Does a Mediterranean way of living only pay off for the well-off? 105,812 Dutch adults, 13 years, and an answer that holds at every income level

There is an old objection to almost every study that says a healthy way of living goes with a longer life. The people who eat vegetables, exercise, sleep well and see their friends are, on average, also the people with steadier jobs, more schooling and more money. Money buys better housing, less stress and quicker medical care. So is it the lifestyle that helps, or is the lifestyle just a marker of being comfortable?

A paper published online in The American Journal of Clinical Nutrition on 9 October 2026 goes at that question directly. Researchers from the Universidad Autónoma de Madrid and the University of Groningen did not just adjust for income and education in the background. They split the cohort by them and looked at each layer on its own.

The data come from Lifelines, a long-running population study in the north of the Netherlands. The analysis covers 105,812 adults who joined between 2006 and 2013 and were followed until 2025, a median of 13.25 years. In that time 3,976 of them died, which by our arithmetic is just under 4 in every 100. Deaths came from official records, not from asking relatives.

Lifestyle was scored once, at the start, with something called the MEDLIFE index. It is wider than a Mediterranean diet score. The version used here has 23 items, each worth one point, covering what people eat, how they eat (the summary calls these dietary habits), physical activity, rest and social habits. The idea, which comes from the Spanish food guide pyramid, is that the traditional Mediterranean pattern was never only about what was on the plate. It also took in rest, movement and time with other people.

Across the whole group the pattern was a steady slope: the higher the score, the fewer the deaths. People in the top quarter for MEDLIFE score had a 30% lower risk of dying during follow-up than people in the bottom quarter. The hazard ratio was 0.70, with a 95% confidence interval of 0.64 to 0.77, after adjusting for general, lifestyle and clinical risk factors.

Then the split. Income and education were each divided into three levels, as reported by the participants when they joined. According to the summary, a healthier Mediterranean lifestyle went with lower risk both in the most disadvantaged groups and in the more educated or better-off ones. The objection we started with predicts that the link should fade once you look inside a single income band. Here it did not.

Money still mattered. When the researchers looked at lifestyle and social position together, people with the highest MEDLIFE scores and the highest incomes had a hazard ratio of 0.54 (0.46 to 0.63), a 46% lower risk. For the highest scores combined with the highest education it was 0.67 (0.57 to 0.78), or 33% lower. The authors read this as income changing the association more than education does. They also report that a poor lifestyle score raised the risk of death to a similar degree in people with a lot of schooling and people with little. A degree did not cancel out the habits.

Now the limits, and there are several. We could only read the published summary of this paper; we could not open the full text, so we have not seen the tables. The summary does not say which group the 0.54 and 0.67 figures are measured against, and it gives no separate numbers for the lowest income or education groups. Until someone reads those tables, 'it works at every level' is the authors' description, not something we can show you figure by figure.

This is also an observational study. Nobody was assigned a way of living, so it cannot show that changing your habits would change your odds. Splitting by income and education deals with two obvious confounders and leaves others, such as the neighbourhood you live in or the health you started with. People who are already unwell often move less, sleep worse and see fewer friends, which would make a low score look deadlier than it is. Everything was measured once, at the start, and then assumed to hold for 13 years. And both the income and the education figures were self-reported.

One more thing about place. This is a Mediterranean score applied to people in the north of the Netherlands, a long way from the Mediterranean. That is part of what makes it interesting, since it suggests the pattern travels. It also means a point on the index in a northern Dutch town may not describe the same daily life as a point scored in Spain.

So what is fair to take from it? The link between this broader way of living and a longer life was not confined to people with money, at least in this one Dutch cohort. The authors go further and suggest healthy lifestyles could narrow the gap in death rates between richer and poorer people. That is a hope the study is consistent with, not something it tested. Whether people on low incomes have the time, money and surroundings to live this way is a separate question, and this paper does not answer it.