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Comparative ecologic relationships of saturated fat, sucrose, food groups, and a Mediterranean food pattern score to 50-year coronary heart disease mortality rates among 16 cohorts of the Seven Countries Study

European Journal of Clinical Nutritionvolume 72pages11031110 (2018) | Download Citation



We studied the ecologic relationships of food groups, macronutrients, eating patterns, and an a priori food pattern score (Mediterranean Adequacy Index: MAI) with long-term CHD mortality rates in the Seven Countries Study.


Sixteen cohorts (12,763 men aged 40–59 years) were enrolled in the 1960s in seven countries (US, Finland, The Netherlands, Italy, Greece, former Yugoslavia: Croatia/Serbia, Japan). Dietary surveys were carried out at baseline and only in a subsample of each cohort. The average food consumption of each cohort was chemically analyzed for individual fatty acids and carbohydrates.


Ecologic correlations of diet were computed across cohorts for 50-year CHD mortality rates; 97% of men had died in cohorts with 50-year follow-up. CHD death rates ranged 6.7-fold among cohorts. At baseline, hard fat was greatest in northern Europe, olive oil in Greece, meat in the US, sweet products in northern Europe and the US, and fish in Japan. The MAI was high in Mediterranean and Japanese cohorts. The 50-year CHD mortality rates of the cohorts were closely positively ecologically correlated (r = 0.68–0.92) with average consumption of hard fat, sweet products, animal foods, saturated fat, and sucrose, but not with naturally occurring sugars. Vegetable foods, starch, and the a priori pattern MAI were inversely correlated (r = −0.59 to −0.91) with CHD mortality rates.


Long-term CHD mortality rates had statistically significant ecologic correlations with several aspects of diet consumed in the 1960s, the traditional Mediterranean and Japanese patterns being rich in vegetable foods, and low in sweet products and animal foods.

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The authors express their gratitude for the role of the late professor Srecko Nedeljkovic from Belgrade, who was for many years the enthusiastic and highly professional principal investigator of the Serbian cohorts in the Seven Countries Study.

Authors contributions

Drs. Menotti and Kromhout had full access to all data of the Seven Countries Study and take responsibility for the integrity of the data and the accuracy of data analysis. Study concept and design: the first generation of investigators lead by the late professor Ancel Keys of the University of Minnesota, Minneapolis conceptualized and designed the Seven Countries Study. Acquisition, analysis, or interpretation of data: all authors Drafting of the manuscript: Kromhout, Menotti, and Jacobs. Critical evaluation of the manuscript for important intellectual content: all authors. Chemical analysis: the first round of chemical analysis from 1959 to 1964 was coordinated by Keys and the second round from 1987 to 1988 by Kromhout. Statistical analysis: Menotti, Puddu, and Jacobs. Obtained funding: Nutrition Council, The Hague; Royal Netherlands Academy of Arts and Sciences, Amsterdam; University of Leiden; National Institute for Public Health and the Environment, Bilthoven; Wageningen University; University of Groningen, all in The Netherlands.

Author information


  1. Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

    • Daan Kromhout
  2. Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands

    • Daan Kromhout
    •  & Peter Hollman
  3. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA

    • Daan Kromhout
    •  & David R. Jacobs Jr
  4. Association for Cardiac Research, Rome, Italy

    • Alessandro Menotti
  5. Human Nutrition Section, Department of Neurosciences, University of Rome, Rome, Italy

    • Adalberta Alberti-Fidanza
  6. Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Rome, Italy

    • Paolo Emilio Puddu
  7. Department of Social Medicine, Preventive Medicine and Nutrition Clinic, University of Crete, Heraklion, Greece

    • Anthony Kafatos
  8. Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland

    • Hanna Tolonen
  9. Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume University, School of Medicine, Kurume, Japan

    • Hisashi Adachi


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Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Paolo Emilio Puddu.

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