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Nutrition in acute and chronic diseases

A Mediterranean diet microsimulation modeling in relation to cardiovascular disease burden: the ATTICA and GREECS epidemiological studies

European Journal of Clinical Nutrition volume 76, pages 434–441 (2022)Cite this article

Subjects

Abstract

Background/objectives

To quantify the changes in 10-year cardiovascular disease (CVD) onset, recurrence, and mortality, in relation to transitioning from low to a higher level of adherence to the Mediterranean diet.

Subjects/methods

An individual-level microsimulation was created based on ATTICA (2002–2012, n = 3042 subjects free-of-CVD) and GREECS (2004–2014, n = 2172 patients with acute coronary syndrome (ACS)) studies (in total n = 5214). Eight scenarios regarding the proportion of participants and the size of improvement of the level of adherence to the Mediterranean diet (corresponding to one to ten point increases in MedDietScore) were compared in terms of relative change in CVD incidence and mortality, as well as, the number of preventable CVD events and deaths.

Results

Improving adherence to the Mediterranean diet in at least 10% of the population, a significant relative percentage reduction could be observed in 10-year CVD onset, recurrence, and mortality. At least 851 first CVD events, 374 recurrent CVD events, and 205 CVD deaths per 100,000 of the population could be averted or delayed. In addition, Mediterranean diet clustering revealed that scoring higher in fruits, vegetables, whole wheat products, and legumes was more important than achieving higher scores in low consumption of meat and full-fat dairy products against CVD (all HRs in the former cluster were lower than the latter, indicating a stronger protective effect).

Conclusions

This microsimulation process confirms the added value of the Mediterranean diet in primary and secondary CVD prevention having great achievements even with modifications in a small part of the population (10%), while challenges the orientation of Mediterranean-diet interventions giving higher weights to plant-based part.

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Fig. 1: Ten-year incidence of first fatal/non-fatal CVD event among apparently healthy men and women from the ATTICA epidemiological study and its relative percentage change after each simulation scenario.
Fig. 2: Ten-year incidence of CVD event and mortality among men and women patients with acute coronary syndrome from the GREECS epidemiological study and its relative percentage change after each simulation scenario.
Fig. 3: Different clusters of Mediterranean diet according to the score in plant- or animal-based food items and their effect on the 10-year risk of first fatal/non-fatal CVD event in apparently healthy men and women as well as on the 10-year risk of recurrent fatal/non-fatal CVD event and CVD mortality in men and women with the established acute coronary syndrome.

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Acknowledgements

The authors would like to thank the ATTICA and GREECS study group, investigators.

Funding

This work was supported by a research grant from the Hellenic Atherosclerosis Society received by Matina Kouvari. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Author information

Authors and Affiliations

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

    Matina Kouvari, Thomas Tsiampalis, Ekavi Georgousopoulou, Venetia Notara, Mary Yannakoulia & Demosthenes B. Panagiotakos

  2. Faculty of Health, University of Canberra, Canberra, Australia

    Matina Kouvari & Demosthenes B. Panagiotakos

  3. First Cardiology Clinic, School of Medicine, University of Athens, Athens, Greece

    Christina Chrysohoou & Christos Pitsavos

  4. School of Medicine, The University of Notre Dame, Sydney, Australia

    Ekavi Georgousopoulou

  5. Medical School, Australian National University, Canberra, Australia

    Ekavi Georgousopoulou

  6. Department of Public and Community Health, School of Public Health, University of West Attica, Athens, Greece

    Venetia Notara

  7. Faculty of Social Sciences, University of Peloponnese, Korinthos, Greece

    Kyriakos Souliotis

  8. Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, University of Athens, Athens, Greece

    Theodora Psaltopoulou

Authors
  1. Matina Kouvari
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Contributions

MK wrote the manuscript and was responsible for the interpretation of the result. TT implemented the statistical analysis. DBP and CP were responsible for the study design and implementation while they critically reviewed the manuscript. EG was involved in the 10-year follow-up of the study and critically reviewed the manuscript. KS, MY, TP, and CC critically reviewed the manuscript.

Corresponding author

Correspondence to Demosthenes B. Panagiotakos.

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Kouvari, M., Tsiampalis, T., Chrysohoou, C. et al. A Mediterranean diet microsimulation modeling in relation to cardiovascular disease burden: the ATTICA and GREECS epidemiological studies. Eur J Clin Nutr 76, 434–441 (2022). https://doi.org/10.1038/s41430-021-00967-6

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