International food group–based diet quality and risk of coronary heart
disease in men and women
Teresa T Fung,1,2 Sheila Isanaka,2 Frank B Hu,2,3 and Walter C Willett2,3
1 Department of Nutrition, Simmons College, Boston, MA; 2 Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA; and 3 Channing
Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
ABSTRACT
Background: Standard diet quality assessment tools, which mea-
sure micronutrient sufficiency and food consumption related to dis-
ease and applicable to different populations, are needed to track
progress in meeting the Sustainable Development Goals related to
hunger, food security, and nutrition. Diet quality scores have been
constructed for high- and low-income countries, but none are simple
to administer or applicable internationally.
Objective: We prospectively examined the association between the
Food Group Index (FGI), the Minimal Diet Diversity Score for
Women (MDDW), and a new Prime Diet Quality Score (PDQS), and
the risk of ischemic heart disease (IHD) in 3 US cohorts.
Design: In total, 75,045 women (baseline age 43–63 y), 43,966 men
(aged 40–75 y), and 93,131 younger women (aged 27–44 y) without
a history of cardiovascular disease were followed up to 28 y. Diet was
assessed multiple times using food frequency questionnaires and the
3 diet quality scores were computed for each individual. The associ-
ation with IHD was modeled with Cox proportional hazard models,
controlling for potential confounders.
Results: During follow-up, we ascertained 2908 incident IHD cases
in the Nurses’ Health Study, 3722 in the Health Professionals Follow-
up Study, and 505 in the Nurses’ Health Study II. The FGI was not
associated with total IHD in any cohort. The PDQS was significantly
associated with IHD in all 3 cohorts separately and the pooled RR
for each SD increase was 0.89 (95% CI: 0.87, 0.91). This was sig-
nificantly different than the pooled RR of 0.93 for MDDW (95% CI:
0.90, 0.96) and the RR of 0.98 for the FGI (95% CI: 0.95, 1.01). The
association did not appear to differ by age.
Conclusion: We found that the PDQS with the most detailed differ-
entiation of healthy and unhealthy foods was associated with a lower
risk of IHD in a high-income country. On the other hand, diet quality
scores that do not account for unhealthy foods had a limited associ-
ation with IHD. Am J Clin Nutr 2018;107:120–129.
Keywords: men, women, diet, nutrition, diet quality, diet scores,
coronary heart disease, cardiovascular
INTRODUCTION
In 2015, the United Nations announced 17 Sustainable De-
velopment Goals for the next 15 y (1). These goals are applica-
ble internationally. Specifically, the second goal involves ending
120 Am J Clin Nutr 2018;107:120–129. Printed in USA. © 2018 American Society for Nutrition. All rights reserved.
Downloaded from https://academic.oup.com/ajcn/article/107/1/120/4825209 by guest on 19 April 2021
hunger, achieving food security, and promoting nutrition. In order
to monitor progress in nutrition, a standard diet quality assess-
ment, which holistically measures sufficiency of micronutrients
and consumption of foods related to noncommunicable disease
and can be applied to different populations, is needed. These as-
sessments should be quick to administer, applicable internation-
ally, able to be used for population monitoring and clinical use,
and related to health outcomes. Often, diet quality is measured by
nutrient adequacy and whether or not an upper limit of unhealthy
dietary components, such as added sugar and sodium, is exceeded
(2–4).
A number of diet quality scores or indexes have been devel-
oped based on recommendations put forth by government or pro-
fessional clinical groups or on empirical evidence. For example,
the Healthy Eating Index was developed by the US Department of
Agriculture and is composed of 12 food and nutrient groups that
measure adherence to the 2010 Dietary Guidelines for Americans
(3). Global cancer prevention recommendations by the World
Cancer Research Fund and the American Institute for Cancer
Research were used to develop the WCRF/AICR score, consist-
ing of 6–7 lifestyle and dietary components (5). In addition, sev-
eral versions of the Mediterranean diet score have been devel-
oped to measure adherence to a traditional Mediterranean diet
(6). Although these dietary quality scores have been associated
with lower risk of noncommunicable disease and mortality, they
were primarily evaluated in high-income countries (4, 7–9). In
Supported by NIH research grants: UM1 CA186107, R01 HL034594,
UM1 CA176726, UM1 CA167552, and R01 HL35464.
Supplemental Tables 1–6 are available from the “Supplementary data” link
in the online posting of the article and from the same link in the online table
of contents at https://academic.oup.com/ajcn/.
Address correspondence to TTF (e-mail: fung@simmons.edu).
Abbreviations: FANTA, Food and Nutrition Technical Assistance project;
FFQ, food-frequency questionnaire; FGI, Food Group Index; HPFS, Health
Professionals’ Follow-up Study; IHD, ischemic heart disease; MDDW, Min-
imal Diet Diversity score for Women; MI, myocardial infarction; NHS,
Nurses’ Health Study; NHS II, Nurses’ Health Study II; PDQS, Prime Diet
Quality Score.
Received February 7, 2017. Accepted for publication November 1, 2017.
First published online January 26, 2018; doi: https://doi.org/10.1093/
ajcn/nqx015.
 FOOD GROUP DIET SCORES AND CORONARY HEART DISEASE
addition, they require software to compute the nutrient composi-
tion of the diet, and the scoring algorithm was based on the intake
level of the population. Therefore, they are not simple to admin-
ister and are difficult to apply across different countries.
Currently, 2 simple food-based diet quality scores have been
developed for use internationally. The WHO and the Pan Amer-
ican Health Organization developed a Food Group Index (FGI)
consisting of 8 broad food groups to measure diet quality in in-
fants and young children in low-income countries (10). A higher
FGI score was associated with better micronutrient adequacy. In
addition, the Minimal Diet Diversity Score for Women (MDDW)
was developed for women of reproductive age in low-income
countries and consists of 10 food groups (11). This score has also
been shown to associate with better micronutrient adequacy (12).
These 2 indexes are based on food groups only and are easy to
administer, but they have not been examined for use in higher-
income countries or beyond predicting nutrient adequacy.
It would be ideal to have a universal diet quality assessment
tool that is associated with the risk of a range of poor health out-
comes in both higher- and lower-income countries. Therefore, in
this analysis, we examined the association between the FGI and
MDDW and the risk of ischemic heart disease (IHD) in 3 US co-
horts to test the utility of these 2 scores in a higher-income coun-
try. We also developed a 21-food group Prime Diet Quality Score
(PDQS), which aims to combine simplicity in assessing diet qual-
ity with the ability to differentiate healthy foods from unhealthy
ones, and examined its association with the risk of IHD.
METHODS
Study population
Participants from 3 ongoing long-standing cohorts in the
United States were included in this study: the Nurses’ Health
Study (NHS), the Health Professionals’ Follow-up Study
(HPFS), and the Nurses’ Health Study II (NHS II). The NHS co-
hort began in 1976 and is comprised of women nurses who were
35–55 y old at the time (13). The HPFS cohort began in 1986
with 51,529 male health professionals aged 40–75 y (14). The
NHS II began in 1989 with 116,671 women nurses aged 25–42
y (15). Participants of each cohort receive a questionnaire every
2 y to assess health outcomes, lifestyle, and medication use. A
validated food frequency questionnaire (FFQ) is sent every 4 y
to assess usual dietary intake, including vitamin and mineral sup-
plements (16).
In this analysis, we used the year 1984 as the baseline for NHS
because that was when a detailed FFQ was first administered.
For HPFS, 1986 was used as the baseline and 1991 was used
for NHS II. We included participants who returned the FFQ in
1984 (NHS), 1986 (HPFS), and 1991 (NHS II), whose energy in-
take was within a plausible range (500–3500 kcal/d for women,
800–4000 kcal/d for men). At baseline, we excluded those who
reported a history of coronary heart disease or stroke. A total of
75,045 NHS, 43,966 HPFS, and 93,131 NHS II participants were
included. This study was approved by the Institutional Review
Board at Brigham and Women’s Hospital, Boston, MA.
Diet assessment and computation of diet quality scores
In NHS, the FFQ was administered in 1984 and 1986, and
every 4 y thereafter for a total of 8 times until 2010. In HPFS,
121
the FFQ was administered 6 times between 1986 and 2006, and
was administered 5 times between 1991 and 2007 in NHS II.
Each FFQ contained ∼135 items and each item had 9 frequency
choices, ranging from <1 time/mo to ≥6 times/d. A standard por-
tion size was also provided.
Three diet quality scores were computed, which were based
entirely on food groups with predetermined intake levels for score
assignments (Supplemental Table 1). The FGI score was de-
veloped by the Food and Nutrition Technical Assistance project
(FANTA) and is based on 8 food groups considered to predict
nutrient adequacy in infants and children in 10 developing coun-
tries (17). These food groups are fruits and vegetables, legumes
and nuts, animal flesh (red, processed, poultry, fish), eggs, dairy,
grains and roots, vegetables with >130 RE/100 g, and added fats
and oils. A scoring algorithm was designed for data collected by
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the 24-h recall method, with 1 point assigned to each food group
if it was consumed within the last 24 h and 0 if not. Because each
food group in this score covers a broad range of food, the high diet
diversity in our cohorts would result in many participants achiev-
ing high scores. To adhere to the characteristics of the FGI score
but also adapt the scoring algorithm for use with the FFQ, we as-
signed 1 point for consumption of ≥3 times/wk and 0 points for
less. Points for all food groups were summed to arrive at the total
score. The FGI ranges from 0 to 8 points.
The MDDW was developed by FANTA and the Food and Agri-
culture Organization of the WHO. It is based on 10 food groups
that predicted micronutrient intake adequacy in women of re-
productive age from low-income countries (18). This score has
been proposed for global use to measure diet quality of women
(19). The food groups included are grains and starchy vegeta-
bles, pulses, nuts and seeds, dairy, animal flesh, eggs, dark green
leafy vegetables, vitamin A–rich vegetables and fruits, other veg-
etables, other fruits. The original scoring criteria was 1 point for
each food group when intake was ≥1 serving/d and 0 for less. Ad-
ditionally, 5 total points was used as the minimum cutoff value for
achieving diet diversity. Because of this predetermined cutoff, as
well as the detailed groupings of plant foods which reflect diet
quality more precisely than the FGI, we adhered to the original
scoring criteria using 1 serving/d as cutoff when computing the
MDDW for our cohorts. The MDDW total score ranges from 0
to 10 points.
The PDQS was based on the Prime Screen questionnaire, a
short diet assessment tool developed for clinical use to quickly
assess diet quality (20). Foods were classified as healthy and
unhealthy based on 2 major considerations: 1) data from the
literature on the direction of association with the risk of non-
communicable diseases; and 2) nutrient contribution in the world-
wide setting. The food groups included that were considered
healthy were dark leafy green vegetables, cruciferous vegetables,
carrots, other vegetables, whole citrus fruits, other whole fruits,
legumes, nuts, poultry, fish, eggs, whole grains, and liquid veg-
etable oils. The unhealthy food groups included in the score were
red meat, potatoes, processed meat, whole milk dairy, refined
grains and baked goods, sugar sweetened beverages, fried foods
obtained away from home, and desserts and ice cream. Points
were assigned according to the following criteria: 0–1 serving/wk
(0 point) compared with 2–3 servings/wk (1 point) compared with
≥4 servings/wk (2 points) for the healthy food groups. Scoring
was reversed and points deducted for the unhealthy food groups.
Points for each food group were then summed to give an overall
122 FUNG ET AL.
score. The PDQS has 21 food groups and ranges from 0 to 42
total points.
Assessment of outcomes
IHD was defined as non-fatal myocardial infarction (MI) and
fatal coronary disease in this study. When a participant self-
reported a IHD event in each biennial questionnaire during the
follow-up period, permission from the participants or their next of
kin (for deceased participants) was obtained to allow study physi-
cians (who were unaware of the participant’s dietary intake) to
verify the event by reviewing the medical record. Non-fatal MI
was verified using WHO criteria which includes clinical symp-
toms and changes on electrocardiogram or cardiac enzymes (21).
Our analysis also included “probable” cases, in which the self-
report was affirmed by interview or letter but medical records
were not released (or available).
All deaths, including fatal cardiovascular disease, were identi-
fied by searching state vital records or the National Death Index,
or reported by participants’ next of kin or the postal system. Fa-
tal cardiovascular disease was considered “definite” if confirmed
by review of hospital or autopsy records, or when the participant
had a history of IHD and the death certificate listed IHD as the
cause of death. Fatal cases confirmed by death certificate only
were classified as “presumed” cases.
Assessment of lifestyle characteristics
Participants report lifestyle characteristics in the biennial ques-
tionnaires, which include current smoking status and the number
of cigarettes per day. Women also reported menopausal status and
menopausal hormone use, including the specific type and dura-
tion. We computed updated BMI using weight reported in each
2-y period and height reported at baseline. Average duration of
leisure-time physical activity over the past year was assessed us-
ing 10 questions that included the most common types of leisure
time activities. Family history of MI was assessed in 1976, 1984,
and 1996 in the NHS; in 1986 in the HPFS; and 1989, 1993, 1997,
2001, and 2005 in the NHS II.
Statistical analysis
We calculated each participant’s person-years from the date of
return of the baseline FFQ to the date of diagnosis of IHD, return
of the last questionnaire, death, or the end of follow-up (30 June
2012 for NHS, 31 January 2010 for HPFS, and 30 June 2011 for
NHS II).
We computed cumulative averages of each diet score to reduce
intraperson variation and to better reflect long-term diet qual-
ity (22). However, we stopped updating dietary intake when a
participant reported a diagnosis of hypertension, hyperlipidemia,
angina, or diabetes, as individuals might improve their diet in
response to these diagnoses but diet might have limited impact
on IHD outcome at that stage. We categorized the FGI and the
MDDW scores into 5 categories. The cutoffs were determined to
avoid having a small number of cases in each score category while
allowing for as many categories as possible to detect a change in
risk with a change in score, especially in the upper range of the
score. For the FGI, many individuals in our cohorts achieved high
scores, therefore it was categorized as <5.0, 5.0 to <6.0, 6.0 to
<7.0, 7.0 to <8.0, and 8 points (full score) for NHS and HPFS. In
NHS II, the number of cases were fewer, therefore, scores were
classified into 4 categories: <5.0, 5.0 to <6.0, 6.0 to <7.0, and
≥7.0 points. For the MDDW, all 3 cohorts were categorized into
either 0 to <3.0 points, 3.0 to <4.0 points, 4.0 to <5.0 points, 5.0
to <6.0 points, or ≥6 points (full score was 10 points). The PDQS
has a wide score range, and therefore we ranked individuals into
quintiles.
Spearman correlation coefficients were computed for the 3 diet
quality scores. We used time-dependent Cox proportional haz-
ard models conditioning on age and follow-up cycle to examine
the association between the diet score and IHD, using the low-
est score category as reference. Models were fitted separately for
each cohort. Multivariable models were adjusted for age (contin-
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uous), energy intake (quintiles), family history of MI (yes or no),
physical activity (5 categories), BMI (9 categories), alcohol in-
take (5 categories), smoking (5 categories), and menopausal sta-
tus and postmenopausal hormone use (4 categories). Except for
family history, all of the variables were time-dependent variables
updated every 2 y. To compare the magnitude of the association
between various diet quality indexes and IHD, we first assigned
z scores to each dietary quality score and modeled 1 SD increase
in score for total IHD. We then pooled the β coefficients for each
diet score from all 3 cohorts using the method of DerSimonian
and Laird (23). Finally, we tested for difference in the β coef-
ficients 2 diet quality scores at a time using the Wald test. In
this analysis, the number of individuals with missing values was
generally <5%, except for physical activity where it was ∼12%.
Missing values were assigned to a missing indicator variable.
For the sensitivity analysis, we created an alternative version
of the FGI using 1 serving/d as the cutoff (as originally desig-
nated by FANTA and WHO), as well as an alternative version
of the PDQS also with a 1 serving/d cutoff to mimic the same
scoring algorithm as the alternative FGI and MDDW. To exam-
ine if the association was consistent among different age groups,
we also stratified our analysis into <65.0 y, 65.0 to <75.0 y, and
≥75.0 y for the NHS and the HPFS. Because women in NHS
II were younger, the age groups were stratified into <55.0
and ≥55.0 y. We also examined the association of individual
food groups, adjusting for other food groups and potential con-
founders, to understand if certain food groups may influence the
direction of association of the diet quality scores. Analysis was
conducted using SAS version 9.4 (SAS Institute).
RESULTS
In ≤28 y of follow-up, we ascertained 2908 incidents of IHD
in NHS, 3722 in HPFS, and 531 in NHS II. The Spearman corre-
lations between the diet quality scores were generally the highest
between the PDQS and MDDW (Spearman r = 0.62 in NHS,
0.59 in HPFS, and 0.66 in NHS II, all P < 0.001) and the lowest
between the FGI and the PDQS (Spearman r = 0.49 in NHS, 0.34
in HPFS, and 0.50 in NHS II, all P < 0.001). Men and women
with a higher FGI score tended to have a slightly higher BMI,
whereas those with a higher MDDW score and PDQS tended to
have a somewhat lower BMI (Tables 1–3). On the other hand,
individuals who scored higher in any of the food quality scores
were less likely to be current smokers, had higher levels of phys-
ical activity, and had higher energy intake. Intake of specific food
TABLE 1
Age-standardized baseline characteristics of NHS, HPFS, and NHS II for the bottom, middle, and top categories of the FGI score1

NHS HPFS NHS II

Points 0 to <5.0 6.0 to <7.0 8.0 0 to <5.0 6.0 to <7.0 8.0 0 to < 5.0 6.0 to <7.0 ≥7.0
n 3500 22,377 13,340 2344 13,967 6218 6921 32,005 25,041
BMI, kg/m2 24.5 ± 4.5 25.0 ± 4.8 25.3 ± 4.8 24.7 ± 4.7 24.9 ± 4.9 25.2 ± 5.2 24.1 ± 5.2 24.7 ± 5.3 24.8 ± 5.4
Current smokers, % 33 25 19 9 10 10 16 12 10
Physical activity (METs) 12 ± 17 13 ± 20 16 ± 23 20 ± 28 21 ± 29 23 ± 33 20 ± 29 21 ± 27 23 ± 28
MDDW 2.7 ± 1.1 4.2 ± 1.2 5.5 ± 1.1 3.1 ± 1.3 4.3 ± 1.3 5.5 ± 1.2 2.4 ± 1.3 4.4 ± 1.3 5.1 ± 1.2
PDQS 16.0 ± 4.2 19.3 ± 4.2 24.1 ± 4.0 18.6 ± 5.1 20.2 ± 4.8 23.8 ± 3.8 16.8 ± 4.6 21.1 ± 4.4 23.9 ± 4.2
Energy intake, kcal/d 1170 ± 384 1652 ± 459 2093 ± 512 1407 ± 435 1896 ± 537 2443 ± 618 1233 ± 407 1830 ± 485 2144 ± 518
Fiber, g/d 14.7 ± 5.5 15.6 ± 4.8 18.5 ± 4.2 20.5 ± 9.3 20.5 ± 7.2 22.4 ± 5.4 17.4 ± 6.5 18.4 ± 5.4 20.0 ± 5.1
Alcohol intake, g/d 7.0 ± 12.5 7.0 ± 11.5 6.8 ± 10.7 10.8 ± 16.2 11.4 ± 15.4 11.7 ± 15.0 2.8 ± 5.9 3.1 ± 6.1 3.2 ± 6.1
Fruit, servings/d 1.3 ± 1.2 1.9 ± 1.3 2.9 ± 1.5 1.9 ± 1.6 2.2 ± 1.6 2.9 ± 1.6 1.2 ± 1.1 1.9 ± 1.3 2.5 ± 1.5
Vegetables, servings/d 2.1 ± 1.3 3.3 ± 1.6 5.4 ± 2.1 2.3 ± 1.7 2.8 ± 1.7 4.4 ± 1.9 1.1 ± 0.8 1.7 ± 1.1 2.2 ± 1.3
Legumes, servings/d 0.1 ± 0.1 0.2 ± 0.1 0.3 ± 0.2 0.2 ± 0.2 0.2 ± 0.3 0.4 ± 0.3 0.1 ± 0.2 0.2 ± 0.2 0.4 ± 0.3
Nuts, servings/d 0.1 ± 0.2 0.3 ± 0.4 0.5 ± 0.5 0.7 ± 1.5 1.5 ± 1.8 2.1 ± 1.7 0.1 ± 0.2 0.3 ± 0.3 0.4 ± 0.4
Grains and tubers, servings/d 3.8 ± 1.8 4.9 ± 2.1 5.6 ± 2.2 2.4 ± 1.7 3.3 ± 1.8 4.1 ± 1.9 2.6 ± 1.4 3.9 ± 1.7 4.6 ± 1.8
Eggs, servings/d 0.1 ± 0.2 0.3 ± 0.3 0.5 ± 0.3 0.1 ± 0.2 0.3 ± 0.4 0.6 ± 0.4 0.1 ± 0.1 0.2 ± 0.2 0.3 ± 0.2
Dairy, servings/d 0.4 ± 0.7 1.4 ± 1.0 1.9 ± 1.1 0.6 ± 1.0 1.4 ± 1.1 1.9 ± 1.3 0.7 ± 0.9 1.8 ± 1.2 2.2 ± 1.3
Animal flesh, servings/d 0.9 ± 0.5 1.3 ± 0.6 1.6 ± 0.6 1.2 ± 0.7 1.6 ± 0.7 2.1 ± 0.8 1.0 ± 0.6 1.5 ± 0.7 1.8 ± 0.7
Sweets and desserts, servings/d 0.8 ± 1.0 1.1 ± 1.2 1.3 ± 1.2 1.0 ± 1.2 1.4 ± 1.4 1.7 ± 1.5 0.8 ± 0.9 1.0 ± 1.0 1.1 ± 1.0
Sugar sweetened beverages, servings/d 0.3 ± 0.7 0.3 ± 0.6 0.3 ± 0.5 0.3 ± 0.7 0.4 ± 0.6 0.4 ± 0.5 0.5 ± 1.0 0.5 ± 0.8 0.5 ± 0.8
1 Values are means ± SDs unless otherwise indicated. NHS and HPFS: 5 categories total, categories 1, 3, 5 are shown; NHS II: 4 categories total, categories 1, 3, 4 are shown. FGI, Food Group Index;
FOOD GROUP DIET SCORES AND CORONARY HEART DISEASE

HPFS, Health Professionals’ Follow-up Study; MDDW, Minimal Diet Diversity score for Women; MET, metabolic equivalent task; NHS, Nurses’ Health Study; NHS II, Nurses’ Health Study II; PDQS, Prime
Diet Quality Score.
123

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 124

TABLE 2
Age-standardized baseline characteristics of NHS, HPFS, and NHS II for the bottom, middle, and top categories of the MDDW score1

NHS HPFS NHS II

Points 0 to <3.0 4.0 to <5.0 >6.0 0 to <3.0 4.0 to <5.0 >6.0 0 to <3.0 4.0 to <5.0 >6.0
n 6746 17,628 18,010 3771 11,306 10,298 12,956 22,857 16,576
BMI, kg/m2 24.6 ± 4.6 24.9 ± 4.7 25.2 ± 4.8 24.9 ± 5.1 24.9 ± 5.1 24.9 ± 5.0 24.4 ± 5.4 24.6 ± 5.3 24.8 ± 5.2
Current smokers, % 35 25 19 15 10 8 17 12 9
Physical activity (METs) 10 ± 18 13 ± 19 18 ± 25 16 ± 24 20 ± 27 26 ± 35 16 ± 24 20 ± 26 28 ± 32
FGI 5.1 ± 1.0 6.2 ± 1.0 7.1 ± 0.8 5.3 ± 1.0 6.2 ± 1.0 7.0 ± 0.9 4.9 ± 0.9 5.8 ± 0.9 6.6 ± 0.9
PDQS 15.2 ± 3.8 19.4 ± 3.9 24.1 ± 3.9 16.1 ± 4.3 20.0 ± 4.2 24.4 ± 4.0 15.8 ± 4.1 20.1 ± 4.0 25.4 ± 3.6
Fiber, g/d 13.2 ± 4.1 15.8 ± 4.5 18.6 ± 4.9 16.5 ± 6.0 20.1 ± 6.3 24.1 ± 7.2 15.5 ± 4.8 17.9 ± 5.3 21.7 ± 5.6
Energy intake, kcal/d 1219 ± 386 1652 ± 256 2072 ± 509 1373 ± 404 1874 ± 507 2438 ± 606 1230 ± 379 1760 ± 447 2210 ± 510
Alcohol intake, g/d 6.6 ± 12.0 6.8 ± 6.4 7.1 ± 10.6 11.5 ± 16.3 11.3 ± 15.5 11.5 ± 15.0 2.8 ± 6.1 3.1 ± 6.1 3.5 ± 6.1
Fruit, servings/d 0.9 ± 0.7 1.9 ± 1.2 3.0 ± 1.5 1.1 ± 1.2 2.2 ± 1.4 3.3 ± 1.9 0.8 ± 0.6 1.8 ± 1.1 2.9 ± 1.6
FUNG ET AL.

Vegetables, servings/d 1.7 ± 0.7 3.2 ± 1.3 5.6 ± 2.3 1.4 ± 0.7 2.6 ± 1.2 4.8 ± 2.2 0.7 ± 0.5 1.5 ± 0.8 2.8 ± 1.5
Legumes, servings/d 0.1 ± 0.1 0.2 ± 0.2 0.3 ± 0.2 0.1 ± 0.1 0.2 ± 0.2 0.4 ± 0.4 0.1 ± 0.1 0.2 ± 0.2 0.3 ± 0.4
Nuts, servings/d 0.2 ± 0.2 0.3 ± 0.4 0.5 ± 0.7 1.1 ± 1.5 1.4 ± 1.7 2.1 ± 2.0 0.1 ± 0.2 0.2 ± 0.3 0.4 ± 0.5
Grains and tubers, servings/d 4.1 ± 1.9 4.9 ± 2.1 5.5 ± 2.2 2.3 ± 1.5 3.3 ± 1.7 4.2 ± 2.0 2.6 ± 1.4 3.8 ± 1.6 4.7 ± 1.8
Eggs, servings/d 0.2 ± 0.2 0.3 ± 0.3 0.5 ± 0.4 0.2 ± 0.3 0.3 ± 0.4 0.5 ± 0.6 0.1 ± 0.1 0.2 ± 0.2 0.2 ± 0.3
Dairy, servings/d 0.6 ± 0.6 1.3 ± 1.0 2.1 ± 1.1 0.7 ± 0.7 1.3 ± 1.1 2.0 ± 1.3 0.8 ± 0.8 1.7 ± 1.2 2.3 ± 1.2
Animal flesh, servings/d 0.9 ± 0.4 1.3 ± 0.6 1.6 ± 0.6 1.2 ± 0.6 1.7 ± 0.7 2.0 ± 0.9 1.0 ± 0.5 1.5 ± 0.7 1.8 ± 0.7
Sweets and desserts, servings/d 1.0 ± 1.1 1.1 ± 1.1 1.2 ± 1.2 1.2 ± 1.3 1.5 ± 1.4 1.6 ± 1.5 0.9 ± 1.0 1.0 ± 1.0 1.0 ± 1.0
Sugar sweetened beverages, servings/d 0.4 ± 0.7 0.3 ± 0.6 0.2 ± 0.5 0.4 ± 0.7 0.4 ± 0.6 0.3 ± 0.6 0.5 ± 1.0 0.5 ± 0.9 0.4 ± 0.7
1 Values are means ± SDs unless otherwise indicated. Five categories total, categories 1, 3, 5 are shown. FGI, Food Group Index; HPFS, Health Professionals’ Follow-up Study; MDDW, Minimal Diet

Diversity score for Women; MET, metabolic equivalent task; NHS, Nurses’ Health Study; NHS II, Nurses’ Health Study II; PDQS, Prime Diet Quality Score.

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TABLE 3
Age-standardized baseline characteristics of NHS, HPFS, and NHS II for quintiles of the PDQS1

NHS HPFS NHS II

Q1 Q3 Q5 Q1 Q3 Q5 Q1 Q3 Q5
BMI, kg/m2 25.1 ± 5.1 24.9 ± 4.6 24.9 ± 4.5 25.1 ± 5.2 25.0 ± 5.0 24.5 ± 5.0 25.1 ± 6.0 24.6 ± 5.3 24.2 ± 4.8
Current smokers, % 35 23 16 17 9 5 19 11 8
Physical activity (METs) 10 ± 17 14 ± 18 20 ± 29 15 ± 23 21 ± 29 29 ± 37 14 ± 20 20 ± 25 30 ± 34
FGI 5.6 ± 1.0 6.4 ± 1.1 7.1 ± 0.9 5.8 ± 1.0 6.4 ± 1.1 6.7 ± 1.0 5.2 ± 0.9 5.9 ± 1.0 6.6 ± 0.9
MDDW 3.3 ± 1.2 4.5 ± 1.2 5.6 ± 1.1 3.3 ± 1.2 4.5 ± 1.2 5.6 ± 1.3 2.8 ± 1.2 4.2 ± 1.2 5.5 ± 1.1
PDQS 13.8 ± 2.2 20.5 ± 0.5 27.0 ± 2.0 13.8 ± 2.2 21.0 ± 0.8 28.0 ± 1.9 13.6 ± 2.3 21.0 ± 0.8 27.8 ± 1.8
Fiber, g/d 12.8 ± 3.3 16.2 ± 3.9 20.2 ± 5.1 15.4 ± 4.3 20.5 ± 5.5 27.3 ± 7.5 14.0 ± 3.4 18.2 ± 4.4 23.2 ± 5.9
Energy intake, kcal/d 1657 ± 525 1736 ± 535 1852 ± 526 1878 ± 591 2011 ± 631 2091 ± 618 1638 ± 537 1784 ± 541 1987 ± 527
Alcohol intake, g/d 6.5 ± 12.0 7.0 ± 11.2 6.8 ± 10.4 11.9 ± 17.2 11.6 ± 15.6 10.4 ± 13.7 2.5 ± 6.0 3.2 ± 6.0 3.7 ± 6.4
Fruit, servings/d 1.2 ± 1.0 2.1 ± 1.3 3.1 ± 1.5 1.3 ± 1.1 2.4 ± 1.4 3.6 ± 2.0 0.9 ± 0.8 1.9 ± 1.2 2.9 ± 1.6
Vegetables, servings/d 2.3 ± 1.2 3.6 ± 1.5 5.5 ± 2.4 1.7 ± 0.9 3.0 ± 1.4 5.0 ± 2.3 0.9 ± 0.6 1.6 ± 0.9 2.6 ± 1.4
Legumes, servings/d 0.2 ± 0.1 0.2 ± 0.2 0.3 ± 0.2 0.2 ± 0.2 0.3 ± 0.2 0.4 ± 0.4 0.1 ± 0.1 0.2 ± 0.2 0.4 ± 0.4
Nuts, servings/d 0.2 ± 0.3 0.3 ± 0.4 0.5 ± 0.6 1.3 ± 1.7 1.6 ± 1.8 1.8 ± 1.8 0.2 ± 0.3 0.2 ± 0.3 0.4 ± 0.4
Grains and tubers, servings/d 5.2 ± 2.1 5.1 ± 2.2 4.8 ± 2.1 3.2 ± 1.8 3.5 ± 1.9 3.7 ± 2.0 3.3 ± 1.6 3.8 ± 1.7 4.3 ± 1.8
Eggs, servings/d 0.3 ± 0.3 0.4 ± 0.3 0.4 ± 0.3 0.3 ± 0.4 0.3 ± 0.4 0.3 ± 0.4 0.2 ± 0.2 0.2 ± 0.2 0.2 ± 0.2
Dairy, servings/d 1.0 ± 0.9 1.5 ± 1.1 2.0 ± 1.2 1.2 ± 1.1 1.5 ± 1.2 1.7 ± 1.2 1.2 ± 1.1 1.8 ± 1.2 2.2 ± 1.3
Animal flesh, servings/d 1.3 ± 0.6 1.3 ± 0.6 1.5 ± 0.7 1.8 ± 0.9 1.7 ± 0.8 1.6 ± 0.8 1.5 ± 0.7 1.5 ± 0.7 1.5 ± 0.7
Sweets and desserts, servings/d 1.3 ± 1.2 1.2 ± 1.1 0.9 ± 1.0 1.8 ± 1.6 1.6 ± 1.4 1.0 ± 1.2 1.2 ± 1.1 1.0 ± 1.0 0.8 ± 0.9
Sugar sweetened beverages, servings/d 0.6 ± 0.9 0.3 ± 0.5 0.1 ± 0.3 0.6 ± 0.8 0.3 ± 0.5 0.1 ± 0.3 0.9 ± 1.2 0.4 ± 0.7 0.2 ± 0.4
1 Values are means ± SDs unless otherwise indicated. FGI, Food Group Index; HPFS, Health Professionals’ Follow-up Study; MDDW, Minimal Diet Diversity Score for Women; MET, metabolic task
FOOD GROUP DIET SCORES AND CORONARY HEART DISEASE

equivalent; NHS, Nurses’ Health Study; NHS II: Nurses’ Health Study II; PDQS, Prime Diet Quality Score; Q, quintile.
125

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126 FUNG ET AL.
TABLE 4
RRs (95% CIs) for diet quality scores and total IHD1

Score category

1 2 3 4 5 Point increase
FGI2
NHS
Cases, n 153 636 1163 785 171
Age and energy adjusted 1 0.89 (0.74, 1.06) 0.90 (0.75, 1.08) 0.84 (0.70, 1.02) 1.00 (0.79, 1.26) 0.93 (0.89, 0.98)
Multivariable adjusted3 1 0.94 (0.79, 1.13) 0.97 (0.81, 1.16) 0.90 (0.75, 1.09) 0.94 (0.74, 1.19) 0.96 (0.92, 1.01)
HPFS
Cases, n 208 744 1404 1067 299
Age and energy adjusted 1 0.89 (0.76, 1.04) 0.90 (0.77, 1.05) 0.95 (0.81, 1.12) 1.14 (0.94, 1.38) 1.02 (0.98, 1.06)
Multivariable adjusted3 1 0.91 (0.78, 1.06) 0.91 (0.78, 1.06) 0.93 (0.79, 1.10) 1.04 (0.86, 1.27) 1.01 (0.97, 1.05)
NHS II
Cases, n 53 214 185 79 —

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Age and energy adjusted 1 1.04 (0.76, 1.42) 0.84 (0.60, 1.18) 0.78 (0.52, 1.15) — 0.85 (0.76, 0.96)
Multivariable adjusted3 1 1.06 (0.78, 1.45) 0.91 (0.65, 1.27) 0.83 (0.56, 1.24) — 0.91 (0.81, 1.02)
MDDW4
NHS
Cases, n 252 519 936 821 380
Age and energy adjusted 1 0.88 (0.76, 1.03) 0.89 (0.76, 1.03) 0.78 (0.66, 0.91) 0.73 (0.61, 0.88) 0.90 (0.87, 0.94)
Multivariable adjusted3 1 0.97 (0.83, 1.13) 1.01 (0.87, 1.18) 0.90 (0.76, 1.05) 0.84 (0.70, 1.01) 0.95 (0.91, 0.99)
HPFS
Cases, n 274 679 1070 1022 677
Age and energy adjusted 1 1.04 (0.90, 1.20) 0.93 (0.81, 1.08) 0.92 (0.79, 1.06) 0.87 (0.74, 1.02) 0.94 (0.91, 0.97)
Multivariable adjusted3 1 1.07 (0.93, 1.24) 0.98 (0.85, 1.13) 0.97 (0.83, 1.12) 0.92 (0.78, 1.08) 0.96 (0.93, 0.99)
NHS II
Cases, n 82 115 165 120 49
Age and energy adjusted 1 0.85 (0.63, 1.14) 0.83, 0.61, 1.12) 0.69, 0.49, 0.96) 0.58 (0.38, 0.88) 0.84 (0.77, 0.91)
Multivariable adjusted3 1 0.92 (0.69, 1.24) 1.01 (0.75, 1.37) 0.91 (0.65, 1.27) 0.79 (0.52, 1.20) 0.93 (0.85, 1.01)
PDQS5
NHS
Cases, n 684 599 627 525 473
Age and energy adjusted 1 0.77 (0.69, 0.86) 0.73 (0.65, 0.81) 0.59 (0.53, 0.66) 0.51 (0.45, 0.57) 0.76 (0.73, 0.79)
Multivariable adjusted3 1 0.88 (0.79, 0.98) 0.89 (0.79, 0.99) 0.77 (0.68, 0.87) 0.70 (0.61, 0.79) 0.87 (0.83, 0.91)
HPFS
Cases, n 723 775 795 779 650
Age and energy adjusted 1 0.90 (0.81, 0.99) 0.84 (0.76, 0.93) 0.79 (0.71, 0.87) 0.67 (0.60, 0.75) 0.85 (0.82, 0.88)
Multivariable adjusted3 1 0.96 (0.87, 1.06) 0.93 (0.84, 1.03) 0.91 (0.82, 1.01) 0.79 (0.70, 0.88) 0.90 (0.87, 0.94)
NHS II
Cases, n 142 121 98 99 71
Age and energy adjusted 1 0.79 (0.62, 1.00) 0.61 (0.47, 0.79) 0.57 (0.44, 0.74) 0.39 (0.29, 0.53) 0.70 (0.63, 0.77)
Multivariable adjusted3 1 0.95 (0.74, 1.21) 0.80 (0.61, 1.04) 0.83 (0.63, 1.09) 0.63 (0.46, 0.86) 0.85 (0.76, 0.94)
1 FGI, Food Group Index; HPFS, Health Professionals’ Follow-up Study; IHD, ischemic heart disease; MDDW, Minimal Diet Diversity Score for Women;

NHS, Nurses’ Health Study; NHS II, Nurses’ Health Study II; PDQS: Prime Diet Quality Score; Q, quintile.
2 Score categories for NHS and HPFS: 1, 0 to <5.0; 2, 5.0 to <6.0; 3, 6.0 to <7.0; 4, 7.0 to <8.0; 5, 8.0. Score categories for NHS II: 1, 0 to <5.0; 2, 5.0

to <6.0; 3, 6.0 to <7.0; 4, ≥7.0; 5, none. Point increase: 1.

3 Adjusted for age; energy intake; smoking status; alcohol intake; physical activity; BMI; family history of myocardial infarction; multivitamin use; aspirin

use; baseline history of diabetes, hypertension, or hyperlipidemia; menopausal status, and postmenopausal hormone use (NHS only); and oral contraceptive
use (NHS II only). Data analyzed with Cox proportional hazard models.
4 Score categories: 1, 0 to <3.0; 2, 3.0 to <4.0; 3, 4.0 to <5.0; 4, 5.0 to <6.0; 5, ≥6.0. Point increase: 1.
5 Score categories: quintiles (Q1–Q5).

groups increased in the higher categories of any of the food qual-
ity scores except for the PDQS, in which the increase of animal
flesh intake was not consistently associated with the food quality
score.
In the age- and energy-adjusted model, the FGI was not asso-
ciated with total, nonfatal or fatal IHD in either men or women
(Table 4, Supplemental Tables 2 and 3). After adjusting for po-
tential confounders, the association remained null. In the sen-
sitivity analysis, we created an alternative version of the FGI
in which points were awarded for consumption of 1 time/d for
each food group instead of 3 times/wk. This version of the FGI
was also not associated with total IHD in any of the cohorts
(Supplemental Table 4).
The MDDW showed a modest inverse association with to-
tal IHD and nonfatal IHD in NHS and HPFS (total IHD:
RR for 1-point increase = 0.95 for NHS and 0.96 for HPFS,
 FOOD GROUP DIET SCORES AND CORONARY HEART DISEASE
95% CI: 0.91, 0.99 for NHS, 0.93, 0.99 for HPFS). On the other
hand, we observed a clear inverse association between the PDQS
and total, nonfatal, and fatal IHD in all 3 cohorts. For total IHD,
RRs comparing top to bottom quintiles were 0.70 (95% CI: 0.61,
0.79) for NHS, 0.79 (95% CI: 0.70, 0.88) for HPFS, and 0.63
(95% CI: 0.46, 0.86) for NHS II. RRs for nonfatal and fatal IHD
were similar.
After pooling data from all 3 cohorts, each SD increase in the
PDQS was associated with an RR of 0.89 (95% CI: 0.87, 0.91).
This was significantly different than the pooled RR of 0.93 for
MDDQ (95% CI: 0.90, 0.96) and the RR of 0.98 for the FGI (95%
CI: 0.95, 1.01) (P difference = 0.02 for PDQS compared with
MDDQ, and <0.0001 compared with FGI). The pooled RR for 1
SD increase of MDDQ was also significantly different from that
of the FGI (P difference = 0.02).
127
DISCUSSION
In this analysis, the FGI, which was constructed from 8 broad
food groups, showed no association with IHD in both young
and older men and women. The MDDW, constructed from 10
food groups with more detailed differentiation of plant foods,
was modestly associated with a lower risk of IHD. The PDQS,
composed of 21 food groups that account for both healthy and
unhealthy food consumption, was clearly associated with lower
risk of IHD.
The FGI and MDDW consist of a small number of nonspecific
food groups, and scoring was based on presence or absence of
consumption in the previous 24 h. While the scores achieve sim-
plicity, speed in administration, and broad applicability in differ-
ent countries with these characteristics, it would be more difficult

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When we stratified the analysis by age to explore the hetero-
geneity of these scores by different age groups, we observed sim-
ilar results that showed the FGI was not associated with total IHD
in any age groups (Supplemental Table 5). The RRs for MDDW
were similar across age groups and similar to the main analysis,
but did not reach statistical significance. The PDQS was inversely
associated with total IHD to a similar extent in all age groups. The
test for interaction was not significant in any of the age-stratified
analyses.
When examining individual food groups, animal flesh was as-
sociated with a higher risk of total IHD in men (RR for each
serving: 1.03; 95% CI: 1.00, 1.06) and older women (RR: 1.14;
95% CI: 1.05, 1.22), but the association did not reach statis-
tical significance in younger women (Table 5, Supplemental
Table 6). On the other hand, an inverse association was observed
with nuts in NHS (RR: 0.87; 95% CI: 0.77, 0.97), and leafy veg-
etables in HPFS (RR: 0.88; 95% CI: 0.82, 0.95).
to detect variability in diet quality in countries with more varied
dietary patterns. We are not surprised by their limited associa-
tion with IHD in our cohorts. As shown in our examination of
components of FGI and MDDW, these diet quality scores con-
tain food groups that showed a direct and inverse association
with IHD. Therefore, while easy to administer, they do not ap-
pear to be sufficiently sensitive to quantify diet quality in popula-
tions where overconsumption is a significant concern. The PDQS
maintained a reasonable level of simplicity, exemplified by the
FGI and MDDW, but expanded the number of food groups to 21.
In addition, the food groups included both healthy and unhealthy
components, and the scoring algorithm was designed to encour-
age an overall healthy diet. The PDQS also has greater gradation
of scoring in order to better categorize the healthfulness of the
diet yet keep the administration procedure manageable. Our re-
sults showed that the PDQS is better able to predict IHD risk than
the FGI and MDDW in both young and older men and women.
A number of indexes created specifically to measure diet qual-
ity have long been available, and many were associated with

TABLE 5
Multivariable RR (95% CI) of 1 serving of score components of FGI and MDDW scores for total IHD1

Score components NHS HPFS NHS II

Food groups common to both FGI and MDDW
Grains and tubers 1.00 (0.97, 1.02) 0.98 (0.96, 1.00) 0.92 (0.85, 1.00)
Animal flesh 1.13 (1.05, 1.22) 1.03 (1.00, 1.06) 1.11 (0.94, 1.32)
Dairy 1.01 (0.96, 1.03) 0.99 (0.96, 1.03) 0.97 (0.88, 1.07)
Eggs 1.09 (0.95, 1.27) 1.05 (0.96, 1.14) 0.84 (0.54, 1.31)
High–β carotene fruits and vegetables 0.87 (0.77, 0.98) 0.96 (0.87, 1.06) 1.11 (0.87, 1 42)
Food groups unique to FGI
Legume and nuts 0.94 (0.86, 1.02) 0.98 (0.94, 1.04) 0.87 (0.68, 1.12)
Other fruits and vegetables2 1.00 (0.97, 1.02) 0.99 (0.97, 1.01) 0.95 (0.90, 1.00)
Added fat 1.00 (0.96, 1.03) 1.01 (0.98, 1.05) 1.07 (0.98, 1.16)
Food groups unique to MDDW
Legumes 1.12 (0.90, 1.40) 0.92 (0.82, 1.03) 0.89 (0.55, 1.43)
Nuts 0.87 (0.77, 0.97) 0.99 (0.94, 1.05) 0.81 (0.59, 1.12)
Leafy vegetables 0.92 (0.84, 1.00) 0.88 (0.82, 0.95) 0.91 (0.73, 1.13)
Other vegetables2 1.03 (0.98, 1.08) 1.05 (1.01, 1.10) 0.96 (0.86, 1.08)
Other fruits2 1.02 (0.98, 1.05) 0.99 (0.97, 1.03) 0.94 (0.85, 1.04)
1 Adjusted for age; energy intake; smoking status; alcohol intake; physical activity; BMI; family history of myocardial infarction; multivitamin use; aspirin

use; baseline history of diabetes, hypertension, or hyperlipidemia; menopausal status and postmenopausal hormone use (NHS only); and oral contraceptive use
(NHS II only). Food groups in the same diet quality scores are mutually adjusted for each other. Data analyzed with Cox proportional hazard models. FGI, Food
Group Index; HPFS, Health Professionals’ Follow-up Study; IHD, ischemic heart disease; MDDW, Minimal Diet Diversity score for Women; NHS, Nurses’
Health Study; NHS II, Nurses’ Health Study II.
2 Other than high–β carotene fruits and vegetable.
128 FUNG ET AL.
disease risk in higher-income countries. However, many were
not created with ease of administration or scoring in mind. The
Healthy Nordic Diet score consists of 6 components that reflect
healthy food in a traditional Nordic diet (24). Although the num-
ber of components is manageable and the score is associated with
a lower risk of mortality, assigning points for each food group
depends on population-specific intake level, thus making appli-
cation in different countries complicated. In addition, the food
groups are specific to those consumed in northern Europe only.
The Elderly Dietary Index consists of a slightly larger number of
food groups (10 groups) and uses 4 levels of intake for scoring
(25). This score has been associated with a lower risk of mortal-
ity in elderly British men. While the scoring algorithm allows for
differentiation between low and high intake of each food group,
whole compared with refined grains, and red or processed meats
compared with poultry were not separately assessed. Other diet
quality scores, such as the Healthy Eating Index and the Alternate
Healthy Eating Index, require the assessment of both foods and
nutrients (2, 3). The additional complexity in the scoring proce-
dure thus limits their use in settings where speed and a low tech-
nology burden are essential.
Given the characteristics of current dietary quality scores that
are predictive of chronic diseases, a measurement tool that is sim-
pler and applicable across different countries is needed. Future
studies should investigate if the PDQS and other simple diet qual-
ity scores are associated with a wide range of health outcomes rel-
evant to diverse populations in both high- and low-income coun-
tries. This would then provide an efficient field tool without the
need for elaborate diet assessment methods that require extensive
development or data analysis such as the FFQ and 24-h recall.
A major strength of this analysis is the availability of repeated
measurements of diet. This allowed us to take into account di-
etary changes during the long follow-up period. However, for
individuals who developed intermediate endpoints such as hy-
perlipidemia and hypertension, we stopped updating the dietary
data because they may change their diet upon these diagnoses.
Another strength is the availability of detailed and updated in-
formation on lifestyle and health information, which we used to
finely adjust for potential confounders. Nonetheless, since this
is an observational study, residual confounding cannot be com-
pletely ruled out. In addition, because health and dietary infor-
mation was self-reported, some degree of misreporting cannot be
avoided. However, we have documented reliable reporting from
the validated FFQ compared to multiple-week diet records (16).
For the construction of the PDQS, we assigned equal weight to
each food group, though it is unlikely that each of them make
an equal contribution to the development of IHD. However, our
goal was to evaluate an assessment score that would be applicable
to other noncommunicable diseases as well, for which different
food groups would have different amounts of influence. There-
fore, to maintain simplicity in score construction, we did not at-
tempt to assign different weights to food groups. All 3 cohorts in
this analysis are health professionals, therefore our results need
to be confirmed in other populations, especially those outside the
United States and lower-income countries. In addition, further
examination of the PDQS and other health outcomes is necessary
to evaluate the potential of this diet quality score to be used as an
assessment tool for the UN Sustainable Development Goals.
In conclusion, we found that the PDQS with most detailed
differentiation of healthy and unhealthy foods was associated
with a lower risk of IHD in a high-income country. On the other
hand, crude diet quality scores that include a smaller number of
food groups and do not account for unhealthy foods had limited
(MDDW) or no (FGI) association with IHD.
The authors’ contributions are as follows—TTF: conducted the statistical
analysis and wrote the manuscript, and is fully responsible for the results and
writing of the manuscript; and all authors: contributed to the design of the
statistical analysis, critiqued and revised the manuscript, had full access to
the data, and read and approved the manuscript. None of the authors reported
a conflict of interest related to the study.
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