AIMS: The Southern European Atlantic diet (SEAD) is the traditional dietary pattern of northwestern Spain and northern Portugal, but it may resemble that of central, eastern, and western European countries. The SEAD has been found associated with lower risk of myocardial infarction and mortality in older adults, but it is uncertain whether this association also exists in other European populations and if it is similar as that found in its countries of origin. METHODS AND RESULTS: We conducted a prospective analysis of four cohorts with 35 917 subjects aged 18-96 years: ENRICA (Spain), HAPIEE (Czechia and Poland), and Whitehall II (United Kingdom). The SEAD comprised fresh fish, cod, red meat and pork products, dairy, legumes and vegetables, vegetable soup, potatoes, whole-grain bread, and moderate wine consumption. Associations were adjusted for sociodemographic variables, energy intake, lifestyle, and morbidity. After a median follow-up of 13.6 years (range = 0-15), we recorded 4 973 all-cause, 1 581 cardiovascular, and 1 814 cancer deaths. Higher adherence to the SEAD was associated with lower mortality in the pooled sample. Fully adjusted hazard ratios and 95% confidence interval per 1-standard deviation increment in the SEAD were 0.92 (0.89, 0.95), 0.91 (0.86, 0.96), and 0.94 (0.89, 0.99) for all-cause, cardiovascular, and cancer mortality, respectively. The association of the SEAD with all-cause mortality was not significantly different between countries [Spain = 0.93 (0.88, 0.99), Czechia = 0.94 (0.89,0.99), Poland = 0.89 (0.85, 0.93), United Kingdom = 0.98 (0.89, 1.07); P for interaction = 0.16]. CONCLUSION: The SEAD was associated with lower all-cause, cardiovascular, and cancer mortality in southern, central, eastern, and western European populations. Associations were of similar magnitude as those found for existing healthy dietary patterns.

Aging Research Center Department of Neurobiology Care Sciences and Society Karolinska Institutet and Stockholm University Tomtebodavägen 18 A SE 171 77 Stockholm Sweden

Cardiovascular and Nutritional Epidemiology Group CEI UAM CSIC IMDEA Research Institute on Food and Health Sciences Carretera de Canto Blanco 8 28049 Madrid Spain

Center for Networked Biomedical Research in Epidemiology and Public Health Avenida de Monforte de Lemos 3 5 28029 Madrid Spain

Department of Environmental Health and Population Health Monitoring National Institute of Public Health Šrobárova 49 48 100 00 Prague Czech Republic

Department of Epidemiology and Population Studies Faculty of Health Sciences Institute of Public Health Jagiellonian University Medical College Ulica Skawińska 8 31 066 Krakow Poland

Department of Epidemiology and Public Health University College London 1 19 Torrington Place London WC1E 7HB UK

Department of Preventive Medicine and Public Health Universidad Autónoma de Madrid Calle del Arzobispo Morcillo 4 28029 Madrid Spain

Independent researcher

RECETOX Faculty of Science Masaryk University Kotlářská 267 2 611 37 Brno Czech Republic

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