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Relationship between dietary inflammatory index and chronic diseases in older U.S. Adults: NHANES 1999–2018

BMC Public Health volume 25, Article number: 1498 (2025) Cite this article

Abstract

Background

Chronic diseases pose a significant public health challenge, especially among the aging population. Understanding the potential impact of an inflammatory diet on the prevalence of chronic diseases is crucial for effective health interventions.

Objective

This study assesses the relationship between the Dietary Inflammatory Index (DII) and chronic diseases in older adults.

Methods

Data from the National Health and Nutrition Examination Surveys (NHANES) were utilized, with the DII calculated from 28 food parameters obtained through 24-hour dietary recalls and food records. Five major chronic diseases, including cardiovascular disease, hypertension, diabetes, COPD, and cancer, were used in the analysis. Logistic multivariable regression was used to determine odds ratios for chronic diseases across DII quartiles and with one unit increment in DII.

Results

16,512 adults aged over 60 years were included in the study, with DII scores ranging from − 5.28 to 5.48. In the fourth DII quartile, individuals with one or more chronic diseases were more prevalent than those without. Compared to the first quartile, individuals in the fourth quartile had 28% higher odds of having CVD, 17% higher odds of having diabetes, and 19% higher odds of having hypertension, after adjusting for age, sex, smoking status, drinking status, BMI, ethnicity, poverty, marital status, education, annual family income, and citizenship. Similarly, one unit increase in DII was significantly associated with higher odds of CVD (OR [95%CI] = 1.05[1.02,1.09]) and hypertension (OR [95%CI] = 1.03 [1.00,1.06]). In Model 2, one unit increase in DII was positively associated with the number of chronic diseases (β[95%CI], 0.02[0.01, 0.03], p = 0.003).

Conclusion

Higher DII scores were associated with increased odds of cardiovascular disease, diabetes, and hypertension in older adults. Following an anti-inflammatory diet may be beneficial for preventing and treating chronic diseases in an older population.

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Introduction

Chronic diseases, such as heart disease, stroke, cancer, chronic lung disease, and diabetes, are responsible for 41 million deaths annually. Cardiovascular diseases are the leading cause, followed by cancer, chronic respiratory diseases, and diabetes [1]. Although people of all age groups, regions, and countries are affected by chronic diseases, these conditions are often associated with older age groups [2]. The prevalence of multimorbidity, or multiple chronic conditions, is increasing, particularly among older adults [3,4,5]. The reported prevalence of multimorbidity in older persons ranges from 55–98%6. Multimorbid individuals have a shorter lifespan, are more likely to be hospitalized, and report higher rates of functional decline, disability, and poor quality of life [6]. A better understanding of the association between modifiable risk factors, such as dietary habits, and chronic diseases is imperative in addressing the growing concern surrounding chronic diseases among older adults.

The Dietary Inflammatory Index (DII) is a literature-derived scoring algorithm developed by Shivappa et al. [7] that measures individuals’ diets’ inflammatory potential. It enables the quantification of the pro- or anti-inflammatory impact of specific foods, with a higher DII indicating a more pro-inflammatory diet and a lower DII suggesting a more anti-inflammatory diet. Numerous studies have already utilized the DII to investigate the role of diet in the incidence of various diseases [8].

Chronic low-grade inflammation, marked by consistently elevated levels of circulating pro-inflammatory cytokines throughout one’s life, has been linked to the onset of both age [9] and diet-related chronic diseases [10]. Inflammation plays a crucial role in chronic diseases, and ongoing research is exploring the relationship between diet and chronic diseases [8, 11]. Despite recent NHANES studies revealing positive correlations between the highest DII quantile and various diseases, including cardiovascular disease [12], COPD [13, 14], hypertension [15], and prediabetes [12], an understanding of these associations specifically among older adults remains unclear. The increasing prevalence of multimorbidity among older persons highlights the importance of elucidating the role of dietary measures, such as the DII, in the development and management of chronic diseases in this population. Therefore, by utilizing a nationally representative sample of U.S. adults aged over 60 years, our study aims to address this gap and provide valuable insights into the impact of DII on chronic diseases, including cardiovascular diseases, hypertension, diabetes, COPD, and cancers in this vulnerable demographic.

Methods and materials

Study population

The NHANES (National Health and Nutrition Examination Surveys) is a nationally representative, continuous cross-sectional study designed to assess the health and nutritional status of adults and children in the United States. This survey contains information on demographic, socioeconomic, dietary, and health-related factors acquired through interviews, medical, dental, and physiological measurements, and laboratory tests administered and obtained by the examiners. Detailed information is available at NHANES official website [16]. Our study was based on data from participants aged over 60 years who participated in the 1999 through 2018 cycles of the NHANES. Participants were excluded if they were missing information needed to identify chronic diseases; and further excluded if they were missing the parameters needed to calculate the dietary inflammatory index (DII) (Fig. 1).

The National Center for Health Statistics (NCHS) Research Ethics Review Board approved the NHANES protocol, and written informed consent was obtained before data collection.

Fig. 1
figure 1

Flow chart of participant selection

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The Dietary Inflammatory Index (DII)

Dietary data from day one collected through 24-hour dietary recall interviews were used to calculate DII. The development and validation of the DII scoring algorithm have previously been reported [7, 17]. Shivappa et al. [7] also provided literature-derived and population-based inflammatory effect scores of food parameters, which were used for DII score calculation. To briefly describe the calculation, The Z-score is created by subtracting the global average daily intake [7] from the reported mean amount of a certain food parameter and dividing it by the standard deviation. This is then converted into a percentile score. To achieve a symmetrical distribution with values centered on 0 (null) and bounded between − 1 (maximally anti-inflammatory) and + 1 (maximally pro-inflammatory), each percentile score is doubled, and then ‘1’ is subtracted. the centered percentile value is then multiplied by the respective overall inflammation effect score to obtain the “DII score”. By summing each DII score, we can get an individual “overall DII score” [7]. The overall food parameter-specific inflammatory effect score is presented in Supplementary Table 1. DII scores range from negative to positive, with lower scores indicating greater anti-inflammatory effects and higher scores implying stronger pro-inflammatory effects of the diet [7]. A total of 28 food parameters were available in NHANES and were used for the calculation of DII, including energy, carbohydrates, proteins, fats, fiber, cholesterol, saturated fatty acid, mono-unsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), n-3 fatty acid, n-6 fatty acid, niacin, vitamins (A, B1, B2, B6, B12, C, D and E), iron, magnesium, zinc, selenium, folic acid, beta carotene, caffeine, and alcohol.

Ascertainment of chronic diseases

We included five chronic diseases: cardiovascular disease, hypertension, diabetes, COPD, and cancer. COPD was defined based on the self-reported history, pre-bronchodilator FEV1/FVC ratio < 0.7, and post-bronchodilator FEV1/FVC ratio > 0.7, or use of related drugs. Cardiovascular disease (CVD) was defined as having a self-reported history of coronary heart disease, congestive heart failure, heart attack, stroke, and angina. Participants were considered diabetic if they had doctor-diagnosed diabetes, Glycohemoglobin HbA1c (%) ≥ 6.5, fasting glucose (mmol/l) ≥ 7.0, random blood glucose (mmol/l) ≥ 11.1, two-hour OGTT blood glucose (mmol/l) ≥ 11.1, use of anti-diabetic medicine or insulin. Hypertension was defined based on self-report, blood pressure > 140/90mmHg, or use of anti-hypertensives. Cancer was defined based on participants’ self-report; specific questions were “Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?” and “What kind of cancer was it?”. Types of cancers participants could report on can be found on the NHANES website [18].

Data on age, sex, race/ethnicity, citizenship, educational level, marital status, annual household income, Poverty income ratio (PIR), and BMI were collected using questionnaires.

Statistical analysis

All participants were categorized into quantiles according to DII (Q1: DII < 0.395, Q2: 0.395 ≤ DII < 1.908, Q3: 1.908 ≤ DII < 3.042, Q4: DII ≥ 3.042). Continuous variables and categorical variables in each DII quartile are presented as mean ± SD and count(percentage), respectively. The characteristics of participants in the DII quartiles were compared by Chi-squared test (categorical variable) and Kruskal–Wallis test (continuous variable). Participants were classified into four quartiles based on the DII, and logistic regression was used to estimate the Odds Ratio (OR) and 95% confidence interval (95% CI) for chronic diseases in DII quartiles. We also analyzed the association between one-unit increase in DII and chronic diseases. Furthermore, linear regression was employed to estimate the association between the DII score and the number of chronic diseases. Three models were created, including crude model (without adjustment), Model 1 (adjusted for age and sex), and Model 2 (further adjusted for smoking status, drinking status, BMI, ethnicity, poverty, marital status, education, annual family income, and citizenship).

All analyses were performed using NHANES guidelines which include using sampling weights and accounting for complex multistage cluster survey design (by using “survey” R-package). All analyses were performed with statistical computing software R version 4.3.1 and P < 0.05 (2-tailed) was considered statistically significant.

Results

In the final sample, 1,294 individuals (7.83%) were diagnosed with COPD, 4,146 (25.14%) with CVD, 5,185 (31.39%) with diabetes, 11,734 (71.14%) with hypertension, and 3,309 (20.03%) with cancer. The prevalence of chronic diseases by DII quartile is illustrated in Fig. 2. Those in the fourth quartile showed the highest prevalence of chronic diseases, excluding cancer. Surprisingly, the 1st DII quartile had a higher prevalence of cancer than the other quartiles.

Fig. 2
figure 2

Proportion of chronic diseases in each dietary inflammatory index quartile

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The DII scores ranged from − 5.28 to 5.48. Participants’ characteristics across quartiles of DII are shown in Table 1. Compared to the first quartile, the fourth quartile showed a higher mean age, lower mean poverty income ratio, increased prevalence of chronic diseases (including cardiovascular disease, diabetes, hypertension, and cancer), higher BMI, larger waist circumference, higher mean white blood cell count (WBC), neutrophils, and C-reactive protein (CRP). Demographically, the fourth quartile had a higher percentage of females (64.94% vs. males) and a lower proportion of non-Hispanic whites, married individuals, and those with higher education levels than the first quartile. Similar trends were observed for those with one or more chronic diseases compared to those without (Table 2). With increasing DII score, the number of chronic diseases also increased (Table 3). In the fourth DII quartile, individuals with five chronic diseases were more prevalent than those without (29.60% vs. 17.82%).

Table 1 Characteristics of participants stratified by dietary inflammatory index quartile. NHANES 1999–2018
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Table 2 Characteristics of participants stratified by chronic disease status. NHANES 1999–2018
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Table 3 Number of chronic diseases present in participants stratified by DII quartiles. NHANES 1999–2018
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Table 4 presents odds ratios (OR) with 95% confidence intervals (CI) for different chronic diseases across quartiles (Q1-Q4) of the Dietary Inflammatory Index (DII). A consistent pattern was observed where the odds ratios increased across DII quartiles for COPD, cardiovascular disease, diabetes, and hypertension. Compared to those in the first quartile, the fourth quartile had significantly higher odds of having one or more chronic diseases in crude model and model 1 but not model 2 (Model 2, Q4 vs. Q1, OR [95%CI], 1.19[0.97,1.46], p = 0.10). In Model 2, For those in the fourth quartile, the odds were significantly increased by 28%, 17%, and 19% for CVD, diabetes, and hypertension, respectively. Although the odds of COPD were higher in Model 1, the association did not remain stable in Model 2. Interestingly, those in the fourth quartile had decreased odds of cancer in model 1. However, the significance was diminished in Model 2 (OR [95%CI], 0.92[0.78,1.07], p = 0.27).

Table 4 Weighted logistic regression analysis on the association between DII (quartile) and chronic diseases. NHANES 1999–2018
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One unit increase in DII was associated with higher odds of all chronic diseases before adjustment except cancer, where DII increase associated with lower odds (Table 5). After adjustment for age, sex, smoking status, drinking status, BMI, ethnicity, poverty, marital status, education, annual family income, and citizenship, one unit increase in DII was significantly associated with increased odds of CVD (OR [95%CI], 1.05[1.02,1.09]) and hypertension (OR [95%CI], 1.03 [1.00,1.06]). Moreover, an increase in DII score was initially associated with higher odds of COPD, and diabetes, and lower odds of cancer, but the significance was lost after adjusting for confounders. Moreover, one unit increase in DII was positively associated with the number of chronic diseases (Model 2, β[95%CI], 0.02[0.01, 0.03], p = 0.003).

Table 5 Weighted logistic regression analysis on the association between DII (one unit increase) and chronic diseases. NHANES 1999–2018
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Discussion

Using a nationally representative cohort of U.S. adults aged over 60 years, our objective was to assess the association between a pro-inflammatory diet measured by the Dietary Inflammatory Index (DII) and chronic diseases. We found that the highest DII quartile was associated with higher odds of cardiovascular disease (CVD), diabetes, and hypertension, even after adjusting for potential confounding factors. Additionally, each one-unit increase in DII score was linked to significantly higher odds of CVD and hypertension. We initially observed increased odds of chronic obstructive pulmonary disease (COPD) and decreased odds of cancer, though these associations did not persist after adjusting for confounders.

Various studies show a consistent positive association between the Dietary Inflammatory Index (DII) and diabetes and pre-diabetes [19,20,21,22]. However, conflicting evidence includes studies reporting inverse [23, 24] or no associations [25,26,27,28]. In a study involving 1174 Mexicans, the highest DII quantile was associated with increased T2DM odds, especially in those aged 55 and older [19]. In a Longitudinal E3N study on women, the anti-inflammatory potential of diet reduced T2DM risk over 20 years [21]. Despite evidence, association between DII and diabetes in older population remain unclear. Our study indicated that a higher DII is associated with an elevated risk of diabetes in older U.S. adults. It is worth mentioning that DII has been linked to diabetes markers like fasting plasma glucose (FPG) [22], fasting serum insulin (FSI) [29], glycated hemoglobin (HbA1c) [30], and homeostatic model assessment of insulin resistance (HOMA-IR) [29, 31, 32]. Even though the majority of findings point towards a positive DII-diabetes association, conflicting evidence exists, warranting further clarification.

Consistent with most of the existing literature, our study found that cardiovascular diseases (including coronary heart disease, congestive heart failure, heart attack, stroke, and angina) were positively associated with a pro-inflammatory diet among older U.S. adults. In recent NHANES studies using similar survey cycles as our study, the DII was positively associated with atherosclerosis cardiovascular disease (ASCVD) [12] and heart failure [33]. However, the authors did not focus on the life stage. In an umbrella review of meta-analyses of observational studies by Marx et al. [34], a strong association (Class 1) was found between high DII scores and myocardial infarction. Multiple longitudinal studies from different countries, including the U.S [35,36,37]., Australia [38, 39], Europe [40, 41], Japan [42], and Korea [43] have reported increased incidences of cardiovascular events and the risk of CVD mortality. Nonetheless, these associations are unclear among the older population. Our findings indicate that an anti-inflammatory diet may be used as a therapeutic intervention for cardiovascular disease.

Our study showed a significant positive correlation between the Dietary Inflammatory Index (DII) and hypertension across all quartiles, with the highest DII quartile showing increased likelihood compared to the lowest quartile. Previous studies have mostly investigated the association between DII and hypertension, with hypertension included as a cardiovascular or cardiometabolic risk factor [8]. However, our findings are consistent with these studies. The most recent NHANES study by Zhou et al. found that an increase in DII was associated with the risk of hypertension after adjusting for confounding factors (OR = 1.26)15. The PONS study discovered that proinflammatory DII was linked to higher DBP [26]. while other studies found a positive association between SBP and E-DII [44, 45]. The E3N cohort study also reported a weak association between DII and hypertension, with stronger associations in healthy and lean women [46]. This systemic review and meta-analysis, utilizing nine studies, confirmed a positive association between DII and the incidence of hypertension [47]. Our study findings and existing evidence emphasize the importance of a healthy diet in reducing the risk of hypertension in later life.

Research suggests that a pro-inflammatory diet may reduce the risk of COPD, particularly in smokers [14, 48, 49]. In prior related literature, Individuals with COPD had higher DII scores than those without [50], and an increase in DII score was associated with an increased risk of early COPD [13] by 90.3% and airway obstruction [51] by 17%. In addition, lung function indices (FEV1 and FVC) were inversely associated with DII score [13, 52] and better diet (higher Alternative Healthy Eating Index) [48, 49]. Our study found that the highest quartile had 12% higher odds of developing COPD in older adults, but this wasn’t statistically significant after adjusting for smoking and other factors. The loss of significance may be due to confounding factors like smoking, along with the fewer observations.

Various studies have explored the association between the Dietary Inflammatory Index (DII) and gastrointestinal tract cancers, including a meta-analysis reporting association with colorectal cancer [53]. Studies on DII and other cancers, such as esophageal [54], lung [55,56,57], and prostate cancer [58], consistently show an increased risk for those in higher DII quartiles. In contrast, our study indicates that the highest DII quartile and one unit increase in DII score were associated with lower odds of cancer. However, these findings were not statistically significant possibly due to confounding. We hypothesize that the contradictory results were due to the fewer cancer patients. A larger sample size may provide more reliable insights.

Exact mechanisms involving the inflammatory potential of diet and chronic diseases remain to be elucidated. However, some theories exist that may explain the observed positive association between DII and chronic diseases. Dietary elements like trans- and saturated fatty acids can potentially increase inflammation by affecting toll-like receptor 4 expression and influencing the composition of the gut microbiome [59, 60]. Consumption of diets with pro-inflammatory properties triggers the activation of inflammatory pathways and the secretion of cytokines such as IL-1 and TNF-α. This process causes the migration of white blood cells into vascular tissues [61]. Additionally, inflammatory indicators upregulate the expression of adhesion molecules like selectins and cadherins [61, 62]. This may be worsened by obesity and contribute to the development of T2DM and CVD [8, 63,64,65].

Globally, chronic diseases among the older population are a significant public health concern, especially in developing and low-income countries. Modifiable risk factors can play an essential role in addressing this issue. A pro-inflammatory diet has a negative impact on the occurrence of chronic diseases, and promoting a healthy and anti-inflammatory diet may prove beneficial. Public awareness of the effects of specific dietary items on health is also necessary.

Our study has several notable strengths. Initially, it represents, to the best of our knowledge, the first study of the correlation between DII and chronic diseases among older adults in the United States. Obtaining a large sample size and employing complex sampling techniques from the general population, allows us to extend our findings to the broader U.S. population. Our findings not only provide valuable insights for future investigations but also serve as a basis for making dietary recommendations tailored to the ageing demographic. However, there are a few limitations to keep in mind while interpreting our findings. Firstly, due to the study’s cross-sectional nature, we cannot determine a causal relationship. Further research is needed to investigate causal links. Secondly, subjective bias may exist as we relied on self-reported dietary information and covariates obtained from the NHANES questionnaires. Thirdly, we only used single and self-reported dietary recall to calculate DII which may introduce recall and subjective bias. However, various studies have used similar methods [12, 20, 33]. Fourthly, our study only included U.S. adults, so our findings may not apply to other populations. Lastly, residual confounding cannot be ruled out entirely. Future studies should investigate potential mediators between DII and chronic disease risk for better understanding of the underlying mechanisms.

Conclusion

In older U.S. adults, a higher DII was associated with increased odds of CVD, diabetes, and hypertension, while one-unit increase in DII was associated with CVD and hypertension after full adjustment. Adopting a diet with anti-inflammatory potential may help reduce the risk of developing chronic diseases in older adults.

Data availability

The original NHANES dataset to support this study is available from the National Center for Health Statistics. (https://wwwn.cdc.gov/nchs/nhanes/default.aspx).

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Acknowledgements

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Funding

This work was supported by the National Natural Science Foundation of China (grant number 82270866). The authors are solely responsible for the design and conduct of this study, all study analyses, drafting and editing of the manuscript, and final content.

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  1. Ikramulhaq Patel and XingYao Tang contributed equally to this work.

Authors and Affiliations

  1. Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China

    Ikramulhaq Patel & JianBo Zhou

  2. Capital Medical University, Beijing, China

    XingYao Tang

  3. Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China

    Zhihui Song

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Contributions

Ikramulhaq Patel, Jianbo Zhou, and Zhihui Song were responsible for the study's conception, design, and implementation. Xingyao Tang performed the data analysis. Ikramulhaq Patel drafted the manuscript and revised its content. All authors critically reviewed and approved the final version of the manuscript.

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Correspondence to Zhihui Song or JianBo Zhou.

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Supplementary Table 1. Overall food parameter-specific inflammatory effect score stratified by chronic disease status. NHANES 1999–2018. Supplementary Table 2. Association between DII (one unit increase) and number of chronic diseases

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Patel, I., Tang, X., Song, Z. et al. Relationship between dietary inflammatory index and chronic diseases in older U.S. Adults: NHANES 1999–2018. BMC Public Health 25, 1498 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-025-22544-3

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