Mediterranean lifestyle linked to 30% lower death rate in 105,812 Dutch adults, across income levels

The questionnaire behind a “Mediterranean lifestyle” score asks about more than olive oil. In the version used in a 2023 British study, people were scored on fruit, vegetables and whole grains, on habits around meals such as limiting added salt, and on rest, exercise and social life, including taking regular naps and spending time with friends. A team of researchers has now applied the same kind of score to more than 100,000 people in the northern Netherlands, a long way from the Mediterranean. They asked a question earlier studies had mostly left aside: does the lifestyle go with longer life for people with little money as well as for the well off?

It did. Among 105,812 adults in the Lifelines cohort, followed for a median of 13 years, those whose habits came closest to the Mediterranean pattern had a death rate about 30% lower than those whose habits were furthest from it. The link held across income and education levels, and people who combined the healthiest habits with the highest incomes had the lowest risk of all.

The study, by Javier Maroto-Rodriguez and colleagues with Eva Corpeleijn as senior author, was published on October 1 in the American Journal of Clinical Nutrition. The authors note that there has been “little investigation into how traditional lifestyles associate with health”, or into whether that link differs by socioeconomic status. That term covers a person’s income, education and the advantages that come with them.

What the Mediterranean lifestyle index measures

The score is the Mediterranean Lifestyle index, known as MEDLIFE. It was designed in Spain and based on the Spanish Mediterranean food guide pyramid. The original version had 28 items in three groups: 15 on which foods people eat, seven on traditional eating habits, and six on physical activity, rest and social interaction. Each item earns a point, so a higher score means more Mediterranean habits. Its creators described it as the first index to assess overall lifestyle habits in this way, rather than diet alone.

The same research group took the index to Britain in 2023. In 110,799 UK Biobank participants aged 40 to 75, those with higher scores had a 29% lower risk of death from any cause than those with lower scores. The strongest link was with the rest, exercise and social part of the score. “This study suggests that it’s possible for non-Mediterranean populations to adopt the Mediterranean diet using locally available products and to adopt the overall Mediterranean lifestyle within their own cultural contexts,” Mercedes Sotos-Prieto, who led that study, said at the time. Sotos-Prieto is also an author of the new one.

The Lifelines version had 23 items, on food, eating habits, physical activity, rest and social habits, again one point each, measured once when people joined.

How the Lifelines study looked at income and education

Lifelines recruited its participants between 2006 and 2013, inviting inhabitants of the northern part of the Netherlands, along with their families, to take part. It enrolled 167,729 people aged from six months to 93 years, and this analysis used the adults. Participants had a physical examination and filled in long questionnaires about their health and habits.

For this analysis, income and education were self-reported at baseline and each split into three levels, from lowest to highest. The researchers also combined the two into a single measure. Deaths up to 2025 came from official death records, and the comparisons were adjusted for general, lifestyle and clinical risk factors.

This is an observational study. People were not asked to change their habits, so the study can show that those who lived more Mediterranean lives died at lower rates. It cannot show that adopting the lifestyle would lengthen anyone’s life. People with healthier habits often differ in other ways too, and income and education are themselves among those differences, which is why the study looked at them directly.

How the Mediterranean lifestyle related to death rates at each income level

By 2025, after a median follow-up of 13.25 years, 3,976 of the participants had died. Death rates fell as MEDLIFE scores rose, in what the authors describe as an inverse dose-response relationship. Comparing the quarter of participants with the highest scores with the quarter with the lowest, and after accounting for the other factors, the top group had a death rate about 30% lower.

The pattern held in every social group the study compared, from the most disadvantaged to the more educated or affluent. The authors also found that a poor lifestyle raised death rates by a similar amount whether people had a little education or a lot.

Income and education did not behave the same way. In joint analyses that looked at lifestyle and social position together, the highest adherence combined with the highest income went with a death rate about 46% lower than the reference group in that analysis. The highest adherence combined with the highest education went with a rate about 33% lower. Those joint figures blend the advantage of money or schooling with that of the habits, so they are not the lifestyle’s effect alone. From them the authors conclude that income changed the link between lifestyle and death more than education did, and they call income the strongest modifier of this association.

How much of the income gap in mortality a healthy lifestyle can explain

Poorer people tend to die younger. A 2017 study of 1.75 million people in 48 cohorts, published in The Lancet, found that low socioeconomic status was associated with a 2.1-year reduction in life expectancy between the ages of 40 and 85. That is a loss comparable to the effects of physical inactivity or high blood pressure in the same analysis, and larger than those of obesity or heavy drinking. Low status also kept much of its link with early death in mutually adjusted models that took account of smoking, drinking, inactivity, high blood pressure, diabetes and obesity: the extra risk shrank from about 42% in men and 34% in women to about 26%.

The obvious hope is that healthier habits could close some of that gap, and the Lifelines authors lean that way, writing that healthy lifestyles could mitigate socioeconomic mortality gaps. A 2021 study in The BMJ, by a separate team, tested the idea directly in 44,462 US adults and 399,537 UK adults. It found that people of low socioeconomic status had roughly twice the death rate of those of high status. Unhealthy lifestyles mediated a small proportion of that difference, about 12% in the United States and 4% in Britain.

That team drew a careful conclusion. Healthy habits were linked to lower death rates in every socioeconomic group, which supports their value for anyone. But promoting them alone might not substantially reduce the gap, and measures aimed at the social conditions themselves would be needed. The Lifelines results fit both halves of that: the lifestyle went with lower risk at every income level, and the people who did best had both the habits and the income.

What other evidence says about Mediterranean eating

The Lifelines result echoes the earlier UK Biobank analysis, where the link also ran in a dose-response manner, with risk lower in each higher quarter of MEDLIFE scores. Both are observational, and both come from the same research network.

For the diet part of the lifestyle, there is randomized trial evidence. In the Spanish PREDIMED trial, 7,447 adults aged 55 to 80, at high cardiovascular risk but without heart disease, were assigned to a Mediterranean diet with extra olive oil, the same diet with mixed nuts, or advice to cut dietary fat. Over a median 4.8 years, a heart attack, stroke or cardiovascular death occurred in 3.8% of the group assigned to a Mediterranean diet with olive oil, 3.4% of the nuts group and 4.4% of the control group. The trial’s original 2013 report was withdrawn after problems were found with how some participants had been assigned, and the 2018 republication reports results re-analyzed with that in mind. That trial tested diet only, not the rest of the lifestyle.

What the Lifelines lifestyle study cannot show

Habits, income and education were all reported by participants, once, when they joined, and many will have changed over 13 years. A single snapshot can misplace people, and errors of that kind usually weaken an association.

The study was done in one region of a single high-income country, where the gap between the lowest and highest incomes may play out differently than elsewhere. The MEDLIFE index also gives every item the same weight, so a point for one food counts the same as a point for regular exercise. The score cannot say which habits matter most. And because the study counted deaths from all causes together, it does not show which diseases account for the difference.

Most of all, people who eat well, stay active and keep up friendships may also have better health, less stress and more control over their lives in ways that questionnaires miss. Some of those advantages follow income. The researchers adjusted for the factors they measured, but any that escaped measurement could account for part of the link.

What the Mediterranean lifestyle result means for income gaps

The authors conclude that higher adherence “was linked to lower all-cause mortality across all socioeconomic levels”, and they argue for promoting the Mediterranean lifestyle as a public health strategy. The results give no sign that the link is confined to the well off.

Nor do they suggest that habits alone would erase the difference between rich and poor, since the strongest result belonged to people who had both. How diet and lifestyle fit into any one person’s health is assessed by their doctor.

In the Netherlands, eating, moving and socializing the Mediterranean way went with lower death rates across income levels, and the lowest when money was not short.