Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Communication
  • Published:

Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI-Prevenzione trial

European Journal of Clinical Nutrition volume 57, pages 604–611 (2003)Cite this article

A Corrigendum to this article was published on 24 July 2003

Abstract

Objective: To ascertain whether simple dietary advice to increase the consumption of Mediterranean foods, given in a clinical setting, leads to reduced mortality after a myocardial infarction.

Design: Data were used from the GISSI-Prevenzione clinical trial, analysed as a cohort study with adjustment for treatment allocation.

Setting: A total of 172 centres in Italy.

Subjects: A total of 11 323 men and women with myocardial infarction. All subjects received advice to increase their consumption of fish, fruit, raw and cooked vegetables and olive oil.

Measurements: The intakes of the five foods were assessed at baseline, 6, 18 and 42 months. Associations of food intakes, a combined dietary score, and the risk of death over 6.5 y were estimated adjusting for several non-dietary variables, using pooled logistic regression.

Results: Subjects generally improved their diet according to the advice given. All foods were associated with a significant reduction in risk of death. Compared with people in the worst dietary score quarter, the odds ratio for those in the best score quarter was 0.51 (95% CI 0.44–0.59). A good diet had a protective effect in sub-groups defined by age, sex, smoking, randomized treatment and concomitant drug therapy.

Conclusions: Myocardial infarction patients can respond positively to simple dietary advice, and this can be expected to lead to a substantial reduction in the risk of early death. Regardless of any drug treatment prescribed, clinicians should routinely advise patients with myocardial infarction to increase their frequency of consumption of Mediterranean foods.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2
Figure 3

Similar content being viewed by others

References

  • Allison, PD (1995). Survival analysis using the SAS System, a practical guide, Cary, NC: SAS Institute Inc

    Google Scholar 

  • Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group (1994). The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. New Engl. J. Med., 330, 1029–1035.

  • Artaud-Wild, SM, Connor, SL, Sexton, G & Connor, WE (1993). Differences in coronary mortality can be explained by differences in cholesterol and saturated fat intakes in 40 countries but not in France and Finland: a paradox. Circulation, 88, 771–779.

    Article  Google Scholar 

  • Brown, BG, Zhao, X-Q & Chait, A et al (2001). Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. New Engl. J. Med., 345, 1583–1592.

    Article  CAS  Google Scholar 

  • Burr, ML, Fehily, AM & Gilbert, JF et al (1989). Effect of changes in fat, fish, and fiber intakes on death and myocardial reinfarction: Diet and Reinfarction Trial (DART). Lancet, 2, 757–731.

    Article  CAS  Google Scholar 

  • Collaborative Group of the Primary Prevention Project (2001). Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomized trial in general practice. Lancet, 357, 89–95.

  • Cupples, LA, D'Agostino, RB, Anderson, K & Kannel, WB (1988). Comparison of baseline and repeated measure covariate techniques in the Framingham Heart Study. Stats. Med., 7, 205–218.

    Article  CAS  Google Scholar 

  • Dagenais, GR, Marchioli, R, Yusuf, S & Tognoni, G (2000). Beta-carotene, vitamin C, and vitamin E and cardiovascular diseases. Curr. Cardiol. Rep., 2, 293–299.

    Article  CAS  Google Scholar 

  • de Lorgeril, M, Salen, P, Martin, J-L, Monjaud, I, Delaye, J & Mamelle, N (1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation, 99, (6) 779–785.

    Article  CAS  Google Scholar 

  • Fernandez-Jarne, E, Martinez-Losa, E, Prado-Santamaria, M, Brugarolas-Brufau, C, Serrano-Martinez, M & Martinez-Gonzales, MA (2002). Risk of first non-fatal myocardial infarction negatively associated with olive oil consumption: a case–control study in Spain. Int. J. Epidemiol., 31, 474–480.

    Article  CAS  Google Scholar 

  • GISSI-Prevenzione Investigators (1999). Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet, 354, 447–455.

  • Hennekens, CH, Buring, JE & Manson, JE et al (1996). Lack of effect of long-term supplementation with beta-carotene on the incidence of malignant neoplasms and cardiovascular disease. New Engl. J. Med., 334, 1145–1149.

    Article  CAS  Google Scholar 

  • Hooper, L, Summerbell, CD, Higgins, JPT, Thompson, RL, Capps, NE, Smith, GD, Riemersma, RA & Ebrahim, S (2001). Dietary fat intake and prevention of cardiovascular disease: systematic review. Br. Med. J., 31, 757–763.

    Article  Google Scholar 

  • HOPE (Heart Outcomes Prevention Evaluation) Study Investigators (2000). Vitamin E supplementation and cardiovascular events in high-risk patients. N. Engl. J. Med., 342, 154–160.

  • Hu, FB, Stampfer, MJ, Manson, JE, Rimm, E, Colditz, GA, Rosner, BA, Hennekens, CH & Willett, WC (1997). Dietary fat intake and the risk of coronary heart disease in women. New Engl. J. Med., 337, 1491–1499.

    Article  CAS  Google Scholar 

  • Hu, FB, Stampfer, MJ, Rimm, E, Ascherio, A, Rosner, BA, Spielgeman, D & Willet, WC (1999). Dietary fat and coronary heart disease: a comparison of approaches for adjusting for total energy intake and modelling repeated dietary measurements. Am. Journal Epidemiol., 149, 531–540.

    Article  CAS  Google Scholar 

  • Joshipura, KJ, Hu, FB, Manson, JE, Stampfer, MJ, Rimm, EB, Speizer, FE, Colditz, G, Ascherio, A, Rosner, B, Spielgman, D & Willet, WC (2001). The effect of fruit and vegetables intake on risk for coronary heart disease. Ann. Intern. Med., 134, 1106–1114.

    Article  CAS  Google Scholar 

  • Keys, A (1970). Coronary heart disease in seven countries. Circulation, 41, (Suppl I) I-1–I-211.

    Google Scholar 

  • Khaw, KT & Barrett-Connor, E (1987a). Dietary fibre and reduced ischaemic heart disease mortality rates in men and women: a 12 year prospective study. Am. J. Epidemiol., 126, 1093–1102.

    Article  CAS  Google Scholar 

  • Khaw, KT & Barrett-Connor, E (1987b). Dietary potassium and stroke-associated mortality: a 12-year prospective population study. New Engl. J. Med., 316, 235–240.

    Article  CAS  Google Scholar 

  • Knekt, P, Reunanen, A, Jarvinen, R, Seppanen, R, Hellovaara, M & Arommaa, A (1994). Antioxidant vitamin intake and coronary mortality in a longitudinal study. Am. J. Epidemiol., 139, 180–189.

    Article  Google Scholar 

  • Knekt, P, Jarviven, R, Reunanen, A & Maatela, J (1996). Flavonoid intake and coronary mortality in Finland: a cohort study. Br. Med. J., 312, 478–481.

    Article  CAS  Google Scholar 

  • Krauss, RM, Eckel, RH & Howard, B et al (2000). AHA Dietary Guidelines Revision 2000. A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart Association. Circulation, 102, 2296–2311.

    Article  Google Scholar 

  • Marchioli, R (1999). Antioxidant vitamins and prevention of cardiovascular disease: Laboratory, epidemiological and clinical trial data. Pharmac. Res., 40, 227–238.

    CAS  Google Scholar 

  • Marchioli, R (2001). Vitamin E and cardiovascular disease. Thromb. Haemost., 85, 758–760.

    Article  CAS  Google Scholar 

  • Marchioli, R, Avanzini, F, Barzi, F, Chieffo, C, Di Castelnuovo, A, Franzosi, MG, Geraci, E, Maggioni, AP, Marfisi, RM, Mininni, N, Nicolosi, GL, Santini, M, Schweiger, C, Gavazzi, L, Tognoni, G & Valagussa, F on behalf of GISSI-Prevenzione Investigators (2001). An Italian Coronary Risk Chart for patients with recent myocardial infarction: Results of the GISSI-Prevenzione Study. Eur. Heart J., 22, 2085–2103.

    Article  CAS  Google Scholar 

  • MRC/BHF Heart Protection Study Collaborative Group (1999). MRC/BHF Heart Protection Study of cholesterol-lowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease death: early safety and efficacy experience. Eur. Heart J., 20, 725–741.

  • Ness, AR & Powles, JW (1997). Fruit and vegetables, and cardiovascular disease: a review. Int. J. Epidemiol., 26, 1–13.

    Article  CAS  Google Scholar 

  • Omenn, GS (1995). What accounts for the association of vegetables and fruit with lower incidence of cancers and coronary heart disease?. Ann Epidemiol., 5, 333–335.

    Article  CAS  Google Scholar 

  • Omenn, GS, Goodman, GE & Thornquist, MD et al (1996). Effects of beta-carotene and vitamin A on lung cancer and cardiovascular disease. New Engl. J. Med., 334, 1150–1155.

    Article  CAS  Google Scholar 

  • Pietinen, P, Ascherio, A, Korhonen, P, Hartman, AM, Willett, WC, Albanes, D & Virtamo, J (1997). Intake of fatty acids and risk of coronary heart disease in a cohort of Finnish men: the Alpha-Tocopherol, Beta-Carotene Cancer Preventive Study. Am. J. Epidemiol, 145, 1876–1887.

    Article  Google Scholar 

  • Rimm, EB, Stampfer, MJ, Ascherio, A, Giovannucci, E, Colditz, GA & Willett, WC (1993). Vitamin E consumption and the risk of coronary heart disease in men. New Engl. J. Med., 328, 1450–1456.

    Article  CAS  Google Scholar 

  • Rimm, EB, Ascherio, A, Giovannucci, E, Spiegelman, D, Stampfer, MJ & Willett, WC (1996). Vegetable, fruit and cereal fiber intake and risk of coronary heart disease among men. JAMA, 275, 447–451.

    Article  CAS  Google Scholar 

  • Sans, S, Kesteloot, H & Kromhout, D on behalf of the Task Force of the European Society of Cardiology on Cardiovascular Mortality and Morbidity Statistics in Europe (1997). The burden of cardiovascular diseases mortality in Europe. Eur. Heart. J., 18, 1231–1248.

    Article  Google Scholar 

  • Serra-Majem, L, Ribas, L, Lloveras, G & Salleras, L (1993). Changing patterns of fat consumption in Spain. Eur. J. Clin. Nutr., 47, (Suppl, 1) S13–S20.

    PubMed  Google Scholar 

  • Stampfer, MJ, Hennekens, CH, Manson, JE, Colditz, GA, Rosner, B & Willett, WC (1993). Vitamin E consumption and the risk of coronary disease in women. New Engl. J. Med., 328, 1444–1449.

    Article  CAS  Google Scholar 

  • Stampfer, MJ, Hu, FB, Manson, JE, Rimm, EB & Willet, WC (2000). Primary prevention of coronary heart disease in women through diet and lifestyle. New Engl. J. Med., 343, 16–22.

    Article  CAS  Google Scholar 

  • Todd, S, Woodward, M, Tunstall-Pedoe, H & Bolton-Smith, C (1999). Dietary antioxidant vitamins and fiber in the etiology of cardiovascular disease and all-causes mortality: results from the Scottish Health Study. Am. J. Epidemiol, 150, 1073–1080.

    Article  CAS  Google Scholar 

  • Woodward, M (1999). Epidemiology: Study Design and Data Analysis, Boca Raton, FL: Chapman and Hall/CRC

    Google Scholar 

Download references

Acknowledgements

GISSI is endorsed by Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Firenze, Italy and by Istituto di Ricerche Farmacologiche Mario Negri, Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy. GISSI-Prevenzione was supported by Bristol-Myers Squibb, Pharmacia-Upjohn, Societá Prodotti Antibiotici, Pfizer and Bracco. We thank C Pera, B Ferri, A Flamminio, A Polidoro and R Zama for invaluable secretarial help during the course of the study. Federica Barzi was the recipient of a research fellowship from Instituto di Ricerche Farmacologiche M. Negri, Milano, Italy.

Author information

Author notes

  1. F Barzi, M Woodward, R M Marfisi, L Tavazzi, F Valagussa and R Marchioli: The names of GISSI-Prevenzione Investigators are given in GISSI-Prevenzione Investigators, Lancet, 1999.

Authors and Affiliations

  1. Department of Clinical Pharmacology and Epidemiology, Laboratory of Clinical Epidemology of Cardiovascular Disease, Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy

    F Barzi, R M Marfisi & R Marchioli

  2. Institute for International Health, University of Sydney, Sydney, Australia

    F Barzi & M Woodward

  3. Policlinico San Matteo, Pavia, Italy

    L Tavazzi

  4. Ospedale San Gerardo Nuovo, Monza, Italy

    F Valagussa

Authors
  1. F Barzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M Woodward
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R M Marfisi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. L Tavazzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. F Valagussa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. R Marchioli
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of GISSI-Prevenzione Investigators

Contributions

Guarantor: F Barzi.

Contributors: BF was responsible for the data analysis and statistical expertise. MW was responsible for statistical expertise and supervision. RMM contributed to data analysis and statistical expertise. LT contributed to conception and design, to obtain funding and supervision. GT was responsible for conception and design and supervision. FV contributed to conception and design and was responsible for obtaining funding. RM was responsible for conception and design, acquisition of data and supervision. All the authors contributed to manuscript editing.

Corresponding author

Correspondence to F Barzi.

Appendix

Appendix

Let the food frequency recorded at the ith visit (i=1, 2, 3, 4) be Di. Let the time between the ith and the i+1th visit be Ti (i=1,2,3) and let T4 be the time from the last visit to the end of follow-up (death or censoring). The food consumption Cj (j=1,2,3,4) for the jth time interval was calculated as: Cj=j=1, 2, 3, 4.

When Di was missing it was estimated by the most recent non-missing value of D (i.e. last information carried forward).

Rights and permissions

Reprints and permissions

About this article

Cite this article

Barzi, F., Woodward, M., Marfisi, R. et al. Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI-Prevenzione trial. Eur J Clin Nutr 57, 604–611 (2003). https://doi.org/10.1038/sj.ejcn.1601575

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/sj.ejcn.1601575

Keywords

This article is cited by

Search

Advanced search

Quick links