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The International Diet-Health Index: a novel tool to evaluate diet quality for cardiometabolic health across countries
  1. Jifan Wang1,
  2. William A Masters2,3,
  3. Yan Bai2,
  4. Dariush Mozaffarian1,
  5. Elena N Naumova1,
  6. Gitanjali M Singh1
  1. 1 Division of Nutrition Epidemiology and Data Science, Tufts University Friedman School of Nutrition Science and Policy, Boston, Massachusetts, USA
  2. 2 Division of Food and Nutrition Policy and Programs, Tufts University Friedman School of Nutrition Science and Policy, Boston, Massachusetts, USA
  3. 3 Department of Economics, Tufts University School of Arts and Sciences, Medford, Massachusetts, USA
  1. Correspondence to Dr Gitanjali M Singh; Gitanjali.Singh{at}


Introduction Diet is a major modifiable risk factor for cardiometabolic disease; however, interpretable measures capturing impacts of overall diet on health that can be easily used by policymakers at the global/national levels are not readily available.

Methods We developed the International Diet-Health Index (IDHI) to measure health impacts of dietary intake across 186 countries in 2010, using age-specific and sex-specific data on country-level dietary intake, effects of dietary factors on cardiometabolic diseases and country-specific cardiometabolic disease profiles. The index encompasses the impact of 11 foods/nutrients on 12 cardiometabolic diseases, the mediation of health effects of specific dietary intakes through blood pressure and body mass index and background disease prevalence in each country–age–sex group. We decomposed the index into IDHIbeneficial for risk-reducing factors, and IDHIadverse for risk-increasing factors. The flexible functional form of the IDHI allows inclusion of additional risk factors and diseases as data become available.

Results By sex, women experienced smaller detrimental cardiometabolic effects of diet than men: (females IDHIadverse range: −0.480 (5th percentile, 95th percentile: −0.932, –0.300) to −0.314 (−0.543, –0.213); males IDHIadverse range: (−0.617 (−1.054, –0.384) to −0.346 (−0.624, –0.222)). By age, middle-aged adults had highest IDHIbeneficial (females: 0.392 (0.235, 0.763); males: 0.415 (0.243, 0.949)) and younger adults had most extreme IDHIadverse (females: −0.480 (−0.932, –0.300); males: −0.617 (−1.054, –0.384)). Regionally, Central Latin America had the lowest IDHIoverall (−0.466 (−0.892, –0.159)), while Southeast Asia had the highest IDHIoverall (0.272 (−0.224, 0.903)). IDHIoverall was highest in low-income countries and lowest in upper middle-income countries (−0.039 (−0.317, 0.227) and −0.146 (−0.605, 0.303), respectively). Among 186 countries, Honduras had lowest IDHIoverall (−0.721 (−0.916, –0.207)), while Malaysia had highest IDHIoverall (0.904 (0.435, 1.190)).

Conclusion IDHI encompasses dietary intakes, health effects and country disease profiles into a single index, allowing policymakers a useful means of assessing/comparing health impacts of diet quality between populations.

  • nutrition
  • cardiovascular disease
  • diabetes
  • epidemiology
  • public health

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  • Handling editor Sanne Peters

  • Contributors WAM and GMS developed the study concept and designed the study. JW cleaned data, performed index calculation and summarised results. YB provided technical support on index calculation. DM led the Global Dietary Database data collection efforts for dietary exposures and aetiological effects and provided conceptual input on index development. ENN provided mathematical insight on index calculation and interpretation. JW and GMS drafted the paper. All authors contributed to critical revision of the manuscript and have read and approved the final manuscript. The results have been presented, in part, as a poster at the 2018 American Society for Nutrition annual meeting in Boston, Massachusetts.

  • Funding GMS and JW were funded by a grant from the National Heart, Lung, and Blood Institute (R00HL124321).

  • Competing interests DM reports research funding from the National Institutes of Health and the Gates Foundation; personal fees from GOED, Nutrition Impact, Pollock Communications, Bunge, Indigo Agriculture, Amarin, Acasti Pharma, Cleveland Clinic Foundation, America’s Test Kitchen and Danone; scientific advisory board, Elysium Health, Filcitrine, Omada Health and DayTwo; and chapter royalties from UpToDate; all outside the submitted work. Other authors have nothing to disclose.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All the data used in the study are publicly available. Please find Global Dietary Database at, the Non-communicable Disease Risk Factor Collaboration at, the Global Health Data Exchange at and the age-specific relative risk data at and

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