European Journal of Nutrition

, Volume 58, Issue 4, pp 1569–1578 | Cite as

Multiple approaches to associations of physical activity and adherence to the Mediterranean diet with all-cause mortality in older adults: the PREvención con DIeta MEDiterránea study

  • Gabriela Cárdenas-Fuentes
  • Isaac Subirana
  • Miguel A. Martinez-Gonzalez
  • Jordi Salas-Salvadó
  • Dolores Corella
  • Ramon Estruch
  • Montserrat Fíto
  • Carlos Muñoz-Bravo
  • Miguel Fiol
  • José Lapetra
  • Fernando Aros
  • Luis Serra-Majem
  • Josep A. Tur
  • Xavier Pinto
  • Emilio Ros
  • Oscar Coltell
  • Andres Díaz-López
  • Miguel Ruiz-Canela
  • Helmut SchröderEmail author
Original Contribution



Although evidence indicates that both physical activity and adherence to the Mediterranean diet (MedDiet) reduce the risk of all-cause mortality, a little is known about optimal intensities of physical activity and their combined effect with MedDiet in older adults. We assessed the separate and combined associations of leisure-time physical activity (LTPA) and MedDiet adherence with all-cause mortality.


We prospectively studied 7356 older adults (67 ± 6.2 years) at high vascular risk from the PREvención con DIeta MEDiterránea study. At baseline and yearly thereafter, adherence to the MedDiet and LTPA were measured using validated questionnaires.


After 6.8 years of follow-up, we documented 498 deaths. Adherence to the MedDiet and total, light, and moderate-to-vigorous LTPA were inversely associated with all-cause mortality (p < 0.01 for all) in multiple adjusted Cox regression models. The adjusted hazard of all-cause mortality was 73% lower (hazard ratio 0.27, 95% confidence interval 0.19–0.38, p < 0.001) for the combined category of highest adherence to the MedDiet (3rd tertile) and highest total LTPA (3rd tertile) compared to lowest adherence to the MedDiet (1st tertile) and lowest total LTPA (1st tertile). Reductions in mortality risk did not meaningfully differ between total, light intensity, and moderate-to-vigorous LTPA.


We found that higher levels of LTPA, regardless of intensity (total, light and moderate-to-vigorous), and greater adherence to the MedDiet were associated separately and jointly with lower all-cause mortality. The finding that light LTPA was inversely associated with mortality is relevant because this level of intensity is a feasible option for older adults.


Exercise Physical activity Mediterranean diet Mortality Aged Older adults 



CIBERESP and CIBEROBN are initiatives of the Instituto de Salud Carlos III (ISCIII) of Spain, which are supported by FEDER funds (CB06/03). Also supported by ISCIII, the official funding agency for biomedical research of the Spanish government, through grants provided to research networks specifically developed for the trial (RTIC G03/140 and RD 06/0045) through CIBEROBN, and by grants from Centro Nacional de Investigaciones Cardiovasculares (CNIC 06/2007), Fondo de Investigación Sanitaria-Fondo Europeo de Desarrollo Regional (PI04-2239, PI05/2584, CP06/00100, PI07/0240, PI07/1138, PI07/0954, PI 07/0473, PI10/01407, PI10/02658, PI11/01647, and PI11/02505; PI13/00462), Ministerio de Ciencia e Innovación (AGL-2009-13906-C02 and AGL2010-22319-C03), Fundación Mapfre 2010, Consejería de Salud de la Junta de Andalucía (PI0105/2007), Public Health Division of the Department of Health of the Autonomous Government of Catalonia, Generalitat Valenciana (ACOMP06109, GVA-COMP2010-181, GVACOMP2011-151, CS2010-AP-111, and CS2011-AP-042), and the Navarra Regional Government (27/2011). MF was supported by a joint contract of the ISCIII and Health Department of the Catalan Government (Generalitat de Catalunya) (CP 06/00100). The Fundación Patrimonio Comunal Olivarero and Hojiblanca SA (Málaga, Spain), California Walnut Commission (Sacramento, CA), Borges SA (Reus, Spain), and Morella Nuts SA (Reus, Spain) donated the olive oil, walnuts, almonds, and hazelnuts, respectively, used in the study. We appreciate the English revision by Elaine M. Lilly, Ph.D.

Author contributions

GMC and HS conceived the project; MAM, JS-S, DC, RE, MF, EGG, MF, JL, FA, LS-M, JAT, XP, ER, OC, AD-L, and MR-C conducted the research; CMG, IS, and HS analysed the data; CMG wrote the manuscript: CMG and HS had primary responsibility for the final content of the manuscript; all authors read and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests related to the study.

Ethics and consent

The Institutional Review Board of all participating centres approved the study protocol and the trial was conducted following the guidelines of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.

Supplementary material

394_2018_1689_MOESM1_ESM.docx (38 kb)
Supplementary material 1 (DOCX 37 KB)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Gabriela Cárdenas-Fuentes
    • 1
    • 2
  • Isaac Subirana
    • 1
    • 3
  • Miguel A. Martinez-Gonzalez
    • 4
    • 5
    • 6
  • Jordi Salas-Salvadó
    • 5
    • 7
  • Dolores Corella
    • 5
    • 8
  • Ramon Estruch
    • 5
    • 9
  • Montserrat Fíto
    • 1
    • 5
  • Carlos Muñoz-Bravo
    • 10
  • Miguel Fiol
    • 5
    • 11
  • José Lapetra
    • 5
    • 12
  • Fernando Aros
    • 5
    • 13
  • Luis Serra-Majem
    • 5
    • 14
  • Josep A. Tur
    • 5
    • 15
  • Xavier Pinto
    • 5
    • 16
  • Emilio Ros
    • 5
    • 17
  • Oscar Coltell
    • 5
    • 18
  • Andres Díaz-López
    • 5
    • 7
  • Miguel Ruiz-Canela
    • 4
    • 5
  • Helmut Schröder
    • 1
    • 3
    Email author
  1. 1.Cardiovascular Risk and Nutrition Research Group (CARIN)Hospital del Mar Medical Research Institute (IMIM)BarcelonaSpain
  2. 2.PhD Programme in Biomedicine, Department of Experimental and Health SciencesUniversidad Pompeu FabraBarcelonaSpain
  3. 3.CIBER Epidemiologia y Salud Pública (CIBERESP)Instituto de Salud Carlos IIIMadridSpain
  4. 4.Department of Preventive Medicine and Public HealthUniversidad de NavarraPamplonaSpain
  5. 5.CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN)Instituto de Salud Carlos IIIMadridSpain
  6. 6.Department of NutritionHarvard TH Chan School of Public HealthBostonUSA
  7. 7.Human Nutrition Unit, Department of Biochemistry and Biotechnology, Pere Virgili Institute for Health ResearchUniversity Hospital of Sant Joan de Reus, Rovira i Virgili UniversityReusSpain
  8. 8.Department of Preventive Medicine and Public Health, School of MedicineUniversity of ValenciaValenciaSpain
  9. 9.Department of Internal Medicine, Hospital Clínic, IDIBAPSUniversity of BarcelonaBarcelonaSpain
  10. 10.Department of Public Health and PsychiatryUniversity of MálagaMálagaSpain
  11. 11.Institute of Health SciencesUniversity of Balearic Islands and Son Espases HospitalPalma de MallorcaSpain
  12. 12.Department of Family Medicine, Distrito Sanitario Atención Primaria SevillaResearch UnitSevilleSpain
  13. 13.Department of CardiologyUniversity Hospital ArabaVitoriaSpain
  14. 14.Department of Clinical SciencesUniversity of Las Palmas de Gran CanariaLas Palmas de Gran CanariaSpain
  15. 15.Research Group on Community Nutrition and Oxidative StressUniversitat de les Illes BalearsPalma de MallorcaSpain
  16. 16.Lipids and Vascular Risk Units, Internal MedicineUniversity Hospital of Bellvitge, Hospitalet de LlobregatBarcelonaSpain
  17. 17.Lipid Clinic, Endocrinology and Nutrition ServiceInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital ClínicBarcelonaSpain
  18. 18.Department of Computer Languages and SystemsUniversitat Jaume ICastellonSpain

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