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.
Dietary indices Dietary guidelines Death, Golestan Cohort Mediterranean diet DASH
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We are grateful to all participants of the study, and the Golestan Cohort Study for expert help in collecting the data.
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.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
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.
Informed consent was obtained from all individual participants included in the study.
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1.Digestive Oncology Research CenterDigestive Diseases Research Institute, Tehran University of Medical SciencesTehranIran
2.Metabolic Epidemiology Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleUSA
3.Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonUSA
4.Digestive Disease Research CenterDigestive Diseases Research Institute, Tehran University of Medical SciencesTehranIran
5.Liver and Pancreatobiliary Diseases Research CenterDigestive Diseases Research Institute, Tehran University of Medical SciencesTehranIran
6.Department of Biology, School of Computer, Mathematical, and Natural SciencesMorgan State UniversityBaltimoreUSA
7.Departments of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical SciencesTehranIran
8.Section of GeneticsInternational Agency for Research on CancerLyonFrance
9.Tisch Cancer InstituteIcahn School of Medicine at Mount SinaiNew YorkUSA
10.Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical SciencesGorganIran
11.Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population SciencesNational Cancer InstituteBethesdaUSA