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Sustainable, planetary healthy dietary patterns are associated with lower 20-year incidence of cardiovascular disease: the ATTICA study (2002–2022)

European Journal of Clinical Nutrition volume 79, pages 536–543 (2025)Cite this article

Subjects

Abstract

Background/Objectives

Nutrition epidemiology research scarcely focuses on the relationship between dietary patterns that are beneficial for both planet and human health. This study aimed to examine the association between adherence to a sustainable, planetary-healthy dietary pattern, i.e., the EAT-Lancet Reference Diet (EAT-LD), and 20-year cardiovascular disease (CVD) incidence, in a Mediterranean population.

Subjects/Methods

Τhe ATTICA study is a prospective cohort study with a baseline phase in 2002 and 3 consecutive follow-ups (in 2006, 2012, 2022). The EAT-Lancet Index (EAT-LI) and the MedDietScore scales were calculated based on previously published guidelines to assess the adherence to the respective dietary pattern. The current sample consisted of 1,988 Greek adults initially free-of-CVD at baseline. The development of a cardiovascular event was assessed throughout the 20-year period (WHO-ICD-10 classification).

Results

The 20-year incidence of CVD was 3600 cases/10,000 individuals (95%Confidence Interval-CI: 3506 to 3695/10,000). Median (interquartile range) values for EAT-LI and MedDietScore were 17 (6.2) out of possible 42 points and 27 (2.9) out of possible 55 points, respectively. Both diet scales were inversely associated with 20-year CVD incidence [Hazard Ratio-HR (95% CI) per 1 point (of possible 42 points) of EAT-LI: 0.83 (0.77–0.90) and per 1 point (of possible 55 points) of MedDietScore: 0.90 (0.84–0.93)].

Conclusion

Our findings highlight that diets that are good for planetary health, are also healthy for humans. Promoting diets that are culturally acceptable, economically viable, easily accessible, planet-friendly, and sustainable should be a key strategy for enhancing both public and planetary health.

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Fig. 1: Flow-diagram of the ATTICA study participants (2002–2022) included in the current study (n = 1988).
Fig. 2: Graphical representation of effect size measures (HRs; 95% CI) by subgroup analyses concerning the association between EAT-Lancet index and 20-year CVD risk in the ATTICA study (n = 1988).

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Data availability

Data described in the manuscript, code book, and analytic code will be made available upon request to the corresponding author.

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Acknowledgements

The authors would like to thank the ATTICA study group of investigators: Christina Vafia, Elpiniki Vlachopoulou, Petros Spyridonas Adamidis, Konstantina Kyrilli, Amalia Despoina Koutsogianni, Evangelinos Michelis, Asimina Loukina, Giorgos Metzantonakis, Manolis Kambaxis, Kyriakos Dimitriadis, Ioannis Andrikou, Amalia Sofianidi, Natalia Sinou, Aikaterini Skandali, Christina Sousouni, for their assistance on the 20-year follow-up, as well as Ekavi N. Georgousopoulou, Natassa Katinioti, Labros Papadimitriou, Konstantina Masoura, Spiros Vellas, Yannis Lentzas, Manolis Kambaxis, Konstantina Palliou, Vassiliki Metaxa, Agathi Ntzouvani, Dimitris Mpougatsas, Nikolaos Skourlis, Christina Papanikolaou, Georgia-Maria Kouli, Aimilia Christou, Adella Zana, Maria Ntertimani, Aikaterini Kalogeropoulou, Evangelia Pitaraki, Alexandros Laskaris, Mihail Hatzigeorgiou and Athanasios Grekas, Efi Tsetsekou, Carmen Vassiliadou, George Dedoussis, Marina Toutouza-Giotsa, Konstantina Tselika and Sia Poulopoulou and Maria Toutouza for their assistance in the initial and follow-up evaluations. *Note: All named individuals have given their permission.

Funding

The ATTICA study has been funded by research grants from the Hellenic Cardiological Society and the Hellenic Atherosclerosis Society. E.D. has received scholarship from the Hellenic Atherosclerosis Society. The funding sources were not involved nor had restrictions regarding the publication of the present manuscript.

Author information

Authors and Affiliations

  1. Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 17676, Athens, Greece

    Evangelia Damigou & Demosthenes Panagiotakos

  2. Department of Health Behavior, Society and Policy, Rutgers University, Newark, NJ, USA

    Shauna M. Downs

  3. First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 15772, Athens, Greece

    Christina Chrysohoou, Costas Tsioufis & Christos Pitsavos

  4. Department of Internal Medicine, Medical School, University of Ioannina, 45500, Ioannina, Greece

    Fotios Barkas

  5. First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 15772, Athens, Greece

    Evangelos Liberopoulos & Petros P. Sfikakis

Authors
  1. Evangelia Damigou
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  2. Shauna M. Downs
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  3. Christina Chrysohoou
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Contributions

ED and DP conceptualized the current research hypothesis; CC, CP, CT, EL, PPS and DP designed research; ED and FB conducted research; ED analyzed data; ED wrote the paper; SMD and DP reviewed and edited the paper. DP had primary responsibility for final content. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Demosthenes Panagiotakos.

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Competing interests

The authors declare no competing interests.

Ethical approval

The ATTICA study was carried out in accordance with the Declaration of Helsinki (1989) of the World Medical Association and was approved by the Institutional Ethics committee of Athens Medical School (#017/1.5.2001), and the Bioethics Committee of Harokopio University (#38/29.03.2022). All participants provided written consent to participate in the study.

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Damigou, E., Downs, S.M., Chrysohoou, C. et al. Sustainable, planetary healthy dietary patterns are associated with lower 20-year incidence of cardiovascular disease: the ATTICA study (2002–2022). Eur J Clin Nutr 79, 536–543 (2025). https://doi.org/10.1038/s41430-025-01586-1

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