Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Adherence to the Mediterranean diet and 20-year incidence of hypertension: the ATTICA prospective epidemiological study (2002–2022)

European Journal of Clinical Nutrition (2024)Cite this article

Subjects

Abstract

Background/objectives

Dietary habits are a significant predictor of hypertension (HTN). We aimed to evaluate the long-term association between adherence to the Mediterranean diet and HTN incidence.

Subjects/methods

This was a prospective study among 1415 non-hypertensive adults (44% men, age: 41 ± 13 years) followed up for 20 years. Anthropometric, lifestyle, and clinical parameters were evaluated at baseline. Adherence to the Mediterranean diet was evaluated both at baseline and 10 years through the MedDietScore (range: 0–55, higher values indicate greater adherence).

Results

At the 20-year follow-up, 314 new HTN cases were recorded. HTN incidence was 35.5%, 22.5%, and 8.7% in the lowest, middle, and upper tertile of baseline MedDietScore, respectively (p < 0.001). For each 1-point increase in baseline MedDietScore, the 20-year HTN risk decreased by 7% [relative risk (RR): 0.925, 95% confidence interval (CI): 0.906, 0.943], and this effect remained significant after adjustment for age, sex, and baseline lifestyle and clinical confounders, i.e., body mass index, physical activity, smoking, systolic and diastolic blood pressure, family history of HTN, and presence of hypercholesterolemia and diabetes mellitus (RR: 0.973, 95%CI: 0.949, 0.997). In a similar multiadjusted model, compared to subjects who were consistently away from the Mediterranean diet (in the lowest MedDietScore tertile both at baseline and 10 years), only those who were consistently close (in the middle and upper MedDietScore tertiles both at baseline and 10 years) exhibited a 47% lower 20-year HTN risk.

Conclusion

A high adherence to the Mediterranean diet, particularly when longitudinally sustained, is associated with lower incidence of HTN.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Blood pressure indices according to baseline level of adherence to the Mediterranean diet (n = 1415).
Fig. 2: Incidence of HTN at the 20-year follow-up according to participants’ level of adherence to the Mediterranean diet (n = 1415).

Similar content being viewed by others

Data availability

Data described in the manuscript will be made available upon request to the corresponding author.

References

  1. Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18:785–802. https://doi.org/10.1038/s41569-021-00559-8.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16:223–37. https://doi.org/10.1038/s41581-019-0244-2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50. https://doi.org/10.1161/CIRCULATIONAHA.115.018912.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596–e646. https://doi.org/10.1161/CIR.0000000000000678.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Back M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227–337. https://doi.org/10.1093/eurheartj/ehab484.

    Article  PubMed  Google Scholar 

  6. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104. https://doi.org/10.1093/eurheartj/ehy339.

    Article  PubMed  Google Scholar 

  7. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138:e426–e83. https://doi.org/10.1161/CIR.0000000000000597.

    Article  PubMed  Google Scholar 

  8. Boffa RJ, Constanti M, Floyd CN, Wierzbicki AS, Guideline C. Hypertension in adults: summary of updated NICE guidance. BMJ. 2019;367:l5310. https://doi.org/10.1136/bmj.l5310.

    Article  PubMed  Google Scholar 

  9. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75:1334–57. https://doi.org/10.1161/HYPERTENSIONAHA.120.15026.

    Article  CAS  PubMed  Google Scholar 

  10. Yngve A. A historical perspective of the understanding of the link between diet and coronary heart disease. Am J Lifestyle Med. 2009;3:35S–8S. https://doi.org/10.1177/1559827609334887.

    Article  PubMed  Google Scholar 

  11. Menotti A, Puddu PE. How the Seven Countries Study contributed to the definition and development of the Mediterranean diet concept: a 50-year journey. Nutr Metab Cardiovasc Dis. 2015;25:245–52. https://doi.org/10.1016/j.numecd.2014.12.001.

    Article  CAS  PubMed  Google Scholar 

  12. Russo GL, Siani A, Fogliano V, Geleijnse JM, Giacco R, Giampaoli S, et al. The Mediterranean diet from past to future: key concepts from the second “Ancel Keys” International Seminar. Nutr Metab Cardiovasc Dis. 2021;31:717–32. https://doi.org/10.1016/j.numecd.2020.12.020.

    Article  PubMed  Google Scholar 

  13. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr. 2014;17:2769–82. https://doi.org/10.1017/S1368980013003169.

    Article  PubMed  Google Scholar 

  14. Schwingshackl L, Morze J, Hoffmann G. Mediterranean diet and health status: Active ingredients and pharmacological mechanisms. Br J Pharmacol. 2020;177:1241–57. https://doi.org/10.1111/bph.14778.

    Article  CAS  PubMed  Google Scholar 

  15. De Pergola G, D’Alessandro A. Influence of Mediterranean diet on blood pressure. Nutrients. 2018;10. https://doi.org/10.3390/nu10111700.

  16. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2000;284:3043–5.

  17. Pitsavos C, Panagiotakos DB, Chrysohoou C, Stefanadis C. Epidemiology of cardiovascular risk factors in Greece: aims, design and baseline characteristics of the ATTICA study. BMC Public Health. 2003;3:32. https://doi.org/10.1186/1471-2458-3-32.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Nomikos T, Panagiotakos D, Georgousopoulou E, Metaxa V, Chrysohoou C, Skoumas I, et al. Hierarchical modelling of blood lipids’ profile and 10-year (2002-2012) all cause mortality and incidence of cardiovascular disease: the ATTICA study. Lipids Health Dis. 2015;14:108. https://doi.org/10.1186/s12944-015-0101-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Kastorini CM, Panagiotakos DB, Chrysohoou C, Georgousopoulou E, Pitaraki E, Puddu PE, et al. Metabolic syndrome, adherence to the Mediterranean diet and 10-year cardiovascular disease incidence: the ATTICA study. Atherosclerosis. 2016;246:87–93. https://doi.org/10.1016/j.atherosclerosis.2015.12.025.

    Article  CAS  PubMed  Google Scholar 

  20. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28:412–9. https://doi.org/10.1007/bf00280883.

    Article  CAS  PubMed  Google Scholar 

  21. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18:499–502.

    Article  CAS  PubMed  Google Scholar 

  22. American Diabetes Association Professional Practice C 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2022. Diabetes Care. 2022;45:S17–S38. https://doi.org/10.2337/dc22-S002.

    Article  Google Scholar 

  23. Kushner RF. Clinical assessment and management of adult obesity. Circulation. 2012;126:2870–7. https://doi.org/10.1161/CIRCULATIONAHA.111.075424.

    Article  PubMed  Google Scholar 

  24. Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120:1640–5. https://doi.org/10.1161/CIRCULATIONAHA.109.192644.

    Article  CAS  PubMed  Google Scholar 

  25. Katsouyanni K, Rimm EB, Gnardellis C, Trichopoulos D, Polychronopoulos E, Trichopoulou A. Reproducibility and relative validity of an extensive semi-quantitative food frequency questionnaire using dietary records and biochemical markers among Greek schoolteachers. Int J Epidemiol. 1997;26:S118–27. https://doi.org/10.1093/ije/26.suppl_1.s118.

    Article  PubMed  Google Scholar 

  26. Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006;16:559–68. https://doi.org/10.1016/j.numecd.2005.08.006.

    Article  PubMed  Google Scholar 

  27. Papathanasiou G, Georgoudis G, Papandreou M, Spyropoulos P, Georgakopoulos D, Kalfakakou V, et al. Reliability measures of the short International Physical Activity Questionnaire (IPAQ) in Greek young adults. Hellenic J Cardiol. 2009;50:283–94.

    PubMed  Google Scholar 

  28. Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35:1381–95. https://doi.org/10.1249/01.MSS.0000078924.61453.FB.

    Article  PubMed  Google Scholar 

  29. Tzima N, Pitsavos C, Panagiotakos DB, Skoumas J, Zampelas A, Chrysohoou C, et al. Mediterranean diet and insulin sensitivity, lipid profile and blood pressure levels, in overweight and obese people; the Attica study. Lipids Health Dis. 2007;6:22. https://doi.org/10.1186/1476-511X-6-22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Jiang SZ, Lu W, Zong XF, Ruan HY, Liu Y. Obesity and hypertension. Exp Ther Med. 2016;12:2395–9. https://doi.org/10.3892/etm.2016.3667.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Cowell OR, Mistry N, Deighton K, Matu J, Griffiths A, Minihane AM, et al. Effects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Hypertens. 2021;39:729–39. https://doi.org/10.1097/HJH.0000000000002667.

    Article  CAS  PubMed  Google Scholar 

  32. Nunez-Cordoba JM, Valencia-Serrano F, Toledo E, Alonso A, Martinez-Gonzalez MA. The Mediterranean diet and incidence of hypertension: the Seguimiento Universidad de Navarra (SUN) Study. Am J Epidemiol. 2009;169:339–46. https://doi.org/10.1093/aje/kwn335.

    Article  PubMed  Google Scholar 

  33. Razmpoosh E, Moslehi N, Abdollahi S, Soltani S, Mirmiran P, Azizi F. The Mediterranean, DASH, and MIND diets and the incident of hypertension over a median follow-up of 7.4 years in the Tehran Lipid and Glucose Study. BMC Public Health. 2022;22:2374. https://doi.org/10.1186/s12889-022-14843-w.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Damigou E, Kouvari M, Chrysohoou C, Barkas F, Kravvariti E, Pitsavos C, et al. Lifestyle trajectories are associated with incidence of cardiovascular disease: highlights from the ATTICA Epidemiological Cohort Study (2002–2022). Life. 2023;13. https://doi.org/10.3390/life13051142.

  35. Vilarnau C, Stracker DM, Funtikov A, da Silva R, Estruch R, Bach-Faig A. Worldwide adherence to Mediterranean Diet between 1960 and 2011. Eur J Clin Nutr. 2019;72:83–91. https://doi.org/10.1038/s41430-018-0313-9.

    Article  PubMed  Google Scholar 

  36. Georgoulis M, Georgousopoulou EN, Chrysohoou C, Pitsavos C, Panagiotakos DB. Longitudinal trends, determinants, and Cardiometabolic impact of adherence to the Mediterranean diet among Greek Adults. Foods 2022;11.https://doi.org/10.3390/foods11162389.

  37. Damigou E, Faka A, Kouvari M, Anastasiou C, Kosti RI, Chalkias C, et al. Adherence to a Mediterranean type of diet in the world: a geographical analysis based on a systematic review of 57 studies with 1,125,560 participants. Int J Food Sci Nutr. 2023;1–15. https://doi.org/10.1080/09637486.2023.2262781.

  38. Li F, Zhang Y, Pan L, Chen H. Effects of dietary patterns on the all-cause mortality and cardiovascular disease mortality in patients with hypertension: a cohort study based on the NHANES database. Clin Cardiol. 2023;46:1353–70. https://doi.org/10.1002/clc.24118.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Song Y, Chang Z, Cui K, Song C, Cai Z, Shi B, et al. The value of the MIND diet in the primary and secondary prevention of hypertension: A cross-sectional and longitudinal cohort study from NHANES analysis. Front Nutr. 2023;10:1129667. https://doi.org/10.3389/fnut.2023.1129667.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Ndanuko RN, Tapsell LC, Charlton KE, Neale EP, Batterham MJ. Dietary patterns and blood pressure in adults: a systematic review and meta-analysis of randomized controlled trials. Adv Nutr. 2016;7:76–89. https://doi.org/10.3945/an.115.009753.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Nissensohn M, Roman-Vinas B, Sanchez-Villegas A, Piscopo S, Serra-Majem L. The effect of the Mediterranean diet on hypertension: a systematic review and meta-analysis. J Nutr Educ Behav. 2016;48:42–53.e1. https://doi.org/10.1016/j.jneb.2015.08.023.

    Article  PubMed  Google Scholar 

  42. Filippou CD, Thomopoulos CG, Kouremeti MM, Sotiropoulou LI, Nihoyannopoulos PI, Tousoulis DM, et al. Mediterranean diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials. Clin Nutr. 2021;40:3191–200. https://doi.org/10.1016/j.clnu.2021.01.030.

    Article  PubMed  Google Scholar 

  43. Grosso G, Godos J, Currenti W, Micek A, Falzone L, Libra M, et al. The effect of dietary polyphenols on vascular health and hypertension: current evidence and mechanisms of action. Nutrients. 2022;14. https://doi.org/10.3390/nu14030545.

  44. Psaltopoulou T, Naska A, Orfanos P, Trichopoulos D, Mountokalakis T, Trichopoulou A. Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study. Am J Clin Nutr. 2004;80:1012–8. https://doi.org/10.1093/ajcn/80.4.1012.

    Article  CAS  PubMed  Google Scholar 

  45. Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965;58:295–300.

    CAS  PubMed  PubMed Central  Google Scholar 

  46. Rothman KJ, Greenland S. Causation and causal inference in epidemiology. Am J Public Health. 2005;95:S144–50.

    Article  PubMed  Google Scholar 

  47. Charles RL, Rudyk O, Prysyazhna O, Kamynina A, Yang J, Morisseau C, et al. Protection from hypertension in mice by the Mediterranean diet is mediated by nitro fatty acid inhibition of soluble epoxide hydrolase. Proc Natl Acad Sci USA. 2014;111:8167–72. https://doi.org/10.1073/pnas.1402965111.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to thank the ATTICA study group of investigators: Elpiniki Vlachopoulou, Dimitris Dalmyras, Petros Spyridonas Adamidis, Konstantina Kyrili, Evangelinos Michelis, Asimina Loukina, Giorgos Metzantonakis, Manolis Kambaxis, Kyriakos Dimitriadis, Ioannis Andrikou, Amalia Sofianidi, Natalia Sinou, Aikaterini Skandali, Christina Sousouni, for their assistance on the 20-year follow-up, as well as Ekavi N. Georgousopoulou, Natassa Katinioti, Labros Papadimitriou, Konstantina Masoura, Spiros Vellas, Yannis Lentzas, Manolis Kambaxis, Konstantina Palliou, Vassiliki Metaxa, Agathi Ntzouvani, Dimitris Mpougatsas, Nikolaos Skourlis, Christina Papanikolaou, Georgia-Maria Kouli, Aimilia Christou, Adella Zana, Maria Ntertimani, Aikaterini Kalogeropoulou, Evangelia Pitaraki, Alexandros Laskaris, Mihail Hatzigeorgiou and Athanasios Grekas, Efi Tsetsekou, Carmen Vassiliadou, George Dedoussis, Marina Toutouza-Giotsa, Konstantina Tselika and Sia Poulopoulou and Maria Toutouza for their assistance in the initial and follow-up evaluations.

Author information

Authors and Affiliations

  1. Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University of Athens, 17676, Athens, Greece

    Michael Georgoulis, Evangelia Damigou, Evgenia Derdelakou & Demosthenes B. Panagiotakos

  2. Department of Nutrition and Dietetics, School of Physical Education, Sports and Dietetics, University of Thessaly, 38221, Trikala, Greece

    Rena I. Kosti

  3. First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527, Athens, Greece

    Christina Chrysohoou, Costas Tsioufis & Christos Pitsavos

  4. Department of Internal Medicine, Medical School, University of Ioannina, 45500, Ioannina, Greece

    Fotios Barkas

  5. First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 15772, Athens, Greece

    Evrydiki Kravvariti, Evangelos Liberopoulos & Petros P. Sfikakis

Authors
  1. Michael Georgoulis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evangelia Damigou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Evgenia Derdelakou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rena I. Kosti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christina Chrysohoou
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fotios Barkas
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Evrydiki Kravvariti
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Costas Tsioufis
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Christos Pitsavos
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Evangelos Liberopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Petros P. Sfikakis
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Demosthenes B. Panagiotakos
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Michael Georgoulis conceptualized the current study and drafted the manuscript; Michael Georgoulis, Evangelia Damigou and Evgenia Derdelakou performed statistical analysis; Evangelia Damigou, Fotios Barkas, and Evrydiki Kravvariti conducted research; Rena I Kosti, Christina Chrysohoou, Costas Tsioufis, Christos Pitsavos, Evangelos Liberopoulos, Petros P Sfikakis, and Demosthenes B Panagiotakos designed research. Demosthenes B Panagiotakos had the primary responsibility for the final content. All authors critically reviewed the manuscript and approved the final version.

Corresponding author

Correspondence to Demosthenes B. Panagiotakos.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The study was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of the First Cardiology Department of the National and Kapodistrian University of Athens (#017/01.05.2001). All participating subjects provided a signed written consent.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Georgoulis, M., Damigou, E., Derdelakou, E. et al. Adherence to the Mediterranean diet and 20-year incidence of hypertension: the ATTICA prospective epidemiological study (2002–2022). Eur J Clin Nutr (2024). https://doi.org/10.1038/s41430-024-01440-w

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41430-024-01440-w

Search

Advanced search

Quick links