Combined associations of body mass index and adherence to a Mediterranean-like diet with all-cause and cardiovascular mortality: A cohort study

Autoři: Karl Michaëlsson aff001;  John A. Baron aff001;  Liisa Byberg aff001;  Jonas Höijer aff001;  Susanna C. Larsson aff001;  Bodil Svennblad aff001;  Håkan Melhus aff006;  Alicja Wolk aff001;  Eva Warensjö Lemming aff001
Působiště autorů: Department of Surgical Sciences, Uppsala University, Uppsala, Sweden aff001;  Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America aff002;  Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America aff003;  Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America aff004;  Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden aff005;  Department of Medical Sciences, Uppsala University, Uppsala, Sweden aff006
Vyšlo v časopise: Combined associations of body mass index and adherence to a Mediterranean-like diet with all-cause and cardiovascular mortality: A cohort study. PLoS Med 17(9): e32767. doi:10.1371/journal.pmed.1003331
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003331



It is unclear whether the effect on mortality of a higher body mass index (BMI) can be compensated for by adherence to a healthy diet and whether the effect on mortality by a low adherence to a healthy diet can be compensated for by a normal weight. We aimed to evaluate the associations of BMI combined with adherence to a Mediterranean-like diet on all-cause and cardiovascular disease (CVD) mortality.

Methods and findings

Our longitudinal cohort design included the Swedish Mammography Cohort (SMC) and the Cohort of Swedish Men (COSM) (1997–2017), with a total of 79,003 women (44%) and men (56%) and a mean baseline age of 61 years. BMI was categorized into normal weight (20–24.9 kg/m2), overweight (25–29.9 kg/m2), and obesity (30+ kg/m2). Adherence to a Mediterranean-like diet was assessed by means of the modified Mediterranean-like diet (mMED) score, ranging from 0 to 8; mMED was classified into 3 categories (0 to <4, 4 to <6, and 6–8 score points), forming a total of 9 BMI × mMED combinations. We identified mortality by use of national Swedish registers. Cox proportional hazard models with time-updated information on exposure and covariates were used to calculate the adjusted hazard ratios (HRs) of mortality with their 95% confidence intervals (CIs). Our HRs were adjusted for age, baseline educational level, marital status, leisure time physical exercise, walking/cycling, height, energy intake, smoking habits, baseline Charlson’s weighted comorbidity index, and baseline diabetes mellitus. During up to 21 years of follow-up, 30,389 (38%) participants died, corresponding to 22 deaths per 1,000 person-years. We found the lowest HR of all-cause mortality among overweight individuals with high mMED (HR 0.94; 95% CI 0.90, 0.98) compared with those with normal weight and high mMED. Using the same reference, obese individuals with high mMED did not experience significantly higher all-cause mortality (HR 1.03; 95% CI 0.96–1.11). In contrast, compared with those with normal weight and high mMED, individuals with a low mMED had a high mortality despite a normal BMI (HR 1.60; 95% CI 1.48–1.74). We found similar estimates among women and men. For CVD mortality (12,064 deaths) the findings were broadly similar, though obese individuals with high mMED retained a modestly increased risk of CVD death (HR 1.29; 95% CI 1.16–1.44) compared with those with normal weight and high mMED. A main limitation of the present study is the observational design with self-reported lifestyle information with risk of residual or unmeasured confounding (e.g., genetic liability), and no causal inferences can be made based on this study alone.


These findings suggest that diet quality modifies the association between BMI and all-cause mortality in women and men. A healthy diet may, however, not completely counter higher CVD mortality related to obesity.

Klíčová slova:

Body mass index – Body weight – Cardiovascular diseases – Death rates – Diet – Educational attainment – Medical risk factors – Obesity


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