RESEARCH
Review
Diet Quality as Assessed by the Healthy Eating
Index, Alternate Healthy Eating Index, Dietary
Approaches to Stop Hypertension Score, and
Health Outcomes: An Updated Systematic
Review and Meta-Analysis of Cohort Studies
Lukas Schwingshackl, MSc, PhD; Berit Bogensberger; Georg Hoffmann, PhD
ARTICLE INFORMATION
Article history:
Submitted 20 March 2017
Accepted 16 August 2017
Available online 27 October 2017
Keywords:
Alternate Healthy Eating Index
Dietary Approaches to Stop Hypertension (DASH)
diet
Health status
Healthy Eating Index
Meta-analysis
Supplementary materials:
Figures 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, and 15 and
Tables 3, 4, 5, 6, 7, and 8 are available at www.
jandonline.org
2212-2672/Copyright ª 2018 by the Academy of
Nutrition and Dietetics. This is an open access
article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jand.2017.08.024
ABSTRACT
Background Diets of the highest quality have been associated with a significantly
lower risk of noncommunicable diseases.
Objective It was the aim of this study to update a previous systematic review investigating
the associations of diet quality as assessed by the Healthy Eating Index (HEI),
Alternate Healthy Eating Index (AHEI), and Dietary Approaches to Stop Hypertension
(DASH) score and multiple health outcomes. As an additional topic, the associations of
these diet quality indices with all-cause mortality and cancer mortality among cancer
survivors were also investigated.
Design A literature search for prospective cohort studies that were published up to
May 15, 2017 was performed using the electronic databases PubMed, Scopus, and
Embase. Summary risk ratios (RRs) and 95% CIs were estimated using a random effects
model for high vs low adherence categories.
Results The updated review process showed 34 new reports (total number of reports
evaluated¼68; including 1,670,179 participants). Diets of the highest quality, as assessed
by the HEI, AHEI, and DASH score, resulted in a significant risk reduction for all-cause
mortality (RR 0.78, 95% CI 0.77 to 0.80; I2¼59%; n¼13), cardiovascular disease (incidence
or mortality) (RR 0.78, 95% CI 0.76 to 0.80; I2¼49%; n¼28), cancer (incidence or
mortality) (RR 0.84, 95% CI 0.82 to 0.87; I2¼66%; n¼31), type 2 diabetes (RR 0.82, 95% CI
0.78 to 0.85; I2¼72%; n¼10), and neurodegenerative diseases (RR 0.85, 95% CI 0.74 to 0.98;
I2¼51%; n¼5). Among cancer survivors, the association between diets for the highest
quality resulted in a significant reduction in all-cause mortality (RR 0.88, 95% CI 0.81 to
0.95; I2¼38%; n¼7) and cancer mortality (RR 0.90, 95% CI 0.83 to 0.98; I2¼0%; n¼7).
Conclusions In the updated meta-analyses, diets that score highly on the HEI, AHEI,
and DASH were associated with a significant reduction in the risk of all-cause mortality,
cardiovascular disease, cancer, type 2 diabetes, and neurodegenerative disease by 22%,
22%, 16%, 18%, and 15%, respectively. Moreover, high-quality diets were inversely associated
with overall mortality and cancer mortality among cancer survivors.
J Acad Nutr Diet. 2018;118:74-100.
IN FEBRUARY 2015, A SYSTEMATIC REVIEW AND METAanalysis
of prospective cohort studies investigating the
associations between diet quality, as assessed by the
Healthy Eating Index (HEI), Alternate Healthy Eating Index
(AHEI), and Dietary Approaches to Stop Hypertension
(DASH) score, and the risk of all-cause mortality, cardiovascular
disease mortality or events, cancer mortality or incidence,
type 2 diabetes, and neurodegenerative diseases was
published.1 Diets of the highest quality were associated with
a lower risk of all-cause mortality, cardiovascular disease,
cancer, and type 2 diabetes.1 However, due to the large
number of studies that have been published since the release
of the previous meta-analysis, it seems important to update
the original analysis.
According to the National Cancer Institute, the number of
cancer survivors is growing rapidly, with an estimated
number of 26.1 million by 2040 compared to 15.5 million in
2016.2 Due to the urgent need to establish evidence-based
nutrition recommendations for cancer survivors, it was
decided not only to re-execute the original search, but to
74 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
ª 2018 by the Academy of Nutrition and Dietetics. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).