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The mountainous Cretan dietary patterns and their relationship with cardiovascular risk factors: the Hellenic Isolated Cohorts MANOLIS study

  • Aliki-Eleni Farmaki (a1), Nigel William Rayner (a2) (a3) (a4), Angela Matchan (a2), Panagiota Spiliopoulou (a1), Arthur Gilly (a2), Vasiliki Kariakli (a1), Chrysoula Kiagiadaki (a5), Emmanouil Tsafantakis (a5), Eleftheria Zeggini (a2) and George Dedoussis (a1)...



We carried out de novo recruitment of a population-based cohort (MANOLIS study) and describe the specific population, which displays interesting characteristics in terms of diet and health in old age, through deep phenotyping.


Cross-sectional study where anthropometric, biochemical and clinical measurements were taken in addition to interview-based completion of an extensive questionnaire on health and lifestyle parameters. Dietary patterns were derived through principal component analysis based on a validated FFQ.


Geographically isolated Mylopotamos villages on Mount Idi, Crete, Greece.


Adults (n 1553).


Mean age of the participants was 61·6 years and 55·8 % were women. Of the population, 82·7 % were overweight or obese with a significantly different prevalence between overweight men and women (43·4 v. 34·7 %, P=0·002). The majority (70·6 %) of participants were married, while a larger proportion of women were widowed than men (27·8 v. 3·5 %, P<0·001). Smoking was more prevalent in men (38·7 v. 8·2 %, P<0·001), as 88·8% of women had never smoked. Four dietary patterns emerged as characteristic of the population; these were termed ‘local’, ‘high fat and sugar, ‘Greek café/tavern’ and ‘olive oil, fruits and vegetables’. Individuals more adherent to the local dietary pattern presented higher blood glucose (β=4·026, P<0·001). Similarly, individuals with higher compliance with the Greek café/tavern pattern had higher waist-to-hip ratio (β=0·012, P<0·001), blood pressure (β=1·015, P=0·005) and cholesterol (β=5·398, P<0·001).


Profiling of the MANOLIS elderly population identifies unique unhealthy dietary patterns that are associated with cardiometabolic indices.

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1. World Health Organization (2015) Cardiovascular Diseases (CVDs). Fact Sheet no. 317. Geneva: WHO.
2. Zimmet, P, Alberti, KG & Shaw, J (2001) Global and societal implications of the diabetes epidemic. Nature 414, 782787.
3. Palacios, C, Perez, CM, Guzman, M et al. (2011) Association between adiposity indices and cardiometabolic risk factors among adults living in Puerto Rico. Public Health Nutr 14, 17141723.
4. Ashwell, M, Gunn, P & Gibson, S (2012) Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis. Obes Rev 13, 275286.
5. Kahn, R, Buse, J, Ferrannini, E et al. (2005) The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 28, 22892304.
6. Grundy, SM (2007) Metabolic syndrome: a multiplex cardiovascular risk factor. J Clin Endocrinol Metab 92, 399404.
7. Yamaoka, K & Tango, T (2012) Effects of lifestyle modification on metabolic syndrome: a systematic review and meta-analysis. BMC Med 10, 138.
8. Visscher, PM, Brown, MA, McCarthy, MI et al. (2012) Five years of GWAS discovery. Am J Hum Genet 90, 724.
9. Speliotes, EK, Willer, CJ, Berndt, SI et al. (2010) Association analyses of 249,796 individuals reveal 18 new loci associated with body mass index. Nat Genet 42, 937948.
10. National Research Council, National Committee on Diet and Health (1989) Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academies Press.
11. Keys, A, Menotti, A, Karvonen, MJ et al. (1986) The diet and 15-year death rate in the seven countries study. Am J Epidemiol 124, 903915.
12. Friedewald, WT, Levy, RI & Fredrickson, DS (1972) Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 18, 499502.
13. Yannakoulia, M, Melistas, L, Solomou, E et al. (2007) Association of eating frequency with body fatness in pre- and postmenopausal women. Obesity (Silver Spring) 15, 100106.
14. Ainsworth, BE, Haskell, WL, Herrmann, SD et al. (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43, 15751581.
15. Bountziouka, V, Bathrellou, E, Giotopoulou, A et al. (2012) Development, repeatability and validity regarding energy and macronutrient intake of a semi-quantitative food frequency questionnaire: methodological considerations. Nutr Metab Cardiovasc Dis 22, 659667.
16. Ministry of Health and Welfare, Supreme Scientific Health Council (1999) Dietary guidelines for adults in Greece. Arch Hellenic Med 16, 516524.
17. Goldberg, GR, Black, AE, Jebb, SA et al. (1991) Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur J Clin Nutr 45, 569581.
18. World Health Organization (1985) Energy and Protein Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. WHO Technical Report Series no. 724. Geneva: WHO.
19. Mardia, KV, Kent, JT & Bibby, JM (1979) Multivariate Analysis. New York: Academic Press.
20. Hu, FB (2002) Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 13, 39.
21. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol In Adults (2001) Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 285, 24862497.
22. Panoutsopoulou, K, Hatzikotoulas, K, Xifara, DK et al. (2014) Genetic characterization of Greek population isolates reveals strong genetic drift at missense and trait-associated variants. Nat Commun 5, 5345.
23. Tyrovolas, S, Zeimbekis, A, Bountziouka, V et al. (2009) Factors associated with the prevalence of diabetes mellitus among elderly men and women living in Mediterranean Islands: the MEDIS Study. Rev Diabet Stud 6, 5463.
24. Kanoni, S & Dedoussis, GV (2008) Design and descriptive characteristics of the GHRAS: the Greek Health Randomized Aging Study. Med Sci Monit 14, CR204CR212.
25. Dedoussis, GV, Kanoni, S, Mariani, E et al. (2008) Mediterranean diet and plasma concentration of inflammatory markers in old and very old subjects in the ZINCAGE population study. Clin Chem Lab Med 46, 990996.
26. Kafatos, A, Diacatou, A, Labadarios, D et al. (1993) Nutrition status of the elderly in Anogia, Crete, Greece. J Am Coll Nutr 12, 685692.
27. Missoni, S (2009) Metabolic syndrome among the inhabitants of the island of Vis. Coll Antropol 33, 12811287.
28. Athyros, VG, Bouloukos, VI, Pehlivanidis, AN et al. (2005) The prevalence of the metabolic syndrome in Greece: the MetS-Greece Multicentre Study. Diabetes Obes Metab 7, 397405.
29. Panagiotakos, D, Pitsavos, C, Chrysohoou, C et al. (2009) Dietary patterns and 5-year incidence of cardiovascular disease: a multivariate analysis of the ATTICA study. Nutr Metab Cardiovasc Dis 19, 253263.
30. Panagiotakos, DB, Zeimbekis, A, Boutziouka, V et al. (2007) Long-term fish intake is associated with better lipid profile, arterial blood pressure, and blood glucose levels in elderly people from Mediterranean islands (MEDIS epidemiological study). Med Sci Monit 13, CR307CR312.
31. Moschandreas, J, Kafatos, A, Aravanis, C et al. (2005) Long-term predictors of survival for the Seven Countries Study cohort from Crete: from 1960 to 2000. Int J Cardiol 100, 8591.
32. Manios, Y, Antonopoulou, S, Kaliora, AC et al. (2005) Dietary intake and biochemical risk factors for cardiovascular disease in two rural regions of Crete. J Physiol Pharmacol 56, Suppl. 1, 171181.
33. Aravanis, C, Mensink, RP, Corcondilas, A et al. (1988) Risk factors for coronary heart disease in middle-aged men in Crete in 1982. Int J Epidemiol 17, 779783.
34. Kafatos, A, Schlienger, JL, Deslypere, JP et al. (1991) Nutritional status: serum lipids. Euronut SENECA investigators. Eur J Clin Nutr 45, Suppl. 3, 5361.
35. Sandker, GW, Kromhout, D, Aravanis, C et al. (1993) Serum cholesteryl ester fatty acids and their relation with serum lipids in elderly men in Crete and The Netherlands. Eur J Clin Nutr 47, 201208.
36. Sofi, F, Abbate, R, Gensini, GF et al. (2010) Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 92, 11891196.
37. Trichopoulou, A, Costacou, T, Bamia, C et al. (2003) Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 348, 25992608.
38. Knoops, KT, de Groot, LC, Kromhout, D et al. (2004) Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 292, 14331439.
39. Trichopoulos, D & Lagiou, P (2001) Dietary patterns and mortality. Br J Nutr 85, 133134.
40. McCrory, MA, Howarth, NC, Roberts, SB et al. (2011) Eating frequency and energy regulation in free-living adults consuming self-selected diets. J Nutr 141, 148153.
41. Fung, TT, Rimm, EB, Spiegelman, D et al. (2001) Association between dietary patterns and plasma biomarkers of obesity and cardiovascular disease risk. Am J Clin Nutr 73, 6167.
42. Su, Q, Rowley, KG, Itsiopoulos, C et al. (2002) Identification and quantitation of major carotenoids in selected components of the Mediterranean diet: green leafy vegetables, figs and olive oil. Eur J Clin Nutr 56, 11491154.
43. Psaltopoulou, T, Naska, A, Orfanos, P et al. (2004) Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study. Am J Clin Nutr 80, 10121018.
44. Papamichael, CM, Karatzi, KN, Papaioannou, TG et al. (2008) Acute combined effects of olive oil and wine on pressure wave reflections: another beneficial influence of the Mediterranean diet antioxidants? J Hypertens 26, 223229.
45. Alonso, A, Ruiz-Gutierrez, V & Martinez-Gonzalez, MA (2006) Monounsaturated fatty acids, olive oil and blood pressure: epidemiological, clinical and experimental evidence. Public Health Nutr 9, 251257.
46. Ferrara, LA, Raimondi, AS, d’Episcopo, L et al. (2000) Olive oil and reduced need for antihypertensive medications. Arch Intern Med 160, 837842.
47. Gutierrez-Repiso, C, Soriguer, F, Rojo-Martinez, G et al. (2014) Variable patterns of obesity and cardiometabolic phenotypes and their association with lifestyle factors in the study. Nutr Metab Cardiovasc Dis 24, 947955.
48. Serra-Majem, L, Ribas, L, Tresserras, R et al. (1995) How could changes in diet explain changes in coronary heart disease mortality in Spain? The Spanish paradox. Am J Clin Nutr 61, 6 Suppl., 1351S1359S.
49. Walker, P, Rhubart-Berg, P, McKenzie, S et al. (2005) Public health implications of meat production and consumption. Public Health Nutr 8, 348356.
50. Katan, MB (1998) Effect of low-fat diets on plasma high-density lipoprotein concentrations. Am J Clin Nutr 67, 3 Suppl., 573S576S.
51. Michas, G, Micha, R & Zampelas, A (2014) Dietary fats and cardiovascular disease: putting together the pieces of a complicated puzzle. Atherosclerosis 234, 320328.
52. Mozaffarian, D, Katan, MB, Ascherio, A et al. (2006) Trans fatty acids and cardiovascular disease. N Engl J Med 354, 16011613.
53. Tachmazidou, I, Dedoussis, G, Southam, L et al. (2013) A rare functional cardioprotective APOC3 variant has risen in frequency in distinct population isolates. Nat Commun 4, 2872.


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