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



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.


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).


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.


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

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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).

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


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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.

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Authors and Affiliations



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.

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Correspondence to Demosthenes B. Panagiotakos.

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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.

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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).

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