Background
Methods
Inclusion and exclusion criteria
Search strategy
Study selection and data extraction
Assessment of methodological quality
Outdated and overlapping publications
Credibility assessment
Statistical analysis
Assessment of SHR
Assessment of heterogeneity
Assessment of publication bias and small study effects
Assessment of excess significance bias
Subgroup analysis and sensitivity analysis
Results
Characteristics of the included meta-analyses
Author/Year | Country | Exposure (including dose of exposure) | No. of included studies | Cohort | Case control | Pooled study | Effects model | No. of participants/no. of cases | MA metric | Comparison | Range/amount | Quality appraisal tool | Information on funding | Conflict of interests |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Alizadeh 2017 [64] | Iran | Healthy dietary pattern | 4 | 1 | 3 | 0 | fixed | 51,709/1327 | OR | High vs low | Higher adherence vs lower adherence | NOS | NA | No |
Unhealthy/western pattern | 4 | 1 | 3 | 0 | 51,709/1327 | OR | ||||||||
Drinking pattern | 2 | 1 | 1 | 0 | 47,705/554 | OR | ||||||||
Bai 2013 [65] | China | Fish | 15 | 3 | 12 | 0 | fixed | 608,753/9324 | RR | High vs low | Higher adherence vs lower adherence | NOS | No | No |
Boyle 2014 [66] | France | Sweetened carbonated beverage | 5 | 2 | 2 | 1 | random | NA/NA | RR | High vs low | Higher adherence vs lower adherence | NA | Yes | No |
Cheng 2011 [67] | China | Beer | 8 | 0 | 8 | 0 | fixed | NA/5538 | OR | High vs low | Higher adherence vs lower adherence | NA | NA | NA |
Wine | 8 | 0 | 8 | 0 | random | NA/5538 | OR | |||||||
Spirits | 9 | 0 | 9 | 0 | random | NA/6393 | OR | |||||||
Clasen 2020 [68] | UK | Riboflavin | 3 | 1 | 2 | 0 | Bayesian | 39,789/1971 | RR | High vs low | Higher adherence vs lower adherence | NOS | Yes | No |
Vitamin B6 | 5 | 3 | 2 | 0 | 164,883/2407 | RR | ||||||||
Folate | 6 | 2 | 4 | 0 | 136,319/3166 | RR | ||||||||
Vitamin B12 | 3 | 2 | 1 | 0 | 127,390/1578 | RR | ||||||||
Methionine | 2 | 2 | 0 | 0 | 125,094/436 | RR | ||||||||
Choline | 2 | 2 | 0 | 0 | 125,094/436 | RR | ||||||||
Betaine | 2 | 2 | 0 | 0 | 125,094/436 | RR | ||||||||
Faramawi 2007 [15] | USA | All meat | 11 | 0 | 11 | 0 | fixed | 15,237/4835 | OR | High vs low | Higher adherence vs lower adherence | NA | NA | NA |
Hu 2013 [69] | China | Tea | 12 | 2 | 10 | 0 | random | 1,571,852/6636 | RR | High vs low | Higher adherence vs lower adherence | NA | Yes | NA |
Huang 2014 [70] | China | Fruit fiber | 3 | 1 | 2 | 0 | random | 496,292/2906 | RR | High vs low | Higher adherence vs lower adherence | NOS | NA | No |
Vegetable fiber | 3 | 1 | 2 | 0 | 496292/2906 | RR | ||||||||
Cereal fiber | 3 | 1 | 2 | 0 | 496,292/2906 | RR | ||||||||
Legume fiber | 1 | 1 | 0 | 0 | 491,841/1816 | RR | ||||||||
Jayedi 2018 [71] | Iran | Dietary Inflammatory Index | 2 | 1 | 1 | 0 | random | 36,118/1030 | RR | Dose-response | 1-unit increment | NOS | No | No |
Jia 2015 [72] | China | Vitamin C | 10 | 3 | 7 | 0 | fixed | 274,864/5182 | RR | High vs low | Higher adherence vs lower adherence | NA | NA | No |
Lee 2008 [16] | USA | Total fat | 13 | 13 | 0 | 0 | random | 774,952/1478 | RR | High vs low | Higher adherence vs lower adherence | NA | YES | NA |
Saturated fat | 13 | 13 | 0 | 0 | 774,952/1478 | RR | ||||||||
Monounsaturated fat | 13 | 13 | 0 | 0 | 774952/1478 | RR | ||||||||
Polyunsaturated fat | 13 | 13 | 0 | 0 | 774952/1478 | RR | ||||||||
Animal fat | 8 | 8 | 0 | 0 | 417,093/900 | RR | ||||||||
Plant fat | 8 | 8 | 0 | 0 | 417,093/900 | RR | ||||||||
Cholesterol | 13 | 13 | 0 | 0 | 774,952/1478 | RR | ||||||||
Total protein | 13 | 13 | 0 | 0 | 774,952/1478 | RR | ||||||||
Animal protein | 8 | 8 | 0 | 0 | 530,410/1019 | RR | ||||||||
Plant protein | 8 | 8 | 0 | 0 | 530,410/1019 | RR | ||||||||
Poultry | 12 | 12 | 0 | 0 | NA/1407 | RR | ||||||||
Seafood | 12 | 12 | 0 | 0 | NA/1375 | RR | ||||||||
Llaha 2021 [73] | Spain | Sweet beverages (include ASB and SSB) | 3 | 1 | 2 | 0 | random | 143,194/1589 | RR | High vs low | Higher adherence vs lower adherence | ROBINS-E NOS | Yes | No |
Shen 2015 [74] | China | Vitamin E | 13 | 6 | 7 | 0 | NA | 471,006/6944 | RR | High vs low | Higher adherence vs lower adherence | NA | Yes | No |
Wijarnpreecha 2017 [75] | USA | Coffee | 22 | 6 | 16 | 0 | random | 1,991,863/NA | RR | High vs low | Higher adherence vs lower adherence | NOS | No | No |
Wu 2020 [76] | China | Vitamin D | 6 | 3 | 3 | 0 | fixed | 187,560/NA | RR | High vs low | Higher adherence vs lower adherence | NOS | NA | No |
Xie 2016 [77] | China | Dietary nitrate | 3 | 2 | 1 | 0 | random | NA/NA | RR | high vs low | Higher adherence vs lower adherence | NO | NA | No |
Dietary nitrite | 2 | 1 | 1 | 0 | fixed | NA/NA | RR | |||||||
Xu 2019 [78] | China | Dietary fiber | 7 | 2 | 5 | 0 | random | 942,582/6590 | RR | high vs low | Higher adherence vs lower adherence | NOS | Yes | No |
Glycemic index | 5 | 2 | 3 | 0 | 502,119/4281 | RR | ||||||||
Glycemic load | 5 | 2 | 3 | 0 | 502119/4281 | RR | ||||||||
Xu 2015 [79] | China | Alcohol (light) | 6 | 5 | 0 | 1 | random | 3,720,850/5214 | RR | Light | <12.5 g/day (<1 drink/day) | NOS | Yes | No |
Alcohol (moderate) | 8 | 7 | 0 | 1 | 4,139,301/5364 | RR | Moderate | 12.5–37.5 g/day (2–3 drinks/day) | ||||||
Alcohol (heavy) | 3 | 3 | 0 | 0 | 2,065,995/363 | RR | Heavy | >37.5 g/day (>3 drinks/day) | ||||||
Alcohol (any) | 8 | 7 | 0 | 1 | 4,867,646/5503 | RR | High vs low | Higher adherence vs lower adherence | ||||||
Zhang 2017 [80] | China | Vegetables | 16 | 2 | 13 | 1 | random | 1,365,634/9353 | RR | High vs low | Higher adherence vs lower adherence | NOS | NA | No |
Fruits | 17 | 3 | 13 | 1 | 1,398,778/9150 | RR | ||||||||
Zhang 2017 [17] | China | Red meat | 19 | 4 | 14 | 1 | random | 1,826,171/12631 | RR | High vs low | Higher adherence vs lower adherence | NOS | NA | No |
Processed meat | 19 | 3 | 15 | 1 | 1,793,675/14240 | RR | ||||||||
Zhao 2013 [81] | China | Cruciferous Vegetables | 12 | 6 | 6 | 0 | random | 1,228,518/5773 | RR | High vs low | Higher adherence v lower adherence | NOS | No | No |
WCRF 2013 [87] | UK | Fruit and non-starchy vegetables | 7 | 7 | 0 | 0 | random | 756,544/1215 | RR | Dose-response | Per 100 g/d | NA | Yes | NA |
Non-starchy vegetables | 8 | 8 | 0 | 0 | 1,248,385/3031 | Dose-response | Per 100 g/d | |||||||
Tomatoes | 3 | 3 | 0 | 0 | NA/427 | Dose-response | Per 50 g/d | |||||||
Citrus fruit | 7 | 7 | 0 | 0 | NA/2735 | Dose-response | Per 50 g/d | |||||||
Total fat | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Saturated fat | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Monounsaturated fat | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Polyunsaturated fat | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Total protein | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Animal protein | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Plant protein | 14 | 14 | 0 | 0 | 1,210,245/1985 | Dose-response | 5% energy | |||||||
Alpha-carotene | 4 | 4 | 0 | 0 | 284,501/787 | Dose-response | Per 600 μg/d | |||||||
Beta-cryptoxanthin | 4 | 4 | 0 | 0 | 284,501/787 | Dose-response | Per 100 μg/d | |||||||
Lutein and zeaxanthin | 4 | 4 | 0 | 0 | 284,501/787 | Dose-response | Per 1000 μg/d | |||||||
Lycopene | 4 | 4 | 0 | 0 | 284,501/787 | Dose-response | Per 4000 μg/d | |||||||
Total calcium (food and supplements) | 3 | 3 | 0 | 0 | NA/1711 | Dose-response | Per 200 mg/d | |||||||
Dietary calcium | 3 | 3 | 0 | 0 | NA/1574 | Dose-response | Per 200 mg/d | |||||||
Calcium from supplements | 3 | 3 | 0 | 0 | NA/1482 | High vs low | Higher adherence v lower adherence |
Methodological quality
Overlapping and nonoverlapping associations
Associations and level of evidence
Exposure | Reference | No of primary studies | No. of participants/no. of cases | Adjusted SHR (95%-CI) | P value | I2 | 95%-PI | Small study effects | Excess significance bias | Largest study significant | Level of evidence |
---|---|---|---|---|---|---|---|---|---|---|---|
Dietary patterns or dietary quality indices | |||||||||||
Healthy dietary pattern | Alizadeh 2017 | 4 | 51,709/1327 | 0.66 (0.51 to 0.85) | 0.001449 | 19.4% | 0.27 to 1.63 | No | No | No | IV |
Unhealthy/Western pattern | Alizadeh 2017 | 4 | 51,709/1327 | 1.54 (1.19 to 2.01) | 0.001232 | 24.70% | 0.62 to 3.84 | No | No | No | IV |
Drinking pattern | Alizadeh 2017 | 2 | 47,705/554 | 0.69 (0.47 to 1.01) | 0.057101 | 0.00% | NA | NA | No | No | NS |
Dietary Inflammatory Index | Jayedi 2018 | 2 | 36,118/1030 | 1.08 (1.03 to 1.13) | 0.00276 | 0.00% | NA | NA | No | No | IV |
Glycemic index | Xu 2019 | 5 | 502,119/4281 | 1.18 (1.02 to 1.37) | 0.026826 | 26.00% | 0.79 to 1.75 | No | No | No | IV |
Glycemic load | Xu 2019 | 5 | 502,119/4281 | 1.16 (0.73 to 1.84) | 0.522525 | 82.40% | 0.21 to 6.45 | No | No | No | NS |
Foods | |||||||||||
Fish | Bai 2013 | 15 | 608,753/9324 | 0.97 (0.84 to 1.10) | 0.612245 | 24.10% | 0.63 to 1.47 | No | No | No | NS |
All meat | Faramawi 2007 | 11 | 15,237/4835 | 1.27 (1.08 to1.49) | 0.003529 | 0.00% | 0.83 to 1.94 | No | No | No | IV |
seafood* | Lee 2008 | 12 | NA/1375 | 1.05 (0.82 to 1.35) | NA | NA | NA | NA | NA | NA | - |
Vegetables | Zhang 2017 | 16 | 1,365,634/9353 | 0.74 (0.63 to 0.86) | 0.000073 | 51.30% | 0.44 to 1.23 | Yes | No | Yes | III |
Fruits | Zhang 2017 | 17 | 1,398,778/9150 | 0.84 (0.69 to 1.02) | 0.075352 | 50.90% | 0.39 to 1.78 | No | No | Yes | NS |
Red meat† | Zhang 2017 | 19 | 1,826,171/12631 | 1.40 (1.15 to 1.70) | 0.000807 | 71.40% | 0.63 to 3.13 | Yes | No | No | III |
Processed meat | Zhang 2017 | 19 | 1,793,675/14240 | 1.13 (1.01 to 1.26) | 0.030876 | 46.80% | 0.78 to 1.64 | No | No | No | IV |
Poultry# | Faramawi 2007; Lee 2008 | 16 | NA/4165 | 1.23 (1.02 to 1.47) | 0.030824 | 0.00% | 0.88 to 1.70 | No | No | Yes | IV |
Cruciferous vegetables | Zhao 2013 | 12 | 1,228,518/5773 | 0.81 (0.71 to 0.92) | 0.001107 | 55.70% | 0.54 to 1.20 | No | No | Yes | IV |
Fruit and non-starchy vegetables | WCRF 2013 | 7 | 756,544/1215 | 0.99 (0.93 to 1.05) | 0.748236 | 0.00% | 0.85 to 1.15 | Yes | No | No | NS |
Non-starchy vegetables | WCRF 2013 | 8 | 1,248,385/3031 | 0.99 (0.91 to 1.09) | 0.942029 | 0.00% | 0.80 to 1.24 | No | No | No | NS |
Tomatoes | WCRF 2013 | 3 | NA/427 | 1.11 (0.92 to 1.35) | 0.28285 | 0.00% | 0.27 to 4.51 | No | No | No | NS |
Citrus fruit | WCRF 2013 | 7 | NA/2735 | 0.98 (0.90 to 1.05) | 0.53534 | 0.00% | 0.80 to 1.19 | No | No | Yes | NS |
Beverages | |||||||||||
Sweetened carbonated beverage | Boyle 2014 | 5 | NA/NA | 1.35 (0.86 to 2.11) | 0.187219 | 60.10% | 0.28 to 6.51 | No | No | NA | NS |
Sweet beverages (include ASB and SSB) | Llaha 2021 | 3 | 143,194/1589 | 1.33 (0.74 to 2.40) | 0.336717 | 85.60% | 0.0008 to 2156.90 | No | No | No | NS |
Tea | Hu 2013 | 12 | 1,571,852/6636 | 1.05 (0.83 to 1.33) | 0.680841 | 71.50% | 0.44 to 2.49 | No | No | No | NS |
Coffee | Wijarnpreecha 2017 | 22 | 1,991,863/NA | 0.99 (0.84 to 1.18) | 0.949021 | 32.60% | 0.50 to 1.98 | No | No | No | NS |
Alcoholic beverages | |||||||||||
Beer | Cheng 2011 | 8 | NA/5538 | 0.84 (0.70 to 1.00) | 0.052184 | 14.80% | 0.52 to 1.34 | No | No | No | NS |
Wine | Cheng 2011 | 8 | NA/5538 | 0.70 (0.52 to 0.94) | 0.019297 | 56.00% | 0.30 to 1.70 | No | No | Yes | IV |
Spirits | Cheng 2011 | 9 | NA/6393 | 0.80 (0.64 to 0.99) | 0.048382 | 74.30% | 0.39 to 1.62 | No | No | Yes | IV |
Alcohol (light) | Xu 2015 | 6 | 3,720,850/5214 | 0.91 (0.81 to 1.02) | 0.102662 | 39.60% | 0.64 to 1.28 | No | No | No | NS |
Alcohol (moderate) | Xu 2015 | 8 | 4,139,301/5364 | 0.77 (0.58 to 1.02) | 0.069063 | 29.20% | 0.30 to 1.98 | No | No | Yes | NS |
Alcohol (heavy) | Xu 2015 | 3 | 2,065,995/363 | 0.93 (0.27 to 3.22) | 0.9134 | 81.20% | 0.0000 to 3904180.81 | No | Yes | Yes | NS |
Alcohol (any) | Xu 2015 | 8 | 4,867,646/5503 | 0.88 (0.63 to 1.22) | 0.439292 | 62.90% | 0.27 to 2.81 | No | Yes | Yes | NS |
Macronutrients | |||||||||||
Fruit fiber | Huang 2014 | 3 | 496,292/2906 | 0.91 (0.74 to 1.11) | 0.346662 | 0.00% | 0.14 to 6.06 | No | No | No | NS |
Vegetable fiber | Huang 2014 | 3 | 496,292/2906 | 0.68 (0.44 to 1.06) | 0.089923 | 76.90% | 0.003 to 139.60 | Yes | No | No | NS |
Cereal fiber | Huang 2014 | 3 | 496,292/2906 | 1.05 (0.88 to 1.26) | 0.569512 | 0.00% | 0.22 to 4.94 | No | No | No | NS |
Legume fiber* | Huang 2014 | 1 | 491,841/1816 | 0.80 (0.69 to 0.93) | NA | NA | NA | NA | NA | NA | - |
Total fat | WCRF 2013 | 14 | 1,210,245/1985 | 1.02 (0.98 to 1.07) | 0.360753 | 0.00% | NA | NA | No | No | NS |
Saturated fat | WCRF 2013 | 14 | 1,210,245/1985 | 1.05 (0.88 to 1.24) | 0.60759 | 41.30% | NA | NA | No | No | NS |
Monounsaturated fat | WCRF 2013 | 14 | 1,210,245/1985 | 0.98 (0.83 to 1.15) | 0.762472 | 0.00% | NA | NA | No | No | NS |
Polyunsaturated fat | WCRF 2013 | 14 | 1,210,245/1985 | 0.90 (0.75 to 1.07) | 0.219824 | 18.90% | NA | NA | No | No | NS |
Animal fat* | Lee 2008 | 8 | 417,093/900 | 1.01 (0.96 to 1.07) | NA | NA | NA | NA | NA | NA | - |
Plant fat* | Lee 2008 | 8 | 417,093/900 | 0.99 (0.93 to 1.05) | NA | NA | NA | NA | NA | NA | - |
Cholesterol* | Lee 2008 | 13 | 774,952/1478 | 1.03 (0.94 to 1.14) | NA | NA | NA | NA | NA | NA | - |
Total protein | WCRF 2013 | 14 | 1,210,245/1985 | 1.08 (0.99 to 1.19) | 0.09981 | 0.00% | NA | NA | No | No | NS |
Animal protein | WCRF 2013 | 14 | 1,210,245/1985 | 1.10 (1.00 to 1.20) | 0.04936 | 0.00% | NA | NA | No | No | IV |
Plant protein | WCRF 2013 | 14 | 1,210,245/1985 | 0.98 (0.80 to 1.22) | 0.88739 | 0.00% | NA | NA | No | No | NS |
Dietary fiber | Xu 2019 | 7 | 942,582/6590 | 0.82 (0.71 to 0.95) | 0.007181 | 27.60% | 0.55 to 1.22 | No | No | Yes | IV |
Micronutrients | |||||||||||
Riboflavin | Clasen 2020 | 3 | 39,789/1971 | 0.89 (0.70 to 1.13) | 0.343247 | 0.00% | 0.14 to 5.84 | No | No | No | NS |
Vitamin B6 | Clasen 2020 | 5 | 164,883/2407 | 0.85 (0.70 to 1.04) | 0.113403 | 0.00% | 0.58 to 1.27 | No | No | No | NS |
Folate | Clasen 2020 | 6 | 136,319/3166 | 0.84 (0.69 to 1.03) | 0.088191 | 6.00% | 0.52 to 1.36 | No | No | No | NS |
Vitamin B12 | Clasen 2020 | 3 | 127,390/1578 | 1.13 (0.88 to 1.46) | 0.331795 | 0.00% | 0.19 to 6.65 | No | No | No | NS |
Methionine | Clasen 2020 | 2 | 125,094/436 | 1.29 (0.90 to 1.85) | 0.170519 | 0.00% | NA | NA | No | No | NS |
Choline | Clasen 2020 | 2 | 125,094/436 | 0.87 (0.63 to 1.22) | 0.433326 | 0.00% | NA | NA | No | No | NS |
Betaine | Clasen 2020 | 2 | 125,094/436 | 1.01 (0.62 to 1.65) | 0.962844 | 58.80% | NA | NA | No | No | NS |
Vitamin C | Jia 2015 | 10 | 274,864/5182 | 0.77 (0.66 to 0.90) | 0.000636 | 0.00% | 0.54 to 1.10 | No | No | No | III |
Vitamin D | Wu 2020 | 6 | 187,560/NA | 0.89 (0.71 to 1.11) | 0.286865 | 36.50% | 0.48 to 1.64 | No | No | No | NS |
Dietary nitrate | Xie 2016 | 3 | NA/NA | 0.78 (0.40 to 1.55) | 0.482996 | 89.20% | 0.0002 to 3013.70 | No | No | NA | NS |
Dietary nitrite | Xie 2016 | 2 | NA/NA | 0.99 (0.81 to 1.21) | 0.892113 | 0.00% | NA | NA | No | No | NS |
Vitamin E | Shen 2015 | 13 | 471,006/6944 | 0.81 (0.69 to 0.94) | 0.006361 | 49.20% | 0.52 to 1.26 | No | No | No | IV |
Alpha-carotene | WCRF 2013 | 4 | 284,501/787 | 0.96 (0.86 to 1.07) | 0.448428 | 33.10% | 0.32 to 2.86 | No | No | No | NS |
Beta-cryptoxanthin | WCRF 2013 | 4 | 284,501/787 | 0.97 (0.83 to 1.13) | 0.700635 | 59.10% | 0.19 to 4.91 | No | No | Yes | NS |
Lutein and zeaxanthin | WCRF 2013 | 4 | 284,501/787 | 0.99 (0.95 to 1.04) | 0.827912 | 0.00% | 0.71 to 1.40 | Yes | No | No | NS |
Lycopene | WCRF 2013 | 4 | 284,501/787 | 1.03 (0.73 to 1.47) | 0.849859 | 5.90% | 0.04 to 30.00 | No | No | No | NS |
Total calcium (food and supplements) | WCRF 2013 | 3 | NA/1711 | 0.96 (0.94 to 0.99) | 0.017337 | 0.00% | 0.78 to 1.19 | No | No | Yes | IV |
Dietary calcium | WCRF 2013 | 3 | NA/1574 | 0.98 (0.90 to 1.06) | 0.614121 | 0.00% | 0.45 to 2.12 | No | No | No | NS |
Calcium (supplements) | WCRF 2013 | 3 | NA/1482 | 0.80 (0.64 to 0.99) | 0.039569 | 0.00% | NA | NA | No | No | IV |