Description of the healthy eating indices-based diet quality in Turkish adults: a cross-sectional study
Koksal et al. Environmental Health and Preventive Medicine
Description of the healthy eating indices-based diet quality in Turkish adults: a cross-sectional study
Eda Koksal 0
Merve Seyda Karacil Ermumcu 0
Hande Mortas 0
0 Faculty of Health Sciences, Department of Nutrition and Dietetics, Gazi University , Ankara , Turkey
Objectives: This study aims to describe the dietary status of Turkish adults using two different versions of the Healthy Eating Index (HEI). Methods: In this cross sectional study, 494 healthy participants (311 females) with randomly selected and living in Ankara were included between September 2013 and March 2014. A questionnaire was completed and anthropometric measurements (weight and height) were performed. The 24-h dietary recall of individuals was collected. Diet quality was measured through HEI-2005 and HEI-2010 scores. Results: The mean age, body mass index (BMI), HEI-2005 and HEI-2010 scores of individuals were 32.9 ± 10.8 years; 25.0 ± 4.8 kg/m2; 56.1 ± 13.9 and 41.5 ± 13.7 points, respectively. Significant differences were found between mean HEI-2005 and HEI-2010 scores (p < 0.05). The individual's whose diet quality needs to be improved according to mean HEI-2005 score, had poorer diet based on mean HEI-2010 scores. The highest mean HEI-2005 and HEI-2010 scores were stated in female, in subjects had low education levels, aged 51 years or older and in overweight groups (p <0.05). Both versions of healthy eating indices were correlated positively with BMI and age Conclusion: Diet qualities of the individuals are associated with age, gender, education and BMI. Although the components and scores in HEI-2010 version were changed from the version of HEI-2005, the changes may encourage healthy choices of some food group. HEI-2010 gives more attention to food quality than HEI-2005. Thus, in the present study it was concluded that HEI-2010 provided more precise results about diet quality.
Many health problems including dyslipidemia, obesity
and metabolic syndrome are found to be related to poor
and unbalanced diet in recent years [1–4]. The health
status of individuals is influenced by the total dietary
intake in addition to one nutrient [5, 6]. There have been
many studies about single nutrients [7, 8], various foods
[9–11] and food groups [12, 13] to achieve etiology of
diseases related to nutrition. Similarly, many researchers
have investigated diet quality and health interactions
[6, 14–17] while in Turkey, there are a few studies
investigated the diet quality, especially performed
using the diet quality indices [18–21]. The indices
used to evaluate the diet quality were developed to
measure the degree of compliance with a standard
which is considered a healthy diet . A diet quality
index measures most important dietary components
and scores depending on these components. The
assessment of adequacy, diversity and proportionality
of diet is carried with diet quality indices [23, 24].
Today, individuals can consider their own diet to have
high quality due to low levels of diet quality information
with some objective evaluation methods . Therefore, it
is very important that correct assessment of individuals’
diet quality. Healthy eating indices are indicated as
important tools to assess compliance diet quality with
dietary guidelines . Various healthy eating indices are
developed in order to reveal the interaction between diet
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
quality and health . Healthy Eating Index (HEI) is
among the leading indices assessing the diet quality
to maintain health and improve well-being. It is
updated at every five years [22, 24, 27]. HEI score
was found to be negatively associated with diseases
such as abdominal obesity, hypertension, cancer in
many studies [22, 23, 28].
In our present knowledge this study is the first one
conducted in Turkey to evaluate diet quality using
HEI2010. In this study, in addition to describe diet quality of
individuals using two different versions of HEI, it was
aimed to investigate influence of baseline factors such as
body weight, age, gender and education level which may
affect the diet quality.
Materials and methods
Study design and sample
In this cross sectional study, 494 healthy participants
(311 females) randomly selected were included between
September 2013 and March 2014 (the response rate of
the study was 76%). The study was carried out in
Ankara, the capital city of Turkey. Each participant
signed a voluntary participation form and filled in the
questionnaires in accordance with the declaration of
Helsinki (World Medical Association). Questionnaire
including the demographic and general characteristics
(age (year), education (illiterate, no schooling-literate,
basic/primary school, secondary school, high school and
university which are classified according to duration
(year)) and body mass index (BMI) was administered to
individuals by face-to-face interviews. All
anthropometric measurements were taken by two trained dieticians.
Height was measured to the nearest 0.1 cm, and weight
to nearest 0.5 kg in light clothing and without shoes.
BMI was calculated as body weight (kg)/[height (m)]2.
After BMI was calculated, the results were classified as
underweight, normal and overweight according to
World Health Organization’s classification . The
threshold of education level was set as 8 years, the
compulsory education level in Turkey.
Assessment of diet quality
The 24-h dietary recall was obtained to determine the
diet quality of the participants. Nutrition Information
Systems (Beslenme Bilgi Sistemi-BeBiS) which is a food
software program in compliance with Turkish food was
used for assessment nutrients, food and food groups.
Further HEI-2010 and HEI-2005 were used for evaluation
of the diet quality. These indices consist of twelve
components namely nine adequacy and three proportionality
components, takes into account the consumption of both
healthy and non-healthy foods .
Calculation of the HEI-2005 and HEI-2010 scores
The intakes of foods and nutrients are represented on a
density basis, as amounts per 1,000 cal for each index.
According to HEI-2005, whole and total fruits, total
vegetables, dark green and orange vegetables and legumes,
total and whole grains, milk, meat and legumes, oils
were scored from 0 to 20 for consumption amounts per
1000 kcal. Saturated fats, sodium and calories from solid
fat, alcoholic beverages and added sugars (SoFAAS) were
awarded for lower intakes. These components were
scored in reverse. With all scores collected were reached
the total HEI-2005 score. The collected HEI score can
potentially range from a minimum of zero to a
maximum of 100. Total HEI-2010 score was calculated
similar to HEI-2005. But there were some updated or added
foods in HEI-2010. “Dark green and orange vegetables
and legumes” component was changed as “green and
beans”. “Milk” component was changed as “dairy”. “Meat
and beans” component was changed as “total protein
foods”. “SoFAAS” component was changed as “empty
calories”. Total grain was eliminated. Also, “seafood and
plant protein” and “fatty acids and refined grains”
components were added. There were made no change in
total scoring and was defined as the maximum score of
100 . Possible scores range from 0 to 100, with 100
points referring to perfect diet quality and lower results
indicating larger deviations from the recommended
intakes. Diet quality indices were categorized into three
stages. A total score of ≤50 was described as “poor diet
quality”, scores of 51–80 considered “needs
improvement” and scores of >80 indicated “good” [18, 30].
Comparison of components and scoring standards in the
HEI-2005 and HEI-2010 was shown Table 4 .
Assessment of the study data was carried out using
Statistical Package for the Social Sciences 16.0 (SPSS).
Independent groups were analyzed for mean differences
and significance of data providing parametric conditions
(ANOVA, t test and Mann–Whitney U test). The
Chi-square test was used to compare the proportions
in different groups. The correlation coefficients and
significance were calculated using Pearson test. Moreover,
the inter-rater agreement between the two indices in
determining the diet quality as poor and needed
improvement was investigated using the Kappa test. A p-value of
less than 0.05 was considered to show a statically result.
Socio-demographic and nutritional characteristics
Socio-demographic and nutritional characteristics of the
participants were presented in Table 1. Mean age and BMI
of individuals were 32.9 ± 10.8 years; 25.0 ± 4.8 kg/m2,
respectively (data not shown in the tables). The mean age
Table 1 Socio-demographic characteristics, daily energy and
nutrient intakes of the participants
Males (n = 183) Females (n = 311)
t = −1.540; p = 0.124
t = −0.553; p = 0.580
Energy and Nutrients**, mean (SD) Males
Age (years), mean (SD)
BMI (kg/m2), mean (SD)
Educational status, n (%)
No schooling, literate
Dietary cholesterol (mg)
Carbohydrate (% energy)
Vitamin B6 (mg)
*p < 0.05, Independent-Sample T-Test; **According to the 24-h dietary recall
BMI body mass index, SD standard deviation, SFA saturated fatty acid, MUFA
monounsaturated fatty acid, PUFA polyunsaturated fatty acid
of females and males were 33.5 ± 10.2 and 31.9 ± 11.7 years,
respectively (Table 1). Females (25.1 ± 5.2) had higher
mean BMI than males (24.9 ± 4.0) but difference between
them was not significant (t = −0.553; p = 0.580). In total,
17.0% of females and 24.0% of males were university
graduates. Also, the proportion of the individuals who were
secondary school graduates (compulsory education level in
Turkey) was higher in males than females (13.1 and 9.3%,
respectively). In general, significant differences were found
between the males and females without the mean daily
intakes of vitamin A (μg), vitamin E (mg) and vitamin C
(mg). The daily intake of energy and total protein was
1906.5 kcal and 69.1 g in males and 1571.4 kcal and 52.3 g
Comparison of diet quality according to two version of
Healthy Eating Indices
The percentage of individuals in the “needs improvement”
diet category was 68.0% according to HEI-2005 scores
while this ratio were 29.4% in HEI-2010 (κ = 0.302-fair
agreement; p = 0.000; data not shown in the tables).
Subjects have good diet quality were found at the ratio of
1.4% in HEI-2005 (data not shown in the tables). There
was no individual had good diet quality according to
The mean total scores and diet quality indices’
components of HEI-2005 and HEI-2010 according to gender, age
group, education level and obesity status of individuals
were shown in Table 2. The mean scores HEI-2005 and
HEI-2010 of individuals were found 56.1 ± 13.9 and 41.5
± 13.7, respectively (data not shown in the tables). It was
determined that females had higher mean total scores
than males and differences between groups were
significant in both indices (p < 0.05) (Table 2).
According to both versions of diet quality indices,
females had significantly higher scores than that of males
in some components including consumption of total
fruits and vegetables, dark green and orange vegetables
and legumes (HEI-2005), greens and beans (HEI-2010).
Scores obtained from “sodium” and “calories from
SoFAAS” were lower in males than that of females
according to HEI 2005 and likewise, the mean scores of
refined grains, sodium, fatty acids and empty calories
was lower in males than that of females according to
HEI-2010 (p < 0.05). Mean scores of whole fruits, whole
grains, milk, meat and beans, saturated fats and oils in
the HEI-2005 and mean scores of whole grains, dairy,
whole fruit, total protein foods, seafood and plant
protein in the HEI-2010 were similar in male and female.
There were no significant differences between groups
(p > 0.05).
It was found that individuals with lower education
level had higher scores from whole fruit, dark green and
orange vegetables, legumes and sodium intake in both
versions (p < 0.05).
The youngest age group (19–30 years) had lowest
scores of both for HEI-2005 (52.8 ± 14.9) and for
HEI2010 (38.7 ± 14.6) and the differences between other age
itttssyau lraoNm :()425n aSen±DM ..4220± ..9222± ..7218± a..9119± ..9403± ..0000± ..1326± ..2638± a..8647± a..5620± ..7341± ..47183± a..395147± aSen±DM ..3220± ..9222± ..7218± a..7221± ..0000± ..6218± ..4318± a..3322± ..2009± b..1319± ..3741± ..14583± ..397144±
ob ita t
,raeenodgg )s -0153 :)(622n aSen±DM ,ab..9152± b..1223± ..8103± b..0282± ..5094± ..0000± b..8263± ..8376± b..2487± b..0207± ..1413± b..07661± b..251585± aSen±DM ,ab..9152± b..1223± ..8103± b..0233± ..0000± b..8192± ..7173± b..9183± ..9020± ..9131± ..1413± b..70561± ..124634±
g e a
ircca01ond (ryeuoggpA -3091 :)(632n aSen±DM a..2402± a..2922± ..1782± a..1991± ..0944± ..0003± a..2826± ..3369± a..4767± a..2560± ..6432± a..93187± a..825149± aSen±DM a..4202± a..9222± ..7218± a..7221± ..0003± a..4217± ..4318± a..2322± ..2011± ..4120± ..6342± a..38187± ..873146±
3 og rse
4 D 9 .5
saend reendG lsaeM :)(381n aSen±DM ..9122± ..2292± ..8152± ..9112± ..1094± ..0000± ..5292± ..7366± ..6496± ..1296± ..6332± ..98431± ..61645± aSen±M ..9122± ..2292± ..8152± ..1282± ..0000± ..7162± ..6163± ..2233± ..5010± ..7190± ..6332± ..8331± .1437± itttcaeoonw rtsccaaaehm
groups were significant (p < 0.05). The mean scores from
whole fruits, dark green and orange vegetables and
legumes, milk, saturated fats, oils and energy from
SoFAAS in the HEI-2005 was found lowest in 19–30
ages group and differences between other age groups were
significant (p < 0.05). And also the mean scores from
whole fruits, greens and beans, seafood and vegetable
protein foods, dairy with empty calories in the HEI-2010 was
found lowest in 19–30 ages group and differences between
other age groups were significant (p < 0.05).
Mean total scores of both versions of HEI were higher
among overweight individuals than normal individuals
in the diet quality indices. While there was not any
significant difference between underweight and overweight
individuals in total scores of HEI-2005 and HEI-2010
(p > 0.05) but difference between normal and overweight
individuals was significant (p < 0.05).
When diet quality of individuals was assessed according
to gender, age groups, education level and BMI
classification it was found that individuals needed improvement
their diet quality according to HEI-2005 scores and their
diet quality was poor according to HEI-2010 scores in all
groups of age, education levels and BMI.
Diet quality of individuals according to baseline
Baseline characteristic of the participants by classification
of HEI scores was presented in Table 3. Females who
have good diet quality were more than males in
HEI2005 (χ2 = 18.990; p = 0.000). The percentages of males in
the “needs improvement” and “poor” diet categories were
57.4% and 42.1%, respectively. The percentage of females
who had poor diet quality were lower (64.3%) than males
according to HEI-2010 (χ2 = 16.269; p = 0.000) (Table 3).
The ratio of participants have poor diet quality was 34.6%
in high education level (>8 years) while this ratio was
24.8% in low education level according to HEI-2005. But
the difference was not significant (p > 0.05). Percentage of
participants in the “needs improvement” diet category was
higher than the ratios of other diet categories in all age
groups according to HEI-2005. According to HEI-2010, in
only “≥51 years” age group, diet quality of the most
individuals was classified as “need improvement”. The
percentages of participants who have poor diet quality
were higher significantly in the other age group than that
of “≥51 years” age group. Overweight participants who
have poor diet quality were less (22.2%) than
underweight (38.0%) and normal subjects (33.3%) (χ2 =
15.947; p = 0.003) according to HEI-2005. There was
no significant difference between normal and
underweight individuals (p > 0.05). Similarly according to
HEI-2010 overweight subjects in “poor” diet quality
category were less (64.0%) than the others (χ2 =
10.426; p = 0.005). Also, most of the overweight
subjects’ diet qualities were evaluated to need improvement
according to HEI-2005 while the most overweight
individuals were evaluated to have poor diet quality in HEI-2010.
Components and scoring standards of HEI-2005 and
HEI2010 were presented in Table 4. There are some changes
in the evaluation standards of the HEI-2005 when
developing the HEI-2010. For example, ≥12 g oil per
1000 kcal is required for a maximum score of 10
according to HEI-2005, while in HEI-2010, for a
maximum score of 10, the standard is presented that sum
of polyunsaturated fatty acids (PUFAs) and
monounsaturated fatty acids (MUFAs) to saturated fatty acids
(SFAs) ratio of greater than two and a half [(PUFAs +
MUFAs)/SFAs >2.5]. This change encourages healthy
choices of protein and fat. Also, HEI-2010 gives more
attention to food quality than HEI-2005. HEI-2010
includes only whole grains instead of total grains
contrary to HEI-2005.
Table 3 Evaluation of diet quality of individuals according to healthy eating indices by gender, education level, age group and BMI
classification, n (%)
184 (75.1)a 144 (64.0)b
Needs improvement 105 (57.4) 231 (74.3) 149 (73.8) 187 (64.0) 138 (58.5)a 170 (75.2)b 28 (87.5)b 16 (66.7)a, b
147 (60.0)a 173 (76.9)b
77 (42.1) 74 (23.8) 50 (24.8)
101 (34.6) 93 (39.4)a
149 (81.4) 200 (64.3) 130 (64.4) 219 (75.0) 184 (78.0)a 150 (66.4)b 15 (46.9)c 21 (87.5)a
Needs improvement 34 (18.6) 111 (35.7) 72 (35.6)
a,b,cDifferent characters p < 0.05, same characters p > 0.05 for the data classified into three categories
Table 4 Comparison of components and scoring standards in the HEI-2005 and HEI-2010 
Light gray rows indicate components found in both the HEI–2005 and HEI–2010; Black rows indicate components found only in the HEI–2005; Dark gray rows
indicate components found only in the HEI–2010
aIntakes between the minimum and maximum standards are scored proportionately except for Saturated Fat and Sodium
bIntakes between the minimum and maximum standards are scored proportionately
cIncludes 100% fruit juice
dIncludes all forms except juice
eIncludes any beans and peas (called Legumes in HEI–2005) not counted as Total Protein Foods (called Meat and Beans in HEI–2005)
fgIBneclaundseasnadll pmeialks parreodinuccltusd,seudchhearse f(launidd mn oiltk,wyiothguvretg,aentadblcehse)ewseh,eanntdhefoTrtoiftiaeldPsrootyebinevFeoroadgses(called Meat and Beans in HEI–2005) standard is otherwise not met
ihInInccluluddeessnsoenaf-ohoyddr,onguetns,asteeeddvse,gsoeytapbrleodouilcstsan(odthoeilrs tihnafnishb,envuertas,gaens)dassewedesll as beans and peas counted as Total Protein Foods
jRatio of poly- and monounsaturated fatty acids to saturated fatty acids
kSaturated Fat and Sodium get a score of 8 for the intake levels that reflect the 2005 Dietary Guidelines, <10% of calories from saturated fat and 1.1 g of
sodium/1,000 kcal, respectively. Intakes between the standards for scores of 0 and 8 and between 8 and 10 are scored proportionately
lCalories from solid fats, alcoholic beverages, and added sugars
mCalories from solid fats, alcoholic beverages, and added sugars; threshold for counting alcohol is >13 g/1,000 kcal
The correlation of age and BMI with HEI-2005 and
HEI-2010 scores of individuals was found to be
significantly correlated. There was a positive correlation
between both version of HEI with age and BMI values.
Besides, HEI-2005 and HEI-2010 scores correlated positively
with each other (r = 0.893; p = 0.000; data not shown in
Diet quality of participants was low according to both
versions of healthy eating indices and male had lower score
than that of female. When comparing HEI-2010 with
HEI-2005, males had higher score in HEI-2005 (p < 0.05).
In a study performing through HEI-2010 and HEI-2005,
diet quality was found similar to our study and male had
poor diet quality . Similarly, Drewnowski et al. (2016)
demonstrated that women had higher quality diets than
men according to HEI-2005 (p < 0.0001) and similar
results were observed for HEI-2010 scores . But another
study evaluated diet quality by HEI-2005 there was no
significant difference between genders . In another study
evaluating the diet quality it was emphasized that
individuals with healthy eating habits had higher diet quality
index score and lower obesity risk . There are many
studies about evaluated relationship between diet quality
and BMI [36–39]. It was determined that diet quality
index score was negatively correlated with BMI at
some studies which are compared BMI and diet quality
[35, 40–42]. But in our study, diet quality score of
overweight individuals was higher. Similarly, in a prospective
cohort study included 50,434 African-Americans, 24,054
white individuals, and 3,084 individuals of other racial/
ethnic groups, it has been found that HEI score was
positively associated with BMI. Also, according to the same
study HEI-2005 has been strongly correlated with
HEI2010 score (rp = 0.91) . This association was found in
the present study with Pearson correlation coefficient of
0.893. According to Kappa statistical results, the
agreement between HEI-2005 and HEI-2010 was statistically
significant (κ = 0.302-fair agreement).
Hiza et al. (2013) found that there are growing healthy
eating consciousness and interest to be protected
chronic disease with increasing age . In the present
study, it was stated that individuals older than 51 years
have more total scores at both versions of healthy eating
indices and in another study it was determined that diet
quality correlates their ages in this age . Thus, older
ages have better diet quality than younger ages 
similar to our results. Monfort-Pires et al. demonstrated
that the mean HEI-2005 score of individuals aged
between 18 and 62 years was 65.0 ± 10.8 . This result
was higher than that of our study (56.1 ± 13.9) but
according to mean score it was emphasized that they have
to improve their diet quality similar our study. In this
research, subjects have good diet quality were found the
ratio of 1.4% in HEI-2005 while there was no individual had
good diet quality according to HEI-2010 scores. Similarly,
HEI-2010 scores of US population aged 2 and older have
been found to be low (49.9 points)  based on The
National Health and Nutrition Examination Survey
(NHANES) data. According to US food supply data, it was
demonstrated that the HEI-2010 score ranges from 48
points in 1970 to 55 points in 2010 . In Turkey, there
was no study assessed the changes in diet quality from
year to year using HEI-2010. So, this study provides an
important contribution to the literature.
Personal development at cultural, economic and
education field of individuals is inversely associated with
diet quality at many studies. The reason of this has been
expressed as increased frequency of ready and
unhealthy foods with eating out of home. And because
of this, consumption of sugar and sodium by
individuals with high educational level has been increased
[47–49]. Similarly in our study, individuals who have
higher education level had lower diet quality. But this
result was inconsistent with other studies [33, 34].
The other studies asserted that with the increased
education level and awareness of healthy nutrition,
diet quality was increased .
In present study, it was determined that according to
HEI-2005 many individuals (57.5% in males and 74.3%
in females) had to improve their diet quality and in
many studies were found results similar to our study
[50, 51]. When we investigate the components used in
the determination of diet quality, it was shown that
lower scores obtained from vegetables, fruit and dairy
components and these results are very similar in a study
conducted in adults . Low intake of vegetables, fruits
and dairy adversely affects diet quality and low diet
quality often occurs as a result of highly oil consumption
. Scores obtained from saturated fats and oils were
higher than the other components in HEI-2005 but fatty
acids was found to be contributed to total score less
than the other components in HEI-2010. This situation
arises because of content of the total oils consumed by
individuals. Scores of total grain which is subcomponent
of HEI-2005 were higher than that of whole grain and
there was a significant difference between genders. Total
grain score was not present and scores of whole grains
was low in HEI-2010. Score obtained from whole grain
was very low in another study which was evaluating
diet quality similar to our study . Consumption of
recommended amounts whole grain is effective at
weight control and prevention of chronic diseases.
Increasing consumption of whole grain which is
subcomponent of the both of indices will contribute to diet
quality and improvement of food intake . Also, diet
quality is inversely associated with the consumption of
foods and drinks, the sources of the “empty calories” .
In this research, contribution of “calories from SoFAAS”
which is component of HEI-2005 and of “empty calories”
which is component of HEI-2010 to total indices scores
was greater than other component. Thus, it was found
that consumption of foods and drinks containing empty
calories obtained from saturated fat, alcohol and added
sugar was low in this study.
The present study includes a number of limitations.
The major limitation of this cross sectional study include
that socioeconomic status didn’t examine that affect the
diet quality. But it is difficult to evaluate this variable in
Turkey because most of individuals don’t want to give
information about their income. This study includes
only people who are living in central Anatolia and does
not reflect the whole of Turkey. Therefore, studies are
needed that are homogeneous, wide and could represent
In conclusion, studies that evaluate the diet quality of
individuals using HEI-2005 and HEI-2010 are limited in
Turkey. In accordance with the results of this study, diet
qualities of individuals are affected by age, gender,
education and BMI. Although the mean score of the indices
were found to be almost close and they were strongly
correlated with each other, HEI-2010 provided more
precise results. Also, many individuals’ diets in “needs
improvement” group according to HEI-2005 were
assessed as “poor” in HEI-2010. At this regard, it should
be noted that various indices using for diet quality
assessment can lead to differences. Indices provide most
precise results and current should be preferred. Also, it
may be more useful to support these results with using
other dietary assessment methods such as nutrient
adequacy ratio, mean adequacy ratio and/or other
indices in addition to the HEI.
EK designed the study, wrote the manuscript and provided critical inputs on
the draft. MSKE and HM conducted the field study, helped for the
measurements and data collection. MSKE performed the statistical analyses
and wrote the manuscript. HM interpreted the data and submitted the
manuscript. All authors read and approved the final manuscript.
1. Ding G , Zhao W , Chen J. Actively promote nutrition and health surveillance, achieve the national nutrition and health goals (abstract) . Zhonghua Yu Fang Yi Xue Za Zhi . 2016 ; 50 ( 3 ): 201 - 3 . doi:10.3760/cma.j.issn. 0253 - 9624 . 2016 . 03.001.
2. Lee G , Ham OK . Factors affecting underweight and obesity among elementary school children in south korea . Asian Nurs Res (Korean Soc Nurs Sci) . 2015 ; 9 ( 4 ): 298 - 304 . doi:10.1016/j.anr. 2015 .07.004.
3. Yang H , Kim H , Kim JM , Chung HW , Chang N. Associations of dietary intake and metabolic syndrome risk parameters in Vietnamese female marriage immigrants in South Korea: The KoGES follow-up study . Nutr Res Pract . 2016 ; 10 ( 3 ): 313 - 20 . doi:10.4162/nrp.2016. 10 .3. 313 .
4. Zhang J , Wang Z , Wang H , Du W , Su C , Zhang J , et al. Association between dietary patterns and blood lipid profiles among Chinese women . Public Health Nutr . 2016 ; 29 : 1 - 8 . doi:10.1017/s136898001600197x.
5. Wirt A , Collins CE . Diet quality-what is it and does it matter? Public Health Nutr . 2009 ; 12 ( 12 ): 2473 - 92 . doi:10.1017/S136898000900531X.
6. Cuenca-García M , Artero EG , Sui X , Lee D , Hebert JR , Blair SN . Dietary indices, cardiovascular risk factors and mortality in middle-aged adults: findings from the aerobics center longitudinal study . Ann Epidemiol . 2014 ; 24 : 297 - 303 . doi:10.1016/j.annepidem. 2014 .01.007.
7. Christenson J , Whitby SJ , Mellor D , Thomas J , McKune A , Roach PD , Naumovski N. The Effects of Resveratrol Supplementation in Overweight and Obese Humans: A Systematic Review of Randomized Trials . Metab Syndr Relat Disord . 2016 . [Epub ahead of print] doi:10.1089/met.2016.0035.
8. Ortega JF , Morales-Palomo F , Fernandez-Elias V , Hamouti N , Bernardo FJ , Martin-Doimeadios RC , et al. Dietary supplementation with omega-3 fatty acids and oleate enhances exercise training effects in patients with metabolic syndrome . Obesity (Silver Spring) . 2016 ; 24 ( 8 ): 1704 - 11 . doi:10.1002/oby.21552.
9. Demmer E , Van Loan MD , Rivera N , Rogers TS , Gertz ER , German JB , et al. Consumption of a high-fat meal containing cheese compared with a vegan alternative lowers postprandial C-reactive protein in overweight and obese individuals with metabolic abnormalities: a randomised controlled cross-over study . J Nutr Sci . 2016 ; 9 ( 5 ) :e9 . doi:10.1017/jns.2015.40.
10. Damsgaard CT , Ritz C , Dalskov SM , Landberg R , Stark KD , Biltoft-Jensen A , et al. Associations between school meal-induced dietary changes and metabolic syndrome markers in 8-11-year-old Danish children . Eur J Nutr . 2016 ; 55 ( 5 ): 1973 - 84 . doi:10.1007/s00394- 015 - 1013 -z.
11. Lee YJ , Seo JA , Yoon T , Seo I , Lee JH , Im D , et al. Effects of low-fat milk consumption on metabolic and atherogenic biomarkers in Korean adults with the metabolic syndrome: a randomised controlled trial . J Hum Nutr Diet . 2016 ; 29 ( 4 ): 477 - 86 . doi:10.1111/jhn.12349.
12. Narasimhan S , Nagarajan L , Vaidya R , Gunasekaran G , Rajagopal G , Parthasarathy V , et al. Dietary fat intake and its association with risk of selected components of the metabolic syndrome among rural South Indians . Indian J Endocrinol Metab . 2016 ; 20 ( 1 ): 47 - 54 . doi:10.4103/ 2230 - 8210 .172248.
13. Jia X , Zhong L , Song Y , Hu Y , Wang G , Sun S. Consumption of citrus and cruciferous vegetables with incident type 2 diabetes mellitus based on a meta-analysis of prospective study . Prim Care Diabetes . 2016 ; 10 ( 4 ): 272 - 80 . doi:10.1016/j.pcd. 2015 .12.004.
14. Kant AK , Schatzkin A , Graubard BI , Schairer C. A prospective study of diet quality and mortality in women . JAMA . 2000 ; 283 ( 16 ): 2109 - 15 . doi:10.1001/jama.283.16.2109.
15. Dias JA , Wirfalt E , Drake I , Gullberg B , Hedblad B , Persson M , et al. A high quality diet is associated with reduced systemic inflammation in middleaged individuals . Atherosclerosis . 2015 ; 238 : 38 - 44 . doi:10.1016/j. atherosclerosis. 2014 .11.006.
16. Reedy J , Krebs-Smith SM , Miller PE , Liese AD , Kahle LL , Park Y , Subar AF . Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults . J Nutr . 2014 ; 144 ( 6 ): 881 - 9 . doi:10.3945/jn.113.189407.
17. Kurotani K , Akter S , Kashino I , Goto A , Mizoue T , Noda M , Sasazuki S , Sawada N , Tsugane S , Japan Public Health Center based Prospective Study Group . Quality of diet and mortality among Japanese men and women: Japan Public Health Center based prospective study . BMJ . 2016 ; 352 :i1209. doi:10.1136/bmj.i1209.
18. Acar Tek N , Yildiran H , Akbulut G , Bilici S , Koksal E , Gezmen Karadag M , et al. Evaluation of dietary quality of adolescents using Healthy Eating Index. Nutr Res Pract . 2011 ; 5 ( 4 ): 322 - 8 . doi:10.4162/nrp. 2011 .5.4. 322 .
19. Sahingoz SA , Sanlier N. Compliance with mediterranean diet quality index (KIDMED) and nutrition knowledge levels in adolescents. A case study from turkey . Appetite . 2011 ; 57 : 272 - 7 . doi:10.1016/j.appet. 2011 .05.307.
20. Dekker LH , Snijder MB , Beukers MH , Vries JHM , Brants HAM , Boer EJ , et al. A prospective cohort study of dietary patterns of non-western migrants in the Netherlands in relation to risk factors for cardiovascular diseases: HELIUS-Dietary Patterns . BMC Public Health . 2011 ; 11 :441. doi:10.1186/ 1471 - 2458 - 11 - 441 .
21. Giannopoulou D , Grammatikopoulou MG , Poulimeneas D , Maraki M , Dimitrakopoulos L , Tsigga M. Nutritional surveillance of christian orthodox minority adolescents in istanbul . J Immigr Minor Health . 2016 . doi:10.1007/s10903- 016 - 0412 -4.
22. Azadbakht L , Akbari F , Esmaillzadeh A. Diet quality among Iranian adolescents needs improvement . Public Health Nutr . 2014 ; 12 : 1 - 7 . doi:10.1017/S1368980014000767.
23. Huffman FG , Vaccaro JA , Zarini GG , Dixon Z. Comparison of Two indices of diet quality with acculturation factors and demographics in Haitian americans . Ecol Food Nutr . 2014 ; 53 : 42 - 57 . doi:10.1080/03670244.2013. 774674.
24. Guenther PM , Casavale KO , Kirkpatrick SI , Reedy J , Hiza HA , Kuczynski KJ et al. 2013 . Diet quality of Americans in 2001-02 and 2007-08 as measured by the Healthy Eating Index-2010 . 51. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion (Nutrition Insight).
25. Powell-Wiley TM , Miller PE , Agyemang P , Agurs-Collins T , Reedy J. Perceived and objective diet quality in US adults: a cross-sectional analysis of the national health and nutrition examination survey (NHANES) . Public Health Nutr . 2014 ; 17 ( 12 ): 1 - 9 . doi:10.1017/S1368980014000196.
26. Dd A , Barros MB , Fisberg RM , Carandina L, Goldbaum M , Cesar CL . Diet quality among adolescents: a population-based study in Campinas, Brazil . Rev Bras Epidemiol . 2012 ; 15 ( 3 ): 605 - 16 . doi:10.1590/S1415-790X2012000300014.
27. Guenther PM , Casavale KO , Reedy J , Kirkpatrick SI , Hiza HA , Kuczynski KJ , et al. Update of the healthy eating index: HEI-2010. J Acad Nutr Diet . 2013 ; 113 : 569 - 80 . doi:10.1016/j.jand. 2012 .12.016.
28. Bosire C , Stampfer MJ , Subar AF , Park Y , Kirkpatrick SI , Chiuve SE , Hollenbeck AR , Reedy J. Index-based dietary patterns and the risk of prostate cancer in the NIH-AARP diet and health study . Am J Epidemiol . 2013 ; 177 ( 6 ): 504 - 13 . doi:10.1093/aje/kws261.
29. WHO. Physical status: the use and interpretation of anthropometry, report of a WHO expert committee , technical report series No . 854. Geneva: World Health Organization ; 1995 .
30. https://epi.grants.cancer.gov/hei/tools.html. Accessed 19 Nov 2015 .
31. https://epi.grants.cancer.gov/hei/comparing.html#f7. Accessed 19 Nov 2015 .
32. Guenther PM , Kirkpatrick SI , Reedy J , Krebs-Smith SM , Buckman DW , Dodd KW . The healthy eating index-2010 is a valid and reliable measure of diet quality according to the 2010 dietary guidelines for americans . J Nutr . 2014 ; 144 ( 3 ): 399 - 407 . doi:10.3945/jn.113.183079.
33. Drewnowski A , Aggarwal A , Cook A , Stewart O , Moudon AV . Geographic disparities in healthy eating index scores (HEI-2005 and 2010) by residential property values: findings from seattle obesity study (SOS) . Prev Med . 2016 ; 83 : 46 - 55 . doi:10.1016/j.ypmed. 2015 .11.021.
34. McCabe-Sellers BJ , Bowman S , Stuff JE , Champagne CM , Simpson PM , Bogle ML . Assessment of the diet quality of US adults in the lower Mississippi delta . Am J Clin Nutr . 2007 ; 86 ( 3 ): 697 - 706 .
35. Drewnowski A , Fiddler EC , Dauchet L , Galan P , Hercberg S. Diet quality measures and cardiovascular risk factors in France: applying the healthy eating index to the SU .VI. MAX study . J Am Coll Nutr . 2009 ; 28 ( 1 ): 22 - 9 . doi:10.1080/07315724.2009.10719757.
36. Chiplonkar SA , Tupe R. Development of a diet quality index with special reference to micronutrient adequacy for adolescent girls consuming a lacto-vegetarian diet . J Am Diet Assoc . 2010 ; 110 : 926 - 31 . doi:10.1016/j.jada. 2010 .03.016.
37. Feskanich D , Rockett HR , Colditz GA . Modifying the healthy eating index to assess diet quality in children and adolescents . J Am Diet Assoc . 2004 ; 04 : 1375 - 83 . doi:10.1016/j.jada. 2004 .06.020.
38. Golley RK , Hendrie GA , McNaughton SA . Scores on the dietary guideline index for children and adolescents are associated with nutrient intake and socio-economic position but not adiposity . J Nutr . 2011 ; 141 : 1340 - 7 . doi:10.3945/jn.110.136879.
39. Kosti RI , Panagiotakos DB , Mariolis A , Zampelas A , Athanasopoulas P , Tounas Y. The diet-lifestyle index evaluating the quality of eating and lifestyle behaviours in relation to the prevalence of overweight/obesity in adolescents . Int J Food Sci Nutr . 2009 ; 60 (Suppl 3): 34 - 47 . doi:10.1080/09637480802534525.
40. Tardivo AP , Nahas-Neto J , Nahas EA , Maesta N , Rodrigues MA , Orsatti FL . Associations between healthy eating patterns and indicators of metabolic risk in postmenopausal women . Nutr J . 2010 ; 9 :64. doi:10.1186/ 1475 - 2891 - 9 - 64 .
41. Knaapila AJ , Sandell MA , Vaarno J , Hoppu U , Puolimatka T , Kaljonen A , et al. Food neophobia associates with lower dietary quality and higher BMI in Finnish adults . Public Health Nutr . 2014 ; 22 : 1 - 11 . doi:10.1017/S1368980014003024.
42. Sundararajan K , Campbell MK , Choi YH , Sarma S. The relationship between diet quality and adult obesity: evidence from Canada . J Am Coll Nutr . 2014 ; 33 ( 1 ): 1 - 17 . doi:10.1080/07315724.2013.848157.
43. Yu D , Sonderman J , Buchowski MS , McLaughlin JK , Shu XO , Steinwandel M , et al. Healthy eating and risks of total and cause-specific death among Low-income populations of african-americans and other adults in the southeastern united states: a prospective cohort study . PLoS Med . 2015 ; 12 ( 5 ) :e1001830 . doi:10.1371/journal.pmed.1001830.
44. Hiza HA , Casavale KO , Guenther PM , Davis CA. Diet quality of americans differs by age , sex, race/ethnicity, income, and education level. J Acad Nutr Diet . 2013 ; 113 : 297 - 306 . doi:10.1016/j.jand. 2012 .08.011.
45. Monfort-Pires M , Salvador EP , Folchetti LD , Siqueira-Catania A , Barros CR , Ferreira SR . Diet quality is associated with leisure-time physical activity in individuals at cardiometabolic risk . J Am Coll Nutr . 2014 ; 33 ( 4 ): 297 - 305 . doi:10.1080/07315724.2013.874928.
46. Miller PE , Reedy J , Kirkpatrick SI , Krebs-Smith SM . The united states food supply is not consistent with dietary guidance: evidence from an evaluation using the healthy eating index-2010 . J Acad Nutr Diet . 2015 ; 115 : 95 - 100 . doi:10.1016/j.jand. 2014 .08.030.
47. Perez-Escamilla R. Acculturation , nutrition, and health disparities in Latinos . Am J Clin Nutr . 2011 ; 93 ( 5 ): 1163 - 7 . doi:10.3945/ajcn.110.003467.
48. Dubowitz T , Subramanian SV , Acevedo-Garcia D , Osypuk TL , Peterson KE . Individual and neighborhood differences in diet among low-income foreign and US-born women . Womens Health Issues . 2008 ; 18 : 181 - 90 . doi:10.1016/j.whi. 2007 .11.001.
49. McWilliams JM , Meara E , Zaslavsky AM , Ayanian JZ . Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: US trends from 1999 to 2006 and effects of medicare coverage . Ann Intern Med . 2009 ; 150 : 505 - 15 . doi:10.7326/ 0003 - 4819 - 150 - 8 - 200904210 - 00005 .
50. Burriel FC , Urrea RS , Daouas T , Soria AD , Meseguer MJG . Hábitos alimentarios y evaluación nutricional en una población universitaria tunecina . Nutr Hosp . 2014 ; 30 (n06): 1350 - 8 . doi:10.3305/nh.2014. 30 .6. 7954 .
51. Garcia-Meseguer MJ , Burriel FC , Garcia CV , Serrano-Urrea R. Adherence to Mediterranean diet in a spanish university population . Appetite . 2014 ; 78 : 156 - 64 . doi:10.1016/j.appet. 2014 .03.020.
52. Pinheiro AC , Atalah E. Proposal of a method to assess global quality of diet . Rev Med Chil . 2005 ; 133 ( 2 ): 175 - 182 .22. doi:10.4067/S0034- 98872005000200004 .
53. O'Neil CE , Nicklas TA , Zanovec M , Cho SS , Kleinman R. Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the national health and nutrition examination survey 1999-2004 . Public Health Nutr . 2011 ; 14 : 347 - 55 . doi:10.1017/ S1368980010002466.