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Dietary diversity score and obesity: a systematic review and meta-analysis of observational studies

Subjects

Abstract

Background/Objectives:

Studies examining the association between dietary diversity score (DDS) and obesity have led to inconsistent findings. Therefore, the purpose of this review is to summarize and elucidate the source of heterogeneous results reported in different studies.

Methods:

PubMed, ISI Web of Science, Scopus and Google Scholar were searched through December 2013 to identify all relevant articles. Sixteen publications met the inclusion criteria for the systematic review and 10 articles were entered into the meta-analysis. Eight studies had data on the odds ratio (OR) for overweight/obesity and eight compared the mean body mass index (BMI) among subjects with highest versus the lowest DDS.

Results:

A meta-analysis on eligible studies failed to show a significant association on either overweight/obesity OR (OR: 0.72; 95% confidence interval (CI): 0.45–1.16; P=0.174) or mean differences (MD) in BMI (MD: 0.22; 95% CI: −0.70–1.14; P=0.643) comparing the highest and lowest diverse diets. Between-study heterogeneity was high, and subgroup analysis failed to identify the source of heterogeneity.

Conclusions:

Our systematic review and meta-analysis showed that there was no significant association between DDS and BMI status, which may be due to use of different methods for assessing dietary intake and determination of DDS. Thus, well-designed prospective studies with similar approaches to assess DDS are highly recommended.

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References

  1. Obesity and overweight. World Health Organization http://www.who.int/mediacentre/factsheets/fs311/en/index.html. Updated March 2013.

  2. Seo DC, Niu J . Trends in underweight and overweight/obesity prevalence in Chinese Youth, 2004–2009. Int J Behav Med 2013; 21: 682–690.

    Article  Google Scholar 

  3. Astrup A, Finer N . Redefining type 2 diabetes: 'diabesity' or 'obesity dependent diabetes mellitus'? Obes Rev 2000; 1: 57–59.

    Article  CAS  PubMed  Google Scholar 

  4. Ni Mhurchu C, Parag V, Nakamura M, Patel A, Rodgers A, Lam TH . Body mass index and risk of diabetes mellitus in the Asia-Pacific region. Asia Pac J Clin Nutr 2006; 15: 127–133.

    PubMed  Google Scholar 

  5. Pontiroli AE, Galli L . Duration of obesity is a risk factor for non-insulin-dependent diabetes mellitus, not for arterial hypertension or for hyperlipidaemia. Acta Diabetol 1998; 35: 130–136.

    Article  CAS  PubMed  Google Scholar 

  6. Ni Mhurchu C, Rodgers A, Pan WH, Gu DF, Woodward M . Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants. Int J Epidemiol 2004; 33: 751–758.

    Article  CAS  PubMed  Google Scholar 

  7. Reaven GM . Insulin resistance: the link between obesity and cardiovascular disease. Med Clin North Am 2011; 95: 875–892.

    Article  CAS  PubMed  Google Scholar 

  8. Hoppichler F . [The metabolic syndrome: epidemiology and diagnosis]. Acta Med Austriaca 2004; 31: 130–132.

    PubMed  Google Scholar 

  9. Zabetian A, Hadaegh F, Sarbakhsh P, Azizi F . Weight change and incident metabolic syndrome in Iranian men and women; a 3 year follow-up study. BMC Public Health 2009; 9: 138.

    Article  PubMed  PubMed Central  Google Scholar 

  10. De Pergola G, Silvestris F . Obesity as a major risk factor for cancer. J Obes 2013; 2013: 291546.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Berentzen TL, Gamborg M, Holst C, Sorensen TI, Baker JL . Body mass index in childhood and adult risk of primary liver cancer. J Hepatol 2013; 60: 325–330.

    Article  PubMed  Google Scholar 

  12. Andersson SO, Wolk A, Bergstrom R, Adami HO, Engholm G, Englund A et al. Body size and prostate cancer: a 20-year follow-up study among 135006 Swedish construction workers. J Natl Cancer Inst 1997; 89: 385–389.

    Article  CAS  PubMed  Google Scholar 

  13. Hursting SD, Digiovanni J, Dannenberg AJ, Azrad M, Leroith D, Demark-Wahnefried W et al. Obesity, energy balance, and cancer: new opportunities for prevention. Cancer Prev Res (Phila) 2012; 5: 1260–1272.

    Article  CAS  Google Scholar 

  14. Martinez JA, Moreno MJ, Marques-Lopes I, Marti A . [Causes of obesity]. An Sist Sanit Navar 2002; 25: 17–27.

    PubMed  Google Scholar 

  15. Nobre LN, Monteiro JB . [Dietetic determinants on food intake and effects in body weight regulation]. Arch Latinoam Nutr 2003; 53: 243–250.

    PubMed  Google Scholar 

  16. Hu FB . Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 2002; 13: 3–9.

    Article  CAS  PubMed  Google Scholar 

  17. Millen BE, Quatromoni PA, Pencina M, Kimokoti R, Nam BH, Cobain S et al. Unique dietary patterns and chronic disease risk profiles of adult men: the Framingham nutrition studies. J Am Diet Assoc 2005; 105: 1723–1734.

    Article  PubMed  Google Scholar 

  18. Vandevijvere S, De Vriese S, Huybrechts I, Moreau M, Van Oyen H . Overall and within-food group diversity are associated with dietary quality in Belgium. Public Health Nutr 2010; 13: 1965–1973.

    Article  PubMed  Google Scholar 

  19. Mirmiran P, Azadbakht L, Esmaillzadeh A, Azizi F . Dietary diversity score in adolescents - a good indicator of the nutritional adequacy of diets: Tehran lipid and glucose study. Asia Pac J Clin Nutr 2004; 13: 56–60.

    CAS  PubMed  Google Scholar 

  20. Oldewage-Theron WH, Kruger R . Food variety and dietary diversity as indicators of the dietary adequacy and health status of an elderly population in Sharpeville, South Africa. J Nutr Elder 2008; 27: 101–133.

    Article  PubMed  Google Scholar 

  21. Kant AK, Graubard BI . A comparison of three dietary pattern indexes for predicting biomarkers of diet and disease. J Am Coll Nutr 2005; 24: 294–303.

    Article  CAS  PubMed  Google Scholar 

  22. Oldewage-Theron WH, Egal AA . A cross-sectional baseline survey investigating the relationship between dietary diversity and cardiovascular risk factors in women from the Vaal Region, South Africa. J Nurs Educ Pract 2013; 4: p50.

    Google Scholar 

  23. Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi F . Dietary diversity score and cardiovascular risk factors in Tehranian adults. Public Health Nutr 2006; 9: 728–736.

    Article  PubMed  Google Scholar 

  24. Azadbakht L, Mirmiran P, Azizi F . Dietary diversity score is favorably associated with the metabolic syndrome in Tehranian adults. Int J Obes (Lond) 2005; 29: 1361–1367.

    Article  CAS  Google Scholar 

  25. Kant AK, Schatzkin A, Ziegler RG . Dietary diversity and subsequent cause-specific mortality in the NHANES I epidemiologic follow-up study. J Am Coll Nutr 1995; 14: 233–238.

    Article  CAS  PubMed  Google Scholar 

  26. Azadbakht L, Esmaillzadeh A . Dietary diversity score is related to obesity and abdominal adiposity among Iranian female youth. Public Health Nutr 2011; 14: 62–69.

    Article  PubMed  Google Scholar 

  27. Jayawardena R, Byrne NM, Soares MJ, Katulanda P, Yadav B, Hills AP . High dietary diversity is associated with obesity in Sri Lankan adults: an evaluation of three dietary scores. BMC Public Health 2013; 13: 314.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Azadbakht L, Esmaillzadeh A . Dietary energy density is favorably associated with dietary diversity score among female university students in Isfahan. Nutrition 2012; 28: 991–995.

    Article  PubMed  Google Scholar 

  29. Hasan-Ghomi M, Mirmiran P, Amiri Z, Asghari G, Sadeghian S, Sarbazi N et al. The association of food security and dietary variety in subjects aged over 40 in District 13 of Tehran. Iranian Journal of Endocrinology and Metabolism 2012; 14: 360–368.

    Google Scholar 

  30. Kimura Y, Okumiya K, Sakamoto R, Ishine M, Wada T, Kosaka Y et al. Comprehensive geriatric assessment of elderly highlanders in Qinghai, China IV: comparison of food diversity and its relation to health of Han and Tibetan elderly. Geriatr Gerontol Int 2009; 9: 359–365.

    Article  PubMed  Google Scholar 

  31. Benefice E, Lopez R, Monroy SL, Rodriguez S . Fatness and overweight in women and children from riverine Amerindian communities of the Beni River (Bolivian Amazon). Am J Hum Biol 2007; 19: 61–73.

    Article  PubMed  Google Scholar 

  32. Savy M, Martin-Prevel Y, Sawadogo P, Kameli Y, Delpeuch F . Use of variety/diversity scores for diet quality measurement: relation with nutritional status of women in a rural area in Burkina Faso. Eur J Clin Nutr 2005; 59: 703–716.

    Article  CAS  PubMed  Google Scholar 

  33. Savy M, Martin-Prevel Y, Traissac P, Delpeuch F . Measuring dietary diversity in rural Burkina Faso: comparison of a 1-day and a 3-day dietary recall. Public Health Nutr 2007; 10: 71–78.

    Article  CAS  PubMed  Google Scholar 

  34. Savy M, Martin-Prevel Y, Traissac P, Eymard-Duvernay S, Delpeuch F . Dietary diversity scores and nutritional status of women change during the seasonal food shortage in rural Burkina Faso. J Nutr 2006; 136: 2625–2632.

    Article  CAS  PubMed  Google Scholar 

  35. Egger M, Smith GD, Altman DG . Systematic Reviews in Health Care: Meta-analysis in context, 2nd ed. BMJ: London. pp xviii 487, 2001.

    Book  Google Scholar 

  36. Ajani SR . An assessment of dietary diversity in six Nigerian states. Afr J Biomed Res 2010; 13: 161–167.

    Google Scholar 

  37. Savy M, Martin-Prevel Y, Danel P, Traissac P, Dabire H, Delpeuch F . Are dietary diversity scores related to the socio-economic and anthropometric status of women living in an urban area in Burkina Faso? Public Health Nutr 2008; 11: 132–141.

    Article  CAS  PubMed  Google Scholar 

  38. Higgins JP, Thompson SG . Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539–1558.

    Article  PubMed  Google Scholar 

  39. Egger M, Davey Smith G, Schneider M, Minder C . Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–634.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Ponce X, Ramirez E, Delisle H . A more diversified diet among Mexican men may also be more atherogenic. J Nutr 2006; 136: 2921–2927.

    Article  CAS  PubMed  Google Scholar 

  41. Mayega RW, Makumbi F, Rutebemberwa E, Peterson S, Ostenson CG, Tomson G et al. Modifiable socio-behavioural factors associated with overweight and hypertension among persons aged 35 to 60 years in eastern Uganda. PLoS One 2012; 7: e47632.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Lee M-S, Huang Y-C, Su H-H, Lee M-Z, Wahlqvist ML . A simple food quality index predicts mortality in elderly Taiwanese. J Nutr Health Aging 2011; 15: 815–821.

    Article  PubMed  Google Scholar 

  43. Kant AK, Schatzkin A, Harris TB, Ziegler RG, Block G . Dietary diversity and subsequent mortality in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Am J Clin Nutr 1993; 57: 434–440.

    Article  CAS  PubMed  Google Scholar 

  44. Bezerra IN, Sichieri R . Household food diversity and nutritional status among adults in Brazil. Int J Behav Nutr Phys Act 2011; 8: 22.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ruel MT . Operationalizing dietary diversity: a review of measurement issues and research priorities. J Nutr 2003; 133: 3911S–3926SS.

    Article  CAS  PubMed  Google Scholar 

  46. Jeurnink SM, Büchner FL, Bueno-De-Mesquita HB, Siersema PD, Boshuizen HC, Numans ME et al. Variety in vegetable and fruit consumption and the risk of gastric and esophageal cancer in the European prospective investigation into cancer and nutrition. Int J Cancer 2012; 131: E963–E973.

    Article  CAS  PubMed  Google Scholar 

Download references

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Correspondence to L Azadbakht.

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Salehi-Abargouei, A., Akbari, F., Bellissimo, N. et al. Dietary diversity score and obesity: a systematic review and meta-analysis of observational studies. Eur J Clin Nutr 70, 1–9 (2016). https://doi.org/10.1038/ejcn.2015.118

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