Objective: To investigate the association of dietary pattern and mortality in international data. Design: Cohort study with 20 years’ follow up of mortality. Setting: Five cohorts in Finland, the Netherlands, and Italy. Subjects: Population based random sample of 3045 men aged 50‐70 years in 1970. Main outcome measures: Food intake was estimated using a cross check dietary history. In this dietary survey method, the usual food consumption pattern in the 6‐12 months is estimated. A healthy diet indicator was calculated for the dietary pattern, using the World Health Organisation’s guidelines for the prevention of chronic diseases. Vital status was verified after 20 years of follow up, and death rates were calculated. Results: Dietary intake varied greatly in 1970 between the three countries. In Finland and the Netherlands the intake of saturated fatty acids and cholesterol was high and the intake of alcohol was low; in Italy the opposite was observed. In total 1796 men (59%) died during 20 years of follow up. The healthy diet indicator was inversely associated with mortality (P for trend <0.05). After adjustment for age, smoking, and alcohol consumption, the relative risk in the group with the healthiest diet indicator compared with the group with the least healthy was 0.87 (95% confidence interval 0.77 to 0.98). Estimated relative risks were essentially similar within each country. Conclusions: Dietary intake of men aged 50‐70 is associated with a 20 year, all cause mortality in different cultures. The healthy diet indicator is useful in evaluating the relation of mortality to dietary patterns. Key messages <l type="unord"> Studying dietary patterns instead of single nutrients in relation to mortality takes into account the intercorrelation of nutrients in the diet A healthy diet, as measured by an indicator based on WHO recommendations, is associated with a reduction of 13% after 20 years in all cause mortality for men aged 50‐70 The dietary pattern as a whole is more important than specific dietary ...