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Healthy Eating Index Diet Quality in Randomized Weight Loss Trials: A Systematic Review

Published:August 10, 2022DOI:https://doi.org/10.1016/j.jand.2022.08.114

      Abstract

      Background

      Weight loss interventions focus on dietary and physical activity changes to induce weight loss. Both through weight loss and independent of it, diet quality is important for reducing chronic disease risk. However, whether and how diet quality changes over the course of a behavioral intervention is unclear.

      Objective

      To systematically review the evidence from randomized controlled trials on the effect of behavioral interventions on diet quality as defined by the Healthy Eating Index (HEI) among adults with overweight and obesity.

      Methods

      PubMed, Ebscohost CINAHL, Embase, OVID APA PsycInfo, Scopus, and Web of Science were searched through May 2021. Inclusion criteria comprised randomized controlled trial design, a primary or secondary aim of weight loss, a sample of US adults with overweight or obesity, measurement using the HEI-2005, 2010, or 2015, and assessment of the time by treatment effect. Interventions must have included behavioral components and lasted at least 3 months. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The systematic review protocol was published on Open Science Framework.

      Results

      Of 3,707 citations retrieved, 18 studies met inclusion criteria. A wide array of behavioral interventions were assessed, including in-person and mobile health interventions as well as those prescribing intake of specific foods. Risk of bias in the included studies primarily arose from the measurement of the outcome variable. Sample sizes ranged from 34 to 413 participants. Nine studies used multiple dietary recalls, with few using the recommended method of Healthy Eating Index calculation. Changes in diet quality ranged from no improvement to a 20-point improvement. More often, improvement was in the 4- to 7-point range.

      Conclusions

      The evidence for the efficacy of behavioral weight loss interventions for improving diet quality among adults with overweight and obesity is limited. Modest improvements in HEI scores were observed in the reviewed studies.

      Keywords

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      References

        • Guo X.
        • Warden B.A.
        • Paeratakul S.
        • Bray G.A.
        Healthy Eating Index and obesity.
        Eur J Clin Nutr. 2004; 58: 1580-1586
        • Tande D.L.
        • Magel R.
        • Strand B.N.
        Healthy Eating Index and abdominal obesity.
        Public Health Nutr. 2010; 13: 208-214
        • Hales C.M.
        • Carroll M.D.
        • Fryar C.D.
        • Ogden C.L.
        Prevalence of obesity and severe obesity among adults: United States, 2017-2018.
        NCHS Data Brief. 2020; : 1-8
        • Mozaffarian D.
        • Hao T.
        • Rimm E.B.
        • Willett W.C.
        • Hu F.B.
        Changes in diet and lifestyle and long-term weight gain in women and men.
        N Engl J Med. 2011; 364: 2392-2404
        • Webber K.H.
        • Lee E.
        The diet quality of adult women participating in a behavioural weight-loss programme.
        J Hum Nutr Diet. 2011; 24: 360-369
        • Garvey W.T.
        • Mechanick J.I.
        • Brett E.M.
        • et al.
        American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity.
        Endocr Pract. 2016; 22: 1-203
        • Flegal K.M.
        • Panagiotou O.A.
        • Graubard B.I.
        Estimating population attributable fractions to quantify the health burden of obesity.
        Ann Epidemiol. 2015; 25: 201-207
        • Psota T.L.
        • Tindall A.M.
        • Lohse B.
        • Miller P.E.
        • Petersen K.S.
        • Kris-Etherton P.M.
        The Weight Optimization Revamping Lifestyle using the Dietary Guidelines (WORLD) study: Sustained weight loss over 12 months.
        Obesity (Silver Spring). 2020; 28: 1235-1244
        • Svetkey L.P.
        • Ard J.D.
        • Stevens V.J.
        • et al.
        Predictors of long-term weight loss in adults with modest initial weight loss, by sex and race.
        Obesity (Silver Spring). 2012; 20: 1820-1828
        • Butryn M.L.
        • Webb V.
        • Wadden T.A.
        Behavioral treatment of obesity.
        Psychiatr Clin North Am. 2011; 34: 841-859
        • Camhi S.M.
        • Whitney Evans E.
        • Hayman L.L.
        • Lichtenstein A.H.
        • Must A.
        Healthy eating index and metabolically healthy obesity in U.S. adolescents and adults.
        Prev Med. 2015; 77: 23-27
        • Reedy J.
        • Lerman J.L.
        • Krebs-Smith S.M.
        • et al.
        Evaluation of the Healthy Eating Index-2015.
        J Acad Nutr Diet. 2018; 118: 1622-1633
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
      1. National Center for Health Statistics. 2015. What we eat in America/National Health and Nutrition Examination Survey, 2013-2014 (Healthy Eating Index-2015, Scores—U.S. Department of Agriculture, Center for Nutrition Policy and Promotion).

        • Brauer P.
        • Royall D.
        • Rodrigues A.
        Use of the Healthy Eating Index in intervention studies for cardiometabolic risk conditions: A systematic review.
        Adv Nutr. 2021; 12: 1317-1331
        • Cheng J.
        • Liang H.W.
        • Klem M.L.
        • Burke L.E.
        Healthy Eating Index Diet Quality in Randomized Weight Loss Trials: A Systematic Review.
        J Acad Nutr Diet. 2022 Aug 10; (In press)https://doi.org/10.1016/j.jand.2022.08.114
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • et al.
        The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
        • Guenther P.M.
        • Reedy J.
        • Krebs-Smith S.M.
        • Reeve B.B.
        Evaluation of the Healthy Eating Index-2005.
        J Am Diet Assoc. 2008; 108: 1854-1864
        • Guenther P.M.
        • Reedy J.
        • Krebs-Smith S.M.
        Development of the Healthy Eating Index-2005.
        J Am Diet Assoc. 2008; 108: 1896-1901
        • Guenther P.M.
        • Casavale K.O.
        • Reedy J.
        • et al.
        Update of the Healthy Eating Index: HEI-2010.
        J Acad Nutr Diet. 2013; 113: 569-580
        • Guenther P.M.
        • Kirkpatrick S.I.
        • Reedy J.
        • et al.
        The Healthy Eating Index-2010 is a valid and reliable measure of diet quality according to the 2010 Dietary Guidelines for Americans.
        J Nutr. 2014; 144: 399-407
        • Bramer W.M.
        • Giustini D.
        • de Jonge G.B.
        • Holland L.
        • Bekhuis T.
        De-duplication of database search results for systematic reviews in EndNote.
        J Med Libr Assoc. 2016; 104: 240-243
      2. DistillerSR. Version 2.35. Evidence Partners, 2021
        https://www.evidencepartners.com/
        Date accessed: May 4, 2020
        • Centers for Disease Control and Prevention
        Defining adult overweight & obesity.
        2021
        • Sterne J.A.C.
        • Savovic J.
        • Page M.J.
        • et al.
        RoB 2: A revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
        • Kwarteng J.L.
        • Beyer K.M.M.
        • Banerjee A.
        • Stolley M.R.
        Facilitators of behavior change and weight loss in an intervention for African American Breast Cancer Survivors. Article.
        Cancer Causes and Control. 2020; 31: 737-747
        • Hughes S.L.
        • Tussing-Humphreys L.
        • Schiffer L.
        • et al.
        Fit & strong! Plus trial outcomes for obese older adults with osteoarthritis.
        Gerontologist. 2020; 60: 558-570
        • Berkowitz S.A.
        • O’Neill J.
        • Sayer E.
        • et al.
        Health center-based community-supported agriculture: An RCT.
        Am J Prev Med. 2019; 57: S55-S64
        • Alpaugh M.
        • Pope L.
        • Trubek A.
        • Skelly J.
        • Harvey J.
        Cooking as a health behavior: Examining the role of cooking classes in a weight loss intervention.
        Nutrients. 2020; 12: 3669
        • Anderson C.
        • Harrigan M.
        • George S.M.
        • et al.
        Changes in diet quality in a randomized weight loss trial in breast cancer survivors: The lifestyle, exercise, and nutrition (LEAN) study.
        NPJ Breast Cancer. 2016; 216026
        • Demark-Wahnefried W.
        • Jones L.W.
        • Snyder D.C.
        • et al.
        Daughters and Mothers Against Breast Cancer (DAMES): Main outcomes of a randomized controlled trial of weight loss in overweight mothers with breast cancer and their overweight daughters.
        Cancer. 2014; 120: 2522-2534
        • Evans W.E.
        • Raynor H.A.
        • Howie W.
        • et al.
        Associations between lifestyle intervention-related changes in dietary targets and migraine headaches among women in the Women's Health and Migraine (WHAM) randomized controlled trial.
        Obes Sci Pract. 2020; 6: 119-125
        • Fitzgibbon M.L.
        • Tussing-Humphreys L.
        • Schiffer L.
        • et al.
        Fit and strong! Plus: Twelve and eighteen month follow-up results for a comparative effectiveness trial among overweight/obese older adults with osteoarthritis. Promotion & Maintenance of Health & Wellness 3365.
        Randomized Controlled Trial. 2020; 141106267
        • Folta S.C.
        • Paul L.
        • Nelson M.E.
        • et al.
        Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial.
        Int J Behav Nutr Phys Act. 2019; 16: 91
        • Janumala I.
        • Toro-Ramos T.
        • Widen E.
        • et al.
        Increased visceral adipose tissue without weight retention at 59 weeks postpartum.
        Obesity. 2020; 28: 552-562
        • Kwarteng J.L.
        • Matthews L.
        • Banerjee A.
        • Sharp L.K.
        • Gerber B.S.
        • Stolley M.R.
        The association of stressful life events on weight loss efforts among African American breast cancer survivors.
        J Cancer Surviv. 2022; 16: 604-613
        • Lewis K.H.
        • Roblin D.W.
        • Leo M.
        • Block J.P.
        The personal shopper: A pilot randomized trial of grocery store-based dietary advice.
        Clin Obes. 2015; 5: 154-161
        • Njike V.Y.
        • Annam R.
        • Costales V.C.
        • Yarandi N.
        • Katz D.L.
        Which foods are displaced in the diets of adults with type 2 diabetes with the inclusion of eggs in their diets? A randomized, controlled, crossover trial.
        BMJ Open Diabetes Res Care. 2017; 5e000411
        • Ptomey L.T.
        • Steger F.L.
        • Lee J.
        • et al.
        Changes in energy intake and diet quality during an 18-month weight-management randomized controlled trial in adults with intellectual and developmental disabilities.
        J Acad Nutr Diet. 2018; 118: 1087-1096
        • Rock C.L.
        • Zunshine E.
        • Nguyen H.T.
        • et al.
        Effects of pistachio consumption in a behavioral weight loss intervention on weight change, cardiometabolic factors, and dietary intake.
        Nutrients. 2020; 12: 2155
        • Svetkey L.P.
        • Batch B.C.
        • Lin P.H.
        • et al.
        Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology.
        Obesity (Silver Spring). 2015; 23: 2133-2141
        • Ventura Marra M.
        • Lilly C.L.
        • Nelson K.R.
        • Woofter D.R.
        • Malone J.
        A pilot randomized controlled trial of a telenutrition weight loss intervention in middle-aged and older men with multiple risk factors for cardiovascular disease.
        Nutrients. 2019; 11: 229
        • Washburn R.A.
        • Honas J.J.
        • Ptomey L.T.
        • et al.
        Energy and macronutrient intake in the Midwest Exercise Trial 2 (MET-2).
        Med Sci Sports Exerc. 2015; 47: 1941-1949
        • Wiltheiss G.A.
        • Lovelady C.A.
        • West D.G.
        • Brouwer R.J.
        • Krause K.M.
        • Ostbye T.
        Diet quality and weight change among overweight and obese postpartum women enrolled in a behavioral intervention program.
        J Acad Nutr Diet. 2013; 113: 54-62
        • Wing R.R.
        • Becofsky K.
        • Wing E.J.
        • et al.
        Behavioral and cardiovascular effects of a behavioral weight loss program for people living with HIV.
        AIDS Behav. 2020; 24: 1032-1041
        • Gallagher D.
        • Rosenn B.
        • Toro-Ramos T.
        • et al.
        Greater neonatal fat-free mass and similar fat mass following a randomized trial to control excess gestational weight gain.
        Obesity (Silver Spring). 2018; 26: 578-587
        • Njike V.Y.
        • Ayettey R.G.
        • Rajebi H.
        • Treu J.A.
        • Katz D.L.
        Egg ingestion in adults with type 2 diabetes: Effects on glycemic control, anthropometry, and diet quality—A randomized, controlled, crossover trial.
        BMJ Open Diabetes Res Care. 2016; 4e000281
        • Batch B.C.
        • Tyson C.
        • Bagwell J.
        • et al.
        Weight loss intervention for young adults using mobile technology: Design and rationale of a randomized controlled trial—Cell Phone Intervention for You (CITY).
        Contemp Clin Trials. 2014; 37: 333-341
        • Donnelly J.E.
        • Washburn R.A.
        • Smith B.K.
        • et al.
        A randomized, controlled, supervised, exercise trial in young overweight men and women: The Midwest Exercise Trial II (MET2).
        Contemp Clin Trials. 2012; 33: 804-810
        • Trubek A.B.
        • Carabello M.
        • Morgan C.
        • Lahne J.
        Empowered to cook: The crucial role of ‘food agency’ in making meals.
        Appetite. 2017; 116: 297-305
        • Bond D.S.
        • Thomas J.G.
        • Lipton R.B.
        • et al.
        Behavioral weight loss intervention for migraine: A randomized controlled trial.
        Obesity (Silver Spring). 2018; 26: 81-87
        • Stolley M.R.
        • Sharp L.K.
        • Fantuzzi G.
        • et al.
        Study design and protocol for moving forward: A weight loss intervention trial for African-American breast cancer survivors.
        BMC Cancer. 2015; 15: 1018
        • Ptomey L.T.
        • Saunders R.R.
        • Saunders M.
        • et al.
        Weight management in adults with intellectual and developmental disabilities: A randomized controlled trial of two dietary approaches.
        J Appl Res Intellect Disabil. 2018; 31: 82-96
        • Ostbye T.
        • Zucker N.L.
        • Krause K.M.
        • et al.
        Kids and adults now! Defeat Obesity (KAN-DO): rationale, design and baseline characteristics.
        Contemp Clin Trials. 2011; 32: 461-469
        • Kirkpatrick S.I.
        • Reedy J.
        • Krebs-Smith S.M.
        • et al.
        Applications of the healthy eating index for surveillance, epidemiology, and intervention research: considerations and caveats.
        J Acad Nutr Diet. 2018; 118: 1603-1621
        • National Institutes of Health
        • National Cancer Institute
        Dietary Assessment Primer, Evaluating the Effect of an Intervention.
        • Wilson M.M.
        • Reedy J.
        • Krebs-Smith S.M.
        American diet quality: Where it is, where it is heading, and what it could be.
        J Acad Nutr Diet. 2016; 116: 302-310
        • Livingstone K.M.
        • Celis-Morales C.
        • Navas-Carretero S.
        • et al.
        Characteristics of participants who benefit most from personalised nutrition: Findings from the pan-European Food4Me randomised controlled trial.
        Br J Nutr. 2020; 123: 1396-1405
        • Samdal G.B.
        • Eide G.E.
        • Barth T.
        • Williams G.
        • Meland E.
        Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults: Systematic review and meta-regression analyses.
        Int J Behav Nutr Phys Act. 2017; 14: 42
        • Wharton C.M.
        • Johnston C.S.
        • Cunningham B.K.
        • Sterner D.
        Dietary self-monitoring, but not dietary quality, improves with use of smartphone app technology in an 8-week weight loss trial.
        J Nutr Educ Behav. 2014; 46: 440-444
        • Baranowski T.
        24-Hour recall and diet record methods. Chapter 4.
        in: Willett W. Nutritional Epidemiology. Monographies in Epidemiology and Biostatistics. 3 rd ed. Oxford University Press, 2013: 49-69
        • McNutt S.
        • Palmer Zimmerman T.
        • Colaiezzi B.
        Computer-assisted dietary assessment methods. Chapter 3.
        in: Schoeller D.A. Westerterp-Plantenga M.A. Advances in the Assessment of Dietary Intake. CRC Press, Boca Raton, FL2017: 45-66
        • Farshchi H.R.
        • Macdonald I.
        • Madjd A.
        • Taylor M.A.
        Benefits and limitations of traditional self-report instruments. Chapter 1.
        in: Schoeller D.A. Westerterp-Plantenga M.A. Advances in the Assessment of Dietary Intake. CRC Press, Boca Raton, FL2017: 1-18
        • National Institutes of Health, National Cancer Institute
        Dietary assessment primer, learn more about reactivity.
        • Zepeda L.
        • Deal D.
        Think before you eat: Photographic food diaries as intervention tools to change dietary decision making and attitudes.
        Int J Consumer Studies. 2008; 32: 692-698
        • Freedman L.S.
        • Commins J.M.
        • Moler J.E.
        • et al.
        Pooled results from 5 validation studies of dietary self-report instruments using recovery biomarkers for energy and protein intake.
        Am J Epidemiol. 2014; 180: 172-188
        • Zhang S.
        • Krebs-Smith S.M.
        • Midthune D.
        • et al.
        Fitting a bivariate measurement error model for episodically consumed dietary components.
        Int J Biostat. 2011; 7: 1
        • Zhang S.
        • Midthune D.
        • Guenther P.M.
        • et al.
        A new multivariate measurement error model with zero-inflated dietary data, and its application to dietary assessment.
        Ann Appl Stat. 2011; 5: 1456-1487
        • Freedman L.S.
        • Guenther P.M.
        • Krebs-Smith S.M.
        • Kott P.S.
        A population's mean Healthy Eating Index-2005 scores are best estimated by the score of the population ratio when one 24-hour recall is available.
        J Nutr. 2008; 138: 1725-1729
        • Freedman L.S.
        • Guenther P.M.
        • Krebs-Smith S.M.
        • Dodd K.W.
        • Midthune D.
        A population's distribution of Healthy Eating Index-2005 component scores can be estimated when more than one 24-hour recall is available.
        J Nutr. 2010; 140: 1529-1534
        • National Cancer Institute, Division of Cancer Control & Population Sciences
        Choosing a method: How to choose an analysis method dependent on purpose.
        2020
        • Ricart G.
        • Atoloye A.T.
        • Durward C.M.
        • Guenther P.M.
        New exponential scoring functions for diet quality indexes solve problems caused by truncation.
        J Nutr. 2022; 152: 1168-1173
        • Aljuraiban G.S.
        • Gibson R.
        • Oude Griep L.M.
        • et al.
        Perspective: The application of a priori diet quality scores to cardiovascular disease risk—A critical evaluation of current scoring systems.
        Adv Nutr. 2020; 11: 10-24
        • Liese A.D.
        • Krebs-Smith S.M.
        • Subar A.F.
        • et al.
        The Dietary Patterns Methods Project: Synthesis of findings across cohorts and relevance to dietary guidance.
        J Nutr. 2015; 145: 393-402
        • Waijers P.M.
        • Feskens E.J.
        • Ocké M.C.
        A critical review of predefined diet quality scores.
        Br J Nutr. 2007; 97: 219-231
        • Allaire B.T.
        • Tjaden A.H.
        • Venditti E.M.
        • et al.
        Diet quality, weight loss, and diabetes incidence in the Diabetes Prevention Program (DPP).
        BMC Nutr. 2020; 6: 74
        • Steinberg D.
        • Kay M.
        • Burroughs J.
        • Svetkey L.P.
        • Bennett G.G.
        The effect of a digital behavioral weight loss intervention on adherence to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern in medically vulnerable primary care patients: Results from a randomized controlled trial.
        J Acad Nutr Diet. 2019; 119: 574-584
        • Demark-Wahnefried W.
        • Clipp E.C.
        • Morey M.C.
        • et al.
        Lifestyle intervention development study to improve physical function in older adults with cancer: Outcomes from Project LEAD.
        J Clin Oncol. 2006; 24: 3465-3473
        • Demark-Wahnefried W.
        • Clipp E.C.
        • Lipkus I.M.
        • et al.
        Main outcomes of the FRESH START trial: A sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors.
        J Clin Oncol. 2007; 25: 2709-2718
        • Murphy S.L.
        • Kochanek K.D.
        • Xu J.
        • Arias E.
        Mortality in the United States, 2020.
        NCHS Data Brief. 2021; 427: 1-8
        • McClure S.T.
        • Schlechter H.
        • Oh S.
        • et al.
        Dietary intake of adults with and without diabetes: Results from NHANES 2013-2016.
        BMJ Open Diabetes Res Care. 2020; 8e001681
        • Xu Z.
        • Steffen L.M.
        • Selvin E.
        • Rebholz C.M.
        Diet quality, change in diet quality and risk of incident CVD and diabetes.
        Public Health Nutr. 2020; 23: 329-338
        • Morze J.
        • Danielewicz A.
        • Hoffmann G.
        • Schwingshackl L.
        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.
        J Acad Nutr Diet. 2020; 120: 1998-2031
        • Herman P.M.
        • Nguyen P.
        • Sturm R.
        Diet quality improvement and 30-year population health and economic outcomes: A microsimulation study.
        Public Health Nutr. 2021; : 1-9
        • US Preventive Services Task Force
        Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement.
        JAMA. 2018; 320: 1163-1171
        • Keogh R.H.
        • Shaw P.A.
        • Gustafson P.
        • et al.
        STRATOS guidance document on measurement error and misclassification of variables in observational epidemiology: Part 1—Basic theory and simple methods of adjustment.
        Stat Med. 2020; 39: 2197-2231
        • Shaw P.A.
        • Gustafson P.
        • Carroll R.J.
        • et al.
        STRATOS guidance document on measurement error and misclassification of variables in observational epidemiology: Part 2—More complex methods of adjustment and advanced topics.
        Stat Med. 2020; 39: 2232-2263

      Biography

      J. C. is a PhD student, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA.

      Biography

      H.-W. Liang is a PhD student, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA.

      Biography

      T. C. is an associate professor, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA.

      Biography

      M. L. K. is a librarian, Health Sciences Library System, University of Pittsburgh, PA.

      Biography

      L. E. B. is a professor, Department of Health and Community Systems, School of Nursing, University of Pittsburgh, PA.