Perspective: The Application of A Priori Diet Quality Scores to Cardiovascular Disease Risk - A Critical Evaluation of Current Scoring Systems

Ghadeer S. Aljuraiban, Rachel Gibson, Linda M. Oude Griep, Nagako Okuda, Lyn M. Steffen, Linda Van Horn, Queenie Chan

Research output: Contribution to journalReview articlepeer-review

39 Scopus citations


Healthy dietary habits are the cornerstone of cardiovascular disease (CVD) prevention. Numerous researchers have developed diet quality indices to help evaluate and compare diet quality across and within various populations. The availability of these new indices raises questions regarding the best selection relevant to a given population. In this perspective, we critically evaluate a priori-defined dietary indices commonly applied in epidemiological studies of CVD risk and mortality. A systematic literature search identified 59 observational studies that applied a priori-defined diet quality indices to CVD risk factors and/or CVD incidence and/or CVD mortality. Among 31 different indices, these scores were categorized as follows: 1) those based on country-specific dietary patterns, 2) those adapted from distinct dietary guidelines, and 3) novel scores specific to key diet-related factors associated with CVD risk. The strengths and limitations of these indices are described according to index components, calculation methods, and the application of these indices to different population groups. Also, the importance of identifying methodological challenges faced by researchers when applying an index are considered, such as selection and weighting of food groups within a score, since food groups are not necessarily equivalent in their associations with CVD. The lack of absolute cutoff values, emphasis on increasing healthy food without limiting unhealthy food intake, and absence of validation of scores with biomarkers or other objective diet assessment methods further complicate decisions regarding the best indices to use. Future research should address these limitations, consider cross-cultural and other differences between population groups, and identify translational challenges inherent in attempting to apply a relevant diet quality index for use in CVD prevention at a population level.

Original languageEnglish (US)
Pages (from-to)10-24
Number of pages15
JournalAdvances in Nutrition
Issue number1
StatePublished - Jan 1 2020

Bibliographical note

Funding Information:
Perspective articles allow authors to take a position on a topic of current major importance or controversy in the field of nutrition. As such, these articles could include statements based on author opinions or point of view. Opinions expressed in Perspective articles are those of the author and are not attributable to the funder(s) or the sponsor(s) or the publisher, Editor, or Editorial Board of Advances in Nutrition. Individuals with different positions on the topic of a Perspective are invited to submit their comments in the form of a Perspectives article or in a Letter to the Editor. GSA was supported by a grant from the Research Center of the Female Scientific and Medical Colleges, Deanship of Scientific Research, King Saud University; RG, LVH, and QC were supported by R01-HL135486 from the National Heart, Lung, and Blood Institute, National Institutes of Health (Bethesda, MD). Author disclosures: GSA, RG, LMOG, NO, LMS, LVH, and QC, no conflicts of interest. Supplemental Tables 1–3 are available from the “Supplementary data”link in the online posting of the article and from the same link in the online table of contents at GSA and RG share joint first authorship. Address correspondence to QC (e-mail: Abbreviations used: AHEI, alternative Healthy Eating Index; BP, blood pressure; CAD, coronary artery disease; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DII, Dietary Inflammatory Index; DQI-I, Diet Quality Index-International; EPIC, European Prospective Investigation into Cancer and Nutrition; HEI, Healthy Eating Index; hPDI, healthful Plant-based Diet Index; IMI, Italian Mediterranean Index; MDS, Mediterranean Diet Score; MI, myocardial infarction; NFI, Nordic Food Index; NPS, Nutrient Profile Score; PDI, Plant-based Diet Index; RCI, Recommendation Compliance Index; uPDI, unhealthful Plant-based Diet Index.

Publisher Copyright:
Copyright © American Society for Nutrition 2019.


  • CVD risk factors
  • blood pressure
  • cardiovascular disease
  • diet index
  • diet quality score
  • dietary patterns


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