Maturitas 62 (2009) 1–8

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Dietary quality indices and human health: A review

Georgia Kourlaba, Demosthenes B. Panagiotakos ∗
Department of Nutrition and Dietetics, Harokopio University of Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Indices are composite tools aiming to measure and quantify a variety of clinical conditions, behaviors,
Received 11 November 2008 attitudes and beliefs that are difficult to be measured quantitatively and accurately. In this review, the
Received in revised form methodology used to develop dietary indices and their relationship with health determinants and out-
24 November 2008
comes is discussed. In brief, the already proposed indices are adequate tools concerning the evaluation
Accepted 24 November 2008
of diet quality, but they have shown moderate predictive ability in relation to chronic diseases and health
determinants. The aforementioned weaknesses could be attributed to: inappropriate selection of the
Keywords:
components (i.e., number or content of dietary information), selection of small number of cut-off points
Review
Diet score
for each component and/or equal contribution of all index items to the calculation of the total score. Nev-
Dietary index ertheless, dietary indices are important tools to evaluate not only the diet quality, but also the relationship
Methodology between dietary habits and several health outcomes.
© 2008 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Dietary indices: a brief presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Indices developed for dietary assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.1. Healthy Eating Index (HEI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.2. Diet Quality Index (DQI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3. Healthy Diet Indicator (HDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.4. Mediterranean Diet Scale (MDS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.5. MedDietScore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4. Similarities and differences among existing dietary indices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.1. Index items/components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.2. Cut-off values and scoring system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.3. Contribution of each component to the score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5. Dietary Quality Indices and health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.1. Diet Quality Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.2. Healthy Eating Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5.3. Mediterranean Diet Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1. Introduction of a disease, health-related quality of life, dietary habits, etc.). All

indices are combined measures of individual variables (i.e., index
Indices are composite tools aiming to measure and quan- items/components). Each index item/component expresses a dif-
tify a variety of clinical conditions, behaviors, attitudes and ferent dimension of the index [1,2]. Usually, these components are
beliefs that are very difficult to be measured quantitatively and scored using arbitrary weights and then, they are summed in order
accurately (i.e., psychological symptoms like depression, severity to develop a total score that better describes people’s health con-
ditions, behaviors, and attitudes (Fig. 1).
In addition to the aforementioned reason, indices were also
∗ Corresponding author at: 70 El. Venizelou str., 176 71, Kallithea, Athens, Greece. developed in order to overcome several problems in analysis of
Tel.: +30 2109549332; fax: +30 210 9600719. highly correlated data. It is a widely known fact that the com-
E-mail address: dbpanag@hua.gr (D.B. Panagiotakos). ponents of an index are usually highly correlated and may act

0378-5122/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.maturitas.2008.11.021
2 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8
Fig. 1. Methodology for index development.
synergistically or antagonistically [3,4]. Therefore, the “single com-
ponent” approach may be inadequate to evaluate possible effect
modification among isolated components of the index, as well as
confounding by the effect of other variables. Furthermore, entering
a large number of highly correlated variables (i.e., the compo-
nents of the index) in a model may lead to the multi-collinearity
phenomenon, resulting in less robust estimations of the coeffi-
cients and less accurate predictions [3]. All these issues can be
addressed using composite indices that measure complex concepts
more effectively than single indicators and are more capable in
handling multiple items.
Indices have been used widely in the field of social and
biomedical sciences (i.e., psychology, nutritional epidemiology,
etc.). In nutritional epidemiology, the dominant approach in
the past, that of investigating the association between single
nutrients or foods and the risk of chronic diseases, is fraught with
problems due to the complexity of people’s diet, the possible
correlations in nutrients intake and the possible interactions in
the effect of several foods/nutrients [5]. It is widely accepted
that individuals do not consume isolated nutrients or foods but
complex combinations of foods consisted of several nutrients and
non-nutrients [5]. Nutrients may interact with each other and
influence their bioavailability and absorption. Moreover, increased
consumption of one food (i.e., red meat and products) may be
associated with reduced consumption of other foods (i.e., fruit
and vegetables) since the total energy intake of individuals should
remain stable. All these mentioned above increase the difficulty
of attributing particular effects to isolated foods or nutrients. For
this reason, an alternative approach (i.e., dietary pattern analysis)
has been suggested recently, in order to evaluate the relation-
ship between diet and health outcomes [4,6–8]. However, there
is no direct method to quantify and measure dietary patterns.
Therefore, two indirect approaches have been suggested in order
to determine those. One approach is based on the composition
of predefined diet quality indices using current nutrition knowl-
edge (i.e., specific dietary guidelines). This method is called as
“theoretically defined dietary patterns”. The other approach is
based on statistical techniques such as principal component
analysis and cluster analysis and it is known as “empirical dietary
patterns”.
In this review paper, we focus on dietary quality indices that has
been proposed and validated up to now. The objective of this work
is to review published studies that present the development and
evaluation of dietary indices and to discuss several methodological
issues related to their composition. To identify studies that propose
dietary indices or evaluate the association between such indices
and health outcomes, Pubmed was searched (up to June 2008) using
the keywords diet/dietary score, diet/dietary index, diet quality,
dietary patterns. Moreover, cited references from selected articles
were also used to find additional studies that were not retrieved in
the initial search in Pubmed.
2. Dietary indices: a brief presentation
A large number of indices have been proposed and used in
the literature. The vast majority of them have been constructed to
evaluate diet quality of adults while some specific dietary qual-
ity indices have been developed for children and adolescents.
Generally, indices have been constructed based either on nutri-
tion guidelines/recommendations (i.e., Diet Quality Index (DQI) [9],
Healthy Eating Index (HEI) [10], Healthy Diet Indicator (HDI) [11],
Dietary Guidelines Index (DGI) [12], etc.), or on Mediterranean
dietary pattern (i.e., Mediterranean Diet Scale (MDS), MedDi-
etScore, etc.) [13–17].
Some specific indices have been used widely (i.e., the HEI [10],
the DQI [9], the HDI [11] and the Mediterranean Diet Scale (MDS)
[16]) and a lot of others have been developed performing several
modifications to these. The methodology used for the composition
of selected indices are detailed below, while the methodology used
for the development of many existing indices is presented briefly
in Tables 1 and 2.
3. Indices developed for dietary assessment
3.1. Healthy Eating Index (HEI)
The HEI [10] is an index developed from the U.S. Department
of Agriculture (USDA), based on Dietary Guidelines for Americans
(1995), as a tool to measure compliance with dietary guidance. The
HEI was comprised of 10 components: grains, vegetables, fruits,
milk and meat intakes, total fat and saturated fat intakes as a percent
of total energy intake, cholesterol and sodium intakes as mg and
variety in a person’s diet. Scores between 0 and 10 were assigned
to each component. Score 0 indicates non-compliance with recom-
mended amounts or ranges while score 10 indicate intakes close to
recommended amounts or ranges. The intermediate scores were
computed proportionally. Summing the scores assigned to each
component, an index with values between 0 and 100 was obtained.
After 2000, the HEI was slightly modified to reflect changes in
the Dietary Guidelines [18]. However, the release of the 2005
Dietary Guidelines necessitated a revision of the HEI because of
the increased emphasis on important aspects of diet quality, such
as whole grains, various types of vegetables, specific types of fat
and the introduction of the new concept of “discretionary calories”.
Therefore, the revised HEI was developed recently and called HEI-
2005 [19]. This updated version of HEI consisted of 12 components:
total fruit, whole fruit, total vegetables, dark green and orange veg-
etables and legumes, total grains, whole grains, milk, meat and
beans and oils, saturated fat intake as percentage of total energy
intake, sodium intake as g/1000 kcal and the calories form solid
fat, alcohol and added sugar as percentage of total energy intake
(Table 1). The total score of HEI-2005 ranged between 0 and 100.
Table 1
Description of dietary indices developed based on dietary recommendations.

Authors (year) Index Index components Number of partitions and Range of Main findings
scoring system index

Patterson et al. Diet Quality Index 8 components 3 partitions 0–16 Reflect the diet quality [9]
(1994) [9] (DQI)a Nutrients and food groups 0, 1 and 2 points Correlation with overall and cardiovascular mortality. No association with cancer
mortality [32]
Significant association with inflammation indicators among post-menopausal
women that became non-significant after adjustment for body mass index [50]

Haines et al. Diet Quality Index 10 components Each component contributes 0–100 Reflect diet quality [20]
(1999) [20] Revised (DQI-R)a Nutrients, food groups, from 0 to 10 points No correlation with biochemical indices of cardiovascular diseases [31].
variety
Limited value in predicting breast cancer risk in post-menopausal women [49]

Kim et al. Diet Quality Index 17 components Variety: 0–20 points 0–100 Correlation with nutrients either they are index components or not [22,30]
(2003) [30] International Variety, adequacy, Adequacy: 0–40 points

G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8

(DQI-I)a moderation, overall balance
Moderation: 0–30 points
Overall balance: 0–0 points

Kennedy et al. Healthy Eating 10 components Each component contributes 0–100 No or low association with the risk of chronic diseases. No association with risk of
(1995) [10] Index (HEI)a 0–10 points cancer [36,37]
Nutrients, food groups and High correlation with nutrients [10]
variety
Some studies showed that this index is positive predictor of serum concentrations
of vitamin C, E, folate and all carotenoids (p < 0.001) [35], while others showed no
association [31]
Negative predictors of BMI, serum homocysteine, C-reactive protein, plasma
glucose and hemoglobin A1C (p < 0.05) [35]
Strong association with a wide range of nutritional biomarkers of micronutrients
[33,34]
Limited value in predicting breast cancer risk in post-menopausal women [49]
Significant association with inflammation indicators among post-menopausal
women that became non-significant after adjustment for body mass index [50]

McCullough et Alternative Healthy 9 components 8 components: 0–10 points each 2.5–87.5 Low correlation with the risk of CVD and other chronic diseases. No association
al. (2002) [38] Eating Index one and 2.5 points for the non with cancer [38]
(AHEI)a Nutrients and food groups use of multivitamin and 7.5 Significantly lower risk for colorectal cancer only among men with highest score
points for the use [39]
Associated with lower risk of breast cancer among post-menopausal women [49]
Inversely associated with estrogens levels and positively associated with plasma
levels of sex hormone binding globulin [28]

Shatenstein et Canadian Healthy 9 components 7 components: 0–10 points each 0–100 Reflects adequately diet quality of Canadians [29]
al. (2005) [29] Eating Index one
Food groups and variety Fruit and vegetable components:
0–20 points each one
Guenther et al. Healthy eating 12 6 components: 0–5 points each 0–100 Significantly lower risk for colorectal cancer among men and women with highest
(2007) [19] Index -2005 com- one score [39]
(HEI-05) po- 5 components: 0–10 points each
nents one
1 components: 0–20 points

3
4 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8

3.2. Diet Quality Index (DQI)

Negatively associated with serum lipids, homocysteine and the absolute risk of
Patterson et al. proposed an index for the evaluation of diet

Low correlation with risk of cancer among post-menopausal women [12]

quality (DQI), based on US dietary recommendations from Diet and
Health [9]. This index consisted of eight components: total fat, sat-
urated fat and cholesterol, fruits, vegetables, grains and legumes
intake, protein, sodium and calcium intakes. Scores 0, 1 and 2
were assigned to each one component. Score 0 was assigned to
people achieving a nutritional goal, while score 2 was assigned
to people who did not achieve a goal. An index was obtained by
summing the scores ascribed to the eight components. The val-
ues of the index ranged between 0 (excellent diet) and 16 (poor
diet).
Inverse relationship with mortality [11]

Is associated with risk of obesity [54]

During 1999, Haines and his colleagues revised the DQI in order
to reflect current dietary guidance, to incorporate improved meth-
ods of estimating food servings and to develop and incorporate
ischemic heart disease [55]

measures of dietary variety and moderation [20]. The updated

Reflects diet quality [54]

version of DQI was called DQI-Revised (DQI-R), consisted of 10

components and scores between 0 and 10 were assigned to each
component. Therefore, the total score of DQI-R range from 0 to
Main findings

100. Low scores reflect poor compliance with dietary guidelines

(Table 1).

3.3. Healthy Diet Indicator (HDI)

The HDI was developed from Huijbregts et al., based on WHO

Range of

dietary recommendations for the prevention of several chronic dis-

0–100
index

0–12

eases [11]. Nine food/food groups (i.e., saturated fat, poly-saturated

0–18
0–9

fat, protein, complex carbohydrates, fiber, fruits and vegetables,

legumes/nuts, mono- and disaccharides and cholesterol intakes)
were used as the components of the HDI. Scores 0 and 1 were
Some components contribute up
2 partitions for each component

attributed to each component. Score 1 was ascribed when the intake

Three cut-off point system (1, 2
to 10 points and other up to 5

was close to recommendations and score 0 was assigned when the

0, 1 and 2 points from each
scored with 0 and 1 points
Number of partitions and

intake was away from recommended amounts. Summing the scores

assigned to 9 components, an index ranged between 0 and 9 was
obtained (Table 1).
scoring system

and 3 points)
component

3.4. Mediterranean Diet Scale (MDS)

points

Trichopoulou et al. developed an index to evaluate the degree

of adherence to traditional Mediterranean diet [16]. Eight compo-
nents (i.e., intake of grains, vegetables, fruits and nuts, milk and
dairy products, meat and meat products, legumes, and alcohol as
Nutrients and food groups
Nutrients and food groups

Nutrients and food groups

Description of dietary indices developed based on dietary recommendations.

well as the ratio of mono-saturated to saturated fat) were used for

the composition of this index. Scores 0 and 1 were assigned to each
Index components

component using as a cut-off point the median intake of men and

women participated in the study. Summing the scores assigned
9 components

9 components

9 components

Food groups
Component

to each component, a score ranged between 0 (low adherence to

Mediterranean diet) and 8 (high adherence) was obtained. During
2003, Trichopoulou et al. revised this index in order to include the
fish intake as an additional component [15]. The same scoring sys-
Based on 1990 WHO dietary recommendations.

tem was used. Therefore, the values of the revised version of MDS
ranged from 0 to 9 (Table 2).
Based on US dietary recommendations.
Dietary Guidelines
Indicator (HDI)b

Dietary Quality
Overall dietary

Danish dietary recommendations.

Index-revised

3.5. MedDietScore
Healthy Diet

score (DQS)c
Index (DGI)

(ODI-R)

In 2006, Panagiotakos et al. developed an index to evalu-

Index

ate the degree of adherence to the traditional Mediterranean

dietary pattern [21]. Eleven components of the Mediterranean
diet (i.e., non-refined cereals, fruits, vegetables, potatoes, legumes,
olive oil, fish, red meat, poultry, full fat dairy products and alco-
Huijbregts et al.
Authors (year)

Harnack et al.

hol) were used. Scores 0–5 were assigned to all components.

(2008) [54]

(2007) [55]
(2002) [12]
(1997) [11]

Thus, the total score ranges between 0 and 55. Higher values
Toft et al.
Lee et al.
Table 1

of score indicate greater adherence to Mediterranean pattern

a

(Table 2).
 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8 5

Table 2
Description of dietary indices developed based on Mediterranean diet and only on food groups.

Authors (years) Index Index components Number of partitions and Range of Main findings
scoring system index

Gerber et al. (2000) Mediterranean Diet 7 components 3 partitions for each 0–14 Inverse relationship with vitamin E, ␻ − 3 fatty
[27] Quality Index (MDQI) component acids and beta-carotene. No association with
Nutrients and food 0–2 points cholesterol [27]
groups
Trichopoulou et al. Mediterranean Diet 8 components 2 partitions for each 0–8 Inverse relationship with the overall mortality
(1995) [16] Scale (MDS) component [16,43–45,56]
Food groups and diet 0 and 1 points No association with Body Mass Index and
composition in lipids Waist-to-Hip ratio [51]
Trichopoulou et al. Modified 9 components (8 2 partitions for each 0–9 Significant association with all types of
(2003) [15] Mediterranean Diet components of MDS component mortality [15,41]
Scale (MMDS) and fish consumption)
0 and 1 points

Martinez-Gonzalez et A prior Mediterranean 8 components 5 partitions for each 0–40 Correlation with the risk of myocardial
al. (2002) [47] dietary pattern component infarction [47]
Food groups 0–5 points

Martinez-Gonzalez et Mediterranean Score 9 components 2 partitions for each 0–9 Correlation with the risk of myocardial
al. (2004) [40] component infarction [40]
Food groups 0 and 1 points

Panagiotakos et al. MedDietScore 11 components 5 partitions for each 0–55 Correlation with hypertension,
(2007) [25] component hypercholesterolemia diabetes mellitus and
obesity [25,57]
Food groups 0–5 points Correlation with glucose homeostasis indices [58]

Lowik et al. (1999) [22] Food Based Quality 7 components 2 partitions for each 0–7 Positive correlation with energy intake [22]
Index (FBQI) component
Food groups 0 and 1 points

Osler et al. (2001) [24] Healthy Food Index 4 components 2 partitions for each 0–4 No association with incidence of coronary
(HFI) component heart disease and overall mortality [23,24]
Food groups 0 and 1 points

4. Similarities and differences among existing dietary
indices
Taking into account the aforementioned ones, a lot of differ-
ences and similarities among existing dietary indices concerning
the methodology used for their development were revealed. This
could be attributed to the fact that this methodology is not utterly
clarified. As a consequence, many arbitrary choices related to the
variables/index items/components that should be included in the
index, the cut-off values that should be used for each component
and the weights that should be assigned to each component take
part in the composition of an index. More specifically.
4.1. Index items/components
The components of a dietary quality index may be nutrients
(i.e., total fat intake as percent of total energy intake), food/food
groups (i.e., fruits intake) or a combination of those. Therefore,
some indices consisted of only nutrients, some others contain only
food/food groups and others consisted of both nutrients and foods.
For instance, the Food-Based Quality Index (FBQI) [22], the Healthy
Food Index [23,24] and the MedDietScore [25] have constructed
using only food/food groups. The MDS was constructed using food
groups, the alcohol intake and a ratio that reflects the composition
of diet to fatty acids while two modified versions of MDS contain
only food groups [21,26]. On the contrary, the modified indices of
DQI, HEI and HDI were developed using both nutrients and food
groups. For this reason, in a review paper published at 1996, Kant
categorized indices in three groups: (a) indices derived from nutri-
ent only, (b) indices based on foods or food groups and (c) indices
based on a combination of nutrients and foods [4]. At this point, it
should be highlighted that the content of index components varies
to different indices. That is, different nutrients or foods have been
used in each index. However, there are some specific nutrients
(i.e., fat and cholesterol) and foods (i.e., fruit, vegetables and whole
cereal/grains intake) used in the vast majority of indices because
their health impact is established. Moreover, the number of dietary
variables used in each dietary index varies. It can be observed that
although the vast majority of indices have been constructed using
9 or 10 components, there are some indices developed using 4 or
17 components.
4.2. Cut-off values and scoring system
Once the variables have been selected to be included in an
index (e.g., foods/food groups, nutrients), they need to be quanti-
fied. That is, the number of partitions (i.e., classes/categories) for
each component as well as the score assigned to each partition
should be determined. The simplest method is to use a cut-off
value for each index item and assign a score of “0” if consump-
tion is lower than this value (or higher) and “1” if consumption
is higher (or lower) than this cut-off point, respectively. As it has
been already mentioned above, a large number of indices have
been developed using only one cut-off point for each compo-
nent [11,15,16,22,24]. Group median intake of each component or a
healthy level of intake, based usually on specific dietary guidelines,
has been used as cut-off values. However, there are two draw-
backs of taking the group median as a cut-off value. Firstly, it is
not certain that the median reflects a healthy level of intake per se
and secondly, it will differ between population(s) sample(s). The
advantage of using the median as a cut-off point is that half of
the subjects will score positively and half will score negatively on
each component, ensuring that each item distinguishes well and
in the same way between subjects. Moreover, the use of a cer-
tain intake level as a cut-off value for each component although
seems appealing, has one major disadvantage. It is possible that
the intake of a particular component may be below the cut-off
level for almost all subjects in a group. Thus, this item will not con-
6 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8
tribute extra discriminating power and could just as well be left
out.
Apart from indices constructed using only one cut-off point for
each component (e.g. MDS [16], HDI [11], FBQI [22], HFI [23,24],
etc.), there are indices developed using two or more cut-off points
for each item (e.g., DQI [9], MDQI [27], DQI-R [20], DGI [12], etc.) and
others which the score assigned to each component proportionally
based on the degree of adherence to dietary recommendations (e.g.
HEI [10], etc.).
4.3. Contribution of each component to the score
An important issue which should be addressed during index
composition is the contribution of each component to the total
score. In most existing indices, all items contribute equally to the
total score, that is, all components have the same weight. Only
few indices have been constructed assigning specific weights to
some components (i.e., HEI-05, Canadian HEI [29], DQI-I [30]). How-
ever, the weights were attributed arbitrarily. The authors did not
explain how these weights were calculated. They only reported that
higher weights were assigned to components considered to be more
important for diet quality, based on specific dietary guidelines.
5. Dietary Quality Indices and health outcomes
In the previous parts of the present work, the methodology
used to develop most of the existing indices was presented and
we commended on their similarities and discrepancies. However,
the validity of each index should be checked. Therefore, several
studies have been conducted in order to examine whether these
indices are strongly related to nutrient adequacy or health out-
comes. Tables 1 and 2 illustrate the major findings of these studies.
5.1. Diet Quality Index
Patterson revealed that the DQI was inversely associated with
intakes of important measures of diet quality (i.e., fiber, vitamin C,
etc.) indicating that this tool reflects adequately the overall diet
quality [9]. Other studies conducted later, confirmed the afore-
mentioned finding [20,30]. However, one study that examined the
association between DQI-R and biomarkers of cardiovascular dis-
ease (CVD) showed no significant association [31], while another
study that investigated the effect of DQI on mortality of elderly,
showed that higher values of the index was associated with a sig-
nificant moderate increase in all (in men and women) and CVD (in
women only) mortality and with no effect on cancer mortality [32].
5.2. Healthy Eating Index
In the study that Kennedy presented the development of the HEI,
he also showed that this index is a useful tool to measure overall diet
quality of Americans [10]. Several published studies showed that
the HEI score is related to blood nutrients of dietary intake [33–35].
Concerning the association between the HEI score and morbidity or
mortality, no study was found to correlate this score with mortality
while several studies have examined the association between this
one and morbidity. A weak association was detected between HEI
score and risk of chronic disease with the exception of cancer risk
[36,37]. Moreover, while Kant et al. reported that the HEI score was
associated with obesity and biomarkers of CVD and diabetes [35],
Fung et al. at the same period, published a study indicating that the
HEI is not significantly correlated with any of biomarkers for CVD
[31]. A low correlation was detected between AHEI and risk of CVD
or other chronic diseases, while no association was detected with
cancer risk [38]. By contrast, a recently published study showed a
significantly lower risk for colorectal cancer only among men with
highest AHEI score [39]. In the same study, it was revealed that the
latest version of HEI (HEI-2005) is also inversely correlated with
colorectal cancer risk [39]. Moreover, Fung et al. also reported that
AHEI was significantly inversely associated with several biomarkers
of CVD risk [31].
5.3. Mediterranean Diet Scores
Mediterranean diet indices have received increased attention
and interesting, because several studies have reported a signif-
icant association between Mediterranean diet and reduced CVD
risk as well as several forms of cancer [13,15,16]. As a result, a
lot of indices have been constructed based on the components
of the Mediterranean diet. Several studies have been conducted
to evaluate the association between these indices and various
health outcomes in several European populations [16,27,40–45].
The majority of these studies have been conducted among elderly
adults and have examined the association between Mediterranean
dietary indices and mortality [16,41,43–46]. It has been showed that
greater adherence to Mediterranean diet is correlated with reduced
mortality. Lower mortality was detected in Greek [16], Danish
[45], Spanish [43] and European elderly populations [41]. On the
contrary, Haveman-Nies et al. reported no significant association
between Mediterranean dietary and mortality among European
elderly adults [46]. Moreover, in the study conducted by Lasheras et
al. in a Spanish population, a significant association between score
and mortality was detected only for people older than 80 years old
[43]. Moreover, two studies were found to evaluate the association
between a Mediterranean diet index and myocardial infarction risk
and both revealed a low correlation [40,47]. Finally, Panagiotakos
and his colleagues have examined the association of the Mediter-
ranean diet score with biological markers of CVD risk and other CVD
risk factors (i.e., diabetes mellitus, hypercholesterolemia, hyperten-
sion, obesity) [21,48]. All studies revealed that this score may be a
useful tool in detecting individuals prone to the development of
nutrition-related health conditions and CVD.
Finally, although no study was found to examine whether
existing dietary indices evaluate adequately the diet quality of post-
menopausal women, few studies have examined the association
between existing indices and several health outcomes among post-
menopausal women. The findings of these studies were similar with
those of studies that investigated the association of dietary indices
with health outcomes in other populations. In particular, it has been
detected that the AHEI was significantly inversely associated with
estrogens levels and positively associated with plasma levels of sex
hormone binding globulin [28]. Another study that examined the
relationship of HEI, A-HEI and DQI-R with the breast cancer risk
among post-menopausal women showed that women that scored
high in A-HEI had significantly a lower risk of breast cancer, while
the HEI and DQI-R appeared to be of limited value in predicting
breast cancer [49]. Moreover, although the HEI and DGI-R were
found to be significantly associated with inflammation indicators
in overweight and obese post-menopausal women, these associa-
tions became non-significant after adjustment for body mass index
[50]. In addition, a significant association was detected between
DGI and colon, bronchus, lung, breast and uterus cancer risk [12]
(Table 1). Therefore, further studies should be conducted in order
to investigate whether the existing indices are adequate means to
evaluate overall diet quality among post-menopausal women.
Based on the aforementioned, it is clear that the majority
of existing indices measure adequately diet quality since they
are highly correlated with intake of several macro- and micro-
nutrients [9,10,20,22,27,29,30]. On the contrary, it has revealed
that these indices may not be good predictors for the risk
of several chronic diseases (i.e., CVD, cancer, etc.) or mortality
since some studies showed no association between particular
 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8
dietary indices and biomarkers of CVD, mortality or morbidity
[23,24,31,32,36–38,51] while other studies showed low to moder-
ate associations [11,12,32,36–38]. More problematic seems to be
the indices constructed based on particular dietary guidelines. This
could be attributed to the arbitrary choices performed during index
construction, such as the number and the content of index compo-
nents, the number of cut-off values for each component and the
weight assigned to each component.
In more details:
• As it has been mentioned in the previous parts of this work, the
majority of indices have been developed based either on specific
dietary guidelines or on Mediterranean diet pattern. This means
that the components of the indices have been mainly chosen
among the elements that particular guidelines or pattern gives
increased emphasis on. As it was expected, this method leads to
indices that are adequate tools to measure the degree of adher-
ence to the particular guidelines or pattern. However, it is not
certain that these indices will have increased predictive capacity
for several health outcomes, since the components of particular
guidelines are not necessarily to be good predictors of health sta-
tus. For example, the validation studies of (A)HEI, DQI-(R) and
HDI – indices that have been developed based on guidelines –
have shown that although they are appropriate measures to eval-
uate the diet quality, they are not highly correlated with health
outcomes [9–12,20,29,31,32,36–38]. On the contrary, the stud-
ies that examined the predictive capacity of Mediterranean diet
indices have shown that these indices do not have the best pre-
dictive ability but they have a sufficient one [15,16,40,41,43–47].
This could be attributed to the fact that the elements of Mediter-
ranean diet are strongly associated with reduced risk of coronary
heart disease and several forms of cancer [13,15,16]. Therefore,
although there is not any established method to select the optimal
number of components as well as the content of these, the dom-
inant components of specific dietary recommendations/patterns
or the nutrients/foods proposed to be important determinants of
several chronic diseases could be used as a guide to select the
optimal number of index items as well as their content. However,
the choice of index components based on the foods/food groups
or nutrients proven to have strong health effect may result in a
dietary index with better predictive capacity. That is, the method
that should be used for the choice of number and content of index
items should be driven by the purpose of index.
• The majority of dietary indices have been developed using only
few cut-off points (e.g., one or two cut-off value) for each com-
ponent, resulting in a small scale index. However, it is widely
adopted that categorization of a continuous variable, as well as
reduction on the number of classes in a categorical variable leads
to loss of information [52]. Therefore, constructing an index using
a small number of partitions in each component may result in
loss of information regarding the initial concept measured by
this index. Moreover, it has been revealed that indices devel-
oped using components with small number of partitions have
low diagnostic capacity (e.g., reduced sensitivity) [53]. Therefore,
the use of large number of cut-off points (at least more than two)
is recommended in order to increase the diagnostic capacity of
indices.
• Finally, all components contribute equally to the calculation of
total score in the vast majority of indices. That is, no specific
weights for each component has been used based on the partic-
ular effect of each one on health outcomes (i.e., chronic diseases,
biochemical indices, mortality). However, it is not reasonable that
all nutrients or foods have the same health impact or contribute
equally to diet quality. Therefore, this may also affect the diag-
nostic ability of index, since it seems more plausible to assign
greater weights to items (i.e., foods/food groups/nutrient) that
7
exert greater influence on health or are more important for diet
quality. To be able to do so, data is needed regarding the influ-
ence of each component on health. However, it is difficult to
be determined since each item is correlated in different extent
with different health outcomes (i.e., several chronic diseases).
For instance, the effect of meat intake on large intestine cancer
may be different from that on prostate cancer. Therefore, different
weights should be assigned to the same component according to
the purpose of the developed index.
6. Conclusions
Traditional analyses used in nutritional epidemiology evaluated
the effect of single foods or nutrients on the risk of developing
several chronic diseases. However, taking into account the fact
that individuals eat meals consisted of a combination of foods and
nutrients instead of isolated nutrients; the dietary pattern analy-
sis emerged as an alternative approach to evaluate the association
between overall diet and several health outcomes. Diet Quality
Index is one of the two approaches suggested to quantify dietary
patterns.
Although a large number of indices have been developed and
used in search and public health, several methodological issues
concerning index composition remained unresolved and they may
affect the diagnostic capacity of indices. These problems could be
possible explanations for the weakness of existing indices to pre-
dict chronic diseases and mortality better than isolated items in all
populations that they were applied (i.e., adults, post-menopausal
women, elderly, etc.). Therefore, investigators should pay increased
attention during the construction of an index especially when they
aim to use it for chronic disease prevention. More specifically, the
use of components consisted of large number of partitions (i.e.,
classes) as well as the use of specific weights for each index compo-
nent is recommended. Furthermore, although the use of nutrients
as index components may seem preferable since they can lead to
a more accurate tool in evaluating diet quality, the use of foods or
food groups may result in an easily applied tool.
References
[1] Scale (Social sciences). In. p. From Wikipedia, the free encyclopedia.
http://en.wikipedia.org/wiki/Scale (social sciences).
[2] Scales and indexes. In. p. http://faculty.ncwc.edu/toconnor/308/lect05.htm.
[3] Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology.
Curr Opin Lipidol 2002;13:3–9.
[4] Kant AK. Indexes of overall diet quality: a review. J Am Diet Assoc
1996;96:785–91.
[5] Mertz W. Foods and nutrients. J Am Diet Assoc 1984;84:769–70.
[6] Trichopoulos D, Lagiou P. Dietary patterns and mortality. Br J Nutr
2001;85:133–4.
[7] Kant AK. Dietary patterns and health outcomes. J Am Diet Assoc
2004;104:615–35.
[8] Jacques PF, Tucker KL. Are dietary patterns useful for understanding the role of
diet in chronic disease? Am J Clin Nutr 2001;73:1–2.
[9] Patterson RE, Haines PS, Popkin BM. Diet quality index: capturing a multidi-
mensional behavior. J Am Diet Assoc 1994;94:57–64.
[10] Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and
applications. J Am Diet Assoc 1995;95:1103–8.
[11] Huijbregts P, Feskens E, Rasanen L, et al. Dietary pattern and 20 year mortality
in elderly men in Finland, Italy, and The Netherlands: longitudinal cohort study.
BMJ 1997;315:13–7.
[12] Harnack L, Nicodemus K, Jacobs Jr DR, Folsom AR. An evaluation of the Dietary
Guidelines for Americans in relation to cancer occurrence. Am J Clin Nutr
2002;76:889–96.
[13] Trichopoulou A, Bamia C, Trichopoulos D. Mediterranean diet and survival
among patients with coronary heart disease in Greece. Arch Intern Med
2005;165:929–35.
[14] Trichopoulos D, Lagiou P. Mediterranean diet and cardiovascular epidemiology.
Eur J Epidemiol 2004;19:7–8.
[15] Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a
Mediterranean diet and survival in a Greek population. N Engl J Med
2003;348:2599–608.
[16] Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, et al. Diet and overall survival
in elderly people. BMJ 1995;311:1457–60.
8 G. Kourlaba, D.B. Panagiotakos / Maturitas 62 (2009) 1–8
[17] Kushi LH, Lenart EB, Willett WC. Health implications of Mediterranean diets in
light of contemporary knowledge. 2. Meat, wine, fats, and oils. Am J Clin Nutr
1995;61:1416S–27S.
[18] Basiotis PP, Carlson S, Gerrior SA, Juan WY, Lino M. The Healthy Eating Index:
1999–2000; 2002.
[19] Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development
and Evaluation of the Healthy Eating Index-2005: Technical Report. Center for
Nutrition Policy and Promotion, U.S. Department of Agriculture; 2007.
[20] Haines PS, Siega-Riz AM, Popkin BM. The Diet Quality Index revised: a mea-
surement instrument for populations. J Am Diet Assoc 1999;99:697–704.
[21] Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean
diet score and its relation to clinical and biological markers of cardiovascular
disease risk. Nutr Metab Cardiovasc Dis 2006;16:559–68.
[22] Lowik MR, Hulshof KF, Brussaard JH. Food-based dietary guidelines: some
assumptions tested for The Netherlands. Br J Nutr 1999;81(Suppl. 2):S143–9.
[23] Osler M, Helms Andreasen A, Heitmann B, et al. Food intake patterns and risk
of coronary heart disease: a prospective cohort study examining the use of
traditional scoring techniques. Eur J Clin Nutr 2002;56:568–74.
[24] Osler M, Heitmann BL, Gerdes LU, Jorgensen LM, Schroll M. Dietary patterns
and mortality in Danish men and women: a prospective observational study.
Br J Nutr 2001;85:219–25.
[25] Panagiotakos DB, Pitsavos C, Arvaniti F, Stefanadis C. Adherence to the
Mediterranean food pattern predicts the prevalence of hypertension, hyper-
cholesterolemia, diabetes and obesity, among healthy adults; the accuracy of
the MedDietScore. Prev Med 2007;44:335–40.
[26] Schroder H, Marrugat J, Vila J, Covas MI, Elosua R. Adherence to the traditional
Mediterranean diet is inversely associated with body mass index and obesity
in a Spanish population. J Nutr 2004;134:3355–61.
[27] Gerber MJ, Scali JD, Michaud A, et al. Profiles of a healthful diet and its rela-
tionship to biomarkers in a population sample from Mediterranean southern
France. J Am Diet Assoc 2000;100:1164–71.
[28] Fung TT, Hu FB, Barbieri RL, Willett WC, Hankinson SE. Dietary patterns, the
Alternate Healthy Eating Index and plasma sex hormone concentrations in
postmenopausal women. Int J Cancer 2007;121:803–9.
[29] Shatenstein B, Nadon S, Godin C, Ferland G. Diet quality of Montreal-area
adults needs improvement: estimates from a self-administered food fre-
quency questionnaire furnishing a dietary indicator score. J Am Diet Assoc
2005;105:1251–60.
[30] Kim S, Haines PS, Siega-Riz AM, Popkin BM. 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 2003;133:
3476–84.
[31] Fung TT, McCullough ML, Newby PK, et al. Diet-quality scores and plasma con-
centrations of markers of inflammation and endothelial dysfunction. Am J Clin
Nutr 2005;82:163–73.
[32] Seymour JD, Calle EE, Flagg EW, Coates RJ, Ford ES, Thun MJ. Diet Quality
Index as a predictor of short-term mortality in the American Cancer Soci-
ety Cancer Prevention Study II Nutrition Cohort. Am J Epidemiol 2003;157:
980–8.
[33] Weinstein SJ, Vogt TM, Gerrior SA. Healthy Eating Index scores are associated
with blood nutrient concentrations in the third National Health And Nutrition
Examination Survey. J Am Diet Assoc 2004;104:576–84.
[34] Hann CS, Rock CL, King I, Drewnowski A. Validation of the Healthy Eating Index
with use of plasma biomarkers in a clinical sample of women. Am J Clin Nutr
2001;74:479–86.
[35] Kant AK, Graubard BI. A comparison of three dietary pattern indexes for pre-
dicting biomarkers of diet and disease. J Am Coll Nutr 2005;24:294–303.
[36] McCullough ML, Feskanich D, Stampfer MJ, et al. Adherence to the Dietary
Guidelines for Americans and risk of major chronic disease in women. Am J
Clin Nutr 2000;72:1214–22.
[37] McCullough ML, Feskanich D, Rimm EB, et al. Adherence to the Dietary Guide-
lines for Americans and risk of major chronic disease in men. Am J Clin Nutr
2000;72:1223–31.
[38] McCullough ML, Feskanich D, Stampfer MJ, et al. Diet quality and major chronic
disease risk in men and women: moving toward improved dietary guidance.
Am J Clin Nutr 2002;76:1261–71.
[39] Reedy J, Mitrou PN, Krebs-Smith SM, et al. Index-based dietary patterns and
risk of colorectal cancer: the NIH-AARP Diet and Health Study. Am J Epidemiol
2008;168:38–48.
[40] Martinez-Gonzalez MA, Fernandez-Jarne E, Serrano-Martinez M, Wright M,
Gomez-Gracia E. Development of a short dietary intake questionnaire for the
quantitative estimation of adherence to a cardioprotective Mediterranean diet.
Eur J Clin Nutr 2004;58:1550–2.
[41] Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors,
and 10-year mortality in elderly European men and women: the HALE project.
JAMA 2004;292:1433–9.
[42] Trichopoulou A, Bamia C, Norat T, et al. Modified Mediterranean diet and
survival after myocardial infarction: the EPIC-Elderly study. Eur J Epidemiol
2007;22:871–81.
[43] Lasheras C, Fernandez S, Patterson AM. Mediterranean diet and age with respect
to overall survival in institutionalized, nonsmoking elderly people. Am J Clin
Nutr 2000;71:987–92.
[44] Kouris-Blazos A, Gnardellis C, Wahlqvist ML, Trichopoulos D, Lukito W. Tri-
chopoulou A. Are the advantages of the Mediterranean diet transferable to other
populations? A cohort study in Melbourne, Australia. Br J Nutr 1999;82:57–61.
[45] Osler M, Schroll M. Diet and mortality in a cohort of elderly people in a north
European community. Int J Epidemiol 1997;26:155–9.
[46] Haveman-Nies A, de Groot LP, Burema J, Cruz JA, Osler M, van Staveren WA.
Dietary quality and lifestyle factors in relation to 10-year mortality in older
Europeans: the SENECA study. Am J Epidemiol 2002;156:962–8.
[47] Martinez-Gonzalez MA, Fernandez-Jarne E, Serrano-Martinez M, Marti A, Mar-
tinez JA, Martin-Moreno JM. Mediterranean diet and reduction in the risk of
a first acute myocardial infarction: an operational healthy dietary score. Eur J
Nutr 2002;41:153–60.
[48] Keys A, Menotti A, Karvonen MJ, et al. The diet and 15-year death rate in the
seven countries study. Am J Epidemiol 1986;124:903–15.
[49] Fung TT, Hu FB, McCullough ML, Newby PK, Willett WC, Holmes MD. Diet qual-
ity is associated with the risk of estrogen receptor-negative breast cancer in
postmenopausal women. J Nutr 2006;136:466–72.
[50] Boynton A, Neuhouser ML, Wener MH, et al. Associations between healthy eat-
ing patterns and immune function or inflammation in overweight or obese
postmenopausal women. Am J Clin Nutr 2007;86:1445–55.
[51] Rossi M, Negri E, Bosetti C, et al. Mediterranean diet in relation to body mass
index and waist-to-hip ratio. Public Health Nutr 2008;11:214–7.
[52] Mansuripur M. Introduction to Information Theory. New York: Prentice Hall;
1987.
[53] Kourlaba G, Panagiotakos D, Stavrinos V. The diagnostic accuracy of composite
indices is associated with the number of partitions of their components: A
simulation study. Adv Appl Stat 2008;8:89–99.
[54] Lee MS, Lai CJ, Yang FY, Su HH, Yu HL, Wahlqvist ML. A global overall dietary
index: ODI-R revised to emphasize quality over quantity. Asia Pac J Clin Nutr
2008;17(Suppl. 1):82–6.
[55] Toft U, Kristoffersen LH, Lau C, Borch-Johnsen K, Jorgensen T. The Dietary Quality
Score: validation and association with cardiovascular risk factors: the Inter99
study. Eur J Clin Nutr 2007;61:270–8.
[56] Haveman-Nies A, Tucker KL, de Groot LC, Wilson PW, van Staveren WA. Eval-
uation of dietary quality in relationship to nutritional and lifestyle factors in
elderly people of the US Framingham Heart Study and the European SENECA
study. Eur J Clin Nutr 2001;55:870–80.
[57] Panagiotakos DB, Polystipioti A, Papairakleous N, Polychronopoulos E. Long-
term adoption of a Mediterranean diet is associated with a better health status
in elderly people; a cross-sectional survey in Cyprus. Asia Pac J Clin Nutr
2007;16:331–7.
[58] Panagiotakos DB, Tzima N, Pitsavos C, et al. The association between adherence
to the Mediterranean diet and fasting indices of glucose homoeostasis: the
ATTICA Study. J Am Coll Nutr 2007;26:32–8.