Introduction
Methods
Search strategy
Study selection
Data extraction
Certainty of evidence assessment
Statistical analysis
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Alcohol (within the range vs. higher consumption)
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Cereals (higher vs. lower consumption)
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Dairy (lower vs. higher consumption)
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Fish (higher vs. lower consumption)
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Fruit (higher vs. lower consumption)
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Legumes (higher vs. lower consumption)
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Meat (lower vs. higher consumption)
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Nuts (higher vs. lower consumption)
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Olive oil (higher vs. lower consumption)
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Vegetables (higher vs. lower consumption)
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Whole grains (higher vs. lower consumption)
Results
Database search and study characteristics
Author (year) | Country Study name | Study design | Outcome | Population Follow-up (years) | Age at entry (years) | Sex | Components of score | Adjustment | OR/RR/HR (95% CI) Multivariable adjusted |
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Toledo et al. (2018) | Spain PREDIMED | RCT | Breast cancer | 4152 4.8 years | 60–80 | W | 1. MD supplemented with extra-virgin olive oil; 2. MD supplemented with mixed nuts; 3. control diet (advice to reduce dietary fat); | Age, BMI, waist to hip ratio, use of hormone therapy, leisure-time physical activity, total energy intake, alcohol consumption, age at menopause, baseline adherence to MD, propensity score, recruitment center, educational level | MD with olive oil RR 0.31 (0.13, 0.77) versus control diet MD with nuts RR 0.53 (0.23, 1.26) versus control diet Both MD RR 0.41 (0.19, 0.86) versus control diet |
Boden et al. (2019) | Sweden VIP | Prospective cohort | Colorectal cancer Lung cancer Pancreatic cancer Gastric cancer Prostate cancer Breast cancer | 100,881 15.0 years | 30–60 | M/W | aMDS score range: 0–8. 1.↑ vegetables and potatoes; 2.↑ fruit and fresh juices; 3.↑ fish and fish products; 4.↑ MUFA + PUFA:SFA ratio; 5.↑ whole-grain cereals; 6.↔ alcohol; 7.↓ meat and meat; 8.↓ dairy products; | Energy intake, BMI, physical activity, smoking, educational status | Colorectal cancer HR 1.02 (0.94, 1.10) Lung cancer HR 0.90 (0.80, 1.01) Pancreatic cancer HR 0.90 (0.76, 1.07) Gastric cancer HR 0.85 (0.69, 1.03) Prostate cancer HR 0.98 (0.92, 1.03) Breast cancer HR 0.98 (0.92, 1.05) Per one tertile increase |
Bogumil et al. (2019) | USA MEC | Prospective cohort | Hepatocellular cancer | 169,806 17.0 years | 45–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, sex, race/ethnicity, BMI, history of diabetes, smoking status, energy intake | Hepatocellular cancer HR 0.68 (0.51, 0.90) for fifth versus first quintile |
Bonaccio et al. (2018) | Italy MS | Prospective cohort | Cancer mortality | 5200 8.1 years | ≥ 35 | M/W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ legumes; 3.↑ fruits and nuts; 4.↑ cereals; 5.↑ fish; 6.↑ MUFA:SFA ratio; 7.↓ meat, 8.↓ dairy products; 9.↔ alcohol; | Sex, age, education, household income, leisure-time physical activity, smoking status, BMI, cancer, CVD, diabetes, hypertension, hypercholesterolemia, use of anti-depressants and energy intake | Cancer mortality HR 0.87 (0.57, 1.32) for third versus first tertile |
Dela Cruz et al. (2020) | USA MEC | Prospective cohort | Breast cancer | 101,291 17.4 years | 45–75 | W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, total energy intake, BMI, smoking status, physical activity, education, age at menarche, age at first live birth, parity, age at menopause, family history of breast cancer, estrogen and progestin use | Breast cancer HR 1.01 (0.94, 1.09) for fifth versus first quintile |
Cheng et al. (2018) | USA IWHS | Prospective cohort | Cancer mortality | 35,221 17.1 years | 55–69 | W | aMED score range: 9–45. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, smoking status, education, BMI, physical activity, total energy intake, hormone replacement therapy use, marital status, chronic disease | Cancer mortality HR 0.93 (0.84, 1.03) for fifth versus first quintile |
Cheng et al. (2018) | USA IWHS | Prospective cohort | Colorectal cancer | 35,221 17.1 years | 55–69 | W | MDS score range: 11–15. 1.↑ vegetables; 2.↑ fruits; 3.↑ lean meats; 4.↑ fish; 5.↑ nuts; 6.↑ MUFA:SFA ratio; 7.↓ red and processed meat; 8.↓ sodium; 9.↔ dairy foods; 10.↔ grains and starches; 11.↔ alcohol; | Age, family history of colorectal cancer in a first-degree relative, smoking status, education, BMI, physical activity, total energy intake, arthritis, hormone replacement therapy use | Colorectal cancer HR 1.01 (0.86, 1.18) for fifth versus first quintile |
Gardeazabal et al. (2020) | Spain SUN | Prospective cohort | Breast cancer | 10,713 10.3 years | 18–101 | W | PCA-derived score. ↑ Vegetables; ↑ fruits ↑ legumes; ↑ nuts; ↑ eggs; ↑ fish; ↑ natural fruit juices; ↑ processed meats; ↑ unprocessed red meat, ↑ poultry; ↑ olive oil; ↑ olive oil; ↑ other fruits; | Age, height, smoking habit, leisure-time physical activity, alcohol intake, BMI, age of menarche, pregnancies of at least 6 months, pregnancies before the age of 30 years, lifetime breastfeeding, use of hormone replacement therapy, time of use of hormone replacement therapy, years of university studies, family history breast cancer, age at menopause, total energy intake, diabetes, propensity scores | Breast cancer HR 0.64 (0.30, 1.37) for forth versus first quartile |
Haridass et al. (2018) | USA CTS | Prospective cohort | Breast cancer | 96,959 14.0 years | 22–104 | W | aMED score range: 0–8. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts and legumes; 4.↑ fish; 5.↑ whole grains; 6.↑ MUFA:SFA ratio; 7.↓ red and processed meat; 9.↔ alcohol; | Age, race, family history of breast cancer, age at menarche, oral contraceptive use, parity status, smoking status, SES, physical activity, total energy intake, BMI | Breast cancer HR 0.97 (0.89, 1.06) for fifth versus first quintile |
Hashemian et al. (2019) | Iran GCS | Prospective cohort | Cancer mortality | 42,373 10.6 years | 40–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, sex, BMI, formal education, place of residence, smoking status, opium use, physical activity, wealth score, marital status, history of hypertension, total energy intake | Cancer mortality HR 0.63 (0.46, 0.85) for fifth versus first quintile |
Hoon Lee et al. (2019) | USA NHS HPFS | Prospective cohort | Multiple myeloma | 116,983 23.9 years | 30–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, total energy intake, BMI | Multiple myeloma HR 0.97 (0.88, 1.07) for upper versus lower tertile |
Hoon Lee et al. (2020) | USA NHS HPFS | Prospective cohort | All-cause mortality among multiple myeloma survivors | 423 3.5 years | 30–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age at diagnosis, pre-diagnosis energy intake, pre-diagnosis BMI, time between food frequency questionnaire return date and multiple myeloma diagnosis, year of diagnosis, comorbidity score | All-cause mortality among multiple myeloma survivors HR 0.60 (0.44, 0.83) for upper versus lower tertile |
Karavasiloglou et al. (2019) | USA NHANES III | Prospective cohort | All-cause mortality among cancer survivors | 230 16.0 years | 44.0 (mean) | W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ fruits and nuts; 3.↑ cereals; 4.↑ legumes; 5.↑ fish and seafood; 6.↑ MUFA:SFA ratio; 7.↓ dairy products; 8.↓ meat and processed meat; 9.↔ alcohol; | Age at questionnaire completion, race/ethnicity, time from completion to diagnosis, BMI, marital status, socioeconomic status, smoking status, self-reported prevalent disease at baseline, daily energy consumption, moderate to vigorous activity | All-cause mortality among cancer survivors HR 0.67 (0.41, 1.11) for aMED ≥ 5 versus ≤ 4 |
Lavalette et al. (2018) | France NNSS | Prospective cohort | Breast cancer Prostate cancer Colorectal cancer | 41,543 3.0 years | ≥ 40 | M/W | MEDI-LITE score range: 0–18. 1.↑ fruits; 2.↑ vegetables; 3.↑ legumes; 4.↑ cereals; 5.↑ fish; 6.↑ olive oil; 7.↓ meat and meat products; 8.↓ dairy products; 9.↔ alcohol; | Age, sex, educational level, smoking status, number of 24-h dietary recalls, height, family history of cancer, BMI, physical activity (further for breast cancer: number of biological children, menopausal status, hormonal treatment for menopause, oral contraception use at baseline) | Breast cancer HR 1.13 (0.84, 1.53) Prostate cancer HR 0.95 (0.61, 1.50) Colorectal cancer HR 1.02 (0.51, 2.04) for fifth versus first quintile |
Ma et al. (2019) | USA NHS HPFS | Prospective cohort | Hepatocellular cancer | 138,688 < 32.0 years | 30–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, race, cohort, physical activity level, BMI, smoking, regular aspirin use, total calorie intake, type 2 diabetes | Hepatocellular cancer HR 0.75 (0.49, 1.15) for upper versus lower tertile |
Mahamat-Saleh et al. (2019) | France E3N | Prospective cohort | Skin cancer | 67,322 15.0 years | 40–65 | W | MD score range: 0–9. 1.↑ fruits; 2.↑ vegetables; 3.↑ legumes; 4.↑ cereal products; 5.↑ fish; 6.↑ olive oil; 7.↓ meat products; 8.↓ dairy; 9.↔ alcohol; | Age, birth cohort, skin sensitivity to sun exposure, number of nevi, number of freckles, skin color, hair color, family history of skin cancer, level of residential sun exposure at birth and at baseline, energy intake, BMI, physical activity, smoking status, education level, coffee intake | Skin cancer HR 0.83 (0.73, 0.93) for MD ≥ 6 versus ≤ 3 |
Neelakantan et al. (2018) | China SCHS | Prospective cohort | Cancer mortality | 57,078 17.0 years | 45–74 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, sex, total energy intake, dialect, level of education, smoking status, sleep duration, BMI, history of diabetes mellitus, history of hypertension | Cancer mortality HR 0.88 (0.80, 0.97) for fifth versus first quintile |
Petimar et al. (2019) | USA SS | Prospective cohort | Breast cancer | 45,626 7.6 years | 35–74 | W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Total energy intake, race/ethnicity, income, smoking, BMI, physical activity, height, education, alcohol intake, mother diagnosed with breast cancer, age at first live birth, parity, hormone replacement therapy, age at menopause, oral contraception use, age at menarche, lifetime duration of breastfeeding, time of last mammogram | Breast cancer HR 0.89 (0.76, 1.05) for forth versus first quartile |
Petimar et al. (2018) | USA NHS HPFS | Prospective cohort | Colorectal cancer | 124,707 22.3 years | 30–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Total energy intake, alcohol intake, physical activity, NSAID use, family history of CRC, previous CRC screening via colonoscopy or sigmoidoscopy, history of polyps, smoking, multivitamin use, supplemental calcium intake, young adult BMI (further for ♂ menopausal status, postmenopausal hormone use) | Colorectal cancer HR 0.91 (0.79, 1.05) for fifth versus first quintile |
Ratjen et al. (2017) | Germany PopGen | Prospective cohort | All-cause mortality among colorectal cancer survivors | 1404 7.0 years | 55–66 (IQR age) | M/W | MMDS score range: 0–9. 1.↑ vegetables; 2.↑ fruits and nuts; 3.↑ legumes; 4.↑ cereals; 5.↑ fish; 6.↑ MUFA + PUFA:SFA ratio; 7.↓ meat and poultry products; 8.↓ dairy; 9.↔ alcohol; | Age at diet assessment, sex, BMI, physical activity, survival time from CRC diagnosis until diet assessment, tumor location, occurrence of metastases, occurrence of other cancer, chemotherapy, smoking status, total energy intake, interactions of time with age, BMI, metastases | All-cause mortality among colorectal cancer survivors HR 0.48 (0.32, 0.74) for fourth versus first quartile |
Schulpen et al. (2019) | The Netherlands NLCS | Case-cohort | Colorectal cancer Esophageal cancer (by subtypes) Gastric cancer (by subtypes) Pancreatic cancer Lung cancer Prostate cancer Bladder cancer | 120,852 20.3 years | 55–69 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; aMEDr score range 0–8 Components of aMED excluding alcohol intake mMED score range 0–9. 1.↑ vegetables; 2.↑ fruits and nuts; 3.↑ legumes; 4.↑ cereals; 5.↑ fish; 6.↑ MUFA + PUFA:SFA ratio; 7.↓ meat and poultry products; 8.↓ dairy; 9.↔ alcohol; mMEDr score range 0–8. Components of mMED excluding alcohol intake | Age at baseline, cigarette smoking status, cigarette smoking frequency, cigarette smoking duration, BMI, daily energy intake, highest level of education, non-occupational physical activity, (family history of colorectal, esophageal, gastric, pancreatic, lung, prostate, bladder cancer, respectively) | Colorectal cancer aMED HR 1.03 (0.89, 1.19) Esophageal cancer HR 0.99 (0.64, 1.53) Gastric cancer HR 0.60 (0.44, 0.82) Pancreatic cancer HR 0.89 (0.63, 1.26) Lung cancer HR 0.86 (0.70, 1.05) Prostate cancer HR 1.19 (1.02, 1.40) Bladder cancer HR 0.99 (0.83, 1.18) for aMED ≥ 6 versus ≤ 3 |
Seon Kuan et al. (2019) | UK MWS USA NIH-AARP PLCO | Prospective cohorts | Glioma | 1,262,104 12.2 years | 50–74 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Height, BMI, smoking, alcohol intake, level of educational attainment, region of residence, parity, oral contraceptive use, use of menopausal hormones (for women) | Glioma RR 1.24 (1.05, 1.45) for aMED ≥ 7 versus ≤ 2 |
Sharma et al. (2018) | Canada NFCC | Prospective cohort | All-cause mortality among colorectal cancer survivors | 532 6.3 years | 20–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Energy, stage of cancer, sex, age, marital status, tumor location, screening history, intake of alcohol, radiation and chemotherapy status | All-cause mortality among colorectal cancer survivors HR 0.62 (0.39, 0.96) for fourth versus first quartile |
Solans et al. (2019) | Europe (10 countries) 10 countries | Prospective cohort | Lymphoma (by molecular subtypes) | 476,160 13.9 years | 30–70 | M/W | arMED score range: 0–16. 1.↑ fruits, nuts and seeds; 2.↑ vegetables; 3.↑ legumes; 4.↑ fish and seafood; 5.↑ olive oil; 6.↑ cereals; 7.↓ dairy products; 8.↓ meat; aMED score range 0–18. Components of arMED and alcohol | Age, center, sex, BMI, total energy intake, educational level, height, physical activity, smoking status, alcohol intake (for arMED) | Lymphoma arMED HR: 0.91 (0.80, 1.03) for high (arMED ≥ 10) versus low (≤ 5) adherence |
Sotos-Prieto et al. (2017) | USA NHS HPFS | Prospective cohort | Cancer mortality | 73,739 12.0 years | 30–75 | M/W | aMED score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, initial dietary score, race, family history of myocardial infarction, diabetes or cancer, use or nonuse of aspirin or multivitamins, initial BMI, initial smoking status and changes in smoking status, initial smoking pack-years and changes in smoking pack-years among participants with any history of smoking, initial levels of physical activity and total energy intake and changes in these levels, menopausal status, use or nonuse of hormone-replacement therapy (for women), history of hypertension, hypercholesterolemia or type 2 diabetes, weight change, use or nonuse of cholesterol-lowering and antihypertensive medications | Cancer mortality HR: 0.98 (0.93, 1.03) For 20-percentile increase in score during 12-year period |
Torres Stone et al. (2017) | USA NIH-AARP | Prospective cohort | Colorectal cancer | 398,458 10.3 years | 50–71 | M/W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Age, gender, race-ethnicity, education, smoking, physical activity, energy intake | Colorectal cancer HR: 0.79 (0.71, 0.89) for fifth versus first quintile |
Warensjö Lemming et al. (2018) | Sweden SMC | Prospective cohort | Cancer mortality | 33,341 17.0 years | 40–74 | W | mMED score range: 0–8. 1.↑ fruits and vegetables; 2.↑ legumes and nuts; 3.↑ non-refined and high-fiber grains; 4.↑ fermented dairy products; 5.↑ fish; 6.↑ olive or rapeseed oil for cooking or dressing; 7.↓ red and processed meat; 9.↔ alcohol; | Educational level, living alone, physical activity, smoking habits, Charlson’s weighted comorbidity index, Healthy Nordic Food Index | Cancer mortality HR 0.81 (0.69, 0.94) for mMED ≥ 6 versus ≤ 2 |
Witlox et al. (2019) | Europe, USA, Australia (12 countries) EPIC VITAL NLCS MCCS | Prospective cohort | Bladder cancer | 646,222 10.2 years | ≥ 18 | M/W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ fruits; 3.↑ nuts; 4.↑ legumes; 5.↑ fish; 6.↑ whole grains; 7.↑ MUFA:SFA ratio; 8.↓ red and processed meat; 9.↔ alcohol; | Total energy intake, smoking status, sex, age | Bladder cancer HR 0.85 (0.77, 0.93) for score ≥ 6 versus ≤ 3 |
Author (year) | Country | Study design | Outcome | Cases/controls | Age at entry (years) | Sex | Components of score | Adjustment | OR/RR (95% CI) Multivariable adjusted |
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Bravi et al. (2018) | Italy | Case–control | Bladder cancer | 690/665 | 25–84 | M/W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ legumes; 3.↑ fruits and nuts; 4.↑ cereals; 5.↑ fish; 6.↑ MUFA:SFA ratio; 7.↓ meat, 8.↓ dairy products; 9.↔ alcohol; | Sex, age, year of interview, study center, years of schooling, smoking, BMI, non-alcohol energy intake, history of diabetes, history of cystitis, family history of bladder cancer | Bladder cancer OR 0.66 (0.47, 0.93) for score ≥ 6 versus ≤ 3 |
Castello et al. (2018) | Spain | Case–control | Gastric cancer | 295/3040 | 23–85 | M/W | PCA-derived score. ↑ vegetables (leafy, fruiting root, other); ↑ potatoes; ↑ fruits; ↑ legumes; ↑ seafood/shellfish; ↑ fish (white and oily); ↑ olives and vegetable oil; ↓ juices; | Sex, age, education, BMI, family history of gastric cancer, physical activity, smoking status, caloric intake, alcohol intake, province of residence | Gastric cancer OR 0.53 (0.34, 0.82) for forth versus first quartile |
Castello et al. (2019) | Spain | Case–control | Colorectal cancer | 1629/3509 | 22–85 | M/W | PCA-derived score. ↑ vegetables (leafy, fruiting root, other); ↑ potatoes; ↑ fruits; ↑ legumes; ↑ seafood/shellfish; ↑ fish (white and oily); ↑ olives and vegetable oil; ↓ juices; | Sex, age, education, BMI, family history of colorectal cancer, physical activity, smoking status, caloric intake, alcohol intake, province of residence | Colorectal cancer OR 0.65 (0.53, 0.80) for forth versus first quartile |
Jafari Nasab et al. (2019) | Iran | Case–control | Colorectal cancer | 129/240 | 30–79 | M/W | MSDPS score range: 0–100. 1. whole grain cereals (8 servings/day); 2. fruits (3 servings/day); 3. vegetables (6 servings/day); 4. dairy products (2 servings/day); 5. fish and other seafood (6 servings/week); 6. poultry (4 servings/week); 7. olives/legumes/nuts (4 servings/week); 8. Potatoes and other starchy roots (3 servings/week); 9. eggs (3 servings/week); 10. sweets (3 servings/week); 11. meat (1 serving/week); 12. olive oil (exclusive use); | Age, comorbidity, cancer family history, common ways of cooking, level of salt intake, physical activity, calcium supplement use | Colorectal cancer OR 0.19 (0.09, 0.38) for upper versus lower tertile |
Jalilpiran et al. (2018) | Iran | Case–control | Prostate cancer | 60/60 | 63.7 (mean) | M | PCA-derived score. ↑ fruit/fruit juices; ↑ nonstarchy vegetables; ↑ olive; ↑ nuts; ↑ fish; ↑ low-fat dairy; | Age, BMI, total energy intake, physical activity, smoking, job, education, usage of antihyperlipidemic drugs, antihypertensive drugs, and aspirin | Prostate cancer OR 0.62 (0.22, 1.77) for score ≥ median versus < median |
Krusinska et al. (2018) | Poland | Case–control | Breast cancer | 190/230 | 40–80 | W | Polish-aMED score range: 0–8. 1.↑ vegetables; 2.↑ fruit; 3.↑ wholemeal cereals; 4.↑ fish; 5.↑ legumes; 6.↑ nuts and seeds; 7.↑ ratio of vegetable oils to animal fat, 8.↓ red and processed meat; | Age, BMI, socioeconomic status, overall physical activity, smoking status, abuse of alcohol, age at menarche, menopausal status, number of children, oral contraceptive use, hormone-replacement therapy, family history of breast cancer in first- or second-degree relative, vitamin/mineral supplements use, molecular of breast cancer subtypes | Breast cancer OR 0.52 (0.25, 1.07) for score ≥ 6 versus ≤ 2 |
Ricceri et al. (2017) | Italy | Case–control | Endometrial cancer | 297/307 | 40–74 | W | MD score range: 0–8. 1.↑ legumes; 2.↑ cereals; 3.↑ fruits; 4.↑ vegetables; 5.↑ MUFA:SFA ratio; 6.↓ meat and meat products; 7.↓ milk and dairy products, 8.↔ alcohol; | Age, parity, menopausal status, hormone replacement therapy use, oral contraceptive use, BMI, age at menarche, physical activity, education, smoking status, total energy intake | Endometrial cancer OR 0.51 (0.28, 0.92) for score ≥ 6 versus ≤ 3 |
Russo et al. (2019) | Italy | Case–control | Prostate cancer | 118/238 | 68.7 (mean) | M | MEDI-LITE score range: 0–18. 1.↑ fruits; 2.↑ vegetables; 3.↑ legumes; 4.↑ cereals; 5.↑ fish; 6.↑ olive oil; 7.↓ meat and meat products; 8.↓ dairy products; 9.↔ alcohol; | Age, energy intake, weight status, smoking status, alcohol consumption, physical activity level, family history of prostatic cancer, total polyphenol intake | Prostate cancer OR 0.16 (0.03, 0.72) for score > 7 versus ≤ 3 |
Saraiya et al. (2020) | USA | Case–control | Head and neck cancer | 1170/1303 | 20–80 | M/W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ legumes; 3.↑ fruits; 4.↑ cereals/grains; 5.↑ fish; 6.↑ MUFA:SFA ratio; 7.↓ meat, 8.↓ dairy products; 9.↔ alcohol; | Age, race, sex, BMI, history of loose teeth, educational attainment, lifetime number of years smoking cigarettes, quartile of lifetime intake of alcohol, quartile of energy intake | Head and neck cancer OR 0.88 (0.80, 0.98) for 1-SD increase in score |
Salvatore Benito et al. (2019) | Italy | Case–control | Head and neck cancer | 68/100 | 61.8 (mean) | M/W | MEDAS screener range: 0–14. 1.↑ olive oil (as primary source of fat); 2.↑ olive oil; 3.↑ vegetables; 4.↑ fruits; 5.↑ wine; 6.↑ legumes; 7.↑ fish/seafood; 8.↑ nuts; 9.↑ chicken, turkey, rabbit (as preferred meat); 10.↑ sofrito dishes; 11.↓ red meat/hamburger/sausages; 12.↓ butter/margarine/cream; 13.↓ carbonated/sugar-sweetened beverages; 14.↓ commercial pastry; | Age, gender, smoking, alcohol income level, education level | Head and neck cancer OR 0.48 (0.20, 1.07) for score ≥ 8 versus < 8 |
Solans et al. (2018) | Spain | Case–control | Chronic lymphocytic leukemia | 369/1605 | 20–85 | M/W | PCA-derived score. ↑ vegetables (leafy, fruiting root, other); ↑ potatoes; ↑ fruits; ↑ legumes; ↑ seafood/shellfish; ↑ fish (white and oily); ↑ olives and vegetable oil; ↓ juices; | Age, sex, education, energy intake, province of residence | Chronic lymphocytic leukemia OR 0.89 (0.61, 1.29) for forth versus first quartile |
Turati et al. (2018) | Italy, Switzerland | Case–control | Breast cancer | 3034/3392 | 19–79 | W | MDS score range: 0–9. 1.↑ vegetables; 2.↑ legumes; 3.↑ fruits and nuts; 4.↑ cereals; 5.↑ fish; 6.↑ MUFA:SFA ratio; 7.↓ meat, 8.↓ dairy products; 9.↔ alcohol; | Study centre, age, education, BMI, physical activity, smoking, parity, menopausal status, oral contraceptive use, hormone-replacement therapy use, diabetes, family history of breast cancer, non-alcohol energy intake | Breast cancer OR 0.82 (0.71, 0.95) for score ≥ 6 versus ≤ 3 |
Definitions of Mediterranean diet
Main outcomes
Outcomes | Case–control studies | Cohort studies | Observational studies | Randomized controlled trials | NutriGrade assessment | |||||||||||||
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N | OR | 95% CI | I2 (%) | N | RR | 95% CI | I2 (%) | N | RR | 95% CI | I2 (%) | N | RR | 95% CI | I2 (%) | Cohort studies | RCTs | |
Cancer mortality | – | – | – | – | 18 | 0.87 | 0.82, 0.92 | 83 | – | – | – | – | 1 | 0.75 | 0.17, 3.33 | NA | Moderate | Low |
Biliary tract cancer | – | – | – | – | 1 | 0.44 | 0.29, 0.67 | NA | – | – | – | – | – | – | – | – | Very low | – |
Bladder cancer | 1 | 0.66 | 0.47, 0.93 | NA | 3 | 0.89 | 0.81, 0.97 | 11 | 4 | 0.87 | 0.76, 0.98 | 38 | – | – | – | – | Low | – |
Blood cancer | 2 | 0.89 | 0.68, 1.18 | 0 | 2 | 0.95 | 0.88, 1.02 | 0 | 4 | 0.94 | 0.88, 1.02 | 0 | – | – | – | – | Low | – |
Breast cancer | 11 | 0.87 | 0.82, 0.93 | 6 | 12 | 0.97 | 0.94, 1.00 | 0 | 23 | 0.94 | 0.90, 0.97 | 31 | 1 | 0.41 | 0.19, 0.87 | NA | Low | Low |
Colorectal cancer | 7 | 0.64 | 0.52, 0.79 | 89 | 10 | 0.92 | 0.87, 0.99 | 50 | 17 | 0.83 | 0.76, 0.90 | 82 | – | – | – | – | Moderate | – |
Endometrial cancer | 3 | 0.58 | 0.35, 0.95 | 77 | 1 | 0.98 | 0.82, 1.17 | NA | 4 | 0.67 | 0.41, 1.11 | 91 | – | – | – | – | Very low | – |
Esophageal cancer | 1 | 0.26 | 0.13, 0.52 | NA | 2 | 0.85 | 0.67, 1.09 | 0 | 3 | 0.64 | 0.35, 1.16 | 81 | – | – | – | – | Very low | – |
Gallbladder cancer | – | – | – | – | 1 | 0.42 | 0.23, 0.77 | NA | – | – | – | – | – | – | – | – | Very low | – |
Gastric cancer | 3 | 0.63 | 0.53, 0.75 | 34 | 4 | 0.77 | 0.64, 0.92 | 44 | 7 | 0.70 | 0.61, 0.80 | 52 | – | – | – | – | Low | – |
Glioma | – | – | – | – | 1 | 1.24 | 1.05, 1.45 | NA | – | – | – | – | – | – | – | – | Very low | – |
Head and neck cancer | 8 | 0.54 | 0.40, 0.72 | 92 | 1 | 0.73 | 0.60, 0.89 | NA | 9 | 0.56 | 0.44, 0.72 | 91 | – | – | – | – | Very low | – |
Liver cancer | 1 | 0.51 | 0.34, 0.77 | NA | 3 | 0.67 | 0.56, 0.80 | 0 | 4 | 0.64 | 0.54, 0.75 | 0 | – | – | – | – | Low | – |
Ovarian cancer | – | – | – | – | 1 | 0.91 | 0.71, 1.17 | NA | – | – | – | – | – | – | – | – | Very low | – |
Pancreatic cancer | 1 | 0.48 | 0.35, 0.66 | NA | 3 | 0.92 | 0.81, 1.05 | 0 | 4 | 0.80 | 0.60, 1.06 | 79 | – | – | – | – | Very low | – |
Prostate cancer | 5 | 0.76 | 0.52, 1.13 | 56 | 6 | 0.98 | 0.94, 1.02 | 28 | 11 | 0.98 | 0.93, 1.04 | 39 | – | – | – | – | Low | – |
Respiratory cancer | – | – | – | – | 5 | 0.84 | 0.76, 0.94 | 42 | – | – | – | – | – | – | – | – | Low | – |
Skin cancer | – | – | – | – | 1 | 0.83 | 0.73, 0.93 | NA | – | – | – | – | – | – | – | – | Very low | – |
All–cause mortality among survivors | – | – | – | – | 8 | 0.75 | 0.66, 0.86 | 41 | – | – | – | – | – | – | – | – | Low | – |
Cancer mortality among survivors | – | – | – | – | 4 | 0.96 | 0.82, 1.11 | 0 | – | – | – | – | – | – | – | – | Very low | – |
Cancer reoccurrence among survivors | – | – | – | – | 1 | 0.61 | 0.18, 2.07 | NA | – | – | – | – | – | – | – | – | Very low | – |