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

Open AccessPublished:October 14, 2020DOI:https://doi.org/10.1016/j.jand.2020.08.076

      Abstract

      Background

      Suboptimal diet quality has a large impact on noncommunicable disease burden.

      Objective

      This study aimed to update the body of evidence on the associations between diet quality, as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and the Dietary Approaches to Stop Hypertension score, and health status. Moreover, results of the previous systematic reviews and meta-analyses were extended by evaluating the credibility of the evidence.

      Methods

      PubMed, Embase, and Scopus databases were searched to identify eligible studies published between May 15, 2017 and March 14, 2020. Pooled relative risk (RR) with 95% CI for highest vs lowest category of diet quality were estimated using a random-effects model. Heterogeneity was explored using Cochran's Q test and I2 statistic with 95% CI. Presence of publication bias was detected by using funnel plots and Egger's regression test. The NutriGrade tool was used to assess the credibility of evidence.

      Results

      The current update identified 47 new reports, resulting in a total of 113 reports including data from 3,277,684 participants. Diets of the highest quality, as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension scores, were inversely associated with risk of all-cause mortality (RR 0.80, 95% CI 0.79 to 0.82, I2 = 68%, n= 23), cardiovascular disease incidence or mortality (RR 0.80, 95% CI 0.78 to 0.82, I2 = 59%, n= 45), cancer incidence or mortality (RR 0.86, 95% CI 0.84 to 0.89, I2 = 73%, n= 45), incidence of type 2 diabetes (RR 0.81, 95% CI 0.78 to 0.85, I2 = 76%, n= 16), and incidence of neurodegenerative diseases (RR 0.82, 95% CI 0.75 to 0.89, I2 = 71%, n= 12). In cancer survivors, the highest diet quality was linked with lower risk of all-cause (RR 0.83, 95% CI 0.77 to 0.88, I2 = 45%, n= 12) and cancer mortality (RR 0.82, 95% CI 0.75 to 0.89, I2 = 44%, n= 12). The credibility of evidence for identified associations between overall healthy dietary patterns and included health outcomes was moderate.

      Conclusion

      This updated systematic review and meta-analysis suggests that high diet quality (assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension) is inversely associated with risk of all-cause mortality, cardiovascular disease incidence or mortality, cancer incidence or mortality, type 2 diabetes, and neurodegenerative disease, as well as all-cause mortality and cancer mortality among cancer survivors. Moderate credibility of evidence for identified associations complements the recent 2020 Dietary Guidelines Advisory Committee report recommending healthy dietary patterns for disease prevention.

      Keywords

      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 3 years after the issue date in which the articles are published.
      Research Question: What is the link between high diet quality, as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, and the Dietary Approaches to Stop Hypertension score, and health outcomes?
      Key Findings: Pooled data from 113 reports including 3,277,684 participants suggested that high diet quality was inversely associated with risk of all-cause mortality (20%), cardiovascular disease (20%), cancer (14%), type 2 diabetes (19%), and neurodegenerative disease (18%), as well as all-cause mortality (17%) and cancer mortality (18%) among cancer survivors. The credibility of the evidence for these associations was moderate.
      Noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), cancers, type 2 diabetes (T2D), and neurodegenerative disorders, remain a major cause of disability and death worldwide.
      • Bennett J.E.
      • Stevens G.A.
      • Mathers C.D.
      • et al.
      NCD countdown 2030: Worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4.
      According to data from the Global Burden of Disease Study, suboptimal diet contributed to 11 million death cases from NCDs in 2017.
      • Afshin A.
      • Sur P.J.
      • Fay K.A.
      • et al.
      Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017.
      Therefore, evidence-based recommendations for the health effects of dietary patterns are considered crucial to disease prevention.
      In 2015, we published a systematic review and meta-analysis on 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 risk of all-cause mortality, CVD mortality or events, cancer mortality or incidence, T2D, and neurodegenerative disease.
      • 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.
      Moreover, in an updated version of this systematic review, the associations of these diet quality indices with all-cause mortality and cancer mortality among cancer survivors were also investigated.
      • Schwingshackl L.
      • Bogensberger B.
      • Hoffmann G.
      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.
      Pooled data from 68 prospective cohort studies suggested that diets that scored highly on HEI, AHEI, and DASH were inversely associated with risk of all-cause mortality, CVD, cancer, T2D, and neurodegenerative disease by 22%, 22%, 16%, 18%, and 15%, respectively.
      • Schwingshackl L.
      • Bogensberger B.
      • Hoffmann G.
      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.
      Among cancer survivors, a high-quality diet was inversely associated with risk of all-cause mortality and cancer mortality.
      • Schwingshackl L.
      • Bogensberger B.
      • Hoffmann G.
      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.
      Numerous new studies have appeared since this last publication that are eligible for inclusion in this systematic review. In addition, addressing the credibility of the evidence is crucial in health decision-making. Currently, there is heightened awareness of the need for an appropriate evaluation of the certainty of evidence synthesis in nutrition research.
      • Qian F.
      • Riddle M.C.
      • Wylie-Rosett J.
      • Hu F.B.
      Red and processed meats and health risks: How strong is the evidence?.
      For this reason, this update aimed to extend previous analysis by assessing the credibility of evidence using the NutriGrade tool,
      • Schwingshackl L.
      • Knuppel S.
      • Schwedhelm C.
      • et al.
      Perspective: NutriGrade: A scoring system to assess and judge the meta-evidence of randomized controlled trials and cohort studies in nutrition research.
      which was applied previously in a series of systematic reviews on food groups.
      • Bechthold A.
      • Boeing H.
      • Schwedhelm C.
      • et al.
      Food groups and risk of coronary heart disease, stroke and heart failure: A systematic review and dose-response meta-analysis of prospective studies.
      • Schwingshackl L.
      • Hoffmann G.
      • Lampousi A.M.
      • et al.
      Food groups and risk of type 2 diabetes mellitus: A systematic review and meta-analysis of prospective studies.
      • Schwingshackl L.
      • Schwedhelm C.
      • Hoffmann G.
      • et al.
      Food groups and risk of colorectal cancer.
      • Schwingshackl L.
      • Schwedhelm C.
      • Hoffmann G.
      • et al.
      Food groups and risk of all-cause mortality: A systematic review and meta-analysis of prospective studies.

      Methods

      A predefined protocol for previous versions of this systematic review and meta-analysis was registered in PROSPERO International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/; ID: CRD42013006561). Changes made to the protocol are annotated in the text. The present update of the review was conducted and reported according to the Meta-Analysis of Observational Studies in Epidemiology guidelines.
      • Stroup D.F.
      • Berlin J.A.
      • Morton S.C.
      • et al.
      Meta-analysis of observational studies in epidemiology: A proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.

      Data Sources and Searches

      An updated literature search for studies published from May 15, 2017 through March 14, 2020 was conducted in electronic databases (PubMed, Embase, and Scopus) with no restrictions on the language of publication. The search strategy for the PubMed database was adopted as follows: (“healthy”[All fields] AND (“eating”[All fields] OR “eating”[MeSH Terms])) 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”[All fields] OR “diet”[MeSH Terms]). Reference lists from included articles were checked in order to identify additional eligible studies. One author (J.M.) performed the literature search and any uncertainties were resolved through discussion with another author (L.S.).

      Study Selection

      Studies were considered as eligible for inclusion if they met the following criteria: conducted on adult populations (aged 18 years or older); evaluated the association of diet quality as assessed by the HEI, AHEI, or DASH score on risk of all-cause mortality, CVD incidence or mortality, cancer incidence or mortality, T2D, and neurodegenerative disease in the general population and on all-cause mortality or cancer mortality among cancer survivors; and had a prospective observational design. Studies performed exclusively in patients with chronic diseases (such as CVD, diabetes, chronic kidney disease, or frailty syndrome) were excluded. In the case of 2 reports based on the same study, the one with the longer follow-up or with a larger number of cases was included. Two authors (J.M. and A.D.) independently performed the title and abstract screening, as well as study selection, and any disagreements were resolved by discussion with the third author (L.S.).

      Data Extraction

      After selecting the studies, the following information was extracted from each report: name of the first author, year of publication, study location and name, sample size, age at entry to the study, sex, length of follow-up, outcome, number of cases, diet quality index, adjustment factors, risk estimate (multivariable-adjusted odds ratio [OR], risk ratio [RR], or hazard ratio [HR]), and study quality. In contrast to the previous version of this review, if a study provided separate estimates for men and women, they were pooled using the fixed-effects model before inclusion in the analysis (according to the methodological recommendations of the World Cancer Research Fund
      • Vingeliene S.
      • Chan D.S.M.
      • Vieira A.R.
      • et al.
      An update of the WCRF/AICR systematic literature review and meta-analysis on dietary and anthropometric factors and esophageal cancer risk.
      ). When a study reported multiple risk estimates, the one adjusted for the highest number of confounders was selected. Study data were extracted by one author (J.M.) and verified by another (L.S.).

      Study Quality and Credibility of Evidence Assessment

      The methodological quality of studies was evaluated using the Newcastle Ottawa Assessment Scale for Cohort Studies, as in the previous versions.
      • Wells G.A.
      • Shea B.
      • O'Connell D.
      • et al.
      The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
      The NutriGrade tool was used to quantify the credibility of evidence for the association between diet quality and predefined outcomes.
      • Schwingshackl L.
      • Knuppel S.
      • Schwedhelm C.
      • et al.
      Perspective: NutriGrade: A scoring system to assess and judge the meta-evidence of randomized controlled trials and cohort studies in nutrition research.
      In brief, a summary score was calculated and interpreted as very low (0 to <4 points), low (4 to <6 points), moderate (6 to <8 points), or high (8 to 10 points) credibility of the evidence (details of the NutriGrade tool items are provided in the footnotes for Table 1). Separate judgments on credibility of evidence were made for overall high diet quality (all 3 indices), HEI, AHEI, and DASH score.
      Table 1Item-level scoring for NutriGrade tool and credibility of evidence for association between the diet quality (overall high diet quality, HEI,
      HEI = Healthy Eating Index.
      AHEI,
      AHEI = Alternate Healthy Eating Index.
      or DASH
      DASH = Dietary Approaches to Stop Hypertension.
      score) and all-cause mortality, CVD
      Item-level NutriGrade tool scoring (points).
      incidence or mortality, cancer incidence or mortality, T2D
      Item 1 = Risk of bias, study quality, and study limitations (0 to 2 points)—2 points if mean Newcastle-Ottawa Score for a comparison ≥7.
      , neurodegenerative disease, as well as all-cause mortality and cancer mortality among cancer survivors.
      ComparisonNutriGrade Items
      Item 2 = Precision (0 to 1 point)—1 point if ≥500 events and 95% CI excluded null value or otherwise 95% CI overlaps null value but excludes important benefit or harm (relative risk [RR] <0.8 or >1.2).
      Total scoreCredibility of evidence
      Item 1
      Item 3 = Heterogeneity (0 to 1 point)—1 point if ≥10 studies, heterogeneity measures adequately reported, no important heterogeneity found or otherwise subgroup/sensitivity analyses conducted.
      Item 2
      Item 4 = Directness (0 to 1 point)—1 point if no important differences in the population or intervention; hard clinical outcome.
      Item 3
      Item 5 = Publication bias (0 to 1 point)—1 point if no evidence for publication bias with test or plot (10 or more studies).
      Item 4
      Item 6 = Funding bias (0 to 1 point)—1 point if report from academic or research institution.
      Item 5
      Item 7 = Effect size (0 to 2 points)—1 point if RR <0.80 to 0.50 or >1.20 to 2 and corresponding test statistically significant; 2 points if RR <0.5 or >2.0 and corresponding test statistically significant (highest vs lowest category).
      Item 6
      Item 8 = Dose–response (0 to 1 point)—1 point if significant linear/nonlinear dose–response relation.
      Item 7
      CVD = cardiovascular disease.
      Item 8
      T2D = type 2 diabetes.
      Overall high diet quality
      All-cause mortality21110.51006.5Moderate
      CVD mortality or incidence21110.51006.5Moderate
      Cancer mortality or incidence211111007Moderate
      T2D211111007Moderate
      Neurodegenerative disease211011006Moderate
      All-cause mortality among cancer survivors21110.51006.5Moderate
      Cancer mortality among cancer survivors211011006Moderate
      HEI
      All-cause mortality210.600.51005.1Low
      CVD mortality or incidence210.610.51107.1Moderate
      Cancer mortality or incidence210.600.51005.1Low
      T2D210.3011005.3Low
      Neurodegenerative diseaseNA
      NA = not applicable.
      NANANANANANANANAVery low
      All-cause mortality among cancer survivors210.3001105.3Low
      Cancer mortality among cancer survivors210.3001105.3Low
      AHEI
      All-cause mortality210.610.51006.1Moderate
      CVD mortality or incidence210.6111107.6Moderate
      Cancer mortality or incidence210.6011005.6Low
      T2D210.6111006.6Moderate
      Neurodegenerative disease210.4111006.4Moderate
      All-cause mortality among cancer survivors210101005Low
      Cancer mortality among cancer survivors210001004Low
      DASH score
      All-cause mortality210.610.51006.1Moderate
      CVD mortality or incidence210.6111006.6Moderate
      Cancer mortality or incidence210.610.51006.1Moderate
      T2D210.3111107.3Moderate
      Neurodegenerative disease210.3011005.3Low
      All-cause mortality among cancer survivors210.300.51004.8Low
      Cancer mortality among cancer survivors200.410.51004.9Low
      a HEI = Healthy Eating Index.
      b AHEI = Alternate Healthy Eating Index.
      c DASH = Dietary Approaches to Stop Hypertension.
      d CVD = cardiovascular disease.
      e T2D = type 2 diabetes.
      f Item-level NutriGrade tool scoring (points).
      g Item 1 = Risk of bias, study quality, and study limitations (0 to 2 points)—2 points if mean Newcastle-Ottawa Score for a comparison ≥7.
      h Item 2 = Precision (0 to 1 point)—1 point if ≥500 events and 95% CI excluded null value or otherwise 95% CI overlaps null value but excludes important benefit or harm (relative risk [RR] <0.8 or >1.2).
      i Item 3 = Heterogeneity (0 to 1 point)—1 point if ≥10 studies, heterogeneity measures adequately reported, no important heterogeneity found or otherwise subgroup/sensitivity analyses conducted.
      j Item 4 = Directness (0 to 1 point)—1 point if no important differences in the population or intervention; hard clinical outcome.
      k Item 5 = Publication bias (0 to 1 point)—1 point if no evidence for publication bias with test or plot (10 or more studies).
      l Item 6 = Funding bias (0 to 1 point)—1 point if report from academic or research institution.
      m Item 7 = Effect size (0 to 2 points)—1 point if RR <0.80 to 0.50 or >1.20 to 2 and corresponding test statistically significant; 2 points if RR <0.5 or >2.0 and corresponding test statistically significant (highest vs lowest category).
      n Item 8 = Dose–response (0 to 1 point)—1 point if significant linear/nonlinear dose–response relation.
      o NA = not applicable.

      HEI, AHEI, and DASH Components and Scoring

      Components and scoring of HEI
      • Fung T.T.
      • Hu F.B.
      • McCullough M.L.
      • 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.
      • Kappeler R.
      • Eichholzer M.
      • Rohrmann S.
      Meat consumption and diet quality and mortality in NHANES III.
      • McCullough M.L.
      • Feskanich D.
      • Rimm E.B.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in men.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in women.
      • Shahar D.R.
      • Yu B.
      • Houston D.K.
      • et al.
      Dietary factors in relation to daily activity energy expenditure and mortality among older adults.
      (HEI-2005
      • Agnoli C.
      • Krogh V.
      • Grioni S.
      • et al.
      A priori–defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort.
      • 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.
      • Chiuve S.E.
      • Fung T.T.
      • Rimm E.B.
      • et al.
      Alternative dietary indices both strongly predict risk of chronic disease.
      • 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.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of esophageal and gastric cancer in a large cohort study.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of head and neck cancer in a large prospective study.
      • 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.
      • 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 and Health Study.
      • Thomson C.A.
      • Crane T.E.
      • Wertheim B.C.
      • et al.
      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
      • Xie J.
      • Poole E.M.
      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      • 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.
      • 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.
      and HEI-2010
      • Arem H.
      • Reedy J.
      • Sampson J.
      • et al.
      The Healthy Eating Index 2005 and risk for pancreatic cancer in the NIH–AARP study.
      • Li W.Q.
      • Park Y.
      • McGlynn K.A.
      • et al.
      Index-based dietary patterns and risk of incident hepatocellular carcinoma and mortality from chronic liver disease in a prospective study.
      • 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.
      • 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.
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      ), AHEI
      • Fung T.T.
      • Hu F.B.
      • McCullough M.L.
      • 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.
      ,
      • 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.
      ,
      • 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.
      ,
      • Akbaraly T.N.
      • Ferrie J.E.
      • Berr C.
      • et al.
      Alternative Healthy Eating Index and mortality over 18 y of follow-up: Results from the Whitehall II cohort.
      • Belin R.J.
      • Greenland P.
      • Allison M.
      • et al.
      Diet quality and the risk of cardiovascular disease: The Women’s Health Initiative (WHI).
      • Fung T.T.
      • McCullough M.
      • van Dam R.M.
      • Hu F.B.
      A prospective study of overall diet quality and risk of type 2 diabetes in women.
      InterAct Consortium
      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Diet quality and major chronic disease risk in men and women: Moving toward improved dietary guidance.
      • Qiao Y.
      • Tinker L.
      • Olendzki B.C.
      • et al.
      Racial/ethnic disparities in association between dietary quality and incident diabetes in postmenopausal women in the United States: The Women's Health Initiative 1993–2005.
      • Saaksjarvi K.
      • Knekt P.
      • Lundqvist A.
      • et al.
      A cohort study on diet and the risk of Parkinson's disease: The role of food groups and diet quality.
      • 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.
      • Gao X.
      • Chen H.
      • Fung T.T.
      • et al.
      Prospective study of dietary pattern and risk of Parkinson disease.
      • 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.
      • 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.
      • 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.
      • Smyth A.
      • Dehghan M.
      • O'Donnell M.
      • et al.
      Healthy eating and reduced risk of cognitive decline: A cohort from 40 countries.
      (AHEI-2010
      • 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.
      ,
      • Chiuve S.E.
      • Fung T.T.
      • Rimm E.B.
      • et al.
      Alternative dietary indices both strongly predict risk of chronic disease.
      ,
      • Xie J.
      • Poole E.M.
      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      ,
      • 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.
      • 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.
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      ,
      • 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.
      ,
      • 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.
      ,
      • Mursu J.
      • Steffen L.M.
      • Meyer K.A.
      • Duprez D.
      • Jacobs Jr., D.R.
      Diet quality indexes and mortality in postmenopausal women: The Iowa Women’s Health Study.
      • Dugué 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.
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      • 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?.
      • 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.
      • Yu D.
      • Zhang X.
      • Xiang Y.-B.
      • et al.
      Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 134,000 Chinese adults in urban Shanghai.
      • Mertens E.
      • Markey O.
      • Geleijnse J.M.
      • Lovegrove J.A.
      • Givens D.I.
      Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study.
      • Haridass V.
      Diet Quality Scores and Risk of Incident Breast Cancer in the California Teachers Study 2015. Dissertation. University of California-Irvine; 2015.
      ), and DASH score
      • Agnoli C.
      • Krogh V.
      • Grioni S.
      • et al.
      A priori–defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort.
      ,
      • 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.
      ,
      • 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.
      • 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.
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      ,
      InterAct Consortium
      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
      ,
      • 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.
      ,
      • 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.
      • 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.
      • 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.
      ,
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      ,
      • 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?.
      ,
      • Yu D.
      • Zhang X.
      • Xiang Y.-B.
      • et al.
      Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 134,000 Chinese adults in urban Shanghai.
      • Mertens E.
      • Markey O.
      • Geleijnse J.M.
      • Lovegrove J.A.
      • Givens D.I.
      Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study.
      • Haridass V.
      Diet Quality Scores and Risk of Incident Breast Cancer in the California Teachers Study 2015. Dissertation. University of California-Irvine; 2015.
      • Bertoia M.L.
      • Triche E.W.
      • Michaud D.S.
      • et al.
      Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women.
      • Fitzgerald K.C.
      • Chiuve S.E.
      • Buring J.E.
      • Ridker P.M.
      • Glynn R.J.
      Comparison of associations of adherence to a Dietary Approaches to Stop Hypertension (DASH)-style diet with risks of cardiovascular disease and venous thromboembolism.
      • Folsom A.R.
      • Parker E.D.
      • Harnack L.J.
      Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease.
      • Fung T.T.
      • Hu F.B.
      • Wu K.
      • Chiuve S.E.
      • Fuchs C.S.
      • Giovannucci E.
      The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets and colorectal cancer.
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Consistency with the DASH diet and incidence of heart failure.
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Relation of consistency with the Dietary Approaches to Stop Hypertension diet and incidence of heart failure in men aged 45 to 79 years.
      • Liese A.D.
      • Nichols M.
      • Sun X.
      • Agostino R.B.
      • Haffner S.M.
      Adherence to the DASH diet is inversely associated with incidence of type 2 diabetes: The Insulin Resistance Atherosclerosis Study.
      • Lin P.H.
      • Yeh W.T.
      • Svetkey L.P.
      • et al.
      Dietary intakes consistent with the DASH dietary pattern reduce blood pressure increase with age and risk for stroke in a Chinese population.
      • Miller P.E.
      • Cross A.J.
      • Subar A.F.
      • et al.
      Comparison of 4 established DASH diet indexes: Examining associations of index scores and colorectal cancer.
      • Boggs D.A.
      • Ban Y.
      • Palmer J.R.
      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      • Larsson S.C.
      • Wallin A.
      • Wolk A.
      Dietary Approaches to Stop Hypertension Diet and incidence of stroke: Results from 2 prospective cohorts.
      • 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.
      • 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.
      • Park Y.M.
      • Fung T.T.
      • Steck S.E.
      • et al.
      Diet quality and mortality risk in metabolically obese normal-weight adults.
      • Fung T.T.
      • Chiuve S.E.
      • McCullough M.L.
      • Rexrode K.M.
      • Logroscino G.
      • Hu F.B.
      Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
      were described in detail previously.
      The HEI-2015 (not identified in previous versions of this meta-analysis) is composed of 13 items (overall scoring range from 0 to 100 points): total fruits (5 points), whole fruits (5 points), total vegetables (5 points), greens and beans (5 points), whole grains (10 points), dairy (10 points), total protein foods (5 points), fatty acids (polyunsaturated fatty acid plus monounsaturated fatty acid to saturated fatty acid ratio) (10 points), refined grains (10 points), sodium (10 points), added sugars (10 points), and saturated fats (10 points). Refined grains, sodium, added sugars, and saturated fats as components to be consumed in moderation have a reversed scoring.
      • Krebs-Smith S.M.
      • Pannucci T.E.
      • Subar A.F.
      • et al.
      Update of the Healthy Eating Index: HEI-2015.

      Statistical Analysis

      In accordance with previous versions of this review, studies were grouped according to the different clinical outcomes (i.e., all-cause mortality, CVD incidence or mortality, cancer incidence or mortality, T2D, and neurodegenerative disease and all-cause mortality, or cancer mortality among cancer survivors). Extracted risk estimates (OR, RR, and HR) comparing the highest and lowest category of dietary indices were interpreted as RR and were pooled using a random-effects model with the DerSimonian-Laird method.
      • DerSimonian R.
      • Laird N.
      Meta-analysis in clinical trials.
      The weighting of each study was assigned by calculating the standard error of the log-transformed RR, interpreted as an estimated variance of the log-transformed RR.
      • DerSimonian R.
      • Laird N.
      Meta-analysis in clinical trials.
      Between-study heterogeneity was explored using Cochran’s Q test and I2 statistic. An I2 statistic >50% was regarded as a substantial amount of heterogeneity. Moreover, 95% CI for I2 was calculated with the heterogi command in STATA software.
      Subgroup analyses were performed for dietary indices (HEI, AHEI, and DASH score) and their versions valid for the corresponding time period (HEI, HEI-2005, HEI-2010, HEI-2015, AHEI, AHEI-2010, and DASH-Fung score).
      • Fung T.T.
      • Chiuve S.E.
      • McCullough M.L.
      • Rexrode K.M.
      • Logroscino G.
      • Hu F.B.
      Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
      The DASH-Fung score is composed of 8 components (fruits, vegetables, low-fat dairy, whole grains, nuts/seeds/legumes, red and processed meat, sugar-sweetened beverages, and sodium) scored by quantiles of intake.
      • Fung T.T.
      • Chiuve S.E.
      • McCullough M.L.
      • Rexrode K.M.
      • Logroscino G.
      • Hu F.B.
      Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
      For CVD and cancer, separate analyses were applied to compare mortality and incidence. Additional subgroup analyses were conducted for distinct CVD outcomes (nonfatal or fatal coronary heart disease, stroke, and heart failure), site-specific cancers, and neurodegenerative disease (cognitive impairment and Parkinson disease). To check the robustness of results, analyses were restricted separately to US studies, long-term follow-up (8 years or more), high-quality (Newcastle Ottawa Assessment Scale score 8 points or higher), and men or women. Moreover, pooled estimates were recalculated using the fixed-effect model.
      For comparisons with more than 10 eligible studies available, the publication bias was explored with Egger’s regression test and funnel plots.
      • Page M.P.
      • Higgins J.P.T.
      • Sterne J.A.C.
      Assessing risk of bias due to missing results in a synthesis. In: Higgins JPT, Thomas J, Chandler J, et al, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.0. Updated July 2019. Accessed September 4, 2020.
      All analyses were conducted in Review Manager (RevMan)
      and STATA software.

      Results

      Literature Search and Study Characteristics

      Detailed steps of the database search and study selection are illustrated in Figure 1. The updated search revealed 50 new eligible reports,
      • Abu-Saad K.
      • Novikov I.
      • Gimpelevitz I.
      • et al.
      Micronutrient intake and adherence to DASH diet are associated with incident major adverse cardiovascular events and all-cause mortality in a bi-ethnic population.
      • Agarwal P.
      • Wang Y.
      • Buchman A.S.
      • Holland T.M.
      • Bennett D.A.
      • Morris M.C.
      MIND diet associated with reduced incidence and delayed progression of parkinsonism in old age.
      • Akbaraly T.N.
      • Singh-Manoux A.
      • Dugravot A.
      • Brunner E.J.
      • Kivimaki M.
      • Sabia S.
      Association of midlife diet with subsequent risk for dementia.
      • Bathrellou E.
      • Kontogianni M.D.
      • Chrysanthopoulou E.
      • et al.
      Adherence to a DASH-style diet and cardiovascular disease risk: The 10-year follow-up of the ATTICA study.
      • Bogumil D.
      • Park S.Y.
      • Le Marchand L.
      • et al.
      High-quality diets are associated with reduced risk of hepatocellular carcinoma and chronic liver disease: The Multiethnic Cohort.
      • Campos C.L.
      • Wood A.
      • Burke G.L.
      • Bahrami H.
      • Bertoni A.G.
      Dietary Approaches to Stop Hypertension Diet concordance and incident heart failure: The Multi-Ethnic Study of Atherosclerosis.
      • Chan R.S.M.
      • Yu B.W.M.
      • Leung J.
      • et al.
      How dietary patterns are related to inflammaging and mortality in community-dwelling older Chinese adults in Hong Kong—A prospective analysis.
      • Chebet J.J.
      • Thomson C.A.
      • Kohler L.N.
      • et al.
      Association of diet quality and physical activity on obesity-related cancer risk and mortality in Black women: Results from the Women's Health Initiative.
      • Chen G.C.
      • Koh W.P.
      • Neelakantan N.
      • Yuan J.M.
      • Qin L.Q.
      • van Dam R.M.
      Diet quality indices and risk of type 2 diabetes mellitus: The Singapore Chinese Health Study.
      • Chou Y.C.
      • Lee M.S.
      • Chiou J.M.
      • Chen T.F.
      • Chen Y.C.
      • Chen J.H.
      Association of diet quality and vegetable variety with the risk of cognitive decline in Chinese older adults.
      • Conway B.N.
      • Han X.
      • Munro H.M.
      • et al.
      The obesity epidemic and rising diabetes incidence in a low-income racially diverse southern US cohort.
      • Deshmukh A.A.
      • Shirvani S.M.
      • Likhacheva A.
      • Chhatwal J.
      • Chiao E.Y.
      • Sonawane K.
      The association between dietary quality and overall and cancer-specific mortality among cancer survivors, NHANES III.
      • Djousse L.
      • Ho Y.L.
      • Nguyen X.T.
      • et al.
      DASH score and subsequent risk of coronary artery disease: The findings from Million Veteran Program.
      • Frisby K.
      • Chen J.
      • Sesso H.
      • Wang L.
      • Gaziano J.
      • Djousse L.
      Healthy dietary patterns and risk of abdominal aortic aneurysm in the Physicians' Health Study.
      • Guinter M.A.
      • McCullough M.L.
      • Gapstur S.M.
      • Campbell P.T.
      Associations of pre- and postdiagnosis diet quality with risk of mortality among men and women with colorectal cancer.
      • Hardy D.S.
      • Mersha T.B.
      • Xu H.
      • Garvin J.B.
      • Stallings D.T.
      • Racette S.B.
      Association of the DASH diet and a genetic risk score with type 2 diabetes risk among African-American and White adults.
      • Haridass V.
      • Ziogas A.
      • Neuhausen S.L.
      • Anton-Culver H.
      • Odegaard A.O.
      Diet quality scores inversely associated with postmenopausal breast cancer risk are not associated with premenopausal breast cancer risk in the California Teachers Study.
      • Hashemian M.
      • Farvid M.S.
      • Poustchi H.
      • et al.
      The application of six dietary scores to a Middle Eastern population: A comparative analysis of mortality in a prospective study.
      • Hoon Lee D.
      • Fung T.T.
      • Tabung F.K.
      • et al.
      Dietary pattern and risk of multiple myeloma in two large prospective US cohort studies.
      • Hoon Lee D.
      • Fung T.T.
      • Tabung F.K.
      • et al.
      Prediagnosis dietary pattern and survival in patients with multiple myeloma.
      • Hu E.A.
      • Steffen L.M.
      • Coresh J.
      • Appel L.J.
      • Rebholz C.M.
      Adherence to the Healthy Eating Index-2015 and other dietary patterns may reduce risk of cardiovascular disease, cardiovascular mortality, and all-cause mortality.
      • Jones N.R.V.
      • Forouhi N.G.
      • Khaw K.T.
      • Wareham N.J.
      • Monsivais P.
      Accordance to the Dietary Approaches to Stop Hypertension diet pattern and cardiovascular disease in a British, population-based cohort.
      • Larsson S.C.
      • Wolk A.
      The role of lifestyle factors and sleep duration for late-onset dementia: A cohort study.
      • Larsson S.C.
      • Wolk A.
      • Bäck M.
      Dietary patterns, food groups, and incidence of aortic valve stenosis: A prospective cohort study.
      • Lavalette C.
      • Adjibade M.
      • Srour B.
      • et al.
      Cancer-specific and general nutritional scores and cancer risk: Results from the prospective NutriNet-Sante cohort.
      • Ma Y.
      • Yang W.
      • Simon T.G.
      • et al.
      Dietary patterns and risk of hepatocellular carcinoma among U.S. men and women.
      • Myneni A.A.
      • Giovino G.A.
      • Millen A.E.
      • et al.
      Indices of diet quality and risk of lung cancer incidence and mortality in the Women's Health Initiative Observational Study.
      • Neelakantan N.
      • Koh W.P.
      • Yuan J.M.
      • van Dam R.M.
      Diet-quality indexes are associated with a lower risk of cardiovascular, respiratory, and all-cause mortality among Chinese adults.
      • Nguyen S.
      • Li H.
      • Yu D.
      • et al.
      Adherence to dietary recommendations and colorectal cancer risk: Results from two prospective cohort studies.
      • Panizza C.E.
      • Shvetsov Y.B.
      • Harmon B.E.
      • et al.
      Testing the predictive validity of the Healthy Eating Index-2015 in the multiethnic cohort: Is the score associated with a reduced risk of all-cause and cause-specific mortality?.
      • Petimar J.
      • Smith-Warner S.A.
      • Fung T.T.
      • et al.
      Recommendation-based dietary indexes and risk of colorectal cancer in the Nurses' Health Study and Health Professionals Follow-up Study.
      • Petimar J.
      • Park Y.M.
      • Smith-Warner S.A.
      • Fung T.T.
      • Sandler D.P.
      Dietary index scores and invasive breast cancer risk among women with a family history of breast cancer.
      • Rautiainen S.
      • Gaziano J.M.
      • Christen W.G.
      • et al.
      Effect of baseline nutritional status on long-term multivitamin use and cardiovascular disease risk: A secondary analysis of the Physicians' Health Study II randomized clinical trial.
      • Seon Kuan A.
      • Green J.
      • Kitahara C.M.
      • et al.
      Diet and risk of glioma: Combined analysis of 3 large prospective studies in the UK and USA.
      • Shah N.S.
      • Leonard D.
      • Finley C.E.
      • et al.
      Dietary patterns and long-term survival: A retrospective study of healthy primary care patients.
      • Shakersain B.
      • Rizzuto D.
      • Larsson S.C.
      • Faxen-Irving G.
      • Fratiglioni L.
      • Xu W.L.
      The Nordic prudent diet reduces risk of cognitive decline in the Swedish older adults: A population-based cohort study.
      • Shivappa N.
      • Hebert J.R.
      • Kivimaki M.
      • Akbaraly T.
      Alternative Healthy Eating Index 2010, Dietary Inflammatory Index and risk of mortality: Results from the Whitehall II cohort study and meta-analysis of previous Dietary Inflammatory Index and mortality studies.
      • Solbak N.M.
      • Xu J.Y.
      • Vena J.E.
      • Csizmadi I.
      • Whelan H.K.
      • Robson P.J.
      Diet quality is associated with reduced incidence of cancer and self-reported chronic disease: Observations from Alberta's Tomorrow Project.
      • Sotos-Prieto M.
      • Bhupathiraju S.N.
      • Mattei J.
      • et al.
      Association of changes in diet quality with total and cause-specific mortality.
      • Sun Y.
      • Bao W.
      • Liu B.
      • et al.
      Changes in overall diet quality in relation to survival in postmenopausal women with breast cancer: Results from the Women's Health Initiative.
      • Tait C.A.
      • L'Abbe M.R.
      • Smith P.M.
      • Watson T.
      • Kornas K.
      • Rosella L.C.
      Adherence to predefined dietary patterns and risk of developing type 2 diabetes in the Canadian adult population.
      • Trébuchet A.
      • Julia C.
      • Fézeu L.
      • et al.
      Prospective association between several dietary scores and risk of cardiovascular diseases: Is the Mediterranean Diet equally associated to cardiovascular diseases compared to National Nutritional Scores?.
      • Wang Z.
      • Siega-Riz A.M.
      • Gordon-Larsen P.
      • et al.
      Diet quality and its association with type 2 diabetes and major cardiometabolic risk factors among adults in China.
      • Wang F.
      • Cai H.
      • Gu K.
      • et al.
      Adherence to dietary recommendations among long-term breast cancer survivors and cancer outcome associations.
      • Wu J.
      • Song X.
      • Chen G.C.
      • et al.
      Dietary pattern in midlife and cognitive impairment in late life: A prospective study in Chinese adults.
      • Xu Z.
      • Steffen L.M.
      • Selvin E.
      • Rebholz C.M.
      Diet quality, change in diet quality and risk of incident CVD and diabetes.
      • Zhu J.
      • Xiang Y.B.
      • Cai H.
      • et al.
      A prospective investigation of dietary intake and functional impairments among the elderly.
      • Aigner A.
      • Becher H.
      • Jacobs S.
      • et al.
      Low diet quality and the risk of stroke mortality: the Multiethnic Cohort Study.
      • Biesbroek S.
      • Verschuren W.M.M.
      • Boer J.M.A.
      • et al.
      Does a better adherence to dietary guidelines reduce mortality risk and environmental impact in the Dutch sub-cohort of the European Prospective Investigation into Cancer and Nutrition?.
      • Chan J.K.
      • Mann A.K.
      • Koh-Bell A.
      • Chan J.E.
      • Kapp D.S.
      Relative importance of diet and physical activity in cancer survival: An analysis of the US national health and nutrition examination survey.
      which were assessed for overlapping with results from the 68 reports
      • Fung T.T.
      • Hu F.B.
      • McCullough M.L.
      • 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.
      • Kappeler R.
      • Eichholzer M.
      • Rohrmann S.
      Meat consumption and diet quality and mortality in NHANES III.
      • McCullough M.L.
      • Feskanich D.
      • Rimm E.B.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in men.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in women.
      • Shahar D.R.
      • Yu B.
      • Houston D.K.
      • et al.
      Dietary factors in relation to daily activity energy expenditure and mortality among older adults.
      • Agnoli C.
      • Krogh V.
      • Grioni S.
      • et al.
      A priori–defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort.
      • 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.
      • Chiuve S.E.
      • Fung T.T.
      • Rimm E.B.
      • et al.
      Alternative dietary indices both strongly predict risk of chronic disease.
      • 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.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of esophageal and gastric cancer in a large cohort study.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of head and neck cancer in a large prospective study.
      • 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.
      • 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 and Health Study.
      • Thomson C.A.
      • Crane T.E.
      • Wertheim B.C.
      • et al.
      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
      • Xie J.
      • Poole E.M.
      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      • 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.
      • 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.
      • Arem H.
      • Reedy J.
      • Sampson J.
      • et al.
      The Healthy Eating Index 2005 and risk for pancreatic cancer in the NIH–AARP study.
      • Li W.Q.
      • Park Y.
      • McGlynn K.A.
      • et al.
      Index-based dietary patterns and risk of incident hepatocellular carcinoma and mortality from chronic liver disease in a prospective study.
      • 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.
      • 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.
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • Akbaraly T.N.
      • Ferrie J.E.
      • Berr C.
      • et al.
      Alternative Healthy Eating Index and mortality over 18 y of follow-up: Results from the Whitehall II cohort.
      • Belin R.J.
      • Greenland P.
      • Allison M.
      • et al.
      Diet quality and the risk of cardiovascular disease: The Women’s Health Initiative (WHI).
      • Fung T.T.
      • McCullough M.
      • van Dam R.M.
      • Hu F.B.
      A prospective study of overall diet quality and risk of type 2 diabetes in women.
      InterAct Consortium
      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Diet quality and major chronic disease risk in men and women: Moving toward improved dietary guidance.
      • Qiao Y.
      • Tinker L.
      • Olendzki B.C.
      • et al.
      Racial/ethnic disparities in association between dietary quality and incident diabetes in postmenopausal women in the United States: The Women's Health Initiative 1993–2005.
      • Saaksjarvi K.
      • Knekt P.
      • Lundqvist A.
      • et al.
      A cohort study on diet and the risk of Parkinson's disease: The role of food groups and diet quality.
      • 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.
      • Gao X.
      • Chen H.
      • Fung T.T.
      • et al.
      Prospective study of dietary pattern and risk of Parkinson disease.
      • 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.
      • 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.
      • 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.
      • Smyth A.
      • Dehghan M.
      • O'Donnell M.
      • et al.
      Healthy eating and reduced risk of cognitive decline: A cohort from 40 countries.
      • Mursu J.
      • Steffen L.M.
      • Meyer K.A.
      • Duprez D.
      • Jacobs Jr., D.R.
      Diet quality indexes and mortality in postmenopausal women: The Iowa Women’s Health Study.
      • Dugué 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.
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      • 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?.
      • 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.
      • Yu D.
      • Zhang X.
      • Xiang Y.-B.
      • et al.
      Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 134,000 Chinese adults in urban Shanghai.
      • Mertens E.
      • Markey O.
      • Geleijnse J.M.
      • Lovegrove J.A.
      • Givens D.I.
      Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study.
      • Haridass V.
      Diet Quality Scores and Risk of Incident Breast Cancer in the California Teachers Study 2015. Dissertation. University of California-Irvine; 2015.
      • Bertoia M.L.
      • Triche E.W.
      • Michaud D.S.
      • et al.
      Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women.
      • Fitzgerald K.C.
      • Chiuve S.E.
      • Buring J.E.
      • Ridker P.M.
      • Glynn R.J.
      Comparison of associations of adherence to a Dietary Approaches to Stop Hypertension (DASH)-style diet with risks of cardiovascular disease and venous thromboembolism.
      • Folsom A.R.
      • Parker E.D.
      • Harnack L.J.
      Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease.
      • Fung T.T.
      • Hu F.B.
      • Wu K.
      • Chiuve S.E.
      • Fuchs C.S.
      • Giovannucci E.
      The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets and colorectal cancer.
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Consistency with the DASH diet and incidence of heart failure.
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Relation of consistency with the Dietary Approaches to Stop Hypertension diet and incidence of heart failure in men aged 45 to 79 years.
      • Liese A.D.
      • Nichols M.
      • Sun X.
      • Agostino R.B.
      • Haffner S.M.
      Adherence to the DASH diet is inversely associated with incidence of type 2 diabetes: The Insulin Resistance Atherosclerosis Study.
      • Lin P.H.
      • Yeh W.T.
      • Svetkey L.P.
      • et al.
      Dietary intakes consistent with the DASH dietary pattern reduce blood pressure increase with age and risk for stroke in a Chinese population.
      • Miller P.E.
      • Cross A.J.
      • Subar A.F.
      • et al.
      Comparison of 4 established DASH diet indexes: Examining associations of index scores and colorectal cancer.
      • Boggs D.A.
      • Ban Y.
      • Palmer J.R.
      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      • Larsson S.C.
      • Wallin A.
      • Wolk A.
      Dietary Approaches to Stop Hypertension Diet and incidence of stroke: Results from 2 prospective cohorts.
      • 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.
      • 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.
      • Park Y.M.
      • Fung T.T.
      • Steck S.E.
      • et al.
      Diet quality and mortality risk in metabolically obese normal-weight adults.
      • Fung T.T.
      • Chiuve S.E.
      • McCullough M.L.
      • Rexrode K.M.
      • Logroscino G.
      • Hu F.B.
      Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
      included in 2 previous versions of this systematic review. Five reports
      • Haridass V.
      Diet Quality Scores and Risk of Incident Breast Cancer in the California Teachers Study 2015. Dissertation. University of California-Irvine; 2015.
      ,
      • Fung T.T.
      • Hu F.B.
      • Wu K.
      • Chiuve S.E.
      • Fuchs C.S.
      • Giovannucci E.
      The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets and colorectal cancer.
      ,
      • Aigner A.
      • Becher H.
      • Jacobs S.
      • et al.
      Low diet quality and the risk of stroke mortality: the Multiethnic Cohort Study.
      • Biesbroek S.
      • Verschuren W.M.M.
      • Boer J.M.A.
      • et al.
      Does a better adherence to dietary guidelines reduce mortality risk and environmental impact in the Dutch sub-cohort of the European Prospective Investigation into Cancer and Nutrition?.
      • Chan J.K.
      • Mann A.K.
      • Koh-Bell A.
      • Chan J.E.
      • Kapp D.S.
      Relative importance of diet and physical activity in cancer survival: An analysis of the US national health and nutrition examination survey.
      were excluded at this step because they overlapped other included studies, resulting in a total of 113 reports included in the current update (47 additional reports not identified previously).
      • Fung T.T.
      • Hu F.B.
      • McCullough M.L.
      • 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.
      • Kappeler R.
      • Eichholzer M.
      • Rohrmann S.
      Meat consumption and diet quality and mortality in NHANES III.
      • McCullough M.L.
      • Feskanich D.
      • Rimm E.B.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in men.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Adherence to the Dietary Guidelines for Americans and risk of major chronic disease in women.
      • Shahar D.R.
      • Yu B.
      • Houston D.K.
      • et al.
      Dietary factors in relation to daily activity energy expenditure and mortality among older adults.
      • Agnoli C.
      • Krogh V.
      • Grioni S.
      • et al.
      A priori–defined dietary patterns are associated with reduced risk of stroke in a large Italian cohort.
      • 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.
      • Chiuve S.E.
      • Fung T.T.
      • Rimm E.B.
      • et al.
      Alternative dietary indices both strongly predict risk of chronic disease.
      • 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.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of esophageal and gastric cancer in a large cohort study.
      • Li W.Q.
      • Park Y.
      • Wu J.W.
      • et al.
      Index-based dietary patterns and risk of head and neck cancer in a large prospective study.
      • 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.
      • 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 and Health Study.
      • Thomson C.A.
      • Crane T.E.
      • Wertheim B.C.
      • et al.
      Diet quality and survival after ovarian cancer: Results from the Women's Health Initiative.
      • Xie J.
      • Poole E.M.
      • Terry K.L.
      • et al.
      A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer.
      • 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.
      • 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.
      • Arem H.
      • Reedy J.
      • Sampson J.
      • et al.
      The Healthy Eating Index 2005 and risk for pancreatic cancer in the NIH–AARP study.
      • Li W.Q.
      • Park Y.
      • McGlynn K.A.
      • et al.
      Index-based dietary patterns and risk of incident hepatocellular carcinoma and mortality from chronic liver disease in a prospective study.
      • 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.
      • 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.
      • Cespedes E.M.
      • Hu F.B.
      • Tinker L.
      • et al.
      Multiple healthful dietary patterns and type 2 diabetes in the Women's Health Initiative.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • 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.
      • Akbaraly T.N.
      • Ferrie J.E.
      • Berr C.
      • et al.
      Alternative Healthy Eating Index and mortality over 18 y of follow-up: Results from the Whitehall II cohort.
      • Belin R.J.
      • Greenland P.
      • Allison M.
      • et al.
      Diet quality and the risk of cardiovascular disease: The Women’s Health Initiative (WHI).
      • Fung T.T.
      • McCullough M.
      • van Dam R.M.
      • Hu F.B.
      A prospective study of overall diet quality and risk of type 2 diabetes in women.
      InterAct Consortium
      Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study.
      • McCullough M.L.
      • Feskanich D.
      • Stampfer M.J.
      • et al.
      Diet quality and major chronic disease risk in men and women: Moving toward improved dietary guidance.
      • Qiao Y.
      • Tinker L.
      • Olendzki B.C.
      • et al.
      Racial/ethnic disparities in association between dietary quality and incident diabetes in postmenopausal women in the United States: The Women's Health Initiative 1993–2005.
      • Saaksjarvi K.
      • Knekt P.
      • Lundqvist A.
      • et al.
      A cohort study on diet and the risk of Parkinson's disease: The role of food groups and diet quality.
      • 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.
      • Gao X.
      • Chen H.
      • Fung T.T.
      • et al.
      Prospective study of dietary pattern and risk of Parkinson disease.
      • 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.
      • 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.
      • 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.
      • Smyth A.
      • Dehghan M.
      • O'Donnell M.
      • et al.
      Healthy eating and reduced risk of cognitive decline: A cohort from 40 countries.
      • Mursu J.
      • Steffen L.M.
      • Meyer K.A.
      • Duprez D.
      • Jacobs Jr., D.R.
      Diet quality indexes and mortality in postmenopausal women: The Iowa Women’s Health Study.
      • Dugué 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.
      • Fung T.T.
      • Kashambwa R.
      • Sato K.
      • et al.
      Post diagnosis diet quality and colorectal cancer survival in women.
      • 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?.
      • 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.
      • Yu D.
      • Zhang X.
      • Xiang Y.-B.
      • et al.
      Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 134,000 Chinese adults in urban Shanghai.
      • Mertens E.
      • Markey O.
      • Geleijnse J.M.
      • Lovegrove J.A.
      • Givens D.I.
      Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: Evidence from the Caerphilly Prospective Study.
      ,
      • Bertoia M.L.
      • Triche E.W.
      • Michaud D.S.
      • et al.
      Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women.
      • Fitzgerald K.C.
      • Chiuve S.E.
      • Buring J.E.
      • Ridker P.M.
      • Glynn R.J.
      Comparison of associations of adherence to a Dietary Approaches to Stop Hypertension (DASH)-style diet with risks of cardiovascular disease and venous thromboembolism.
      • Folsom A.R.
      • Parker E.D.
      • Harnack L.J.
      Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease.
      ,
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Consistency with the DASH diet and incidence of heart failure.
      • Levitan E.B.
      • Wolk A.
      • Mittleman M.A.
      Relation of consistency with the Dietary Approaches to Stop Hypertension diet and incidence of heart failure in men aged 45 to 79 years.
      • Liese A.D.
      • Nichols M.
      • Sun X.
      • Agostino R.B.
      • Haffner S.M.
      Adherence to the DASH diet is inversely associated with incidence of type 2 diabetes: The Insulin Resistance Atherosclerosis Study.
      • Lin P.H.
      • Yeh W.T.
      • Svetkey L.P.
      • et al.
      Dietary intakes consistent with the DASH dietary pattern reduce blood pressure increase with age and risk for stroke in a Chinese population.
      • Miller P.E.
      • Cross A.J.
      • Subar A.F.
      • et al.
      Comparison of 4 established DASH diet indexes: Examining associations of index scores and colorectal cancer.
      • Boggs D.A.
      • Ban Y.
      • Palmer J.R.
      • Rosenberg L.
      Higher diet quality is inversely associated with mortality in African-American women.
      • Larsson S.C.
      • Wallin A.
      • Wolk A.
      Dietary Approaches to Stop Hypertension Diet and incidence of stroke: Results from 2 prospective cohorts.
      • 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.
      • 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.
      • Park Y.M.
      • Fung T.T.
      • Steck S.E.
      • et al.
      Diet quality and mortality risk in metabolically obese normal-weight adults.
      • Fung T.T.
      • Chiuve S.E.
      • McCullough M.L.
      • Rexrode K.M.
      • Logroscino G.
      • Hu F.B.
      Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women.
      ,
      • Abu-Saad K.
      • Novikov I.
      • Gimpelevitz I.
      • et al.
      Micronutrient intake and adherence to DASH diet are associated with incident major adverse cardiovascular events and all-cause mortality in a bi-ethnic population.
      • Agarwal P.
      • Wang Y.
      • Buchman A.S.
      • Holland T.M.
      • Bennett D.A.
      • Morris M.C.
      MIND diet associated with reduced incidence and delayed progression of parkinsonism in old age.
      • Akbaraly T.N.
      • Singh-Manoux A.
      • Dugravot A.
      • Brunner E.J.
      • Kivimaki M.
      • Sabia S.
      Association of midlife diet with subsequent risk for dementia.
      • Bathrellou E.
      • Kontogianni M.D.
      • Chrysanthopoulou E.
      • et al.
      Adherence to a DASH-style diet and cardiovascular disease risk: The 10-year follow-up of the ATTICA study.
      • Bogumil D.
      • Park S.Y.
      • Le Marchand L.
      • et al.
      High-quality diets are associated with reduced risk of hepatocellular carcinoma and chronic liver disease: The Multiethnic Cohort.
      • Campos C.L.
      • Wood A.
      • Burke G.L.
      • Bahrami H.
      • Bertoni A.G.
      Dietary Approaches to Stop Hypertension Diet concordance and incident heart failure: The Multi-Ethnic Study of Atherosclerosis.
      • Chan R.S.M.
      • Yu B.W.M.
      • Leung J.
      • et al.
      How dietary patterns are related to inflammaging and mortality in community-dwelling older Chinese adults in Hong Kong—A prospective analysis.
      • Chebet J.J.
      • Thomson C.A.
      • Kohler L.N.
      • et al.
      Association of diet quality and physical activity on obesity-related cancer risk and mortality in Black women: Results from the Women's Health Initiative.
      • Chen G.C.
      • Koh W.P.
      • Neelakantan N.
      • Yuan J.M.
      • Qin L.Q.
      • van Dam R.M.
      Diet quality indices and risk of type 2 diabetes mellitus: The Singapore Chinese Health Study.
      • Chou Y.C.
      • Lee M.S.
      • Chiou J.M.
      • Chen T.F.
      • Chen Y.C.
      • Chen J.H.
      Association of diet quality and vegetable variety with the risk of cognitive decline in Chinese older adults.
      • Conway B.N.
      • Han X.
      • Munro H.M.
      • et al.
      The obesity epidemic and rising diabetes incidence in a low-income racially diverse southern US cohort.
      • Deshmukh A.A.
      • Shirvani S.M.
      • Likhacheva A.
      • Chhatwal J.
      • Chiao E.Y.
      • Sonawane K.
      The association between dietary quality and overall and cancer-specific mortality among cancer survivors, NHANES III.
      • Djousse L.
      • Ho Y.L.
      • Nguyen X.T.
      • et al.
      DASH score and subsequent risk of coronary artery disease: The findings from Million Veteran Program.
      • Frisby K.
      • Chen J.
      • Sesso H.
      • Wang L.
      • Gaziano J.
      • Djousse L.
      Healthy dietary patterns and risk of abdominal aortic aneurysm in the Physicians' Health Study.
      • Guinter M.A.
      • McCullough M.L.
      • Gapstur S.M.
      • Campbell P.T.
      Associations of pre- and postdiagnosis diet quality with risk of mortality among men and women with colorectal cancer.
      • Hardy D.S.
      • Mersha T.B.
      • Xu H.
      • Garvin J.B.
      • Stallings D.T.
      • Racette S.B.
      Association of the DASH diet and a genetic risk score with type 2 diabetes risk among African-American and White adults.
      • Haridass V.
      • Ziogas A.
      • Neuhausen S.L.
      • Anton-Culver H.
      • Odegaard A.O.
      Diet quality scores inversely associated with postmenopausal breast cancer risk are not associated with premenopausal breast cancer risk in the California Teachers Study.
      • Hashemian M.
      • Farvid M.S.
      • Poustchi H.
      • et al.
      The application of six dietary scores to a Middle Eastern population: A comparative analysis of mortality in a prospective study.
      • Hoon Lee D.
      • Fung T.T.
      • Tabung F.K.
      • et al.
      Dietary pattern and risk of multiple myeloma in two large prospective US cohort studies.
      • Hoon Lee D.
      • Fung T.T.
      • Tabung F.K.
      • et al.
      Prediagnosis dietary pattern and survival in patients with multiple myeloma.
      • Hu E.A.
      • Steffen L.M.
      • Coresh J.
      • Appel L.J.
      • Rebholz C.M.
      Adherence to the Healthy Eating Index-2015 and other dietary patterns may reduce risk of cardiovascular disease, cardiovascular mortality, and all-cause mortality.
      • Jones N.R.V.
      • Forouhi N.G.
      • Khaw K.T.
      • Wareham N.J.
      • Monsivais P.
      Accordance to the Dietary Approaches to Stop Hypertension diet pattern and cardiovascular disease in a British, population-based cohort.
      • Larsson S.C.
      • Wolk A.
      The role of lifestyle factors and sleep duration for late-onset dementia: A cohort study.
      • Larsson S.C.
      • Wolk A.
      • Bäck M.
      Dietary patterns, food groups, and incidence of aortic valve stenosis: A prospective cohort study.
      • Lavalette C.
      • Adjibade M.
      • Srour B.
      • et al.
      Cancer-specific and general nutritional scores and cancer risk: Results from the prospective NutriNet-Sante cohort.
      • Ma Y.
      • Yang W.
      • Simon T.G.
      • et al.
      Dietary patterns and risk of hepatocellular carcinoma among U.S. men and women.
      • Myneni A.A.
      • Giovino G.A.
      • Millen A.E.
      • et al.
      Indices of diet quality and risk of lung cancer incidence and mortality in the Women's Health Initiative Observational Study.
      • Neelakantan N.
      • Koh W.P.
      • Yuan J.M.
      • van Dam R.M.
      Diet-quality indexes are associated with a lower risk of cardiovascular, respiratory, and all-cause mortality among Chinese adults.
      • Nguyen S.
      • Li H.
      • Yu D.
      • et al.
      Adherence to dietary recommendations and colorectal cancer risk: Results from two prospective cohort studies.
      • Panizza C.E.
      • Shvetsov Y.B.
      • Harmon B.E.
      • et al.
      Testing the predictive validity of the Healthy Eating Index-2015 in the multiethnic cohort: Is the score associated with a reduced risk of all-cause and cause-specific mortality?.
      • Petimar J.
      • Smith-Warner S.A.
      • Fung T.T.
      • et al.
      Recommendation-based dietary indexes and risk of colorectal cancer in the Nurses' Health Study and Health Professionals Follow-up Study.
      • Petimar J.
      • Park Y.M.
      • Smith-Warner S.A.
      • Fung T.T.
      • Sandler D.P.
      Dietary index scores and invasive breast cancer risk among women with a family history of breast cancer.
      • Rautiainen S.
      • Gaziano J.M.
      • Christen W.G.
      • et al.
      Effect of baseline nutritional status on long-term multivitamin use and cardiovascular disease risk: A secondary analysis of the Physicians' Health Study II randomized clinical trial.
      • Seon Kuan A.
      • Green J.
      • Kitahara C.M.
      • et al.
      Diet and risk of glioma: Combined analysis of 3 large prospective studies in the UK and USA.
      • Shah N.S.
      • Leonard D.
      • Finley C.E.
      • et al.
      Dietary patterns and long-term survival: A retrospective study of healthy primary care patients.
      • Shakersain B.
      • Rizzuto D.
      • Larsson S.C.
      • Faxen-Irving G.
      • Fratiglioni L.
      • Xu W.L.
      The Nordic prudent diet reduces risk of cognitive decline in the Swedish older adults: A population-based cohort study.
      • Shivappa N.
      • Hebert J.R.
      • Kivimaki M.
      • Akbaraly T.
      Alternative Healthy Eating Index 2010, Dietary Inflammatory Index and risk of mortality: Results from the Whitehall II cohort study and meta-analysis of previous Dietary Inflammatory Index and mortality studies.
      • Solbak N.M.
      • Xu J.Y.
      • Vena J.E.
      • Csizmadi I.
      • Whelan H.K.
      • Robson P.J.
      Diet quality is associated with reduced incidence of cancer and self-reported chronic disease: Observations from Alberta's Tomorrow Project.
      • Sotos-Prieto M.
      • Bhupathiraju S.N.
      • Mattei J.
      • et al.
      Association of changes in diet quality with total and cause-specific mortality.
      • Sun Y.
      • Bao W.
      • Liu B.
      • et al.
      Changes in overall diet quality in relation to survival in postmenopausal women with breast cancer: Results from the Women's Health Initiative.
      • Tait C.A.
      • L'Abbe M.R.
      • Smith P.M.
      • Watson T.
      • Kornas K.
      • Rosella L.C.
      Adherence to predefined dietary patterns and risk of developing type 2 diabetes in the Canadian adult population.
      • Trébuchet A.
      • Julia C.
      • Fézeu L.
      • et al.
      Prospective association between several dietary scores and risk of cardiovascular diseases: Is the Mediterranean Diet equally associated to cardiovascular diseases compared to National Nutritional Scores?.
      • Wang Z.
      • Siega-Riz A.M.
      • Gordon-Larsen P.
      • et al.
      Diet quality and its association with type 2 diabetes and major cardiometabolic risk factors among adults in China.
      • Wang F.
      • Cai H.
      • Gu K.
      • et al.
      Adherence to dietary recommendations among long-term breast cancer survivors and cancer outcome associations.
      • Wu J.
      • Song X.
      • Chen G.C.
      • et al.
      Dietary pattern in midlife and cognitive impairment in late life: A prospective study in Chinese adults.
      • Xu Z.
      • Steffen L.M.
      • Selvin E.
      • Rebholz C.M.
      Diet quality, change in diet quality and risk of incident CVD and diabetes.
      • Zhu J.
      • Xiang Y.B.
      • Cai H.
      • et al.
      A prospective investigation of dietary intake and functional impairments among the elderly.
      Figure thumbnail gr1
      Figure 1Flowchart presenting search and selection of studies in the current update of the systematic review and 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.
      Characteristics of the 47 studies identified in the current update are presented in Table 2. Including the previous reports, analyses pooled data from 3,277,684 participants. Considering different clinical outcomes, all-cause mortality risk was assessed in 23 reports, CVD incidence or mortality in 45 reports, cancer incidence or mortality in 45 reports, T2D in 16 reports, neurodegenerative diseases in 12 reports, and all-cause mortality and cancer mortality among cancer survivors in 12 reports (those included breast, colorectal, ovarian, and overall cancer, as well as multiple myeloma survivors).
      Table 2Summary characteristics of 47 prospective studies (identified in the current update of review) evaluating association between diet quality (assessed by HEI,
      HEI = Healthy Eating Index.
      AHEI,
      AHEI = Alternate Healthy Eating Index.
      or DASH
      DASH = Dietary Approaches to Stop Hypertension.
      score) and all-cause mortality, CVD
      CVD = cardiovascular disease.
      incidence or mortality, cancer incidence or mortality, T2D,
      T2D = type 2 diabetes.
      neurodegenerative disease, as well as all-cause mortality and cancer mortality among cancer survivors.
      First author, yearCountryCohortOutcomePopulation, n Follow-up, yAge at entry, ySexDiet quality index/scoreAdjustmentOR
      OR = odds ratio.
      /RR
      RR = risk ratio.
      /HR
      HR = hazard ratio.
      (95% CI), multivariate adjusted
      Newcastle Ottawa Quality Assessment Scale (maximum 9)
      Higher score indicate high quality of studies.
      Abu-Saad, 2017
      • Abu-Saad K.
      • Novikov I.
      • Gimpelevitz I.
      • et al.
      Micronutrient intake and adherence to DASH diet are associated with incident major adverse cardiovascular events and all-cause mortality in a bi-ethnic population.
      IsraeliHadera District StudyCVD events; All-cause mortality883

      11.0
      25-64BothDASH scoreNA
      NA = not applicable.
      CVD events
      • HR 0.71 (0.56 to 0.89)
      All-cause mortality
      • HR 0.79 (0.62 to 1.01)
      Quality assessment not possible because only abstract was available
      Agarwal, 2018
      • Agarwal P. <