Ajcn008250 913..920

Background: The Mediterranean diet has been associated with reduced mortality; few studies have investigated the combined impact of the Mediterranean diet with other modifiable lifestyle factors. Objectives: The objectives were to investigate the association between adherence to the Mediterranean diet and total mortality and to estimate the overall impact of a combined healthy lifestyle on premature death. Design: In 1986 a cohort of 120,852 men and women aged 55–69 y provided information on dietary and other lifestyle habits. A mortality follow-up until 1996 was established by linkage to the Dutch Central Bureau of Genealogy. A combined lifestyle score was constructed by allocating one point per the following healthy lifestyle factors: adhering to the Mediterranean diet, nonsmoking, normal weight [BMI (in kg/m): 18.5 to,25], and regular physical activity. The lifestyle score ranged from 0 to 4 points (least healthy to healthiest). The multivariate case-cohort analysis was based on 9691 deaths and 3576 subcohort members. Results: Adherence to the Mediterranean diet was significantly related to lower mortality in women but not significantly in men. The healthy lifestyle score was strongly inversely related to mortality in women and men. When the least-healthy to the healthiest lifestyle scores were compared, HRs of 4.07 (95% CI: 2.59, 6.40; P-trend,0.001) and 2.61 (95% CI: 1.79, 3.80; P-trend,0.001) were shown in women and men, respectively. For the same comparison, the mortality rate advancement period (“aging effect”) was 15.1 y (95% CI: 9.9, 20.2 y) in women and 8.4 y (95% CI: 5.0, 11.8 y) in men. Conclusion: This study suggests that adherence to 4 modifiable healthy lifestyle factors can substantially reduce premature mortality in women and men. Am J Clin Nutr 2011;94:913–20.