BACKGROUND: Cardiovascular disease (CVD) represents a leading cause of mortality worldwide, especially in the elderly. Lowering the number of CVD deaths requires preventive strategies targeted on the elderly. OBJECTIVE: The objective was to generate evidence on the association between WHO dietary recommendations and mortality from CVD, coronary artery disease (CAD), and stroke in the elderly aged ≥60 y. DESIGN: We analyzed data from 10 prospective cohort studies from Europe and the United States comprising a total sample of 281,874 men and women free from chronic diseases at baseline. Components of the Healthy Diet Indicator (HDI) included saturated fatty acids, polyunsaturated fatty acids, mono- and disaccharides, protein, cholesterol, dietary fiber, and fruit and vegetables. Cohort-specific HRs adjusted for sex, education, smoking, physical activity, and energy and alcohol intakes were pooled by using a random-effects model. RESULTS: During 3,322,768 person-years of follow-up, 12,492 people died of CVD. An increase of 10 HDI points (complete adherence to an additional WHO guideline) was, on average, not associated with CVD mortality (HR: 0.94; 95% CI: 0.86, 1.03), CAD mortality (HR: 0.99; 95% CI: 0.85, 1.14), or stroke mortality (HR: 0.95; 95% CI: 0.88, 1.03). However, after stratification of the data by geographic region, adherence to the HDI was associated with reduced CVD mortality in the southern European cohorts (HR: 0.87; 95% CI: 0.79, 0.96; I(2) = 0%) and in the US cohort (HR: 0.85; 95% CI: 0.83, 0.87; I(2) = not applicable). CONCLUSION: Overall, greater adherence to the WHO dietary guidelines was not significantly associated with CVD mortality, but the results varied across regions. Clear inverse associations were observed in elderly populations in southern Europe and the United States.

Department for Determinants of Chronic Diseases National Institute for Public Health and the Environment Bilthoven Netherlands; Department of Gastroenterology and Hepatology University Medical Centre Utrecht Netherlands; Department of Epidemiology and Biostatistics The School of Public Health Imperial College London London United Kingdom; and Department of Social and Preventive Medicine Faculty of Medicine University of Malaya Kuala Lumpur Malaysia

Department of Epidemiology and Population Studies Jagiellonian University Krakow Poland;

Department of Epidemiology and Public Health University College London London United Kingdom;

Department of Epidemiology Erasmus MC University Medical Centre Rotterdam Netherlands;

Department of Epidemiology Erasmus MC University Medical Centre Rotterdam Netherlands; Global Public Health Leiden University College the Hague Netherlands;

Department of Epidemiology Julius Centre Utrecht Netherlands;

Department of Hygiene Epidemiology and Medical Statistics University of Athens Medical School Athens Greece; Hellenic Health Foundation Athens Greece;

Department of Hygiene Epidemiology and Medical Statistics University of Athens Medical School Athens Greece; The Tisch Cancer Institute Mount Sinai School of Medicine New York NY;

Department of Public Health and Clinical Medicine Nutritional Research Umeå University Umeå Sweden;

Division of Cancer Epidemiology and Genetics National Cancer Institute Bethesda MD;

Division of Human Nutrition Wageningen University Wageningen Netherlands;

Division of Human Nutrition Wageningen University Wageningen Netherlands; Centre of Clinical Epidemiology Institute for Medical Informatics Biometry and Epidemiology University Hospital University Duisburg Essen Essen Germany;

Institute of Internal and Preventive Medicine Siberian Branch of the Russian Academy of Medical Sciences Novosibirsk Russia; Novosibirsk State Medical University Novosibirsk Russia;

National Institute of Public Health Prague Czech Republic;

UKCRC Centre of Excellence for Public Health School of Medicine Dentistry and Biomedical Sciences Queens University Belfast Belfast United Kingdom;

Unit of Nutrition Environment and Cancer Cancer Epidemiology Research Programme Catalan Institute of Oncology Barcelona Spain;

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