The Relationship Between Dietary Inflammatory Index and All-Cause, Cardiovascular Disease-Related, and Cancer-Related Mortality

Figures & data

Figure 1 Study flow chart.

Abbreviation: NHANES, National Health and Nutrition Examination Surveys.

Table 1 Distribution of Baseline Characteristics of NHANES Cohort Across Tertiles of DII

Characteristic	Overall (n=29,013)	T1(n=9671)	T2 (n=9666)	T3 (9676)	P-value
Age, years	47.361 ± 0.220	47.681 ± 0.297	47.270 ± 0.270	47.088 ± 0.274	0.164
Sex, n (%)					< 0.001
Male	14,428 (49.7%)	5969 (20.6%)	4803 (16.6%)	3656 (12.6%)
Female	14,585 (50.3%)	3702 (12.8%)	4863 (16.8%)	6020 (20.7%)
Race, n (%)					< 0.001
Mexican American	4762 (16.4%)	1703 (5.9%)	1635 (5.6%)	1424 (4.9%)
Other Hispanic	2345 (8.1%)	751 (2.6%)	799 (8.3%)	795 (8.2%)
Non-Hispanic White	5727 (19.7%)	1443 (5.0%)	1878 (6.5%)	2406 (8.3%)
Non-Hispanic Black	13,783 (47.5%)	4808 (16.6%)	4599 (15.9%)	4376 (15.1%)
Other race	2396 (8.3%)	966 (3.3%)	755 (2.6%)	675 (2.3%)
Family PIR	3.091 ± 0.032	3.389 ± 0.037	3.106 ± 0.034	2.729 ± 0.036	< 0.001
Education level, n (%)					< 0.001
Less than high school	6837 (23.6%)	1854 (6.4%)	2269 (7.8%)	2714 (9.4%)
High school	2812 (9.7%)	765 (2.6%)	918 (3.2%)	1129 (3.9%)
More than high school	19,364 (66.7%)	7052 (24.3%)	6479 (22.3%)	5833 (20.1%)
Marital status, n (%)					< 0.001
Having a partner	17,819 (61.4%)	6441 (22.2%)	5998 (20.7%)	5380 (18.5%)
No partner	6261 (21.6%)	1724 (5.9%)	2304 (7.0%)	2503 (8.6%)
Unmarried	4933 (17.0%)	1506 (5.2%)	1634 (5.6%)	1793 (6.2%)
Smoker, n (%)					< 0.010
No	15,689 (54.1%)	5357 (18.5%)	5275 (18.2%)	5057 (17.4%)
Former	7438 (25.6%)	2779 (9.6%)	2470 (8.5%)	2189 (7.5%)
Now	5886 (20.3%)	1535 (5.3%)	1921 (6.6%)	2430 (8.4%)
Alcohol user, n (%)					< 0.001
Never	3835 (13.2%)	1053 (3.6%)	1247 (4.3%)	1535 (5.3%)
Former	5049 (17.4%)	1426 (4.9%)	1654 (5.7%)	1969 (6.8%)
Mild	9986 (34.4%)	3822 (13.2%)	3305 (11.4%)	2859 (9.9%)
Moderate	4495 (15.5%)	1450 (5.0%)	1534 (5.3%)	1511 (5.2%)
Heavy	5648 (19.5%)	1920 (6.6%)	1926 (6.6%)	1802 (6.2%)
Hypertension, n (%)					0.002
No	16,498 (56.9%)	5735 (19.8%)	5463 (18.8%)	5300 (18.3%)
Yes	12,515 (43.1%)	3936 (13.6%)	4203 (14.5%)	4376 (15.1%)
DM, n (%)					< 0.001
No	24,062 (82.9%)	8222 (28.3%)	7984 (27.5%)	7856 (27.1%)
Yes	4951 (17.1%)	1449 (5.0%)	1682 (5.8%)	1820 (6.3%)
CHD, n (%)					0.210
No	27,822 (95.9%)	9294 (32.0%)	9272 (32.0%)	9256 (31.9%)
Yes	1191 (4.1%)	377 (1.3%)	394 (1.4%)	420 (1.4%)
CHF, n (%)					< 0.001
No	28,172 (97.1%)	9464 (32.6%)	9370 (32.3%)	9338 (32.2%)
Yes	841 (2.9%)	207 (0.7%)	296 (1.0%)	338 (1.2%)
Angina pectoris, n (%)					0.095
No	28,214 (97.2%)	9437 (32.5%)	9398 (32.4%)	9379 (32.3%)
Yes	799 (2.8%)	234 (0.8%)	268 (0.9%)	297 (1.0%)
Heart attack, n (%)					0.013
No	27,797 (95.8%)	9325 (32.1%)	9261 (31.9%)	9211 (31.7%)
Yes	1216 (4.2%)	346 (1.2%)	405 (1.4%)	465 (1.6%)
Stroke, n (%)					< 0.001
No	27,972 (96.4%)	9426 (32.5%)	9332 (32.2%)	9214 (31.8%)
Yes	1041 (3.6%)	245 (0.8%)	334 (1.2%)	462 (1.6%)
SBP, mmHg	121.840 ± 0.192	121.391 ± 0.268	122.125 ± 0.261	122.052 ± 0.252	0.034
DBP, mmHg	71.157 ± 0.178	71.482 ± 0.211	71.302 ± 0.213	70.623 ± 0.231	0.001
BMI, kg/m^2	28.857 ± 0.072	28.257 ± 0.096	28.929 ± 0.098	29.476 ± 0.098	< 0.001
Waist circumference, cm	98.882 ± 0.187	98.151 ± 0.267	98.991 ± 0.252	99.614 ± 0.235	< 0.001
Mean energy	2134.883 ± 7.410	2574.633 ± 13.458	2089.196 ± 10.074	1673.183 ± 9.842	< 0.001
Intake, kcal
Hb, g/dL	14.358 ± 0.023	14.556 ± 0.026	14.381 ± 0.028	14.103 ± 0.028	< 0.001
FBG, mg/dL	98.225 ± 0.255	97.550 ± 0.412	98.663 ± 0.446	98.532 ± 0.372	0.092
HDL-C, mg/dL	53.308 ± 0.187	53.582 ± 0.271	53.418 ± 0.278	52.870 ± 0.264	0.127
TC, mg/dL	196.549 ± 0.443	194.710 ± 0.693	197.428 ± 0.579	197.730 ± 0.637	< 0.001
TG, mg/dL	150.436 ± 1.118	150.367 ± 1.811	151.591 ± 1.836	149.257 ± 1.565	0.588
BUN, mg/dL	13.524 ± 0.062	14.008 ± 0.082	13.628 ± 0.082	12.847 ± 0.089	< 0.001
UA, mg/dL	5.419 ± 0.013	5.465 ± 0.021	5.444 ± 0.021	5.339 ± 0.021	< 0.001
Scr, mg/dL	0.879 ± 0.003	0.884 ± 0.004	0.878 ± 0.004	0.874 ± 0.004	0.222
eGFR, mL/min/1.73m^2	93.667 ± 0.281	93.750 ± 0.352	93.360 ± 0.350	93.906 ± 0.362	0.345
All-cause mortality, n (%)					< 0.001
No	25,028 (86.3%)	8489 (29.3%)	8275 (28.5%)	8264 (28.5%)
Yes	3985 (13.7%)	1182 (4.1%)	1391 (4.8%)	1412 (4.9%)
Cardiovascular-related					0.051
Mortality, n (%)
No	27,772 (95.7%)	9315 (32.1%)	9224 (31.8%)	9233 (31.8%)
Yes	1241 (4.3%)	356 (1.2%)	442 (1.5%)	443 (1.5%)
Cancer-related					0.172
Mortality, n (%)
No	28,059 (96.7%)	9376 (32.3%)	9327 (32.1%)	9356 (32.2%)
Yes	954 (3.3%)	295 (1.0%)	339 (1.2%)	320 (1.1%)

Notes: T1, −4.838–1.161; T2, 1.162–1.181; T3, 1.182–4.971.

Abbreviations: DII, dietary inflammatory index; family PIR, family poverty income ratio; DM, diabetes mellitus; CHD, coronary heart disease; CHF, congestive heart failure; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; Hb, hemoglobin; FBG, fast blood glucose; HDL-C, high-density lipoprotein-cholesterol; TC, total cholesterol; TG, triglyceride; BUN, blood urea nitrogen; UA, uric acid; Scr, serum creatinine; eGFR, estimated glomerular filtration rate.

Table 2 Cox Regression Analysis of DII for All-Cause Mortality in Participants

DII	Model 1	Model 2	Model 3
	HR (95% CI)	HR (95% CI)	HR (95% CI)
T1	Ref.	Ref.	Ref.
T2	1.247 (1.153, 1.348) ***	1.154 (1.067, 1.248) ***	1.149 (1.059, 1.247) **
T3	1.401 (1.295, 1.516) ***	1.199 (1.106, 1.299) ***	1.186 (1.084, 1.297) ***
P for trend	<0.001	<0.001	<0.001

Notes: T1, −5.281–0.724; T2, 0.725–2.513; T3, 2.514–5.795; **P < 0.01; ***P < 0.001; Model 1 was adjusted for age and sex. Model 2 was further adjusted for education level, marital status, family poverty income ratio, hypertension, diabetes mellitus, smoker, and drinker. Model 3 was further adjusted for coronary heart disease, congestive heart failure, angina pectoris, heart attack, stroke, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, hemoglobin, fast glucose, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, blood urea nitrogen, uric acid, serum creatinine, and estimated glomerular filtration rate.

Abbreviations: DII, dietary inflammatory index; HR, hazard ratio; CI, confidence interval.

Figure 2 The restricted cubic spline plot of the association between DII with (A) all-cause mortality (B) CVD-related mortality (C) cancer-related mortality.

Abbreviations: DII, Dietary inflammation index; CVD, cardiovascular disease.

Table 3 Cox Regression Analysis of DII for CVD-Related Mortality in Participants

DII	Model 1	Model 2	Model 3
	HR (95% CI)	HR (95% CI)	HR (95% CI)
T1	Ref.	Ref.	Ref.
T2	1.336 (1.161, 1.537) ***	1.238 (1.075, 1.426) **	1.197 (1.032, 1.387) *
T3	1.494 (1.296, 1.723) ***	1.280 (1.107, 1.479) **	1.198 (1.019, 1.409) *
P for trend	<0.001	0.002	0.039

Notes: T1, −5.281–0.724; T2, 0.725–2.513; T3, 2.514–5.795. *P < 0.05; **P < 0.01; ***P < 0.001; Model 1 was adjusted for age and sex. Model 2 was further adjusted for education level, marital status, family poverty income ratio, hypertension, diabetes mellitus, smoker, and drinker. Model 3 was further adjusted for coronary heart disease, congestive heart failure, angina pectoris, heart attack, stroke, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, hemoglobin, fast glucose, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, blood urea nitrogen, uric acid, serum creatinine, and estimated glomerular filtration rate.

Abbreviations: DII, dietary inflammatory index; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval.

Table 4 Cox Regression Analysis of DII for Cancer-Related Mortality in Participants

DII	Model 1	Model 2	Model 3
	HR (95% CI)	HR (95% CI)	HR (95% CI)
T1	Ref.	Ref.	Ref.
T2	1.222 (1.045, 1.429) *	1.163 (0.944, 1.362)	1.192 (1.011, 1.405) *
T3	1.280 (1.090, 1.504) **	1.150 (0.976, 1.356)	1.183 (0.985, 1.420)
P for trend	0.006	0.126	0.087

Notes: T1, −5.281–0.724; T2, 0.725–2.513; T3, 2.514–5.795; *P < 0.05; **P < 0.01; Model 1 was adjusted for age and sex. Model 2 was further adjusted for education level, marital status, family poverty income ratio, hypertension, diabetes mellitus, smoker, and drinker. Model 3 was further adjusted for coronary heart disease, congestive heart failure, angina pectoris, heart attack, stroke, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, hemoglobin, fats glucose, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, blood urea nitrogen, uric acid, serum creatinine, and estimated glomerular filtration rate.

Abbreviations: DII, dietary inflammatory index; HR, hazard ratio; CI, confidence interval.

Figure 3 Kaplan-Meier survival curve for (A) all-cause mortality (B) CVD-related mortality (C) cancer-related mortality.

Abbreviation: CVD, cardiovascular disease.

Table 5 Subgroups Analysis for the Associations of DII with All-Cause Mortality

	T1	T2	T3	P for Trend	P for Interaction
	HR (95% CI)	HR (95% CI)	HR (95% CI)
Age					<0.001
< 60	1.00	1.003 (0.831, 1.210)	0.899 (0.728, 1.111)	0.453
≥ 60	1.00	1.081 (0.987, 1.184)	1.117 (1.011, 1.234) *	0.083
Sex					<0.001
Male	1.00	1.155 (1.041, 1.282) **	1.180 (1.048, 1.328) **	0.008
Female	1.00	1.124 (0.982, 1.285)	1.162(1.011, 1.337) *	0.098
Hypertension					0.200
No	1.00	1.104 (0.945, 1.289)	1.244 (1.048, 1.476) *	0.043
Yes	1.00	1.156 (1.049, 1.273) **	1.162 (1.045, 1.291) **	0.006
DM					0.040
No	1.00	1.170 (1.061, 1.290) **	1.253 (1.125, 1.395) ***	<0.001
Yes	1.00	1.108 (0.954, 1.288)	1.049 (0.893, 1.233)	0.381
BMI					0.030
< 30 kg/m^2	1.00	1.226 (1.109, 1.354) ***	1.282 (1.148, 1.431) ***	<0.001
≥ 30 kg/m^2	1.00	1.016 (0.879, 1.173)	1.007 (0.863, 1.176)	0.977

Notes: T1, −5.281–0.724; T2, 0.725–2.513; T3, 2.514–5.795; *P < 0.05; **P < 0.01; ***P < 0.001; Analysis was adjusted for age, sex, education level, marital status, family poverty income ratio, hypertension, diabetes mellitus, smoker, drinker, coronary heart disease, congestive heart failure, angina pectoris, heart attack, stroke, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, hemoglobin, fast glucose, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, blood urea nitrogen, uric acid, serum creatinine, and estimated glomerular filtration rate.

Abbreviations: DII, dietary inflammation index; DM, diabetes mellitus; BMI, body mass index; HR, hazard ratio; CI, confidence interval.

Table 6 Subgroups Analysis for the Associations of DII with CVD-Related Mortality

	T1	T2	T3	P for Trend	P for Interaction
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Age					<0.001
< 60	1.00	0.889 (0.593, 1.334)	0.876 (0.561, 1.369)	0.814
≥ 60	1.00	1.146 (0.978, 1.343)	1.114 (0.935, 1.328)	0.237
Sex					0.001
Male	1.00	1.240 (1.031, 1.490) *	1.114 (0.900, 1.379)	0.068
Female	1.00	1.113 (0.866, 1.430)	1.232 (0.952, 1.594)	0.273
Hypertension					0.054
No	1.00	1.388 (0.988, 1.950)	2.070 (1.435, 2.986) ***	<0.001
Yes	1.00	1.138 (0.965, 1.342)	1.052 (0.877, 1.262)	0.275
DM					0.011
No	1.00	1.114 (0.930, 1.335)	1.224 (1.004, 1.215) *	0.135
Yes	1.00	1.407 (1.082, 1.830) *	1.191 (0.894, 1.588)	0.031
BMI					0.002
< 30 kg/m^2	1.00	1.277 (1.064, 1.533) **	1.324 (1.082, 1.621) **	0.011
≥ 30 kg/m^2	1.00	1.035 (0.803, 1.336)	0.986 (0.750,1.298)	0.907

Notes: T1, −5.281–0.724; T2, 0.725–2.513; T3, 2.514–5.795; *P < 0.05; **P < 0.01; ***P < 0.001; Analysis was adjusted for age, sex, education level, marital status, family poverty income ratio, hypertension, diabetes mellitus, smoker, drinker, coronary heart disease, congestive heart failure, angina pectoris, heart attack, stroke, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, hemoglobin, fast glucose, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, blood urea nitrogen, uric acid, serum creatinine, and estimated glomerular filtration rate.

Abbreviations: DII, dietary inflammation index; CVD, cardiovascular disease; DM, diabetes mellitus; BMI, body mass index; HR, hazard ratio; CI, confidence interval.

Figure 4 The association between DII and covariates.

Abbreviations: DII, dietary inflammation index; family PIR, family poverty-income ratio; smoker, DM, diabetes mellitus; CHD, chronic heart disease; CHF, chronic heart failure; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; Hb, hemoglobin; BUN, blood urea nitrogen; UA, uric acid; Scr, serum creatinine; HDL-C, high density lipoprotein-cholesterol; TC, total cholesterol; TG, triglycerides; eGFR, estimated glomerular filtration rate.

Data Sharing Statement

The survey data are publicly available on the internet for data users and researchers throughout the world (www.cdc.gov/nchs/nhanes/).