The quality of the global diet in 185 countries from 1990 to 2018 shows significant differences by country, age, education and urbanity

GDD is a collaborative effort to systematically identify, aggregate, and standardize nutritional data at the individual level on 53 foods, beverages, and nutrients (Methods). GDD uses Bayesian modeling methods to estimate dietary intake jointly broken down by age, sex, education, level, and urbanization in 185 countries between 1990 and 2018.

The quality of the global and regional diet in 2018

In 2018, the global average AHEI score was 40.3 (95% Uncertainty Interval (UI) 39.4, 41.3), with a regional average ranging from 30.3 (28.7, 32.2) in Latin America and the Caribbean to 45.7 (43.8, 49.3) in South Asia (Fig. 1). Among the score components, the highest global scores for healthy items were legumes/nuts (5.0; 4.8, 5.3), followed by whole grains (4.7; 4.5, 5.0), seafood omega-3 fats (4.2; 3.8, 5.1) and non-starchy vegetables (3.9; 3.8, 4.0); Among the unhealthy items, the highest scores (less or more intake) were for sugar-sweetened beverages (SSBs) (5.8; 5.7, 5.9) and red/processed meat (4.8; 4.5, 5.1). However, these grading components vary greatly by region of the world. For example, the highest scores in South Asia were for the highest whole grains and lower red/processed meats and SSBs, while the highest scores in Latin America and the Caribbean were for the highest legumes/nuts and the lowest sodium.

Figure 1: Average global and regional AHEI component scores by age (all ages, for children only and adults only) in 2018.
shape 1

AHEI score: nine components scored from 0 to 10 each and scaled to ten components (corrected for Across fat appears). Healthy Ingredients: Fruit, non-starchy vegetables, legumes/nuts, whole grains, polyunsaturated foods (PUFA) and omega-3 seafood fats; Unhealthy ingredients: red/processed meat, SSBs and sodium.

The quality of the national diet in 2018

Only ten countries, representing less than 1% of the world’s population, had AHEI scores of 50. Of the world’s 25 most populous countries, the highest average AHEI score was in Vietnam, Iran, Indonesia, and India (54.5 to 48.2) and the lowest in Brazil, Mexico, the United States, and Egypt (27.1-33.5) (Fig. 2). The scores for most components varied widely across these densely populated countries. For example, a 100-fold difference was seen in the sodium score, a 90-fold difference in the red/processed meat score and a 23-fold difference in the SSB score. Among the ingredients, the degrees of polyunsaturated fatty acids (PUFA) and non-starchy vegetables varied (two- and three-fold, respectively) across the densely populated countries.

Figure 2: National average AHEI scores between children (left) and adults (right) in 2018.
Figure 2

Children: from 1 to 19 years old; Adults: ≥20 years old. The AHEI score ranged from 0 to 100. The national average score was calculated as the sum of the scores of the class-level components and aggregated to the national average using the 2018 population-weighted ratios.

Global and regional differences across demographic subgroups

Globally, the mean AHEI score in 2018 was similar among children (39.2; 38.2, 40.3) versus adults (40.8; 39.8, 42.0) (Fig. 1). However, the average AHEI score was significantly higher among adults than among children in Central/Eastern Europe and Central Asia, high-income countries, and the Middle East and North Africa region. By age, most regions had J- or U-shaped relationships, with the highest scores observed among the younger (5 years) and/or older (75 years) age groups (Fig. 3).

Figure 3: Global and regional average AHEI scores, by age (in years) in 2018.
Figure 3

The AHEI score ranged from 0 to 100. Circles represent the global or regional mean for the age group, and error bars represent the corresponding UI 95%. The average and its UI are plotted for the midpoint of each age group (<1, 1-2, 3-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94 and 95 years ).

Among the global AHEI components, four were lower among children versus adults: fruit (2.2 (2.1, 2.3) versus 2.5 (2.4, 2.5), respectively), and non-starchy vegetables (3.1 (3.0, 4.5) versus 4.3) 4.2), 3.2)), SSBs (5.3 (5.1, 5.5) vs. 6.1 (6.0, 6.2)) and omega-3 seafood (3.3 (2.9, 4.0) vs 4.7 (4.2, 5.7)), while two others were higher among children vs. adults: PUFAs (2.1 (2.0, 2.2) vs. 1.4 (1.3, 1.5)) and sodium (4.6 (4.1, 5.1) vs. 3.2 (2.9, 3.5)) (Fig. 1).

By gender, the average AHEI score was generally higher in women versus men at the global and regional levels, with the largest differences in high-income countries (difference +4.4; 3.8, 5.0), Central/Eastern Europe and Central Asia (+3.6; 2.1, 5.3) (Extended Data Figure 1). When assessing the different AHEI components globally, the women scored modestly higher for fruits (+0.2; 0.2, 0.3), non-starchy vegetables (+0.3; 0.1, 0.4) and whole grains (+0.4; 0.2, 0.5).

When assessing differences according to educational attainment, AHEI scores were greater among individuals with a higher level of education globally and in most regions, except for the Middle East and North Africa and Sub-Saharan Africa, where there were no obvious differences (Fig. 4). Between world regions, differences by education were largest in Central/Eastern Europe and Central Asia (+3.6; 2.4, 4.9), Latin America and the Caribbean (+3.5; 0.9, 6.0) and South Asia (+2.9; 1.1, 4.9). Globally, more educated individuals had higher scores for fruits (+0.8; 0.7, 0.9), sodium (+0.7; 0.3, 1.1), whole grains (+0.6; 0.4, 0.8) and non-starchy vegetables (+0.5; 0.4, 0.6). However, in contrast, more educated individuals also had lower scores (less favorable consumption levels) for red/processed meat (−0.6; 0.7, −0.5), SSBs (−0.6; −0.8, −0.4), nuts and legumes (−0.6; −0.8, −0.4). −0.1; 0.2, −0.1) globally.

Figure 4: Mean absolute global and regional differences in scores for AHEI components in children (top) and adults (bottom) in 2018, by high versus low education level.
Figure 4

AHEI score: nine components scored from 0 to 10 each and scaled to ten components (correction not shown). Absolute difference by education was calculated as the class-level difference and aggregated into global and regional mean differences using population-weighted ratios of low education levels (<6 years) and high levels of education (12 years) only (excluding education level ≥6) and <12 years old).

Globally, AHEI scores did not differ significantly by urban versus rural residence (Fig. 5). However, higher scores were evident among urban versus rural individuals in Central/Eastern Europe and Central Asia (difference +2.2; 0.9, 3.5), and Southeast and East Asia (+1.4; 0.6, 2.4), and lower scores between Urban versus rural. Individuals in the Middle East and North Africa (−3.8; 5.5, −2.2). Globally, urban residents had higher scores for fruits (+0.2; 0.2, 0.3) and whole grains (+0.2; 0.1, 0.4), but lower scores for SSBs (−0.5; −0.7, −0.4), red /processed meats (−0.4, −0.5, −0.1) and legumes/nuts (−0.1; 0.2, −0.1).

Figure 5: Global and regional mean absolute differences in AHEI component scores in children (top) and adults (bottom) in 2018, by urban versus rural residence.
Figure 5

AHEI score: nine components scored from 0 to 10 each and scaled to ten components (correction not shown). The absolute difference by age was calculated as the difference at the class level and aggregated into global and regional mean differences using population-weighted ratios.

Changes in dietary pattern scores between 1990 and 2018

Between 1990 and 2018, the global average AHEI score (standardized for 2018 population distributions) increased by +1.5 (1.0, 2.0). Increasing trends occurred in five of seven regions: Central/Eastern Europe and Central Asia (+4.6; 4.0, 5.3); high income countries (+3.2; 2.9, 3.5); Southeast and East Asia (+2.7; 1.7, 3.8); Middle East and North Africa (+2.2; 1.4, 3.0); and Latin America and the Caribbean (+1.3; 0.6, 2.0). No significant change was observed in South Asia (0; −0.9, 1.1), and a decreasing trend was seen in Sub-Saharan Africa (−1.1; -1.8, -0.4) (Fig. 6).

Figure 6: Mean absolute global and regional differences in AHEI component scores in children (top) and adults (bottom), between 2018 and 1990.
Figure 6

AHEI score: nine components scored from 0 to 10 each and scaled to ten components (correction not shown). The absolute difference by time was calculated as the difference at the stratum level and aggregated on the basis of global and regional mean differences using the 2018 population-weighted ratios.

Among the AHEI components globally, scores increased over time for non-starchy vegetables (+1.1; 1.0, 1.2), legumes/nuts (+1.1; 1.0, 1.3) and fruits (+0.1; 0.1, 0.2); decreased for red/processed meat (−1.4; 1.5, −1.2), SSBs (−0.6; 0.7, −0.6) and sodium (−0.4; 0.6, −0.2); It remained stable for whole grains (+0.1; 0, 0.2), PUFAs (0; 0, 0.1) and omega-3s for seafood (0; 0, 0.1).

Among the most populous countries, the largest absolute improvement in AHEI score between 1990 and 2018 occurred in Iran (+12.0; 9.9, 13.9), the United States (+4.6; 4.1, 5.1), and Vietnam (+4.5; 2.4, 7.2) and China (+4.3; 2.8, 5.9), while the largest decreases were found in Tanzania (.3.7; .5.8, .1.5), Nigeria (.3.0; .5.3, .0.7), and Japan (.2.7; .3.1., −2.3) and the Philippines (−1.8; 2.7, −0.9) (Fig. 7).

Figure 7: The absolute national average change in AHEI scores between children (left) and adults (right) between 1990 and 2018.
Figure 7

The AHEI score ranged from 0 to 100. The absolute difference between 2018 and 1990 was calculated as the class-level difference and aggregated on the basis of national mean differences using 2018 weighted population ratios.

DASH and MED . results

Detailed results for the DASH and MED scores are presented in the supplementary information. In summary, the global mean scores for DASH and MED in 2018 were 22.9 (22.6, 23.2) and 4.1 (3.9, 4.2), respectively (Extended Data Figs 2 and 3). Regionally, the averages of these scores were consistently higher in South Asia, and lower in Latin America and the Caribbean (Figs 4 and 5 for extended data). Among the subpopulations, global DASH and MED scores were higher among adults than children (DASH: 23.2 (22.9, 23.4) vs 22.3 (21.9, 22.7; mean: 4.3 (4.1, 4.4) vs 3.7 (3.5, 3.8)), But it did not differ significantly by gender (Figures 2 and 3 from Extended Data). Global mean scores were higher among the most educated versus the least educated individuals (difference +2.6 (2.3, 2.8) and +0.3 (0.2, 0.4), respectively) (Extended Data Fig. 7), and for DASH only, among individuals Urban versus rural individuals (+0.4; 0.2, 0.7) (Extended Data Fig. 8). Worldwide, mean scores for DASH and MED increased slightly between 1990 and 2018, by +1.0 (0.8, 1.1) for DASH and +0.3 (0.2, 0.4) for MED (Figs 6 and 9 of Extended Data) . Across the strata in 2018, the inter-correlationships between dietary pattern scores were 0.8 for AHEI and DASH, 0.5 for AHEI and MED, and 0.6 for DASH and MED.

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