South European Atlantic Diet associated with lower all-cause mortality

1. A prospective cohort study showed higher adherence to the Southern European Atlantic Diet, rich in cod, red meat, and vegetables, was significantly associated with lower all-cause mortality in participants over 60 years old.

2. Moderate consumption of wine was also associated with lower all-cause mortality in this cohort study.

Evidence Rating Level: 2 (Good)

Study Rundown: SEAD, or the Southern European Atlantic Diet, is a traditional dietary pattern of North-Western Spain and Northern Portugal, consisting of staple foods such as fish, particularly cod, red meat and pork products, dairy, vegetables and potatoes (in vegetable soup), whole-grain bread, and wine. Previous studies have shown higher adherence to SEAD was associated with lowering certain cardiovascular risk factors. However, as SEAD involves high consumption of red meat and pork, it has also been hypothesized that adherence to this diet may lead to higher incidences of cardiometabolic disease, cancer, and mortality, and that an increase in potato consumption may potentially increase risk of type 2 diabetes. This prospective cohort study, conducted on 3165 non-institutionalized participants aged >60 years from Spain, demonstrated a significant association between higher adherence to SEAD and lower all-cause mortality over a median follow-up of 10.9 years (fully adjusted HR: 0.86, p<0.001). This association remained robust after adjusting for potential confounders of age, sex, educational level, energy intake, BMI, morbidity, and specific health and social behaviours in their sensitivity analyses. Even after calculating SEAD adherence using reverse scoring for red meat and pork products and potatoes, without considering wine consumption, adjusting for blood pressure and lipid-lowering drugs, and excluding subjects who died within the first two years of follow-up or those with chronic diseases at baseline, this association remained significant. Additionally, moderate wine consumption was significantly and independently associated with lower all-cause mortality (adjusted HR 0.71, 95% CI 0.76-0.92).

However, while data on food consumption from 2000 individuals was available to evaluate 3-year cumulative adherence to the SEAD, only baseline food consumption was available from 1165 participants. Participants lost to follow-up before three years were more likely to be women, slightly older, less educated, and more often suffered from depression. Nonetheless, adherence to SEAD and risk of death were comparable between those subjects who were and were not followed up (HR of the multiplicative interaction 1.17 (95% CI 0.79-1.74).  Ultimately, this study showed an association of SEAD adherence with lower all-cause mortality in older adults at a comparable level to associations with the Mediterranean or AHEI diets. Further research with more frequent measurements and longer-term follow-ups are necessary to measure any cumulative, more insidious effects of diet on mortality.

Click to read the study in BMC Medicine

Relevant Reading: The Relationship of the Atlantic Diet with Cardiovascular Risk Factors and Markers of Arterial Stiffness in Adults without Cardiovascular Disease

In-Depth [prospective cohort study]: In the Seniors-ENRICA-1 cohort study, data was collected from 3165 non-institutionalized individuals 60 years and older in Spain from March 2008 to September 2010. Using stratified cluster sampling, participants were divided by province and size of municipality before households were randomly telephoned. Subjects were both interviewed over the phone about their sociodemographic variables and lifestyle, morbidity, and health services use, while trained personnel collected detailed diet history, comprehensive physical measurements, and a blood test in their home. Participants were contacted again between February and November 2012 to update diet information and followed through until Jan 2020.

Validated electronic diet history was used to estimate adherence to the SEAD, scored by breaking down food items to calculate habitual consumption of the nine main components of this dietary pattern: fresh fish (excluding cod), cod, red meat and pork products, dairy, legumes and vegetables (excluding soup), vegetable soup, potatoes, whole-grain bread, and wine. MEDAS index (for the Mediterranean diet) and AHEI (Alternate Health Eating Index) were also calculated to give context to SEAD. Multiple analyses were conducted dividing participants into sex-specific quartiles based on SEAD scoring, to test the associations they found against potential confounders (ie without wine consumption, excluding patients with prevalent morbidity).

In a median follow-up of 10.9 years, 646 subjects died. Higher adherence to SEAD was significantly associated with a lower risk of death (HR per 1-SD increment in SEAD score: 0.86, 95% CI 0.79-0.94), a protective association comparable to adherence to MEDAS (HR: 0.89, 95% CI 0.80-0.98) and AHEI diets (HR 0.83, 95% CI 0.76-0.92). From MEDAS, high consumption of olive oil, nuts and vegetable sauce as well as low consumption of sugar-sweetened beverages showed the strongest associations with lower mortality; from AHEI, high intake of n-3 fatty acids, moderate alcohol intake, as well as low consumption of sugar-sweetened beverages were similarly associated.  In SEAD, moderate wine consumption alone showed an association with lower all-cause mortality (HR 0.71, 95% CI 0.59-0.86). SEAD adherence also showed a non-significant tendency towards reducing cardiovascular and cancer mortality.

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