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The application of six dietary scores to a Middle Eastern population: a comparative analysis of mortality in a prospective study

  • NUTRITIONAL EPIDEMIOLOGY
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Abstract

Background The associations between dietary indices and mortality have not been evaluated in populations from the Middle East, which have different dietary patterns compared to the US and Europe. In this study, we evaluated the association between six dietary indices and mortality in the Golestan Cohort Study (GCS) in Iran, which is the largest prospective study in the Middle East with 50,045 participants. Methods The six dietary indices, namely the Healthy Eating Index (HEI-2015), Alternative Healthy Eating Index (AHEI-2010), Alternative Mediterranean Diet (AMED), Dietary Approach to Stop Hypertension created by Fung (DASH-Fung) and Mellen (DASH-Mellen), and the World Cancer Research Fund (WCRF/AICR) index, were applied to data from a food frequency questionnaire, computed and divided into quintiles. Adjusted Cox models were used to estimate hazards ratio (HR) and 95% confidence intervals (CI) for overall and cause-specific mortality, using the lowest quintile as a reference group. Results Among 42,373 participants included in the current analyses, 4424 subjects died during 10.6 years of follow-up. Participants with the highest quintile dietary scores, compared with the lowest quintile dietary scores, had significantly decreased overall mortality in the AHEI-2010, AMED, DASH-Fung, and WCRF/AICR indices (HR 0.88, 95% CI = 0.80–0.97; 0.80, 0.70–0.91; 0.77, 0.70–0.86; and 0.79, 0.70–0.90, respectively). A reduced cardiovascular mortality was found for high AHEI-2010 and DASH-Fung scores (17% and 23%, respectively), and a reduced cancer mortality for high HEI-2015, AMED, and DASH-Fung scores (21, 37 and 25%, respectively). Conclusion Various indices of dietary quality are inversely associated with overall mortality, and selectively with cancer and cardiovascular mortality in the GCS, which contribute to the generalizability and validity of dietary guidelines.

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Acknowledgements

We are grateful to all participants of the study, and the Golestan Cohort Study for expert help in collecting the data.

Funding

This work was supported by the World Cancer Research Fund International (Grant Number: WCRF 2016/1633), Tehran University of Medical Sciences (Grant Number: 81/15), Cancer Research UK (grant number: C20/A5860), the Intramural Research Program of the U.S. National Cancer Institute, National Institutes of Health, and the International Agency for Research on Cancer.

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Authors and Affiliations

  1. Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    Maryam Hashemian, Arash Etemadi, Farin Kamangar, Mahdi Sheikh, Akbar Fazeltabar Malekshah & Reza Malekzadeh

  2. Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA

    Maryam Hashemian, Gwen Murphy, Arash Etemadi, Sanford M. Dawsey & Christian C. Abnet

  3. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Maryam S. Farvid

  4. Digestive Disease Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    Akram Pourshams, Sadaf G. Sepanlou, Masoud Khoshnia, Abdolsamad Gharavi & Reza Malekzadeh

  5. Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    Hossein Poustchi & Akram Pourshams

  6. Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, MD, USA

    Farin Kamangar

  7. Departments of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Azita Hekmatdoost

  8. Section of Genetics, International Agency for Research on Cancer, Lyon, France

    Mahdi Sheikh & Paul J. Brennan

  9. Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Paolo Boffetta

  10. Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran

    Masoud Khoshnia & Abdolsamad Gharavi

  11. Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA

    Jill Reedy & Amy F. Subar

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  1. Maryam Hashemian
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  19. Christian C. Abnet
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  20. Reza Malekzadeh
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Corresponding authors

Correspondence to Christian C. Abnet or Reza Malekzadeh.

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The authors declare that they have no conflict of interest.

Ethical approval

The study protocol was approved by the Institutional Review Boards of the U.S. National Cancer Institute (NCI), the International Agency for Research on Cancer (IARC), and the Digestive Disease Research Institute of the Tehran University of Medical Sciences (DDRI). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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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. Eur J Epidemiol 34, 371–382 (2019). https://doi.org/10.1007/s10654-019-00508-3

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