediterranean diet, in 1961-1965 and 2000-2003.
        Public Health Nutr. 2009; 12: 1676-1684
        • Willett W.C.
        • Sacks F.
        • Trichopoulou A.
        • et al.
        Mediterranean diet pyramid: a cultural model for healthy eating.
        Am. J. Clin. Nutr. 1995; 61: 1402s-1406s
        • Tognon G.
        • Lissner L.
        • Saebye D.
        • et al.
        The Mediterranean diet in relation to mortality and CVD: a Danish cohort study.
        Br. J. Nutr. 2014; 111: 151-159
        • Trichopoulou A.
        • Costacou T.
        • Bamia C.
        • et al.
        Adherence to a Mediterranean diet and survival in a Greek population.
        N. Engl. J. Med. 2003; 348: 2599-2608
        • Trichopoulou A.
        • Kouris-Blazos A.
        • Wahlqvist M.L.
        • et al.
        Diet and overall survival in elderly people.
        BMJ. 1995; 311: 1457-1460
        • Trichopoulou A.
        • Orfanos P.
        • Norat T.
        • et al.
        Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study.
        BMJ. 2005; 330: 991
        • Knoops K.T.
        • de Groot L.C.
        • Kromhout D.
        • et al.
        Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
        JAMA. 2004; 292: 1433-1439
        • Mitrou P.N.
        • Kipnis V.
        • Thiebaut A.C.
        • et al.
        Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP diet and health study.
        Arch. Intern Med. 2007; 167: 2461-2468
        • Lopez-Garcia E.
        • Rodriguez-Artalejo F.
        • Li T.Y.
        • et al.
        The Mediterranean-style dietary pattern and mortality among men and women with cardiovascular disease.
        Am. J. Clin. Nutr. 2014; 99: 172-180
        • Fung T.T.
        • Rexrode K.M.
        • Mantzoros C.S.
        • et al.
        Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women.
        Circulation. 2009; 119: 1093-1100
        • Buckland G.
        • Gonzalez C.A.
        • Agudo A.
        • et al.
        Adherence to the Mediterranean diet and risk of coronary heart disease in the Spanish EPIC cohort study.
        Am. J. Epidemiol. 2009; 170: 1518-1529
        • Hoevenaar-Blom M.P.
        • Nooyens A.C.
        • Kromhout D.
        • et al.
        Mediterranean style diet and 12-year incidence of cardiovascular diseases: the EPIC-NL cohort study.
        PLoS One. 2012; 7 (p. e45458)
        • Gardener H.
        • Wright C.B.
        • Gu Y.
        • et al.
        Mediterranean-style diet and risk of ischemic stroke, myocardial infarction, and vascular death: the Northern Manhattan Study.
        Am. J. Clin. Nutr. 2011; 94: 1458-1464
        • Panagiotakos D.B.
        • Georgousopoulou E.N.
        • Pitsavos C.
        • et al.
        Exploring the path of Mediterranean diet on 10-year incidence of cardiovascular disease: the ATTICA study.
        Nutr. Metab. Cardiovasc. Dis. 2015; 25: 327-335
        • Tsivgoulis G.
        • Psaltopoulou T.
        • Wadley V.G.
        • et al.
        Adherence to a mediterranean diet and prediction of incident stroke.
        Stroke. 2015; 46: 780-785
        • Fito M.
        • Estruch R.
        • Salas-Salvado J.
        • et al.
        Effect of the Mediterranean diet on heart failure biomarkers: a randomized sample from the PREDIMED trial.
        Eur. J. Heart Fail. 2014; 16: 543-550
        • de Lorgeril M.
        • Salen P.
        • Martin J.L.
        • et al.
        Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet heart Study.
        Circulation. 1999; 99: 779-785
        • Esposito K.
        • Marfella R.
        • Ciotola M.
        • et al.
        Effect of a mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial.
        Jama. 2004; 292: 1440-1446
        • Vincent-Baudry S.
        • Defoort C.
        • Gerber M.
        • et al.
        The Medi-RIVAGE study: reduction of cardiovascular disease risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet.
        Am. J. Clin. Nutr. 2005; 82: 964-971
        • Levitan E.B.
        • Lewis C.E.
        • Tinker L.F.
        • et al.
        Mediterranean and DASH diet scores and mortality in women with heart failure: the Women's health Initiative.
        Circ. Heart Fail. 2013; 6: 1116-1123
        • Misirli G.
        • Benetou V.
        • Lagiou P.
        • et al.
        Relation of the traditional Mediterranean diet to cerebrovascular disease in a Mediterranean population.
        Am. J. Epidemiol. 2012; 176: 1185-1192
        • Stackelberg O.
        • Bjorck M.
        • Larsson S.C.
        • et al.
        Alcohol consumption, specific alcoholic beverages, and abdominal aortic aneurysm.
        Circulation. 2014; 130: 646-652
        • Bergström L.
        • Kylberg E.
        • Hagman U.
        • et al.
        The food composition database KOST: the national food administration's information system for nutritive values of food.
        Vår Fö. 1991; : 43439-43447
        • Messerer M.
        • Johansson S.E.
        • Wolk A.
        The validity of questionnaire-based micronutrient intake estimates is increased by including dietary supplement use in Swedish men.
        J. Nutr. 2004; 134: 1800-1805
        • Sutton M.G.
        • Sharpe N.
        Left ventricular remodeling after myocardial infarction: pathophysiology and therapy.
        Circulation. 2000; 101: 2981-2988
        • Sofi F.
        • Macchi C.
        • Abbate R.
        • et al.
        Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score.
        Public Health Nutr. 2014; 17: 2769-2782
        • Estruch R.
        • Ros E.
        • Salas-Salvado J.
        • et al.
        Primary prevention of cardiovascular disease with a Mediterranean diet.
        N. Engl. J. Med. 2013; 368: 1279-1290
        • Kontogianni M.D.
        • Panagiotakos D.B.
        Dietary patterns and stroke: a systematic review and re-meta-analysis.
        Maturitas. 2014; 79: 41-47
        • Michaelsson K.
        • Wolk A.
        • Langenskiold S.
        • et al.
        Milk intake and risk of mortality and fractures in women and men: cohort studies.
        Bmj. 2014; (p. g6015): 349
        • Pereira M.A.
        • O'Reilly E.
        • Augustsson K.
        • et al.
        Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies.
        Arch. Intern Med. 2004; 164: 370-376
        • Satija A.
        • Hu F.B.
        Cardiovascular benefits of dietary fiber.
        Curr. Atheroscler. Rep. 2012; 14: 505-514
        • Tang G.
        • Wang D.
        • Long J.
        • et al.
        Meta-analysis of the association between whole grain intake and coronary heart disease risk.
        Am. J. Cardiol. 2015; 115: 625-629
        • Jacobs Jr., D.R.
        • Steffen L.M.
        Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy.
        Am. J. Clin. Nutr. 2003; 78: 508S-513S
        • Strandvik B.
        • Chen Y.
        • Dangardt F.
        • et al.
        From the Swedish to the Mediterranean diet and the omega-6/omega-3 balance.
        World Rev. Nutr. Diet. 2011; 102: 73-80
        • Przybylski R.
        Canola/Rapeseed Oil, in Vegetable Oils in Food Technology.
        Wiley-Blackwell, 2011: 107-136
        • Baxheinrich A.
        • Stratmann B.
        • Lee-Barkey Y.H.
        • et al.
        Effects of a rapeseed oil-enriched hypoenergetic diet with a high content of alpha-linolenic acid on body weight and cardiovascular risk profile in patients with the metabolic syndrome.
        Br. J. Nutr. 2012; 108: 682-691