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Research Review| Volume 118, ISSUE 1, P74-100.e11, January 2018

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

Open AccessPublished:October 27, 2017DOI:https://doi.org/10.1016/j.jand.2017.08.024
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
Previous ArticleDevelopment and Evaluation of a Dietary Approaches to Stop Hypertension Dietary Index with Calorie-Based Standards in Equivalent Units: A Cross-Sectional Study with 24-Hour Dietary Recalls from Adult Participants in the National Health and Nutrition Examination Survey 2007-2010
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      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 evaluated=68; 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; I2=59%; n=13), cardiovascular disease (incidence or mortality) (RR 0.78, 95% CI 0.76 to 0.80; I2=49%; n=28), cancer (incidence or mortality) (RR 0.84, 95% CI 0.82 to 0.87; I2=66%; n=31), type 2 diabetes (RR 0.82, 95% CI 0.78 to 0.85; I2=72%; n=10), and neurodegenerative diseases (RR 0.85, 95% CI 0.74 to 0.98; I2=51%; n=5). 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; I2=38%; n=7) and cancer mortality (RR 0.90, 95% CI 0.83 to 0.98; I2=0%; n=7).

      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.

      Keywords

      Research Question: Does diet quality, measured in term of the Healthy Eating Index, the Alternate Healthy Eating Index, and the Dietary Approaches to Stop Hypertension score, influence health status?
      Key Findings: In this updated systematic review and meta-analysis of 68 reports including 1,670,179 participants, diets that score highly were associated with a significant reduction in the risk of all-cause mortality (22%), cardiovascular disease (22%), cancer (16%), type 2 diabetes (18%), and neurodegenerative disease (15%). High-quality diets were also associated with a significant reduction in the risk of overall mortality (12%) and cancer mortality (10%) among cancer survivors.
      In February 2015, a systematic review and meta-analysis 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.
      • Schwingshackl L.
      • Hoffmann G.
      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.
      J Acad Nutr Diet. 2015; 115: 780-800.e785
      Diets of the highest quality were associated with a lower risk of all-cause mortality, cardiovascular disease, cancer, and type 2 diabetes.
      • Schwingshackl L.
      • Hoffmann G.
      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.
      J Acad Nutr Diet. 2015; 115: 780-800.e785
      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.
      • Bluethmann S.M.
      • Mariotto A.B.
      • Rowland J.H.
      Anticipating the “silver tsunami”: Prevalence trajectories and comorbidity burden among older cancer survivors in the United States.
      Cancer Epidemiol Biomarkers Prevention. 2016; 25: 1029-1036
      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 include associations between diet quality and risk of mortality in cancer survivors as an additional research question.
      Therefore, the aim of this study was to update the previous systematic review and meta-analysis conducted in prospective cohort studies that investigated the association of diet quality as assessed by the HEI, AHEI, and DASH score and health status (risk of all-cause mortality, cardiovascular disease mortality or incidence, cancer mortality or incidence, type 2 diabetes, and neurodegenerative disease). The second objective of this study was to summarize the evidence of diet quality as assessed by the HEI, AHEI, and DASH score and the risk of all-cause mortality and cancer mortality among cancer survivors.

      Methods

      The systematic review protocol of the previous meta-analysis is registered in PROSPERO International Prospective Register of Systematic Reviews (crd.york.ac.uk/prospero/index.asp Identifier: CRD42013006561). The protocol has meanwhile been adapted to the updated version of this systematic review.

      Data Sources and Searches

      A literature search was performed to identify studies published from May 2014 up to May 15, 2017 using the electronic databases PubMed, Embase, and Scopus. For PubMed, the following search terms were used: healthy [All Fields] AND (eating [medical subject heading {MeSH} Terms] OR eating [All Fields]) AND (abstracting and indexing as topic [MeSH Terms] OR (abstracting [All Fields] AND indexing [All Fields] AND topic [All Fields]) OR abstracting and indexing as topic [All Fields] OR index [All Fields]) OR (dash [All Fields] AND (diet [MeSH Terms] OR diet [All Fields]).
      The literature search investigating the association of diet quality indices and all-cause mortality and cancer mortality among cancer survivors was based on a recently published meta-analysis
      • Schwedhelm C.
      • Boeing H.
      • Hoffmann G.
      • Aleksandrova K.
      • Schwingshackl L.
      Effect of diet on mortality and cancer recurrence among cancer survivors: A systematic review and meta-analysis of cohort studies.
      Nutr Rev. 2016; 74: 737-748
      using Scopus as an additional database and was updated to include studies published up to May 15, 2017. The following search terms were used for PubMed: (healthy [All Fields] AND (eating [MeSH Terms] OR eating [All Fields]) AND (abstracting and indexing as topic [MeSH Terms] OR (abstracting [All Fields] AND indexing [All Fields] AND topic [All Fields]) OR abstracting and indexing as topic [All Fields] OR index [All Fields]) OR (dash [All Fields] AND (diet [MeSH Terms] OR diet [All Fields]) AND (cancer [All Fields]) AND (survivors [All Fields] OR survivor [All Fields] OR recurrence [All Fields] OR mortality [All Fields]) AND (prospective [All Fields] OR cohort [All Fields] OR longitudinal [All Fields] OR follow up [All Fields]).
      Both search strategies had no language restrictions. Moreover, the reference lists from retrieved articles were checked to search for further relevant studies. Literature searches were conducted by one author (L.S.), with questions or uncertainties resolved by discussion with another author.

      Study Selection

      Prospective cohort studies were included in the meta-analysis if they met all of the following criteria: evaluated the association of diet quality as assessed by the HEI, and/or AHEI, and/or DASH score on all-cause mortality, and/or cardiovascular disease mortality or incidence, and/or cancer mortality or incidence, and/or type 2 diabetes, and/or neurodegenerative disease; presented risk ratios (RRs) and/or hazard ratios (HRs) with corresponding 95% CI. In addition, the meta-analysis was expanded to include cancer survivors from cohort studies investigating the association of diet quality as assessed by the HEI, and/or AHEI, and/or DASH score and all-cause mortality and/or cancer mortality among cancer survivors. Detailed description of study selection is reported in the previous version,
      • Schwingshackl L.
      • Hoffmann G.
      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.
      J Acad Nutr Diet. 2015; 115: 780-800.e785
      the same study selection strategy was used for the additional research questions of the updated systematic review.

      Data Extraction and Quality Assessment

      The following data were extracted from each study as reported in the previous version
      • Schwingshackl L.
      • Hoffmann G.
      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.
      J Acad Nutr Diet. 2015; 115: 780-800.e785
      : the first author’s last name, year of publication, study origin, cohort name, outcome parameter, sample size, study length (follow up in years), age at entry, sex, diet quality score, adjustment factors, study quality score, and risk estimates (most adjusted HR or RR or highest vs lowest category) with their corresponding 95% CIs. The Newcastle-Ottawa Quality Assessment Scale

      Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed August 13, 2014.

      was used to assess study quality. Data extraction and quality assessment were performed by one author and checked by another (B.B.) for accuracy.

      HEI, AHEI, and DASH Components and Scoring

      A detailed description of the HEI
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      J Nutr. 2006; 136: 466-472
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      Am J Clin Nutr. 2000; 72: 1214-1222
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      Mayo Clin Proc. 2016; 91: 1372-1383
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      (HEI-2005
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      Alternative dietary indices both strongly predict risk of chronic disease.
      J Nutr. 2012; 142: 1009-1018
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      • Fung T.T.
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      Diet-quality scores and the risk of type 2 diabetes in men.
      Diabetes Care. 2011; 34: 1150-1156
      , 
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      Index-based dietary patterns and risk of head and neck cancer in a large prospective study.
      Am J Clin Nutr. 2014; 99: 559-566
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      Clin Gastroenterol Hepatol. 2013; 11: 1130-1136.e1132
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      Index-based dietary patterns and risk of colorectal cancer: The NIH-AARP Diet and Health Study.
      Am J Epidemiol. 2008; 168: 38-48
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      Better postdiagnosis diet quality is associated with reduced risk of death among postmenopausal women with invasive breast cancer in the women's health initiative.
      Cancer Dpidemiol Biomarkers Prev. 2014; 23: 575-583
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      Cancer Causes Control. 2011; 22: 589-598
      , 
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      Prediagnostic lifestyle factors and survival after colon and rectal cancer diagnosis in the National Institutes of Health (NIH)-AARP Diet and Health Study.
      Cancer. 2014; 120: 1540-1547
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      • Crane E
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      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
      J Natl Cancer Inst. 2014; 106
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      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      J Ovarian Res. 2014; 7: 112
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      A priori-defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort.
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      J Natl Cancer Inst. 2013; 105: 1298-1305
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      Index-based dietary patterns and the risk of prostate cancer in the NIH-AARP diet and health study.
      Am J Epidemiol. 2013; 177: 504-513
      and HEI-2010
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      Index-based dietary patterns and risk of incident hepatocellular carcinoma and mortality from chronic liver disease in a prospective study.
      Hepatology (Baltimore, Md.). 2014; 60: 588-597
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      J Nutr. 2014; 144: 881-889
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      Eur J Clin Nutr. 2016; 70: 123-129
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      • Tinker L.
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      Am J Epidemiol. 2016; 183: 622-633
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      Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: Evidence to inform national dietary guidance.
      Am J Epidemiol. 2014; 180: 616-625
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      • George S.M.
      • Ballard R.
      • Shikany J.M.
      • Crane T.E.
      • Neuhouser M.L.
      A prospective analysis of diet quality and endometrial cancer among 84,415 postmenopausal women in the Women's Health Initiative.
      Ann Epidemiol. 2015; 25: 788-793
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      • Haring B.
      • Wu C.
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      No association between dietary patterns and risk for cognitive decline in older women with 9-year follow-up: Data from the Women's Health Initiative Memory Study.
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      Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: The Dietary Patterns Methods Project.
      Am J Clin Nutr. 2015; 101: 587-597
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      Gastroenterology. 2017; 153: 386-394.e2
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      • George S.M.
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      Diet quality and colorectal cancer risk in the Women's Health Initiative Observational Study.
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      ), AHEI
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      • Newby P.K.
      • Willett W.C.
      • Holmes M.D.
      Diet quality is associated with the risk of estrogen receptor-negative breast cancer in postmenopausal women.
      J Nutr. 2006; 136: 466-472
      , 
      • de Koning L.
      • Chiuve S.E.
      • Fung T.T.
      • Willett W.C.
      • Rimm E.B.
      • Hu F.B.
      Diet-quality scores and the risk of type 2 diabetes in men.
      Diabetes Care. 2011; 34: 1150-1156
      , 
      • Reedy J.
      • Mitrou P.N.
      • Krebs-Smith S.M.
      • et al.
      Index-based dietary patterns and risk of colorectal cancer: The NIH-AARP Diet and Health Study.
      Am J Epidemiol. 2008; 168: 38-48
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      • Fung T.T.
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      • et al.
      Alternative dietary indices both strongly predict risk of chronic disease.
      J Nutr. 2012; 142: 1009-1018
      , 
      • Xie J.
      • Poole E.M.
      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      J Ovarian Res. 2014; 7: 112
      , 
      • Bosire C.
      • Stampfer M.J.
      • Subar A.F.
      • et al.
      Index-based dietary patterns and the risk of prostate cancer in the NIH-AARP diet and health study.
      Am J Epidemiol. 2013; 177: 504-513
      , 
      • Reedy J.
      • Krebs-Smith S.M.
      • Miller P.E.
      • et al.
      Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults.
      J Nutr. 2014; 144: 881-889
      , 
      • Anic G.M.
      • Park Y.
      • Subar A.F.
      • Schap T.E.
      • Reedy J.
      Index-based dietary patterns and risk of lung cancer in the NIH-AARP diet and health study.
      Eur J Clin Nutr. 2016; 70: 123-129
      , 
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      Am J Epidemiol. 2016; 183: 622-633
      , 
      • George S.M.
      • Ballard-Barbash R.
      • Manson J.E.
      • et al.
      Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: Evidence to inform national dietary guidance.
      Am J Epidemiol. 2014; 180: 616-625
      , 
      • George S.M.
      • Ballard R.
      • Shikany J.M.
      • Crane T.E.
      • Neuhouser M.L.
      A prospective analysis of diet quality and endometrial cancer among 84,415 postmenopausal women in the Women's Health Initiative.
      Ann Epidemiol. 2015; 25: 788-793
      , 
      • Haring B.
      • Wu C.
      • Mossavar-Rahmani Y.
      • et al.
      No association between dietary patterns and risk for cognitive decline in older women with 9-year follow-up: Data from the Women's Health Initiative Memory Study.
      J Acad Nutr Diet. 2016; 116: 921-930.e921
      , 
      • Harmon B.E.
      • Boushey C.J.
      • Shvetsov Y.B.
      • et al.
      Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: The Dietary Patterns Methods Project.
      Am J Clin Nutr. 2015; 101: 587-597
      , 
      • Jacobs S.
      • Harmon B.E.
      • Boushey C.J.
      • et al.
      A priori-defined diet quality indexes and risk of type 2 diabetes: The Multiethnic Cohort.
      Diabetologia. 2015; 58: 98-112
      , 
      • Jacobs S.
      • Harmon B.E.
      • Ollberding N.J.
      • et al.
      Among 4 diet quality indexes, only the Alternate Mediterranean Diet score is associated with better colorectal cancer survival and only in African American Women in the Multiethnic Cohort.
      J Nutr. 2016; 146: 1746-1755
      , 
      • Park S.Y.
      • Boushey C.J.
      • Wilkens L.R.
      • Haiman C.A.
      • Le Marchand L.
      High-quality diets associate with reduced risk of colorectal cancer: Analyses of diet quality indexes in the multiethnic cohort.
      Gastroenterology. 2017; 153: 386-394.e2
      , 
      • Vargas A.J.
      • Neuhouser M.L.
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      Haridass V. Diet quality scores and risk of incident breast cancer in the California Teachers Study 2015. (Dissertation). http://escholarship.org/uc/item/87t2942b. Accessed July 25, 2017.

      , 
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      Mertens E, Markey O, Geleijnse JM, Lovegrove JA, Givens DI. Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study [published online ahead of print March 14, 2017]. Eur J Nutr. https://doi.org/10.1007/s00394-017-1408-0.

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      ), and DASH score
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      , 
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      • Park Y.
      • Subar A.F.
      • Schap T.E.
      • Reedy J.
      Index-based dietary patterns and risk of lung cancer in the NIH-AARP diet and health study.
      Eur J Clin Nutr. 2016; 70: 123-129
      , 
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      Am J Epidemiol. 2016; 183: 622-633
      , 
      • George S.M.
      • Ballard-Barbash R.
      • Manson J.E.
      • et al.
      Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: Evidence to inform national dietary guidance.
      Am J Epidemiol. 2014; 180: 616-625
      , 
      • George S.M.
      • Ballard R.
      • Shikany J.M.
      • Crane T.E.
      • Neuhouser M.L.
      A prospective analysis of diet quality and endometrial cancer among 84,415 postmenopausal women in the Women's Health Initiative.
      Ann Epidemiol. 2015; 25: 788-793
      , 
      • Haring B.
      • Wu C.
      • Mossavar-Rahmani Y.
      • et al.
      No association between dietary patterns and risk for cognitive decline in older women with 9-year follow-up: Data from the Women's Health Initiative Memory Study.
      J Acad Nutr Diet. 2016; 116: 921-930.e921
      , 
      • Harmon B.E.
      • Boushey C.J.
      • Shvetsov Y.B.
      • et al.
      Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: The Dietary Patterns Methods Project.
      Am J Clin Nutr. 2015; 101: 587-597
      , 
      • Jacobs S.
      • Harmon B.E.
      • Boushey C.J.
      • et al.
      A priori-defined diet quality indexes and risk of type 2 diabetes: The Multiethnic Cohort.
      Diabetologia. 2015; 58: 98-112
      , 
      • Jacobs S.
      • Harmon B.E.
      • Ollberding N.J.
      • et al.
      Among 4 diet quality indexes, only the Alternate Mediterranean Diet score is associated with better colorectal cancer survival and only in African American Women in the Multiethnic Cohort.
      J Nutr. 2016; 146: 1746-1755
      , 
      • Lassale C.
      • Gunter M.J.
      • Romaguera D.
      • et al.
      Diet quality scores and prediction of all-cause, cardiovascular and cancer mortality in a Pan-European Cohort Study.
      PLoS One. 2016; 11: e0159025
      , 
      • Park S.Y.
      • Boushey C.J.
      • Wilkens L.R.
      • Haiman C.A.
      • Le Marchand L.
      High-quality diets associate with reduced risk of colorectal cancer: Analyses of diet quality indexes in the multiethnic cohort.
      Gastroenterology. 2017; 153: 386-394.e2
      , 
      • Vargas A.J.
      • Neuhouser M.L.
      • George S.M.
      • et al.
      Diet quality and colorectal cancer risk in the Women's Health Initiative Observational Study.
      Am J Epidemiol. 2016; 184: 23-32
      , 
      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
      Diabetologia. 2014; 57: 321-333
      , 
      • Tobias D.K.
      • Hu F.B.
      • Chavarro J.
      • Rosner B.
      • Mozaffarian D.
      • Zhang C.
      Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus.
      Arch Intern Med. 2012; 172: 1566-1572
      , 
      • Del Gobbo L.C.
      • Kalantarian S.
      • Imamura F.
      • et al.
      Contribution of major lifestyle risk factors for incident heart failure in older adults: The Cardiovascular Health Study.
      JACC. Heart Fail. 2015; 3: 520-528
      , 
      • Djousse L.
      • Petrone A.
      • Gaziano J.M.
      Alternate Healthy Eating Index, Mediterranean and DASH dietary patterns and risk of death in the physician's health study.
      Cardiology (Switzerland). 2014; 128 (Abstract): 426
      , 
      • Otto M.C.
      • Padhye N.S.
      • Bertoni A.G.
      • Jacobs Jr., D.R.
      • Mozaffarian D.
      Everything in moderation—Dietary diversity and quality, central obesity and risk of diabetes.
      PLoS One. 2015; 10: e0141341
      , 
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      PLoS One. 2014; 9: e115377
      , 

      Haridass V. Diet quality scores and risk of incident breast cancer in the California Teachers Study 2015. (Dissertation). http://escholarship.org/uc/item/87t2942b. Accessed July 25, 2017.

      , 
      • Izano M.A.
      • Fung T.T.
      • Chiuve S.S.
      • Hu F.B.
      • Holmes M.D.
      Are diet quality scores after breast cancer diagnosis associated with improved breast cancer survival?.
      Nutr Cancer. 2013; 65: 820-826
      , 

      Mertens E, Markey O, Geleijnse JM, Lovegrove JA, Givens DI. Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study [published online ahead of print March 14, 2017]. Eur J Nutr. https://doi.org/10.1007/s00394-017-1408-0.

      , 
      • Yu D.
      • Zhang X.
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      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      J Nutr. 2015; 145: 547-554
      , 
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      • Hakansson N.
      • Wolk A.
      Healthy dietary patterns and incidence of biliary tract and gallbladder cancer in a prospective study of women and men.
      Eur J Cancer. 2017; 70: 42-47
      , 
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      • Wallin A.
      • Wolk A.
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      MIND diet associated with reduced incidence of Alzheimer's disease.
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      and its different updates and modifications are reported in the previous version of the systematic review.
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      Statistical Analysis

      The meta-analysis was performed by combining the multivariable adjusted RRs, HR, or ORs of the highest compared with the lowest quantiles of HEI, AHEI, and DASH scores conformance category based on random-effects model using the DerSimonian-Laird method.
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      Because outcomes were not very rare and heterogeneity modeling was deemed important, the random-effects model was used. To evaluate the weighting of each study, the standard error for the logarithm HR/RR/OR of each study was calculated and regarded as the estimated variance of the logarithm HR/RR/OR, using an inverse variance method.
      • DerSimonian R.
      • Laird N.
      Meta-analysis in clinical trials.
      Control Clin Trials. 1986; 7: 177-188
      Meta-analysis was based on the assumption that all measures are RRs.
      Studies were grouped according to the different clinical outcomes (ie, all-cause mortality, cardiovascular disease mortality or incidence, cancer mortality or incidence, type 2 diabetes, neurodegenerative diseases, and all-cause mortality and cancer mortality among cancer survivors). As described previously, subgroup analyses were performed for the HEI, AHEI, and for the DASH score, and by comparing the HEI vs HEI-2005 vs HEI-2010, and the AHEI vs AHEI-2010. Additional subgroup analyses included US studies, longer-term follow-up studies, high-quality studies, stratified analysis by sex, and comparing incidence and mortality outcomes for cardiovascular disease and cancer. Heterogeneity, funnel plots, and test for small study effects were performed as reported in the previous version.
      • Schwingshackl L.
      • Hoffmann G.
      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.
      J Acad Nutr Diet. 2015; 115: 780-800.e785
      The heterogi command in STATA was used to calculate the CIs for the heterogeneity estimates.
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      • Patsopoulos N.A.
      • Evangelou E.
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      BMJ. 2007; 335: 914-916
      All analyses were conducted using the Review Manager by the Cochrane Collaboration (version 5.3)

      Review Manager (RevMan) [computer program]. Version 5.3. Copenhagen, The Netherlands: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014.

      and STATA.

      STATA [computer program]. Release 14. College Station, TX: StataCorp LP; 2015.

      Results

      Literature Search and Study Characteristics

      The detailed steps of the updated meta-analysis article search and selection process are given as an adapted PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram (Figure 1).
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      Figure thumbnail gr1
      Figure 1Updated flow chart for the article selection process for a meta-analysis of the associations of diet quality as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension score and health outcomes. aCVD=cardiovascular disease. bT2D=type 2 diabetes.
      Taken together, 34 additional reports were identified that were not included in the previous meta-analysis.
      • Park Y.M.
      • Fung T.T.
      • Steck S.E.
      • et al.
      Diet quality and mortality risk in metabolically obese normal-weight adults.
      Mayo Clin Proc. 2016; 91: 1372-1383
      , 
      • Shahar D.R.
      • Yu B.
      • Houston D.K.
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      Dietary factors in relation to daily activity energy expenditure and mortality among older adults.
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      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
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      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      J Ovarian Res. 2014; 7: 112
      , 
      • Anic G.M.
      • Park Y.
      • Subar A.F.
      • Schap T.E.
      • Reedy J.
      Index-based dietary patterns and risk of lung cancer in the NIH-AARP diet and health study.
      Eur J Clin Nutr. 2016; 70: 123-129
      , 
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      Am J Epidemiol. 2016; 183: 622-633
      , 
      • George S.M.
      • Ballard-Barbash R.
      • Manson J.E.
      • et al.
      Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: Evidence to inform national dietary guidance.
      Am J Epidemiol. 2014; 180: 616-625
      , 
      • George S.M.
      • Ballard R.
      • Shikany J.M.
      • Crane T.E.
      • Neuhouser M.L.
      A prospective analysis of diet quality and endometrial cancer among 84,415 postmenopausal women in the Women's Health Initiative.
      Ann Epidemiol. 2015; 25: 788-793
      , 
      • Haring B.
      • Wu C.
      • Mossavar-Rahmani Y.
      • et al.
      No association between dietary patterns and risk for cognitive decline in older women with 9-year follow-up: Data from the Women's Health Initiative Memory Study.
      J Acad Nutr Diet. 2016; 116: 921-930.e921
      , 
      • Harmon B.E.
      • Boushey C.J.
      • Shvetsov Y.B.
      • et al.
      Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: The Dietary Patterns Methods Project.
      Am J Clin Nutr. 2015; 101: 587-597
      , 
      • Jacobs S.
      • Harmon B.E.
      • Boushey C.J.
      • et al.
      A priori-defined diet quality indexes and risk of type 2 diabetes: The Multiethnic Cohort.
      Diabetologia. 2015; 58: 98-112
      , 
      • Jacobs S.
      • Harmon B.E.
      • Ollberding N.J.
      • et al.
      Among 4 diet quality indexes, only the Alternate Mediterranean Diet score is associated with better colorectal cancer survival and only in African American Women in the Multiethnic Cohort.
      J Nutr. 2016; 146: 1746-1755
      , 
      • Lassale C.
      • Gunter M.J.
      • Romaguera D.
      • et al.
      Diet quality scores and prediction of all-cause, cardiovascular and cancer mortality in a Pan-European Cohort Study.
      PLoS One. 2016; 11: e0159025
      , 
      • Park S.Y.
      • Boushey C.J.
      • Wilkens L.R.
      • Haiman C.A.
      • Le Marchand L.
      High-quality diets associate with reduced risk of colorectal cancer: Analyses of diet quality indexes in the multiethnic cohort.
      Gastroenterology. 2017; 153: 386-394.e2
      , 
      • Vargas A.J.
      • Neuhouser M.L.
      • George S.M.
      • et al.
      Diet quality and colorectal cancer risk in the Women's Health Initiative Observational Study.
      Am J Epidemiol. 2016; 184: 23-32
      , 
      • Yu D.
      • Sonderman J.
      • Buchowski M.S.
      • et al.
      Healthy eating and risks of total and cause-specific death among low-income populations of African-Americans and other adults in the southeastern United States: A prospective cohort study.
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      • Del Gobbo L.C.
      • Kalantarian S.
      • Imamura F.
      • et al.
      Contribution of major lifestyle risk factors for incident heart failure in older adults: The Cardiovascular Health Study.
      JACC. Heart Fail. 2015; 3: 520-528
      , 
      • Djousse L.
      • Petrone A.
      • Gaziano J.M.
      Alternate Healthy Eating Index, Mediterranean and DASH dietary patterns and risk of death in the physician's health study.
      Cardiology (Switzerland). 2014; 128 (Abstract): 426
      , 
      • Otto M.C.
      • Padhye N.S.
      • Bertoni A.G.
      • Jacobs Jr., D.R.
      • Mozaffarian D.
      Everything in moderation—Dietary diversity and quality, central obesity and risk of diabetes.
      PLoS One. 2015; 10: e0141341
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      • Smyth A.
      • Dehghan M.
      • O'Donnell M.
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      Healthy eating and reduced risk of cognitive decline: A cohort from 40 countries.
      Neurology. 2015; 84: 2258-2265
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      • Dugue P.A.
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      • Brinkman M.T.
      • et al.
      Association between selected dietary scores and the risk of urothelial cell carcinoma: A prospective cohort study.
      Int J Cancer. 2016; 139: 1251-1260
      , 
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      PLoS One. 2014; 9: e115377
      , 

      Haridass V. Diet quality scores and risk of incident breast cancer in the California Teachers Study 2015. (Dissertation). http://escholarship.org/uc/item/87t2942b. Accessed July 25, 2017.

      , 
      • Izano M.A.
      • Fung T.T.
      • Chiuve S.S.
      • Hu F.B.
      • Holmes M.D.
      Are diet quality scores after breast cancer diagnosis associated with improved breast cancer survival?.
      Nutr Cancer. 2013; 65: 820-826
      , 

      Mertens E, Markey O, Geleijnse JM, Lovegrove JA, Givens DI. Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study [published online ahead of print March 14, 2017]. Eur J Nutr. https://doi.org/10.1007/s00394-017-1408-0.

      , 
      • Neelakantan N.
      • Naidoo N.
      • Koh W.P.
      • Yuan J.M.
      • van Dam R.M.
      The Alternative Healthy Eating Index is associated with a lower risk of fatal and nonfatal acute myocardial infarction in a Chinese Adult Population.
      J Nutr. 2016; 146: 1379-1386
      , 
      • Yu D.
      • Zhang X.
      • Xiang Y.B.
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      Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 134,000 Chinese adults in urban Shanghai.
      Am J Clin Nutr. 2014; 100: 693-700
      , 
      • Boggs D.A.
      • Ban Y.
      • Palmer J.R.
      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      J Nutr. 2015; 145: 547-554
      , 
      • Larsson S.C.
      • Hakansson N.
      • Wolk A.
      Healthy dietary patterns and incidence of biliary tract and gallbladder cancer in a prospective study of women and men.
      Eur J Cancer. 2017; 70: 42-47
      , 
      • Larsson S.C.
      • Wallin A.
      • Wolk A.
      Dietary Approaches to Stop Hypertension Diet and incidence of stroke: Results from 2 prospective cohorts.
      Stroke. 2016; 47: 986-990
      , 
      • Morris M.C.
      • Tangney C.C.
      • Wang Y.
      • Sacks F.M.
      • Bennett D.A.
      • Aggarwal N.T.
      MIND diet associated with reduced incidence of Alzheimer's disease.
      Alzheimer Dement. 2015; 11: 1007-1014
      General study characteristics are summarized in Table 1. Sample size varied between 298 and 460,770, with a follow-up time ranging from 3 to 24 years. Overall, 68 reports,
      • Fung T.T.
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      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
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      Diabetes Care. 2009; 32: 1434-1436
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      and cancer mortality among cancer survivors in 7 reports.
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      Cancer Dpidemiol Biomarkers Prev. 2014; 23: 575-583
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      Cancer. 2014; 120: 1540-1547
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      • Thomson C.A.
      • Crane E
      • Wertheim B.C.
      • et al.
      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
      J Natl Cancer Inst. 2014; 106
      , 
      • Jacobs S.
      • Harmon B.E.
      • Ollberding N.J.
      • et al.
      Among 4 diet quality indexes, only the Alternate Mediterranean Diet score is associated with better colorectal cancer survival and only in African American Women in the Multiethnic Cohort.
      J Nutr. 2016; 146: 1746-1755
      , 
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
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      Post diagnosis diet quality and colorectal cancer survival in women.
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      , 
      • Izano M.A.
      • Fung T.T.
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      Table 1Summary of characteristics and results from 34 reports that investigate the associations of diet quality as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, and the Dietary Approaches to Stop Hypertension score and the risk of all-cause mortality, cardiovascular disease mortality, cardiovascular disease incidence, cancer mortality, cancer incidence, type 2 diabetes mellitus, neurodegenerative diseases, as well as all-cause mortality and cancer mortality among cancer survivors
      Author(s), yearCountryCohortOutcomePopulation, n

      Follow up, y      		Age at entry, ySexDiet quality index/scoreAdjustmentRR
      RR=risk ratio.
      /HR
      HR=hazard ratio.
      (95% CI),

      multivariate adjusted
      In case of multiple HR/RR values, the order in which data are given correspond to the respective order of outcomes listed in the “Outcomes” column.
      		Newcastle Ottawa Quality Assessment Scale

      Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed August 13, 2014.

      (maximum 9)
      Higher scores indicate higher-quality studies.
      Anic and colleagues, 2016
      • Anic G.M.
      • Park Y.
      • Subar A.F.
      • Schap T.E.
      • Reedy J.
      Index-based dietary patterns and risk of lung cancer in the NIH-AARP diet and health study.
      Eur J Clin Nutr. 2016; 70: 123-129
      		US
      US=United States.
      		National Institutes of Health, American Association of Retired Persons Diet and Health Study cohortLung cancer460,770

      10.5      		50-71BothHEI
      HEI=Healthy Eating Index.
      (2010)

      AHEI
      AHEI=Alternate Healthy Eating Index.
      (2010)

      DASH
      DASH=Dietary Approaches to Stop Hypertension.
      score      		Age, sex, race/ethnicity, education, BMI, physical activity, energy intake, smoking status, cigarettes per day, time since quitting smoking, regular use of cigars/pipesLung cancer
      • HEI (2010)
        • HR 0.83 (0.77-0.89)
      • AHEI (2010)
        • HR 0.86 (0.80-0.92)
      • DASH score
        • HR 0.84 (0.78-0.90)
      		8
      Boggs and colleagues, 2015
      • Boggs D.A.
      • Ban Y.
      • Palmer J.R.
      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      J Nutr. 2015; 145: 547-554
      		USBlack Women’s Health StudyAll-cause mortality37,001

      16      		30-69♀
      ♀=women.
      		DASH scoreAge, each DASH component, energy intake, education, marital status, physical activity, television watching, smoking status, alcohol consumptionAll-cause mortality
      • DASH score
      • HR 0.75 (0.63-0.89)
      		9
      Cespedes and colleagues, 2016
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      Am J Epidemiol. 2016; 183: 622-633
      		USWHI
      WHI=Women’s Health Initiative.
      -Dietary Modification Trial and WHI- Observational Study      		T2D
      T2D=type 2 diabetes.
      		101,504

      15      		50-79♀HEI (2010)

      AHEI (2010)

      DASH score      		Age, race/ethnicity, education, physical activity during recreational activities, use of postmenopausal HT
      HT=hormone therapy.
      , family history of diabetes, smoking status, study arm, energy intake, BMI
      BMI=body mass index.
      		T2D
      • HEI (2010)
        • HR 0.83 (0.78-0.89)
      • AHEI (2010)
        • HR 0.78 (0.73-0.83)
      • DASH score
        • HR 0.74 (0.69-0.80)
      		8
      Del Gobbo and colleagues, 2015
      • Del Gobbo L.C.
      • Kalantarian S.
      • Imamura F.
      • et al.
      Contribution of major lifestyle risk factors for incident heart failure in older adults: The Cardiovascular Health Study.
      JACC. Heart Fail. 2015; 3: 520-528
      		USCardiovascular Health StudyHeart failure incidence4,490

      21.5      		≥65BothAHEI

      DASH score      		Age, sex, race/ethnicity, enrollment source, education, income, physical activity, walking pace, smoking status, alcohol consumption, BMI, diabetes status, history of coronary heart disease, prevalent treated hypertensionAHEI
      • HR 0.90 (0.74-1.09)
      DASH score
      • HR 1.05 (0.88-1.26)
      		7
      Djousse and colleagues, 2014
      • Djousse L.
      • Petrone A.
      • Gaziano J.M.
      Alternate Healthy Eating Index, Mediterranean and DASH dietary patterns and risk of death in the physician's health study.
      Cardiology (Switzerland). 2014; 128 (Abstract): 426
      		USPhysicians' Health StudyAll-cause mortality

      CVD
      CVD=cardiovascular disease.
      mortality

      Cancer mortality      		19,619

      20      		≥40♂
      ♂=men.
      		AHEI

      DASH score      		NA
      NA=no data available.
      		All-cause mortality
      • AHEI
        • HR 0.59 (0.52-0.68)
      • DASH score
        • HR 0.81 (0.71-0.93)
      CVD mortality
      • AHEI
        • HR 0.62 (0.48-0.80)
      • DASH score
        • HR 0.90 (0.70-1.17)
      Cancer mortality
      • AHEI
        • HR 0.68 (0.54-0.86)
      • DASH score
        • HR 0.93 (0.74-1.18)
      		Quality assessment not possible because only abstract was available
      Dugue and colleagues, 2016
      • Dugue P.A.
      • Hodge A.M.
      • Brinkman M.T.
      • et al.
      Association between selected dietary scores and the risk of urothelial cell carcinoma: A prospective cohort study.
      Int J Cancer. 2016; 139: 1251-1260
      		AustraliaMelbourne Collaborative Cohort StudyUrothelial cell carcinoma incidence41,514

      21.3      		27-76BothAHEI (2010)Sex, country of birth, smoking status, alcohol consumption, BMI; physical activity, education, socioeconomic statusUrothelial cell carcinoma incidence
      • AHEI (2010)
        • HR 1.02 (0.73-1.43)
      		9
      Fung and colleagues, 2014
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      PLoS One. 2014; 9: e115377
      		USNurses’ Health StudyAll-cause mortality

      Colorectal cancer mortality      		1,201 colorectal cancer survivors

      11.2      		61-72♀AHEI (2010)

      DASH score      		Age, physical activity, BMI, weight change, cancer grade, chemotherapy, smoking status, energy intake, colon or rectal cancer, stage of disease, date of colorectal cancer diagnosisAll-cause mortality
      • AHEI (2010)
        • HR 0.71 (0.52-0.98)
      • DASH score
        • HR 0.98 (0.71-1.35)
      Colorectal cancer mortality
      • AHEI (2010)
        • HR 0.72 (0.43-1.21)
      • DASH score
        • HR 0.87 (0.52-1.45)
      		8
      George and colleagues, 2011
      • George S.M.
      • Irwin M.L.
      • Smith A.W.
      • et al.
      Postdiagnosis diet quality, the combination of diet quality and recreational physical activity, and prognosis after early-stage breast cancer.
      Cancer Causes Control. 2011; 22: 589-598
      		USHealth, Eating, Activity, and Lifestyle StudyAll-cause mortality

      Breast cancer mortality      		670 breast cancer survivors

      6      		≥18♀HEI (2005)Energy intake, physical activity, race/ethnicity, stage, tamoxifen use, BMIHEI (2005)
      • All-cause mortality
        • HR 0.40 (0.17-0.94)
      • Breast cancer mortality
        • HR 0.12 (0.02-0.99)
      		8
      George and colleagues, 2014
      • George S.M.
      • Ballard-Barbash R.
      • Shikany J.M.
      • et al.
      Better postdiagnosis diet quality is associated with reduced risk of death among postmenopausal women with invasive breast cancer in the women's health initiative.
      Cancer Dpidemiol Biomarkers Prev. 2014; 23: 575-583
      		USWHI-Dietary Modification Trial and WHI- Observational StudyAll-cause mortality

      Breast cancer mortality      		2,317 breast cancer survivors

      9.6      		50-79♀HEI (2005)Age at screening visit, WHI component, race/ethnicity, income, education, stage of disease, estrogen receptor status, progesterone receptor status, time since diagnosis, energy intake, physical activity, alcohol consumption, use of postmenopausal HTHEI (2005)
      • All-cause mortality
        • HR 0.74 (0.55-0.99)
      • Breast cancer mortality
        • HR 0.91 (0.60-1.40)
      		8
      George and colleagues, 2014
      • George S.M.
      • Ballard-Barbash R.
      • Manson J.E.
      • et al.
      Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: Evidence to inform national dietary guidance.
      Am J Epidemiol. 2014; 180: 616-625
      		USWHI-Observational StudyAll-cause mortality

      CVD mortality

      Cancer mortality      		63,805

      12.9      		50-79♀HEI (2010)

      AHEI (2010)

      DASH score      		Age, energy intake, race/ethnicity, education, marital status, smoking status, physical activity, use of postmenopausal HT, BMI, alcohol consumption (except for AHEI), diabetes statusAll-cause mortality
      • HEI (2010)
        • HR 0.76 (0.70-0.83)
      • AHEI (2010)
        • HR 0.82 (0.76-0.90)
      • DASH score
        • HR 0.76 (0.70-0.83)
      CVD mortality
      • HEI (2010)
        • HR 0.78 (0.65-0.93)
      • AHEI (2010)
        • HR 0.81 (0.68-0.96)
      • DASH score
        • HR 0.76 (0.65-0.90)
      Cancer mortality
      • HEI (2010)
        • HR 0.77 (0.68-0.89)
      • AHEI (2010)
        • HR 0.93 (0.81-1.06)
      • DASH score
        • HR 0.80 (0.70-0.91)
      		8
      George and colleagues, 2015
      • George S.M.
      • Ballard R.
      • Shikany J.M.
      • Crane T.E.
      • Neuhouser M.L.
      A prospective analysis of diet quality and endometrial cancer among 84,415 postmenopausal women in the Women's Health Initiative.
      Ann Epidemiol. 2015; 25: 788-793
      		USWHI-Observational StudyEndometrial cancer incidence84,415

      13.3      		50-79♀HEI (2010)

      AHEI (2010)

      DASH score      		Age, energy intake, race/ethnicity, education, physical activity during recreational activities, diabetes status, use of postmenopausal HT, oral contraceptive use, age at first birth, participant in observational study, participant in HT trial, participant in dietary modification trial, alcohol consumption (except for AHEI (2010), BMIEndometrial cancer incidence
      • HEI (2010)
        • HR 1.11 (0.93-1.33)
      • AHEI (2010)
        • HR 0.98 (0.82-1.17)
      • DASH score
        • HR 1.00 (0.84-1.19)
      		8
      Haridass, 2015

      Haridass V. Diet quality scores and risk of incident breast cancer in the California Teachers Study 2015. (Dissertation). http://escholarship.org/uc/item/87t2942b. Accessed July 25, 2017.

      		USCalifornia

      Teacher Study      		Invasive breast cancer incidence94,404

      16      		22-104♀AHEI (2010)

      DASH score      		Menopausal status, family history of breast cancer, race/ethnicity, age at menarche, smoking status, socioeconomic status, physical activity, BMI, daily vitamin use, energy intakeInvasive breast cancer incidence
      • AHEI (2010)
        • HR 0.87 (0.79-0.97)
      • DASH score
        • HR 0.88 (0.79-0.97)
      		8
      Haring and colleagues, 2016
      • Haring B.
      • Wu C.
      • Mossavar-Rahmani Y.
      • et al.
      No association between dietary patterns and risk for cognitive decline in older women with 9-year follow-up: Data from the Women's Health Initiative Memory Study.
      J Acad Nutr Diet. 2016; 116: 921-930.e921
      		USWHI-Memory StudyMild cognitive impairment or probable dementia incidence6,425

      9      		65-79♀HEI (2010)

      AHEI (2010)

      DASH score      		Age, race/ethnicity, education, WHI Hormone Trial randomization assignment, baseline Modified Mini-Mental State Examination score, smoking status, physical activity, diabetes status, hypertension status, BMI, income, depression, history of CVD, energy intakeMild cognitive impairment or probable dementia incidence
      • HEI (2010)
        • HR 1.12 (0.87-1.44)
      • AHEI (2010)
        • HR 0.82 (0.64-1.07)
      • DASH score
        • HR 0.93 (0.81-1.22)
      		7
      Harmon and colleagues, 2015
      • Harmon B.E.
      • Boushey C.J.
      • Shvetsov Y.B.
      • et al.
      Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: The Dietary Patterns Methods Project.
      Am J Clin Nutr. 2015; 101: 587-597
      		USMulti-ethnic

      Cohort      		All-cause mortality

      CVD mortality

      Cancer mortality      		215,782

      13-18      		45-75BothHEI (2010)

      AHEI (2010)

      DASH score      		Age, BMI, diabetes status, energy intake, race/ethnicity, education, marital status, smoking status, alcohol consumption (except for AHEI (2010)), use of postmenopausal HT (only for ♀), physical activityAll-cause mortality
      • HEI (2010)
        • ♂HR 0.75 (0.71-0.79)
        • ♀HR 0.79 (0.75-0.83)
      • AHEI (2010)
        • ♂HR 0.78 (0.74-0.82)
        • ♀HR 0.78 (0.74-0.82)
      • DASH score
        • ♂HR 0.81 (0.77-0.85)
        • ♀HR 0.80 (0.75-0.84)
      CVD-mortality
      • HEI (2010)
        • ♂HR 0.74 (0.69-0.81)
        • ♀HR 0.77 (0.71-0.84)
      • AHEI (2010)
        • ♂HR 0.79 (0.72-0.86)
        • ♀HR 0.76 (0.69-0.83)
      • DASH score
        • ♂HR 0.83 (0.76-0.91)
        • ♀HR 0.78 (0.71-0.85)
      Cancer mortality
      • HEI (2010)
        • ♂HR 0.76 (0.70-0.83)
        • ♀HR 0.89 (0.81-0.98)
      • AHEI (2010)
        • ♂HR 0.83 (0.76-0.90)
        • ♀HR 0.85 (0.77-0.93)
      • DASH score
        • ♂HR 0.78 (0.71-0.85)
        • ♀HR 0.86 (0.78-0.95)
      		9
      Izano and colleagues, 2013
      • Izano M.A.
      • Fung T.T.
      • Chiuve S.S.
      • Hu F.B.
      • Holmes M.D.
      Are diet quality scores after breast cancer diagnosis associated with improved breast cancer survival?.
      Nutr Cancer. 2013; 65: 820-826
      		USNurses’ Health StudyBreast cancer mortality

      Non-breast cancer mortality      		4,103 breast cancer survivors

      9.33      		30-55♀AHEI (2010)

      DASH score      		Age at diagnosis, energy intake, BMI, BMI change, age at first birth, parity, oral contraceptive use, menopausal status, use of postmenopausal HT, smoking status, stage of disease, radiation treatment, chemotherapy and HT, physical activityBreast cancer mortality
      • AHEI (2010)
        • RR 1.07 (0.77-1.49)
      • DASH score
        • RR 0.85 (0.61-1.19)
      Non-breast cancer mortality
      • AHEI (2010)
        • RR 0.57 (0.42-0.77)
      • DASH score
        • RR 0.72 (0.53-0.99)
      		8
      Jacobs and colleagues, 2015
      • Jacobs S.
      • Harmon B.E.
      • Boushey C.J.
      • et al.
      A priori-defined diet quality indexes and risk of type 2 diabetes: The Multiethnic Cohort.
      Diabetologia. 2015; 58: 98-112
      		USMulti-ethnic

      Cohort      		T2D89,185

      NA      		45-75BothHEI (2010)

      AHEI (2010)

      DASH score      		Physical activity, smoking status, education, energy intake, BMIT2D
      • HEI (2010)
        • ♂HR 0.93 (0.85-1.01)
        • ♀HR 0.92 (0.84-1.01)
      • AHEI (2010)
        • ♂HR 0.88 (0.81-0.96)
        • ♀ HR 0.88 (0.80-0.97)
      • DASH score
        • ♂HR 0.79 (0.73-0.87)
        • ♀ HR 0.77 (0.70-0.84)
      		9
      Jacobs and colleagues, 2016
      • Jacobs S.
      • Harmon B.E.
      • Ollberding N.J.
      • et al.
      Among 4 diet quality indexes, only the Alternate Mediterranean Diet score is associated with better colorectal cancer survival and only in African American Women in the Multiethnic Cohort.
      J Nutr. 2016; 146: 1746-1755
      		USMulti-ethnic

      Cohort      		All-cause mortality

      Colorectal cancer mortality      		4,204 colorectal cancer survivors

      6      		45-75BothHEI (2010)

      AHEI (2010)

      DASH score      		Age at diagnosis, race/ethnicity, stage at diagnosis, energy intake, smoking status, pack-years of smoking, physical activity, education, radiation treatment, chemotherapy, nonsteroidal anti-inflammatory drug use, family history of colorectal cancer, comorbiditiesAll-cause mortality
      • HEI (2010)
        • ♂HR 0.91 (0.76-1.09)
        • ♀HR 0.89 (0.72-1.09)
      • AHEI (2010)
      • ♂HR 1.08 (0.90-1.28)
      • ♀HR 0.83 (0.67-1.03)
      • DASH score
        • ♂HR 1.06 (0.87-1.28)
        • ♀HR 0.97 (0.77-1.22)
      Colorectal cancer mortality
      • HEI (2010)
        • ♂HR 0.85 (0.66-1.08)
        • ♀HR 0.76 (0.58-1.01)
      • AHEI (2010)
        • ♂HR 1.07 (0.84-1.36)
        • ♀HR 0.81 (0.61-1.07)
      • DASH score
        • ♂HR 1.05 (0.81-1.37)
        • ♀HR 0.88 (0.64-1.19)
      		8
      Larsson and colleagues, 2016
      • Larsson S.C.
      • Wallin A.
      • Wolk A.
      Dietary Approaches to Stop Hypertension Diet and incidence of stroke: Results from 2 prospective cohorts.
      Stroke. 2016; 47: 986-990
      		SwedenCohort of Swedish Men and Swedish Mammography cohortIschemic stroke incidence

      Intracerebral hemorrhages incidence

      Subarachnoid hemorrhages incidence      		74,404

      11.9      		45-83Bothm
      m=modified.
      DASH score      		Education, family history of myocardial infarction before 60 years of age, smoking status, pack-years of smoking, aspirin use, walking/bicycling, physical activity, BMI, history of hypertension, hypercholesterolemia, diabetes, and atrial fibrillation, energy intake, alcohol consumptionmDASH score

      Ischemic stroke incidence
      • RR 0.86 (0.78-0.94)
      Intracerebral hemorrhages incidence
      • RR 0.81 (0.63-1.05)
      Subarachnoid hemorrhages incidence
      • RR 0.95 (0.60-1.50)
      		8
      Larsson and colleagues, 2017
      • Larsson S.C.
      • Hakansson N.
      • Wolk A.
      Healthy dietary patterns and incidence of biliary tract and gallbladder cancer in a prospective study of women and men.
      Eur J Cancer. 2017; 70: 42-47
      		SwedenCohort of Swedish Men and Swedish Mammography cohortExtrahepatic biliary tract cancer incidence, Gallbladder cancer incidence, Intrahepatic biliary tract cancer incidence76,014

      13.3      		45-83BothmDASH scoreAge, sex, education, smoking status, pack-years of smoking, diabetes status, BMI, energy intakemDASH score

      Extrahepatic biliary tract cancer incidence
      • HR 0.41 (0.26-0.64)
      Gallbladder cancer incidence
      • HR 0.36 (0.20-0.64)
      Intrahepatic biliary tract cancer incidence
      • HR 0.36 (0.11-1.21)
      		8
      Lassale and colleagues, 2016
      • Lassale C.
      • Gunter M.J.
      • Romaguera D.
      • et al.
      Diet quality scores and prediction of all-cause, cardiovascular and cancer mortality in a Pan-European Cohort Study.
      PLoS One. 2016; 11: e0159025
      		EuropeEuropean Prospective Investigation into Cancer and NutritionAll-cause mortality

      CVD mortality

      Cancer mortality      		451,256

      12.8      		25-70BothHEI (2010)

      DASH score      		Dietary score, age, BMI, physical activity, smoking status, educationAll-cause mortality
      • HEI (2010)
        • HR 0.82 (0.78-0.86)
      • DASH score
        • HR 0.82 (0.78-0.86)
      CVD mortality
      • HEI (2010)
        • HR 0.82 (0.75-0.90)
      • DASH score
        • HR 0.77 (0.70-0.84)
      Cancer mortality
      • HEI (2010)
        • HR 0.87 (0.81-0.92)
      • DASH score
        • HR 0.87 (0.81-0.93)
      		8
      Mertens and colleagues, 2017

      Mertens E, Markey O, Geleijnse JM, Lovegrove JA, Givens DI. Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study [published online ahead of print March 14, 2017]. Eur J Nutr. https://doi.org/10.1007/s00394-017-1408-0.

      		United KingdomCaerphilly Prospective StudyCardiovascular disease1,867

      12      		45-59♂AHEI (2010)

      DASH score      		Age, smoking, social class, physical activity, energy intake, usual alcohol consumptionCardiovascular disease
      • AHEI (2010)
        • HR 0.82 (0.66-1.01)
      • DASH score
        • HR 0.81 (0.66-0.99)
      		7
      Morris and colleagues, 2015
      • Morris M.C.
      • Tangney C.C.
      • Wang Y.
      • Sacks F.M.
      • Bennett D.A.
      • Aggarwal N.T.
      MIND diet associated with reduced incidence of Alzheimer's disease.
      Alzheimer Dement. 2015; 11: 1007-1014
      		USRush Memory and Aging ProjectAlzheimer’s disease incidence923

      4.5      		58-98BothDASH scoreAge, sex, education, apolipoprotein ε4-allele, participation in cognitively stimulating activities, physical activity, energy intake, cardiovascular conditionsAlzheimer’s disease incidence
      • DASH score
        • HR 0.60 (0.37-0.96)
      		6
      Neelakantan and colleagues, 2016
      • Neelakantan N.
      • Naidoo N.
      • Koh W.P.
      • Yuan J.M.
      • van Dam R.M.
      The Alternative Healthy Eating Index is associated with a lower risk of fatal and nonfatal acute myocardial infarction in a Chinese Adult Population.
      J Nutr. 2016; 146: 1379-1386
      		ChinaSingapore Chinese Health StudyAcute myocardial infarction2,194

      NA      		45-75BothAHEI (2010)Age, sex, dialect group, year of interview, year blood was collected, age at interview, energy intake, education, smoking status, physical activity, BMI, history of diabetes, history of hypertension, low- and high density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, glycated hemoglobin, Creatinine, systolic blood pressureAcute myocardial infarction
      • AHEI (2010)
        • OR
          OR=odds ratio.
          0.64 (0.48-0.86)
      		7
      Otto and colleagues, 2015
      • Otto M.C.
      • Padhye N.S.
      • Bertoni A.G.
      • Jacobs Jr., D.R.
      • Mozaffarian D.
      Everything in moderation—Dietary diversity and quality, central obesity and risk of diabetes.
      PLoS One. 2015; 10: e0141341
      		USMulti-Ethnic Study of AtherosclerosisT2D5,160

      10      		45-84BothAHEI

      DASH score      		Age, sex, race/ethnicity, education, field center, smoking, energy intake, physical activity, dietary supplement, BMI, baseline waist circumferenceT2D
      • AHEI
        • HR 0.81 (0.65-1.00)
      • DASH score
        • HR 1.02 (0.79-1.30)
      		7
      Park and colleagues, 2016
      • Park Y.M.
      • Fung T.T.
      • Steck S.E.
      • et al.
      Diet quality and mortality risk in metabolically obese normal-weight adults.
      Mayo Clin Proc. 2016; 91: 1372-1383
      		USThird National Health and Nutrition Examination SurveyAll-cause mortality

      CVD mortality

      Cancer mortality      		2,103

      18.6      		30-90BothHEI

      DASH score      		Age, sex, race/ethnicity, education, income, smoking status, alcohol consumption, physical activity, energy intakeAll-cause mortality
      • HEI
        • HR 0.59 (0.45-0.77)
      • DASH score
        • HR 0.88 (0.71-1.09)
      CVD mortality
      • HEI
        • HR 0.55 (0.33-0.92)
      • DASH score
        • HR 0.52 (0.35-0.77)
      Cancer mortality
      • HEI
        • HR 0.53 (0.29-0.97)
      • DASH score
        • HR 0.85 (0.57-1.27)
      		6
      Park and colleagues, 2017
      • Park S.Y.
      • Boushey C.J.
      • Wilkens L.R.
      • Haiman C.A.
      • Le Marchand L.
      High-quality diets associate with reduced risk of colorectal cancer: Analyses of diet quality indexes in the multiethnic cohort.
      Gastroenterology. 2017; 153: 386-394.e2
      		USMultiethnic Cohort StudyColorectal cancer190,949

      16      		45-75BothHEI (2010)

      AHEI (2010)

      DASH score      		Age, sex, ethnicity, family history of colorectal cancer, history of colorectal polyp, BMI, smoking, multivitamin use, nonsteroidal anti-inflammatory drugs, physical activity, menopausal status, menopausal hormone therapy use, energy intake, alcoholColorectal cancer
      • HEI (2010)
        • ♂HR 0.69 (0.59-0.80)
        • ♀HR 0.82 (0.70-0.96)
      • AHEI (2010)
        • ♂HR 0.75 (0.65-0.85)
        • ♀HR 0.90 (0.78-1.04)
      • DASH score
        • ♂HR 0.75 (0.66-0.86)
        • ♀HR 0.86 (0.75-1.00)
      		9
      Pelser and colleagues, 2014
      • Pelser C.
      • Arem H.
      • Pfeiffer R.M.
      • et al.
      Prediagnostic lifestyle factors and survival after colon and rectal cancer diagnosis in the National Institutes of Health (NIH)-AARP Diet