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European Journal of Epidemiology

, Volume 34, Issue 4, pp 337–349 | Cite as

Adherence to the Mediterranean diet and risk of stroke and stroke subtypes

  • Guo-Chong ChenEmail author
  • Nithya Neelakantan
  • Nerea Martín-Calvo
  • Woon-Puay Koh
  • Jian-Min Yuan
  • Marialaura Bonaccio
  • Licia Iacoviello
  • Miguel A. Martínez-González
  • Li-Qiang Qin
  • Rob M. van DamEmail author
META-ANALYSIS

Abstract

Several meta-analyses including a small number of cohorts showed inverse associations between the Mediterranean Diet (MedDiet) and risk of stroke. However, it remains unclear whether such a relation varies by region of the study population or by major subtypes of stroke. We searched PubMed and EMBASE databases for relevant studies and we further included unpublished results from the Singapore Chinese Health Study (N = 57,078) and the Seguimiento Universidad de Navarra (SUN) study (N = 12,670). We used a random-effects model to calculate summary relative risk (RR) with 95% confidence intervals (CI) of stroke for each 4-point increment of the MedDiet score, roughly corresponding to the difference between extreme quintiles of the MedDiet score among participants of the included studies. The final analyses included 20 prospective cohort studies involving 682,149 participants and 16,739 stroke cases. The summary RRs for each 4-point increment of the MedDiet score were 0.84 (95% CI 0.81–0.88; I2 = 11.5%) for all combined, 0.76 (95% CI 0.65–0.89) for studies in Mediterranean populations and 0.86 (95% CI 0.83–0.89) for those in non-Mediterranean populations. Lower risk of stroke associated with higher MedDiet score also was observed in the analyses stratified by study population and methodological characteristics including study risk of bias, version of the MedDiet index, and definition of moderate alcohol consumption. The MedDiet was similarly associated with lower risk of ischemic stroke (RR 0.86, 95% CI 0.81–0.91; nine studies) and hemorrhagic stroke (RR 0.83, 95% CI 0.74–0.93; eight studies). Our meta-analysis suggests that adhering to the Mediterranean diet was associated with lower risk of stroke in both Mediterranean and non-Mediterranean populations, and for both ischemic stroke and hemorrhagic stroke risk.

Keywords

Mediterranean diet Ischemic stroke Hemorrhagic stroke Cohort studies Meta-analysis 

Notes

Acknowledgements

We thank the authors of the included studies for kindly clarifying the information in the publications and/or providing the unpublished data.

Funding

The Singapore Chinese Health Study was supported by the National Institutes of Health, USA (NIH R01 CA144034 and UM1 CA182876). W.-P.Koh is supported by the National Medical Research Council, Singapore, (NMRC/CSA/0055/2013). M.A. Martínez-Gonzalez was funded by an ERC Advanced Grant (Long-term effects of an energy-restricted Mediterranean diet on mortality and CVD, grant No 340918, PREDIMED-Plus, PI: Martínez-González MA). G.-C.Chen received an award from the China Scholarship Council.

Compliance with ethical standards

Conflict of interest

No conflict of interest existed for any of the authors.

Supplementary material

10654_2019_504_MOESM1_ESM.pdf (1.1 mb)
Supplementary material 1 (PDF 1110 kb)

References

  1. 1.
    Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res. 2017;120(3):439–48.Google Scholar
  2. 2.
    Feigin VL, Krishnamurthi RV, Parmar P, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990–2013: the GBD 2013 study. Neuroepidemiology. 2015;45(3):161–76.Google Scholar
  3. 3.
    Roth GA, Forouzanfar MH, Moran AE, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med. 2015;372(14):1333–41.Google Scholar
  4. 4.
    Feigin VL, Roth GA, Naghavi M, et al. Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol. 2016;15(9):913–24.Google Scholar
  5. 5.
    O’Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112–23.Google Scholar
  6. 6.
    Micha R, Penalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA. 2017;317(9):912–24.Google Scholar
  7. 7.
    Galbete C, Schwingshackl L, Schwedhelm C, Boeing H, Schulze MB. Evaluating Mediterranean diet and risk of chronic disease in cohort studies: an umbrella review of meta-analyses. Eur J Epidemiol. 2018;33(10):909–31.Google Scholar
  8. 8.
    Salas-Salvado J, Guasch-Ferre M, Lee CH, Estruch R, Clish CB, Ros E. Protective effects of the Mediterranean diet on type 2 diabetes and metabolic syndrome. J Nutr. 2016;146:920S–7S.Google Scholar
  9. 9.
    Grosso G, Marventano S, Yang J, et al. A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: are individual components equal? Crit Rev Food Sci Nutr. 2017;57(15):3218–32.Google Scholar
  10. 10.
    Estruch R, Ros E, Salas-Salvado J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med. 2018;378(25):e34.Google Scholar
  11. 11.
    Kontogianni MD, Panagiotakos DB. Dietary patterns and stroke: a systematic review and re-meta-analysis. Maturitas. 2014;79(1):41–7.Google Scholar
  12. 12.
    Psaltopoulou T, Sergentanis TN, Panagiotakos DB, Sergentanis IN, Kosti R, Scarmeas N. Mediterranean diet, stroke, cognitive impairment, and depression: a meta-analysis. Ann Neurol. 2013;74(4):580–91.Google Scholar
  13. 13.
    Rosato V, Temple NJ, La Vecchia C, Castellan G, Tavani A, Guercio V. Mediterranean diet and cardiovascular disease: a systematic review and meta-analysis of observational studies. Eur J Nutr. 2017.Google Scholar
  14. 14.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.Google Scholar
  15. 15.
    Hankin JH, Stram DO, Arakawa K, et al. Singapore Chinese Health Study: development, validation, and calibration of the quantitative food frequency questionnaire. Nutr Cancer. 2001;39(2):187–95.Google Scholar
  16. 16.
    Pan A, De Silva DA, Yuan JM, Koh WP. Sleep duration and risk of stroke mortality among Chinese adults: Singapore Chinese health study. Stroke. 2014;45(6):1620–5.Google Scholar
  17. 17.
    Martinez-Gonzalez MA, Sanchez-Villegas A, De Irala J, Marti A, Martinez JA. Mediterranean diet and stroke: objectives and design of the SUN project. Seguimiento Universidad de Navarra. Nutr Neurosci. 2002;5(1):65–73.Google Scholar
  18. 18.
    Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348(26):2599–608.Google Scholar
  19. 19.
    Fung TT, Rexrode KM, Mantzoros CS, Manson JE, Willett WC, Hu FB. Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women. Circulation. 2009;119(8):1093–100.Google Scholar
  20. 20.
    Hirahatake KM. Diet quality and cardiovascular disease risk in postmenopausal women with type 2 diabetes: the women’s health initiative. Circulation. 2017;135(Suppl 1):A14 (Abstract).Google Scholar
  21. 21.
    Schroder H, Salas-Salvado J, Martinez-Gonzalez MA, et al. Baseline adherence to the Mediterranean diet and major cardiovascular events: prevencion con Dieta Mediterranea trial. JAMA Intern Med. 2014;174(10):1690–2.Google Scholar
  22. 22.
    Paterson KE, Myint PK, Jennings A, et al. Mediterranean diet reduces risk of incident stroke in a population with varying cardiovascular disease risk profiles. Stroke. 2018;49:2415–20.Google Scholar
  23. 23.
    Tong TY, Wareham NJ, Khaw KT, Imamura F, Forouhi NG. Prospective association of the Mediterranean diet with cardiovascular disease incidence and mortality and its population impact in a non-Mediterranean population: the EPIC-Norfolk study. BMC Med. 2016;14(1):135.Google Scholar
  24. 24.
    Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.Google Scholar
  25. 25.
    Bonaccio M, Di Castelnuovo A, Pounis G, et al. High adherence to the Mediterranean diet is associated with cardiovascular protection in higher but not in lower socioeconomic groups: prospective findings from the Moli-sani study. Int J Epidemiol. 2017;46(5):1478–87.Google Scholar
  26. 26.
    Aigner A, Becher H, Jacobs S, et al. Low diet quality and the risk of stroke mortality: the multiethnic cohort study. Eur J Clin Nutr. 2018;72(7):1035–45.Google Scholar
  27. 27.
    Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol. 1992;135(11):1301–9.Google Scholar
  28. 28.
    Orsini N, Bellocco R, Greenland S. Generalized least squares for trend estimation of summarized dose-response data. Stata J. 2006;6(1):40.Google Scholar
  29. 29.
    Hamling J, Lee P, Weitkunat R, Ambuhl M. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med. 2008;27(7):954–70.Google Scholar
  30. 30.
    Agnoli C, Krogh V, Grioni S, et al. A priori-defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort. J Nutr. 2011;141(8):1552–8.Google Scholar
  31. 31.
    Stefler D, Malyutina S, Kubinova R, et al. Mediterranean diet score and total and cardiovascular mortality in Eastern Europe: the HAPIEE study. Eur J Nutr. 2017;56(1):421–9.Google Scholar
  32. 32.
    Chan R, Chan D, Woo J. The association of a priori and a posterior dietary patterns with the risk of incident stroke in Chinese older people in Hong Kong. J Nutr Health Aging. 2013;17(10):866–74.Google Scholar
  33. 33.
    Gardener H, Wright CB, Gu Y, et al. Mediterranean-style diet and risk of ischemic stroke, myocardial infarction, and vascular death: the Northern Manhattan Study. Am J Clin Nutr. 2011;94(6):1458–64.Google Scholar
  34. 34.
    Tektonidis TG, Akesson A, Gigante B, Wolk A, Larsson SC. A Mediterranean diet and risk of myocardial infarction, heart failure and stroke: a population-based cohort study. Atherosclerosis. 2015;243(1):93–8.Google Scholar
  35. 35.
    Tsivgoulis G, Psaltopoulou T, Wadley VG, et al. Adherence to a Mediterranean diet and prediction of incident stroke. Stroke. 2015;46(3):780–5.Google Scholar
  36. 36.
    Veglia F, Baldassarre D, de Faire U, et al. A priori-defined Mediterranean-like dietary pattern predicts cardiovascular events better in north Europe than in Mediterranean countries. Int J Cardiol. 2018.Google Scholar
  37. 37.
    Tognon G, Lissner L, Saebye D, Walker KZ, Heitmann BL. The Mediterranean diet in relation to mortality and CVD: a Danish cohort study. Br J Nutr. 2014;111(1):151–9.Google Scholar
  38. 38.
    Galbete C, Kroger J, Jannasch F, et al. Nordic diet, Mediterranean diet, and the risk of chronic diseases: the EPIC-Potsdam study. BMC Med. 2018;16(1):99.Google Scholar
  39. 39.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.Google Scholar
  40. 40.
    Orsini N, Li R, Wolk A, Khudyakov P, Spiegelman D. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. Am J Epidemiol. 2012;175(1):66–73.Google Scholar
  41. 41.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.Google Scholar
  42. 42.
    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.Google Scholar
  43. 43.
    Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.Google Scholar
  44. 44.
    Hoevenaar-Blom MP, Nooyens AC, Kromhout D, et al. Mediterranean style diet and 12-year incidence of cardiovascular diseases: the EPIC-NL cohort study. PLoS ONE. 2012;7(9):e45458.Google Scholar
  45. 45.
    Misirli G, Benetou V, Lagiou P, Bamia C, Trichopoulos D, Trichopoulou A. Relation of the traditional Mediterranean diet to cerebrovascular disease in a Mediterranean population. Am J Epidemiol. 2012;176(12):1185–92.Google Scholar
  46. 46.
    Sherzai AZ, Ma H, Horn-Ross P, et al. Mediterranean diet and incidence of stroke in the California teachers study. Circulation. 2015;131(1):AMP85 (Abstract).Google Scholar
  47. 47.
    Yau WY, Hankey GJ. Which dietary and lifestyle behaviours may be important in the aetiology (and prevention) of stroke? J Clin Neurosci. 2011;18(1):76–80.Google Scholar
  48. 48.
    Sotos-Prieto M, Bhupathiraju SN, Mattei J, et al. Changes in diet quality scores and risk of cardiovascular disease among US men and women. Circulation. 2015;132(23):2212–9.Google Scholar
  49. 49.
    Martinez-Gonzalez MA, Dominguez LJ, Delgado-Rodriguez M. Olive oil consumption and risk of CHD and/or stroke: a meta-analysis of case-control, cohort and intervention studies. Br J Nutr. 2014;112(2):248–59.Google Scholar
  50. 50.
    Ruiz-Canela M, Martinez-Gonzalez MA. Olive oil in the primary prevention of cardiovascular disease. Maturitas. 2011;68(3):245–50.Google Scholar
  51. 51.
    Larsson SC, Wallin A, Wolk A, Markus HS. Differing association of alcohol consumption with different stroke types: a systematic review and meta-analysis. BMC Med. 2016;14(1):178.Google Scholar
  52. 52.
    Bechthold A, Boeing H, Schwedhelm C, et al. Food groups and risk of coronary heart disease, stroke and heart failure: a systematic review and dose-response meta-analysis of prospective studies. Crit Rev Food Sci Nutr. 2017:1–20.Google Scholar
  53. 53.
    Larsson SC. Dietary approaches for stroke prevention. Stroke. 2017;48(10):2905–11.Google Scholar
  54. 54.
    Iacoviello L, Bonaccio M, Cairella G, et al. Diet and primary prevention of stroke: systematic review and dietary recommendations by the ad hoc Working Group of the Italian Society of Human Nutrition. Nutr Metab Cardiovasc Dis. 2018;28(4):309–34.Google Scholar
  55. 55.
    Esposito K, Kastorini CM, Panagiotakos DB, Giugliano D. Mediterranean diet and weight loss: meta-analysis of randomized controlled trials. Metab Syndr Relat Disord. 2011;9(1):1–12.Google Scholar
  56. 56.
    Gay HC, Rao SG, Vaccarino V, Ali MK. Effects of different dietary interventions on blood pressure: systematic review and meta-analysis of randomized controlled trials. Hypertension. 2016;67(4):733–9.Google Scholar
  57. 57.
    Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011;57(11):1299–313.Google Scholar
  58. 58.
    Schwingshackl L, Chaimani A, Schwedhelm C, et al. Comparative effects of different dietary approaches on blood pressure in hypertensive and pre-hypertensive patients: a systematic review and network meta-analysis. Crit Rev Food Sci Nutr. 2018:1–14.Google Scholar
  59. 59.
    Tosti V, Bertozzi B, Fontana L. Health benefits of the Mediterranean diet: metabolic and molecular mechanisms. J Gerontol A Biol Sci Med Sci. 2018;73(3):318–26.Google Scholar
  60. 60.
    Schwingshackl L, Hoffmann G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis. 2014;24(9):929–39.Google Scholar
  61. 61.
    Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754–832.Google Scholar
  62. 62.
    Traylor M, Farrall M, Holliday EG, et al. Genetic risk factors for ischaemic stroke and its subtypes (the METASTROKE collaboration): a meta-analysis of genome-wide association studies. Lancet Neurol. 2012;11(11):951–62.Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Guo-Chong Chen
    • 1
    • 2
    • 3
    Email author
  • Nithya Neelakantan
    • 1
  • Nerea Martín-Calvo
    • 4
    • 5
    • 6
  • Woon-Puay Koh
    • 7
  • Jian-Min Yuan
    • 8
    • 9
  • Marialaura Bonaccio
    • 10
  • Licia Iacoviello
    • 10
    • 11
  • Miguel A. Martínez-González
    • 4
    • 5
    • 6
    • 12
  • Li-Qiang Qin
    • 2
  • Rob M. van Dam
    • 1
    • 12
    • 13
    Email author
  1. 1.Saw Swee Hock School of Public HealthNational University of Singapore and National University Health SystemSingaporeSingapore
  2. 2.Department of Nutrition and Food Hygiene, School of Public HealthSoochow UniversitySuzhouChina
  3. 3.Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxUSA
  4. 4.Department of Preventive Medicine and Public HealthUniversity of NavarraPamplonaSpain
  5. 5.IdiSNA, Navarra Institute for Health ResearchPamplonaSpain
  6. 6.CIBER Physiopathology of Obesity and Nutrition (CIBERobn)Carlos III Institute of HealthMadridSpain
  7. 7.Health Services and Systems ResearchDuke-NUS Medical SchoolSingaporeSingapore
  8. 8.Division of Cancer Control and Population Sciences, UPMC Hillman Cancer CenterUniversity of PittsburghPittsburghUSA
  9. 9.Department of Epidemiology, Graduate School of Public HealthUniversity of PittsburghPittsburghUSA
  10. 10.Department of Epidemiology and PreventionIRCCS NEUROMEDPozzilliItaly
  11. 11.Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
  12. 12.Department of NutritionHarvard T.H. Chan School of Public HealthBostonUSA
  13. 13.Department of Medicine, Yong Loo Lin School of MedicineNational University of Singapore and National University Health SystemSingaporeSingapore

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