Public Health Article

Healthy eating index diet quality in randomized weight loss trials: A systematic review

Review Quality Rating: 9 (strong)

Citation: Cheng J, Liang HW, Klem ML, Costacou T, & Burke LE. (2023). Healthy eating index diet quality in randomized weight loss trials: A systematic review. Journal of the Academy of Nutrition and Dietetics, 123(1), 117-143.

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BACKGROUND: Weight loss interventions focus on dietary and physical activity changes to induce weight loss. Both through weight loss and independent of it, diet quality is important for reducing chronic disease risk. However, whether and how diet quality changes over the course of a behavioral intervention is unclear.

OBJECTIVE: To systematically review the evidence from randomized controlled trials on the effect of behavioral interventions on diet quality as defined by the Healthy Eating Index (HEI) among adults with overweight and obesity.

METHODS: PubMed, Ebscohost CINAHL, Embase, OVID APA PsycInfo, Scopus, and Web of Science were searched through May 2021. Inclusion criteria comprised randomized controlled trial design, a primary or secondary aim of weight loss, a sample of US adults with overweight or obesity, measurement using the HEI-2005, 2010, or 2015, and assessment of the time by treatment effect. Interventions must have included behavioral components and lasted at least 3 months. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The systematic review protocol was published on Open Science Framework.

RESULTS: Of 3,707 citations retrieved, 18 studies met inclusion criteria. A wide array of behavioral interventions were assessed, including in-person and mobile health interventions as well as those prescribing intake of specific foods. Risk of bias in the included studies primarily arose from the measurement of the outcome variable. Sample sizes ranged from 34 to 413 participants. Nine studies used multiple dietary recalls, with few using the recommended method of Healthy Eating Index calculation. Changes in diet quality ranged from no improvement to a 20-point improvement. More often, improvement was in the 4- to 7-point range.

CONCLUSIONS: The evidence for the efficacy of behavioral weight loss interventions for improving diet quality among adults with overweight and obesity is limited. Modest improvements in HEI scores were observed in the reviewed studies.


Adults (20-59 years), Behaviour Modification (e.g., provision of item/tool, incentives, goal setting), Chronic Diseases, Community, High Risk Group (e.g., adolescent parents, elderly, homeless, substance users), Home, Internet, Mail, Mobile Phone, Narrative review, Nutrition, Obesity, Phone, Seniors (60+ years), Social Support (e.g., counseling, case management, outreach programs)

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