Association Between MIND Diet Adherence and Mortality: Insights from Diabetic and Non-Diabetic Cohorts

Type 2 diabetes mellitus (T2DM) is a major public health issue with high morbidity and mortality and is projected to rise globally. Diet plays a crucial role in prevention and management of diabetes, with whole grains, fruits, vegetables, and dietary patterns like Mediterranean (MED) and DASH improving insulin sensitivity and glycemic control. The MIND diet integrates MED and DASH components with specific emphasis on limiting foods implicated in diabetes pathogenesis (fried/fast foods, sweets, butter/margarine) and promoting green leafy vegetables and berries, offering potential cognitive and cardiometabolic benefits. Despite these theoretical advantages, evidence on the MIND diet’s impact on prognosis in T2DM remains scarce. This study investigates whether higher adherence to the MIND diet is associated with reduced all-cause and cardiovascular mortality in individuals with and without T2DM using NHANES data.

Prior studies have shown the MIND diet to be protective for cognitive outcomes and potentially beneficial for cardiovascular health. Elements of the MIND diet (MED and DASH patterns) have been linked to improved cardiovascular risk profiles and glycemic control, including reductions in blood pressure, triglycerides, glucose, and HbA1c in diabetes. Observational research suggests higher MIND scores correlate with lower mortality risk in older adults and reduced risk of cardiovascular disease and stroke. Evidence specifically in T2DM is limited; one study suggested better cognitive trajectories with MED/MIND adherence in T2DM and a nonsignificant trend toward lower glucose with higher MIND scores. These findings support the hypothesis that MIND adherence may confer survival benefits, particularly in older populations and those with metabolic disease, warranting direct evaluation in T2DM cohorts.

Design and population: Cohort analysis using NHANES 2003–2006 data. Initial N=20,470; exclusions included age <18 (n=9893), missing mortality data (n=12), missing diet data (n=3367), missing smoking status (n=309), and hyperlipidemia diagnosis missing (n=2), yielding a final N=6887 (including 1021 with T2DM). Exposure: MIND diet adherence quantified via a Food Frequency Questionnaire (FFQ) capturing 15 components (10 beneficial, 5 harmful); scores summed (observed range 4.5–13; typical 0–15). Participants were dichotomized at the cohort median MIND score of 8.0: low (≤8.0) vs high (>8.0). Groups for analysis: low/high MIND score stratified by diabetes status (non-DM vs T2DM). Outcomes: Primary outcomes were all-cause mortality and cardiovascular (CV) mortality (deaths due to cardiovascular or cerebrovascular diseases). Follow-up: Median 10 years via linked mortality data. Covariates: Demographics (age, sex, race/ethnicity), socioeconomic factors (education, family income to poverty ratio), lifestyle (smoking status, physical activity), clinical measures (BMI, eGFR, hypertension, hyperlipidemia), and energy intake. Statistical analysis: NHANES survey weights, clustering, and stratification applied for national representativeness. Group differences assessed by ANOVA (continuous) and chi-squared tests (categorical). Missing data: variables with <5% missing imputed with medians; >5% missing assigned to “Unknown.” Time-to-event analyses used multivariable Cox proportional hazards models with three adjustment levels: Model 1 adjusted for age, sex, race/ethnicity; Model 2 additionally adjusted for education, income-to-poverty ratio, smoking, BMI, physical activity; Model 3 additionally adjusted for hypertension, dyslipidemia, energy intake, eGFR (and diabetes status in whole-cohort models). Kaplan–Meier survival curves with log-rank tests were used. Subgroup analyses: stratified by age, sex, race, smoking, physical activity, BMI, and eGFR; interaction testing performed. Sensitivity analyses: sequentially excluded non-Hispanic Black participants, deaths within 1 year, unknown income-to-poverty ratio, and participants with heart failure, ischemic heart disease (IHD, including MI and angina), cerebrovascular disease, dual antiplatelet therapy, statin therapy, and hypoglycemic treatment. Analyses performed in R 4.1.3 with two-tailed alpha 0.05.

• Sample: 6887 participants (1021 with T2DM); median follow-up 10 years; 1087 all-cause deaths and 377 cardiovascular deaths. - T2DM subgroup: High MIND score (>8.0) associated with lower risk of all-cause mortality (HR 0.75, 95% CI 0.59–0.96, P=0.021) and CV mortality (HR 0.50, 95% CI 0.29–0.87, P=0.014), vs low MIND (≤8.0) in fully adjusted models. - Non-DM subgroup: High MIND score associated with reduced all-cause mortality (HR 0.83, 95% CI 0.70–0.99, reported P<0.001) but not significantly associated with CV mortality (HR 0.85, 95% CI 0.62–1.16). Kaplan–Meier log-rank tests in non-DM did not show significant differences (all-cause P=0.071; CV P=0.134). - Whole cohort: Each 1-point increase in MIND score associated with lower risk of all-cause mortality (HR 0.91, 95% CI 0.86–0.95) and CV mortality (HR 0.87, 95% CI 0.79–0.96) in fully adjusted models. High vs low MIND score associated with lower all-cause mortality (HR 0.80, 95% CI 0.69–0.92) and CV mortality (HR 0.69, 95% CI 0.53–0.91). - Combined groups (reference: high MIND/non-DM): Increased all-cause mortality risk for low MIND/non-DM (HR 1.24, 95% CI 1.05–1.48), high MIND/DM (HR 1.58, 95% CI 1.25–1.98), and low MIND/DM (HR 2.00, 95% CI 1.61–2.48), indicating worst outcomes for low MIND/DM. - Subgroups: Significant interaction with age; benefits amplified in older adults >65 years (P for interaction <0.001). - Sensitivity analyses: Results robust after excluding groups with potential confounding (e.g., early deaths, IHD/MI, heart failure, statin/DAPT use, hypoglycemic therapy, non-Hispanic Black participants, unknown income). - No significant linear correlations were found between MIND score and FBG, HbA1c, or LDL-C levels.

The study addresses whether adherence to the MIND diet is associated with reduced mortality in individuals with T2DM. Findings show that higher MIND adherence is linked to significantly lower all-cause and cardiovascular mortality in T2DM, supporting the hypothesis that the MIND diet confers cardiometabolic survival benefits for this group. In the overall population, higher MIND adherence also relates to reduced mortality, while evidence in non-DM participants is mixed (significant in adjusted Cox models for all-cause mortality but not in unadjusted Kaplan–Meier comparisons or for CV mortality). The results align with prior evidence that MIND/MED/DASH diets improve cardiometabolic risk profiles and outcomes and suggest that the MIND pattern may be particularly valuable for older adults, where stronger interactions were observed. Potential mechanisms include improved glycemic tolerance, lipid profiles, and reduced inflammation via higher intake of whole grains, green leafy vegetables, and legumes, and reduced consumption of fast/fried foods, sweets, and butter/margarine. Robustness across sensitivity analyses (excluding participants with IHD, hypoglycemic, statin, or antiplatelet therapies) reduces concerns that these factors explain the association. However, the absence of linear associations with FBG, HbA1c, and LDL-C suggests benefits may be mediated through broader lifestyle or cardiometabolic pathways rather than single biomarkers. Overall, adherence to the MIND diet emerges as a promising dietary strategy to improve longevity, especially among individuals with T2DM and older adults.

Adherence to the MIND diet was inversely associated with all-cause and cardiovascular mortality, with particularly strong associations among individuals with T2DM. The study contributes population-based evidence supporting the MIND diet as a beneficial dietary pattern for survival in T2DM and in the general adult population. Future research should include randomized clinical trials and longitudinal studies with detailed dietary assessment and clinical phenotyping (e.g., cardiac function, plaque characteristics) to establish causality, clarify mechanisms, and explore the impact across specific subgroups (e.g., types of myocardial infarction, medication use).

• Diabetes diagnosis and MIND score assessment relied on self-reported questionnaires without specialist verification, introducing potential misclassification bias. - MIND score was derived solely from FFQ data; 24-hour recall data could not be used due to unit differences, potentially affecting score accuracy. - The association between MIND score and T2DM was examined cross-sectionally, limiting causal inference. - Lack of data on cardiac function and echocardiography in NHANES may bias analyses of CV mortality risk. - Observational design without randomization limits causal conclusions; randomized clinical trials are needed. - NHANES did not provide details on MI subtypes or specific hypoglycemic drugs and plaque stability, limiting mechanistic insights and stratified analyses.