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 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. 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 components with respect to survival among older people The WHO dietary recommendations for the prevention of chronic diseases seem to be effective The healthy diet indicator is useful for evaluating the relation of dietary patterns and mortality in a cross cultural setting