Nutrition 30 (2014) 613–618

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Nutrition
journal homepage: www.nutritionjrnl.com

Review

Diet quality concept

Ala’a Alkerwi M.D., Ph.D. *
Centre de Recherche Public de la Sant
e, Centre d’Etudes en Sant
e, Grand-Duchy of Luxembourg

a r t i c l e i n f o a b s t r a c t

Article history: The term diet quality has recently gained considerable attention in nutritional research. Despite
Received 29 July 2013 widespread use, it is often poorly defined and remains difficult to measure. Confusion surrounds
Accepted 8 October 2013 the term, as there is no consensus on how to define quality of the diet or to pin down a framework
for producing a standard indicator. The composite and cut-off selection of most diet quality indices
Keywords: depend on investigator choices in line with research objectives. In addition to the frequently used
Diet quality
dietary compliance-based approach, innovative approaches have emerged to construct diet quality
Multidimensionality
indices based on antioxidant and anti-inflammatory profiles of diet. Different viewpoints and
Concept
Review overlapping interests may yield different interpretations. Most of the unresolved issues are related
directly or indirectly to the multidimensional and open-textured nature of the concept.
This review aims to elucidate several debated key points to understand the reasons behind this
confusion and address the complexity of how to define and quantify this concept. A standardized
and well-defined framework of diet quality is of great importance for both consumers and sci-
entists from different disciplines.
Ó 2014 Elsevier Inc. All rights reserved.

Introduction The definition of a concept is the encapsulation of total in-

Since early time, humans have attributed to nutrition a
functional role in health and well-being [1]. During the past two
decades, the term diet quality has emerged in the scientific
literature, most often in nutritional epidemiology, to evaluate the
population’s dietary habits and the efficacy of dietary in-
terventions [2,3]. Researchers have also envisioned diet quality
as a risk assessment tool to predict outcomes such as all-cause
mortality, cardiovascular disease, and risk for cancer [4]. Ever
since, the understanding of the relationships between food,
physiological function, and disease has swiftly progressed.
A plethora of studies have been conducted on methods used to
assess overall diet quality with a growing number of scenarios to
identify healthy dietary patterns [5]. Numerous dietary indices
have been developed, tested and validated to reflect various as-
pects of diet quality [6]. These vary in composition from simple
tools measuring adherence to dietary recommendations, to
complex indices requiring substantial analysis of macronutrient
and micronutrient intakes. Despite their frequent uses, recent
systematic reviews have criticized existing indices as having
several drawbacks and most of them are limited in their predictive
capacity, thus casting doubts on their relevance and validity [7,8].
formation about a subject. Although the concept of diet quality
became popular in the research arena, capturing all the aspects
related to diet quality is challenging. The term remains broadly
used, poorly defined, and is often difficult to measure. Confusion
still surrounds the term, as there is no consensus on how to
define diet quality and to determine a framework for producing a
relevant diet quality indicator. Different viewpoints and even
vested interests may influence its significance and hence yield
different constructions of its composite.
This review aims to elucidate several debated key points to
understand the reasons behind the confusion regarding the
concept of diet quality and addresses the complexity in how to
define and quantify this concept. A standardized and well-
defined outline of diet quality is important for both general
public and different actors interested in the subject, particularly
scientists and practitioners working in the fields of nutrition,
public health, toxicology, sociology, and the food industry.
Debated key points
Heterogeneous terminologies

* Corresponding author: Tel.: þ352 26 970 743; Fax: þ352 26 970 719. Although the term diet quality has existed for a long time in
E-mail address: Alaa.alkerwi@crp-sante.lu human history [9], heterogeneous terminologies have been
0899-9007/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2013.10.001
614 A. Alkerwi / Nutrition 30 (2014) 613–618
applied in nutritional epidemiology and related disciplines
to reflect its significance, such as healthy diet, balanced diet,
nutritious food, optimal nutrition, functional foods, overall health-
promoting diet, nutrient-rich foods, and so on. Across the litera-
ture, diet quality is an umbrella term frequently used to describe
how well an individual’s diet conforms to dietary recommen-
dations. A healthy, balanced, and nutritious diet means it is
adapted to special individual needs to reach optimal health [9],
that is, it supplies optimal levels of food and nutrients to main-
tain the body in a healthy state without excess, which may lead
to increase in body weight or toxicity symptoms from some
nutrients. Likewise, it is widely accepted that a high-quality diet
should be safe; hygienic; able to promote optimal growth,
development, and prevention of diseases, and health hazards. So
far, the diet quality is an open-textured notion where no single
static definition exists.
Although the concept has been useful in framing diet-disease
research, the terminology surrounding the diet quality has been
expanded to the extent that there is considerable confusion over
what exactly constitutes a high-quality diet. This heterogeneity
and absence of a clear outline signify that diet quality is still an
ill-defined concept.
Evolutionary concept
Industrialization, urbanization, scientific, and economic
development have accelerated over the past decades. Improved
standards of living have accompanied increased food availability
and diversity of choices. The challenge is no longer on consu-
ming sufficient calories to avoid malnutrition, but how to eat
adequately for optimal health and disease prevention. This
transition has affected the significance of the diet quality
concept. Beyond the provision of meeting basic nutritional
needs, adequate nutrition is required for normal physical growth,
mental performance, and to maintain better health [10,11].
Following contemporary food-related disease outbreaks, food
toxicology has rapidly evolved to ensure safety of the human
food chain [12]. Its main emphasis is placed on determining
biological and environmental safety of the food, from food
development, growth, and production, through harvesting,
processing, storage, and consumption. Currently, public health
authorities have put in place a series of standards and processes
to ensure that a food product is safe, well made, high in quality,
and consistent in its properties. This new area of research on food
safety has induced an important revolution in diet quality, as
violation of quality assurance measures leads to unsafe food
consumption and consequent foodborne diseases.
Over time, the concept of diet quality has also been influenced
by food preferences according to social and cultural backgrounds
[9]. Presently, eating a good-quality diet represents a sign of
prosperity, well-being, and cultural specificity. The modern
concept has hence become more complex with many de-
terminants that are highly dependent on individual beliefs, ex-
pectations, and needs. In prosperous communities, enjoyment,
taste, appearance, gastronomy, culture, and convenience have
become important diet quality factors [9].
Multiple diet quality indices
The concept of diet quality has elicited considerable interest
in the literature following publication of the first dietary quality
index in 1995 [2]. Subsequently, many indices have been sug-
gested, as summary measures of overall diet quality, to assess
dietary compliance to national recommendations [13,14] or to
a priori determined diets [15]. These aimed mainly to identify
whether different groups of population are consuming “good/-
healthy” or “detrimental/unhealthy” foods [6].
Examining existing dietary indices, methods used to derive
these indexes, their differences, limitations, and validation
studies is not the purpose of the present review, as several pre-
vious systematic reviews [6–8,16] have described these issues in
detail. Not surprisingly, the construct of diet quality scores
frequently depends on attributes selected by the investigators, in
line with research objectives [4]. Composing an index of diet
quality involves many choices comprising number of items
(components) to include, their respective cut-off values to define
optimal diet, and scoring criteria [8]. Overall, three major
methods have been applied to design various dietary indices:
Those based on examination of the intake of nutrients [17], food
groups [18,19], or a combination of both [20,21]. Most of the
initial indices were developed for adult populations, with refer-
ence to the American dietary guidelines [2,20] and the Medi-
terranean diet [15]. Successively, other indices have emerged
with some adaptation to reflect dietary guidelines in Europe [13,
14,22], Canada [23], and Australia [24]. Several dietary scores
have focused on specific groups, such as children, adolescents
[25], and pregnant women [26].
Multiple measurement approaches
Most of the suggested approaches to summarize the diet
quality concept have focused on the nutritional quality of the diet.
Traditional dietary compliance-based approach
Since the beginning of the 21st century, health practitioners,
dietitians, and other scientists have been working to create tools
to measure and compare diet quality across populations. The
major traditional approach to determine diet quality has focused
on dietary compliance. Existing diet quality indices have scored
food patterns in terms of alignment with key dietary recom-
mendations and diversity of healthy choices within core food
groups [16]. Assessment of diet quality increases in complexity
with increasing number of nutrients deemed critical to keep
health and to prevent chronic diseases. Although it is considered
relatively straightforward to assess diet quality in terms of con-
sumption of particular food items, substantial misclassification
can result from using single nutrients or foods as indicators of diet
quality [2]. In summary, developing a single indicator for assess-
ment of overall diet quality remains a complex task [27]. It is still
questionable as to whether or not these dietary scores can predict
health outcomes (mortality or chronic diseases) better than in-
dividual dietary factors (i.e., single nutrient or single food) [8].
Innovative approaches
In addition to dietary adequacy and food variety, new features
of dietary quality have developed, such as nutrient density.
Following the 2005 Dietary Guidelines for Americans [28], the
term energy-dense became commonly used to characterize
certain foods as healthy nutritious (i.e., have a high level of nu-
trients compared with the number of calories they contain).
These energy-dense foods are opposed to unhealthy (nutrient-
poor/empty calorie) foods that promote fat storage and weight
gain [29]. Following this direction, the Nutrient Rich Foods
(NRF) Index has been tested and validated against the quality of
the total diet [30]. This energy-density approach is based on
computing the nutrients-to-calorie ratio. It serves as a good
tool for nutritional education and dietary guidance for weight
control [29].
 A. Alkerwi / Nutrition 30 (2014) 613–618
In parallel, the concept of total antioxidant capacity (TAC) has
been introduced, as a proxy measure to describe food quality
[31]. TAC has been used to describe the ability of all the antiox-
idants present in different foods to clean harmful free radicals in
the plasma and body fluids. The roles of new antioxidants
(mainly polyphenols, such as quercetin, luteolin, kaempferol,
anthocyanins, tea catechins, and tomato lycopene) have been
recognized in decreasing risk for disease and maintenance of a
healthy, adequate physiological status [32]. The dietary TAC in-
dicator has been suggested as a novel tool to measure antioxi-
dant intake and as a marker of diet quality. It aims to investigate
potentially healthful effects of dietary antioxidants present in
mixed foods.
Recently, a new approach, based on the inflammatory po-
tential of the diet, has been suggested [33]. The dietary inflam-
matory index (DII) is based on systematic review of the literature
on the effect of diet on inflammation [33]. The DII does not refer
to dietary guidelines or nutritional recommendations of intake,
but incorporates micronutrients and macronutrients, in addition
to commonly consumed components of the diet, such as flavo-
noids, spices, and tea. The rationale behind this method is that an
anti-inflammatory diet may protect individuals from an inflam-
matory response and thus indirectly against the development of
cancer, cardiovascular disease, and other inflammatory-related
conditions [33].
In all, the multiplicity of scores and the lack of consistency in
the criteria used to assign a diet quality index point out the
ambiguity and the absence of a universally accepted definition.
This is translated by the diversity of approaches, with their
respective advantages and drawbacks.
Multiple applications
Existing diet quality indicators vary in their structure and
emphasis, according to researchers’ purposes. The following
applications are among the most cited in the literature:
Indicator for health assessment
In the absence of a comprehensive, regular, nationwide di-
etary monitoring system, a diet quality index could be a useful
summary nutritional indicator for rapid screening. Studying di-
etary quality in relation to adherence to dietary guidelines pro-
vides a practical way to evaluate population health status [34],
thereby contributing to effective and targeted strategies of pre-
vention [23]. Furthermore, when repeated over time, these di-
etary scores can track changes in eating habits and compare
overall diet quality across different groups and populations,
which may provide decision makers and health professionals
valuable insight for planning nutrition interventions [21,35,36].
Marker for risk assessment
The concept of diet quality has been used to examine the
global composition of food and nutrient intake with respect to
several diseases [37]. It has been suggested that diet quality
indices offer a comprehensive approach for chronic disease risk
assessment compared with the “reductionist,” single nutrient-
based approach [17]. In this perspective, several dietary quality
indices have been used to investigate the prediction of cardio-
vascular risk factors [38], short-term chronic disease mortality,
[39], and cancer mortality [40].
Tool for health education
An index to assess diet quality can be used by dietitians and
health care professionals to provide nutrition education and
615
counseling to people of different ages and from different back-
grounds. For example, the NRF approach has been suggested as a
food guidance system, to help the consumer make decisions
about food choices. It provides a useful tool for education and
guidance to select nutritious meals and more healthful diets [41].
Multidimensional concept
The multidimensional nature of the concept has emerged
since the early work on the development of dietary indexes [2].
In addition to nutrient adequacy, attempts have been made to
assess food variety (synonym of diversity) as a specific aspect of
diet quality. Several dietary diversity scores have been sugges-
ted [42–44], as simplified indicators to reflect dietary quality
particularly in developing countries [45,46]. Dietary diversity
reflects the desirability of consuming a variety of foods across
and within food groups over a given reference period [20].
Consuming a diverse range of foods can enhance vitamin and
mineral supplies, and expose the individual to a wide range of
nutritive food components to meet energy and nutritional re-
quirements. However, the use of dietary diversity as the sole
proxy indicator of dietary quality is limited, if not, inappropriate,
as it is often strongly correlated with higher energy intake [43],
as well as overweight and obesity [47].
Moderation criterion reflects the principle of limiting selected
foods that contribute to excess risk for disease [20]. It can be
referred to as controlling or regulation of food intake. Most
guidelines recommend that, a healthy, high-quality diet should
contain a limited amount of saturated fat, sodium, and refined
sugar (but many servings of fruits, vegetables, and whole-grain
products) [45].
Consistent findings in the literature emphasize the impor-
tance of balance among energy-yielding macronutrients in terms
of contribution to total energy intake [48]. The overall balance of
diet ensures that each element of the diet is proportionally in-
tegrated. It has been examined in terms of the macronutrient
ratio (i.e., sources of energy derived from carbohydrates, protein,
and fat) and fatty acid composition [48].
As mentioned above, nutrient density has recently been
introduced as relevant criterion of diet quality, by ranking foods
according to their nutritional composition [30]. Although there is
no commonly agreed on unit to measure nutrient density [41], it
is generally defined as a ratio of nutrient content to the total en-
ergy content. American dietary guidelines recommend selecting
nutrient-rich foods to meet nutrient requirements without
exceeding daily energy needs. Once more, nutrient density re-
flects only part of the complexity of the diet quality concept.
In this context, several diet quality indices have been revised
to incorporate additional parameters including food variety
(both across and within food groups), nutrient adequacy (when
an individual attains the country-specific recommended intake
of dietary components based on energy requirements), moder-
ation (restriction of food and nutrient intake to prevent harmful
effects on health), and overall balance (the proportionality in
energy sources and fatty acid composition) [20,48]. These criteria
are particularly related to the core nutritional value of the diet,
which have mostly been studied and quantified by scientists
interested in nutritional epidemiology.
A field of overlapping interest
Apart from dietitians, the concept of diet quality is relevant
to consumers, public health decision makers, sociologists,
economists, and food industry producers (Fig. 1). Based on a
616 A. Alkerwi / Nutrition 30 (2014) 613–618
Fig. 1. Diet quality: A field of overlapping interest.
holistic approach, dietary quality may be viewed differently; for
example, as a way to measure that food is a social phenomenon,
and the diet should be safe, hygienic, organoleptic, and nutritive.
From a public health standpoint, these overlapping interests may
provide an opportunity for multiple disciplines to interact more
efficiently with one another to evaluate, maintain, and improve
the quality of diet. On the other hand, sharing the interest may
turn the “diet quality” concept into an “omnibus term” that
serves every use and user.
Diet quality versus functional food
Following the progress of scientific knowledge and long-dated
health messages, food manufacturers have pursued the satisfac-
tion of consumer appetite and requirements by developing and
marketing products now referred to as nutraceuticals or functional
foods. Nutraceuticals almost always refer to products isolated or
purified from foods that are generally consumed in medicinal
forms, as pills, capsules, or any form of dietary supplements. A
functional food is, or appears similar to, a conventional food, and is
consumed as part of a usual diet. Functional foods have physio-
logical benefits and/or to reduce the risk for chronic disease
beyond basic nutritional functions (i.e., they contain bioactive
compounds) [49]. These foods comprise raw food (green apple,
nuts) or processed foods with additional healthy ingredients.
Some examples of functional foods include iodized salt, vitamin-
fortified milk, orange juice enriched with calcium, and yogurt
with reduced fat. Although the promotion of these foods may
usually be attract consumers interested in healthy eating, adding
vitamins and minerals to processed foods has long been recog-
nized as vital to compensate for nutrient deficiencies. Against this
background, the production and consumption of functional foods
should have repercussions for the significance, definition, and
composite of scores to measure diet quality.
Toward a new global and standard diet quality definition
In light of the points discussed here, it is challenging to
outline the diet quality concept and to delimit its application. To
date, the nutritional value of diet has almost been extensively
measured in a quantitative manner. In order to capture the
multidimensional nature of diet quality, the concept should
encapsulate, among others, further distinct characteristics,
including the following:
 Sensory organoleptic quality: Assessing the subjective and
cognitive perception of consumed foods could provide use-
ful information to evaluate the diet quality. Appearance and
taste, important quality factors [9], are research issues that
deserve greater attention in the future.
 Food safety: In order to be healthy, food must be both
nutritious and safe to consume. Food safety describes
handling, preparation, and food storage practices to prevent
foodborne diseases and to control harmful hazards. Thereby,
chemical and microbiologic food security is undoubtedly a
fundamental feature to ensure diet quality. For example, the
type of food (snacking or home-made), traditional and
modern food cooking and processing techniques such as
milling, toasting, fermentation, and others, may influence
diet quality by modifying or interfering with digestive en-
zymes or vitamin activities [50]. Toxicologic aspects of foods
therefore merit deep consideration. Additionally, natural
food components, food additives, and food contaminants
(mycotoxins and pesticides) are important items related to
food toxicology that need further research in the context of
diet quality [51].
 The social dimension of food: The pattern of preparing,
presenting, and consuming foods, the habits of eating alone
or in a group, religious beliefs surrounding food selection,
and specific eating habits may reflect individuals belonging
to specific cultural groups. Future food studies need to cover
the complexity behind this sociocultural dimension of diet
quality.
Figure 2 illustrates that diet quality is a multidimensional
concept spurring for a new global definition. The combination of
these features to construct a new model of “global diet quality
index” might help to capture the multifaceted nature of the
concept, and bridge the gap between the different disciplines
sharing the same interest.
Nevertheless, one should be aware that the expansion of the
term to include other fields with vested interests may leave plenty
of room for subjective interpretation and show the complexity of
the concept. Thus, the new model requires careful specification to
avoid further confusion, and interpretation in different ways.
Recommendations for future research
The difficulties inherent in measuring this broadly based,
multidimensional concept explain the multiplicity of existing
scores and their respective approaches and applications. The
following recommendations would be suggested for the future
research:
1. Diet quality needs to be grasped conceptually and clearly
defined, before it can be measured.
2. An integrated approach that combines all the different
characteristics of diet quality is needed to successfully
measure the concept of overall diet quality.
3. Scientists from different disciplines need to work together to
develop a global standardized diet quality definition that
encompasses new elements beside the core structural fea-
tures related to the nutritional value of the diet.
 A. Alkerwi / Nutrition 30 (2014) 613–618
Fig. 2. Diet quality: A multidimensional concept spurring for a new global definition.“Regular foods” mean conventional, ordinary foods, whereas “functional foods” can be
defined as foods that provide a health benefit beyond basic nutrition. A functional food can contain an added ingredient that makes the traditional food functional (e.g.,
probiotic bacteria added to traditional yogurt).
4. Apart from nutritional characteristics, scores to cover other
facets of diet quality (which have currently no quantifiable
thresholds or criteria) still require further research, devel-
opment, and standardization to be used at the global level.
5. Information needs to be collected regarding the intake of
functional foods, dietary supplements, biological products,
cooking and processing techniques, self-perceived taste/
appearance, social dimension, and so on, in population-
based nutritional surveys.
This review is one step toward providing a concise basis for
framing and motivating both the discussion and future work in
this area. Practically, there are two possible options: 1) formulate
a dimension-specific definition; or 2) create a standard com-
prehensive definition, encompassing the different facets of the
concept, based on quantitative measurements of respective
characteristics. In any case, proposing a singular definition for
multidisciplines or a multitude of discipline-specific definitions
of diet quality would be a step toward providing a consistent
reference point for overall diet quality measurement.
Conclusion
The diet quality concept is currently imprecisely defined,
there is a lack of consensus regarding the construct of existing
diet quality indicators, and there is uncertainty regarding their
relevance as predictors of disease risk. Missing from current in-
dicators is important information surrounding eating patterns,
food safety, cultural, and organoleptic properties.
This review presents a simple review of diet quality concept.
Careful analysis is needed to determine the best approach to
617
define the term. Several problems are related to the concept of
diet quality:
1. If any, the definitions are often vague and imprecise.
2. There are too many assorted indicators in the literature.
3. Most indicators were designed for specific purposes.
4. The concept has evolved over time.
5. The term has been expanded to encompass a range of other
disciplines.
Most of these unresolved issues in the construct of existing
diet quality indices are related directly or indirectly to the
multidimensional nature of the concept. Therefore, it is of utmost
importance to reevaluate the concept and to establish valid and
reliable criteria for how to measure the diet quality in the light of
its multidimensional character. Collaboration among the different
disciplines interested in nutritional evaluation is needed to
develop an integrated standard definition of diet quality.
Acknowledgments
The author acknowledges Georgina Crichton for her valuable
comments on this review. The author has no competing interest.
The present review was supported by a research grant from
the National Fund of Research (Fond National de Recherche;
project DIQUA-LUX, 5870404).
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