Mediterranean lifestyle and risk of recurrent cardiovascular events: a prospective study from the UK biobank

Abstract

The Mediterranean Lifestyle Index (MEDLIFE) evaluates adherence to traditional Mediterranean living, encompassing diet, physical activity, rest and conviviality. Although it has been linked to reduced risk of cardiovascular disease (CVD), diabetes, and other chronic diseases, evidence supporting its role in secondary CVD prevention outside the Mediterranean region remains limited. To evaluate the association between the MEDLIFE score and risk of major cardiovascular events (MACE) and death from CVD and all causes in British adults with previous MACE. This analysis included 5,851 individuals aged 40–70 years from the UK Biobank, with history of MACE at baseline (2009–2012), who were followed-up until 2024. The MEDLIFE score was computed based on adherence to 25 item recommendations that included three main blocks: (1) “Mediterranean food consumption”, (2) “Mediterranean dietary habits”, (3) “Physical activity, rest, social habits, and conviviality”. Incident MACE was ascertained through hospital admissions data, while mortality data was obtained from the national death index. Cox proportional-hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for key confounders. During a median follow-up of 10.2–12.1 years, 2,401 recurrent MACE were identified. Compared to participants in the lowest quartile of adherence to MEDLIFE, the HR (95% CI) for MACE was 0.91 (0.82, 1.01) for the second quartile, 0.83 (0.75, 0.93) for the third quartile, and 0.75 (0.65, 0.86) for the fourth quartile ( p -trend < 0.001). This association (Q4 vs. Q1: HR, 95% CI) was even more pronounced for mortality from CVD (0.50, 0.35–0.71) and all-causes (0.69, 0.57–0.83). Each MEDLIFE block contributed significantly to the observed associations. Sensitivity analyses confirmed the robustness of these results. In this cohort of British adults with previous MACE, higher adherence to a modified MEDLIFE was associated with lower risk of recurrent MACE and CVD and all-cause mortality. These findings support the potential value of interventions promoting Mediterranean-like healthy lifestyle behaviors as part of comprehensive secondary cardiovascular prevention strategies.