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Diet Quality as Assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension Score, and Health Outcomes: A Systematic Review and Meta-Analysis of Cohort Studies

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Abstract

Dietary patterns consider synergistic effects compared with isolated foods or nutrients on health outcomes. The aim of this systematic review and meta-analysis was to examine the associations of diet quality as assessed by the Healthy Eating Index (HEI), the Alternate Healthy Eating Index (AHEI), and the Dietary Approaches to Stop Hypertension (DASH) score and the risk of all-cause mortality, cardiovascular mortality or incidence, cancer mortality or incidence, type 2 diabetes mellitus, and neurodegenerative diseases. A literature search was performed using the electronic databases MEDLINE, SCOPUS, and EMBASE with an end date of May 10, 2014. Study-specific risk ratios were pooled using a random effect model by the Cochrane software package Review Manager 5.2. Fifteen cohort studies (34 reports), including 1,020,642 subjects, met the criteria and were included in the meta-analysis. Diets of the highest quality, as assessed by the HEI, AHEI, and DASH score, resulted in a significant risk reduction (RR) for all-cause mortality (RR 0.78, 95% CI 0.76 to 0.80; P<0.00001; I2=61%, 95% CI 20% to 81%), cardiovascular disease (incidence or mortality) (RR 0.78, 95% CI 0.75 to 0.81; P<0.00001; I2=45%, 95% CI 13% to 66%), cancer (incidence or mortality) (RR 0.85, 95% CI 0.82 to 0.88; P<0.00001; I2=77%, 95% CI 68% to 84%), and type 2 diabetes mellitus (RR 0.78, 95% CI 0.72 to 0.85; P<0.00001; I2=74%, 95% CI 52% to 86%). Differences observed for neurodegenerative diseases were not significant. Egger regression tests provided no evidence of publication bias. Diets that score highly on the HEI, AHEI, and DASH are associated with a significant reduction in the risk of all-cause mortality, cardiovascular disease, cancer, and type 2 diabetes mellitus by 22%, 22%, 15%, and 22%, respectively, and therefore is of high public health relevance.

Section snippets

Methods

The review protocol has been registered in PROSPERO: The International Prospective Register of Systematic Reviews (crd.york.ac.uk/prospero/index.asp Identifier: CRD42013006561).

Literature Search and Study Characteristics

The detailed steps of the article selection process are given as a flow chart in Figure 3.

Altogether, 15 cohort studies (34 reports) extracted from 6,506 articles met the inclusion criteria and were included in the meta-analysis.12, 13, 14, 15, 16, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53

General study characteristics are given in Table 1. Sample size varied between 862 and 537,218 with a follow-up time ranging from 5 to

Discussion

There is an urgent need for interventions to reduce the incidence of CVD, cancer, type 2 diabetes mellitus, and neurodegenerative diseases, which continue to be the most common causes of death in the Western world since 1970.54, 55 In recent years, dietary pattern analysis has been used increasingly as an alternative method to traditional single nutrient analysis.56 The use of dietary patterns avoids focusing on single foods or nutrients that can be correlated with, or interact with, each other

Conclusions

Our systematic review and meta-analysis shows that high-quality diets, as assessed by the HEI, AHEI, and DASH scores, are associated with a reduced risk of all-cause mortality, manifestation of type 2 diabetes, and incidence or mortality due to cardiovascular disease and overall cancer, particularly colorectal cancer. This underlines the relevance of these indexes in clinical as well as public health settings.

L. Schwingshackl is a doctoral degree student, Department of Nutritional Sciences, University of Vienna, Austria.

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    L. Schwingshackl is a doctoral degree student, Department of Nutritional Sciences, University of Vienna, Austria.

    G. Hoffmann is a professor of nutritional sciences, Department of Nutritional Sciences, University of Vienna, Austria.

    Supplementary materials: Figures 1, 2, 10, 11, and 12 and Tables 3 through 8 are available online at www.andjrnl.org

    STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

    FUNDING/SUPPORT There is no funding to disclose.

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