Document Type: Original Articles


Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran;


Background: The close relationship between diet and disease emphasizes the need for optimal diet evaluation. The aim of this study was to compare the efficiency by which each of Healthy Eating Index (HEI)-2010, Diet Quality Index-International (DQI), Mediterranean Diet Score (MDS), and Diet Diversity Score (DDS) evaluates the diet. Methods: In a cross-sectional design, 438 adults aged 20-50 years were recruited. Dietary intakes were assessed using a semi-quantitative food frequency questionnaire. HEI-2010, DQI, MDS, and DDS were calculated and scored according to their corresponding criteria.Results: Energy (1917 ± 554 kcal to 2898 ± 933 kcal), saturated fats (17.0 ± 6.8 g to 28.1 ± 11.5 g), and cholesterol (244 ± 195 g to 414 ± 343 g) increased across tertiles of DDS and energy (2017 ± 699 kcal to 2621 ± 748 kcal) increased across tertiles of DQI. In contrast, saturated fats decreased (23.9 ± 12.0 g to 20.8 ± 8.1 g for HEI-2010 and 23.7 ± 10.0 g to 20.5 ± 10.4 g for MDS), but energy and cholesterol did not change significantly across tertiles of HEI-2010 and MDS. Other nutrients either did not change or changed appropriately across tertiles of the different indices.Conclusion: DDS and, to a less extent, DQI may not be good indicators of healthy diet especially in terms of obesity and cardiovascular diseases. 


  1. STEFFEN, L.M., VAN HORN, L., DAVIGLUS, M.L., ZHOU, X., REIS, J.P., LORIA, C.M., JACOBS, D.R., DUFFEY, K.J. (2014): A modified Mediterranean diet score is associated with a lower risk of incident metabolic syndrome over 25 years among young adults: the CARDIA (Coronary Artery Risk Development in Young Adults) study. Br. J. Nutr., 112, 1654-61.
  2. YANG, J., FARIOLI, A., KORRE, M., KALES, S.N. (2014): Modified Mediterranean diet score and cardiovascular risk in a North American working population. PLoS One, 9, e87539.
  3. KIM, S., HAINES, P.S., SIEGA-RIZ, A.M., POPKIN, B.M. (2003): The Diet Quality Index-International (DQI-I) provides an effective tool for cross-national comparison of diet quality as illustrated by China and the United States. J. Nutr., 133, 3476-84.
  4. AZADBAKHT, L., MIRMIRAN, P., ESMAILLZADEH, A., AZIZI, F. (2006): Dietary diversity score and cardiovascular risk factors in Tehranian adults. Public Health Nutr., 9, 728-36.
  5. JAYAWARDENA, R., BYRNE, N.M., SOARES, M.J., KATULANDA, P., YADAV, B., HILLS, A.P. (2013): High dietary diversity is associated with obesity in Sri Lankan adults: an evaluation of three dietary scores. BMC Public Health, 13, 314.
  6. OTTO, M.C., PADHYE, N.S., BERTONI, A.G., JACOBS DR, J.R., MOZAFFARIAN, D. (2015): Everything in Moderation--Dietary Diversity and Quality, Central Obesity and Risk of Diabetes. PLoS One, 10, e0141341.
  7. SARAF-BANK, S., HAGHIGHATDOOST, F., ESMAILLZADEH, A., LARIJANI, B., AZADBAKHT, L. (2016): Adherence to Healthy Eating Index-2010 is inversely associated with metabolic syndrome and its features among Iranian adult women. Eur. J. Clin. Nutr. doi: 10.1038/ejcn.2016.173. [Epub ahead of print]
  8. ONVANI, S., HAGHIGHATDOOST, F., SURKAN, P.J., LARIJANI, B., AZADBAKHT, L. (2016): Adherence to the Healthy Eating Index and Alternative Healthy Eating Index dietary patterns and mortality from all causes, cardiovascular disease and cancer: a meta-analysis of observational studies. J. Hum. Nutr. Diet. doi: 10.1111/jhn.12415. [Epub ahead of print]
  9. LIVINGSTONE, K.M. & MCNAUGHTON, S.A. (2016): Diet quality is associated with obesity and hypertension in Australian adults: a cross sectional study. BMC Public Health, 16, 1037.
  10. MARK PARK, Y.M., FUNG, T.T., STECK, S.E., ZHANG, J., HAZLETT, L.J., HAN, K., LEE, S.H., MERCHANT, A.T. (2016): Diet Quality and Mortality Risk in Metabolically Obese Normal-Weight Adults. Mayo Clin. Proc., 91, 1372-83.
  11. PANAGIOTAKOS, D.B., PITSAVOS, C. & STEFANADIS, C. (2006): Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr. Metab. Cardiovasc .Dis., 16, 559-68.
  12. AZADBAKHT, L., MIRMIRAN, P. & AZIZI, F. (2005): Dietary diversity score is favorably associated with the metabolic syndrome in Tehranian adults. Int. J. Obes., 29, 1361-7.
  13. CONKLIN, A.I., MONSIVAIS, P., KHAW, K.T., WAREHAM, N.J., FOROUHI, N.G. (2016): Dietary diversity, diet cost, and incidence of type 2 diabetes in the United Kingdom: a prospective cohort study. PLoS Med., 13, e1002085.
  14. RICKHAM, P.P. (1964): Human experimentation. Code of ethics of the world medical association. Declaration of Helsinki. Br. Med. J., 2, 177.
  15. ESFAHANI, F.H., ASGHARI, G., MIRMIRAN, P., AZIZI, F. (2010): Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J. Epidemiol., 20, 150-8.
  16. GUENTHER, P.M., CASAVALE, K.O., REEDY, J., KIRKPATRICK, S.I., HIZA, H.A., KUCZYNSKI, K.J., KAHLE, L.L., KREBS-SMITH, S.M. (2013): Update of the Healthy Eating Index: HEI-2010. J. Acad. Nutr. Diet., 113, 569-80.
  17. MADERUELO-FERNANDEZ, J.A., RECIO-RODRÍGUEZ, J.I., PATINO-ALONSO, M.C., PÉREZ-ARECHAEDERRA, D., RODRIGUEZ-SANCHEZ, E., GOMEZ-MARCOS, M.A., GARCÍA-ORTIZ, L. (2015): Effectiveness of interventions applicable to primary health care settings to promote Mediterranean diet or healthy eating adherence in adults: A systematic review. Prev. Med., 76, S39-55.
  18. YE, X., SCOTT, T., GAO, X., MARAS, J.E., BAKUN, P.J., TUCKER, K.L. (2013): Mediterranean diet, Healthy Eating Index 2005, and cognitive function in middle-aged and older Puerto Rican adults. J. Acad. Nutr. Diet., 113, 276-81.
  19. GESTEIRO, E., RODRÍGUEZ BERNAL, B., BASTIDA, S., SÁNCHEZ-MUNIZ, F.J. (2012): Maternal diets with low Healthy Eating Index or Mediterranean diet adherence scores are associated with high cord-blood insulin levels and insulin resistance markers at birth. Eur. J. Clin. Nutr., 66, 1008-15.
  20. FUNK, L.M., JOLLES, S.A. & VOILS, C.I. (2016): Obesity as a disease: has the AMA resolution had an impact on how physicians view obesity? Surg. Obes. Relat. Dis., 12, 1431-1435.
  21. HOOPER, L., MARTIN, N. & ABDELHAMID, A. (2015): Cochrane corner: what are the effects of reducing saturated fat intake on cardiovascular disease and mortality? Heart, 101, 1938-40.
  22. BERGER, S., RAMAN, G., VISHWANATHAN, R., JACQUES, P.F., JOHNSON, E.J. (2015): Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis. Am. J. Clin. Nutr., 102, 276-94.
  23. RUEL, M.T. (2003): Operationalizing dietary diversity: a review of measurement issues and research priorities. J. Nutr., 133, 3911S-3926S.
  24. AZADBAKHT, L. & ESMAILLZADEH, A. (2011): Dietary diversity score is related to obesity and abdominal adiposity among Iranian female youth. Public Health Nutr., 14, 62-9.
  25. VADIVELOO, M.K. & PAREKH, N. (2015): Dietary variety: an overlooked strategy for obesity and chronic disease control. Am. J. Prev. Med., 49, 974-9.
  26. JOHNSON, F. & WARDLE, J. (2014): Variety, palatability, and obesity. Adv. Nutr., 5, 851-9.