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REVIEW

CURRENT
OPINION Assessing the (anti)-inflammatory potential of diets
Lina Samira Bahr a, Kristina Franz b, and Anja Mähler a,c

Purpose of review
It is accepted that several chronic diseases are associated with inflammation. Dietary habits and the
consumption of certain nutrients have been shown to influence inflammation. In this narrative review, we
discuss currently developed tools to assess the inflammatory potential of diets and compare them with
established tools.
Recent findings
Four new indices were recently developed. The Inflammatory Score of the Diet is a modified version of
the established Dietary Inflammatory Index (DII). The novel Empirical DII works without previous dietary
intake assessment and the Anti-Inflammatory Diet Index was specifically developed in a northern
European population. The Dietary and Lifestyle Inflammation Score addresses additional confounders.
The informative value of dietary indices relies on the accuracy and completeness of dietary intake
assessment.
Summary
Dietary inflammatory indices are important tools to assess, compare and validate the inflammatory potential
of diets across populations without the need for biomarker assessments. They allow to investigate
associations between an (anti)-inflammatory diet with disease risk and course. Although the DII remains the
most used index worldwide, currently developed indices allow more flexibility, have a different focus or
simplify assessment. Additional foods, that were recently shown to modulate inflammation, but are not
(fully) considered yet, may deserve more attention in the future.
Keywords
anti-inflammatory diet, Dietary Inflammatory Index, inflammatory potential, low-grade inflammation

INTRODUCTION DIETARY INFLAMMATORY INDEX AND

Low-grade inflammation is a common feature of
several chronic diseases [1], initiates age-related dis-
eases and accelerates the ageing process [2]. Various
nutrients, food components and dietary patterns
have regulatory effects on the inflammatory status
[1,3], which may be reflected in the production of
inflammatory cytokines. Healthy dietary patterns
and the consumption of certain foods have been
shown to ameliorate low-grade inflammation in
healthy persons and persons with cardiovascular
risk factors [4]. Associations between health out-
comes and disease risks with the inflammatory
potential of diets are currently investigated in dif-
ferent clinical settings, e.g., in patients with inflam-
matory bowel disease [5], chronic obstructive
pulmonary disease [6], cancer [7,8], Alzheimer’s dis-
ease [9], cardiovascular disease [10], neurodegener-
ative disease including multiple sclerosis and
cognitive decline [11], aortic aneurysm [12], depres-
sion [13], sarcopenia [14], Covid-19 [15] as well as
with regard to all-cause mortality [16].
EMPIRICAL DIETARY INFLAMMATORY
INDEX
The first Dietary Inflammatory Index (DII) was
developed on the basis of a literature review in
2009 and re-devised in 2014 [17]. The aim of the
DII was to categorize a subject’s individual diet into
a pro-inflammatory or anti-inflammatory diet.
Between 1950 and 2010, 1943 peer-reviewed origi-
nal articles that investigated the effects of 45 dietary
a
Charité – Universitätsmedizin Berlin, Corporate Member of Freie Uni-
versität Berlin and Humboldt-Universität zu Berlin, ECRC Experimental
and Clinical Research Center, bCharité – Universitätsmedizin Berlin,
Corporate Member of Freie Universität Berlin and Humboldt-Universität
zu Berlin, Research Group on Geriatrics and cDZHK (German Centre for
Cardiovascular Research), Berlin, Germany
Correspondence to Lina Samira Bahr, MSc, Charitéplatz 1, 10117
Berlin, Germany. Tel: +49 30 450 539 736;
e-mail: Lina.Bahr@charite.de
Curr Opin Clin Nutr Metab Care 2021, 23:000–000
DOI:10.1097/MCO.0000000000000772

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Assessment of nutritional and metabolic status
KEY POINTS
 The Dietary Inflammatory Index (DII), a literature-
derived index, and the Empirical Dietary Inflammatory
Index (EDII), a data-driven index, are the most-
established tools for assessing an individual’s dietary
inflammatory potential.
 These assessments provide valuable information and
may reveal areas for dietary improvement as well as
associations with disease risk or course; using indices
allows comparability and validation in large-scale
studies without the need for extensive
biomarker assessments.
 The accuracy and informative value of most dietary
inflammatory indices highly depend on dietary
assessment methods and considerations of confounders.
 New tools address limitations of established tools, such
as the Dietary and Lifestyle Inflammation Score (DIS/
LIS), by considering additional lifestyle factors, or the
Anti-Inflammatory Diet Index (AIDI) that was specifically
developed and validated in a northern European
population and the novel Empirical Dietary
Inflammatory Index eDII by reducing the burden of
laborious dietary assessments.
 The inflammatory potential of additional foods and
dietary factors, that are currently not included in the
dietary indices, such as high salt intake and the degree
of food-processing, may receive more attention in
the future.
components including macronutrients, micronu-
trients, flavonoids, spices and other bioactive com-
ponents on the six most established inflammatory
markers IL-1ß, IL-4, IL-6, IL-10, tumor necrosis fac-
tor (TNF)-alpha and c-reactive protein (CRP), were
considered to develop an inflammatory effect score.
Results were weighted higher when derived from
human trials and lower when derived from animal
or cell studies. A ’þ1’ is given to a food component if
the intake was associated with increased pro-inflam-
matory or decreased anti-inflammatory cytokines. A
’–1’ is given if the intake was associated with
increased anti-inflammatory or decreased pro-
inflammatory cytokines and ‘0’ if there was no effect
on the cytokines [17]. Eleven food consumption
data sets were used to develop a reference popula-
tion. According to the authors, any dietary assess-
ment tool that provides dietary intake data can be
&&
used [18 ]. The DII has been employed in more than
200 studies and evaluated in twelve meta-analyses
&&
[18 ]. It was recently validated against a compre-
hensive, low-grade inflammation score in 20.823
Italian men and women [19]. Further, the DII has
been used in an interventional study investigating
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the DII as a tool for estimating the efficacy to reduce
inflammation through diet longitudinally [20].
However, analysis of the DII is time-consuming.
Furthermore, dietary patterns rather than single
food components used in the DII might be more
useful in the evaluation of complex diet-disease
interactions. Certain dietary patterns have already
been shown to effect low-grade inflammation. For
example, a Mediterranean and Western dietary pat-
tern seems to be associated with positive and nega-
&&
tive effects on inflammation, respectively [21,22 ].
Tabung et al. developed the first Empirical DII
(eDII) based on dietary patterns in 2016 [23]. Food
groups were analyzed to identify a dietary pattern
that was most predictive for the pro-inflammatory
markers IL-6, CRP and TNF-alpha receptor 2 in the
Nurses’ Health Study. The eDII was recently vali-
dated in a multiethnic cohort of postmenopausal
women in the USA [24]. The eDII is an empirical-
derived index, whereas the DII is literature-derived.
The DII includes a list of 45 food components, the
eDII focuses on dietary patterns and only includes
18 Food Frequency Questionnaire (FFQ)-derived
food groups including beverages (nine anti-inflam-
matory and nine pro-inflammatory food groups).
Currently, the DII and eDII are the most estab-
lished tools for assessing the inflammatory potential
of diet. However, they do not necessarily produce
consistent results: In a study from 2020, only the DII
predicted frailty and disability, whereas the eDII did
not [25]. In a study from 2021, the eDII could
successfully predict changes of fecal calprotectin,
an established biomarker for intestinal inflamma-
tion, and was positively associated with symptoms
of inflammatory bowel disease, whereas the DII did
not show any associations [26]. Both tools have
limitations that were addressed in the recently
developed tools.
INFLAMMATORY SCORE OF THE DIET
The Inflammatory Score of the Diet (ISD) was devel-
oped in 2018 within the European Prospective
Investigation into Cancer and Nutrition (EPIC)
study [27] using the DII as a foundation [17], but
modified in some important points: The DII
includes total fat, but also saturated fat, monoun-
saturated fat, and polyunsaturated fat. To avoid
overestimation of the effects of fat, the ISD excluded
total fat. Furthermore, within the DII ‘alcohol’ is
assigned to be anti-inflammatory [17], but the neg-
ative relation with pro-inflammatory markers was
demonstrated only for moderate consumption.
Therefore, for individuals with higher intake, ‘alco-
hol’ was set to 0 in the ISD, which reflects no effect
on inflammatory cytokines. However, it remains
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Assessing the (anti)-inflammatory potential of diets Bahr et al.
controversial if high alcohol intake is not even pro-
&&
inflammatory [28 ]. Another difference to the DII is
the study population that is used as a reference (EPIC
study population vs. global data bases). Dietary
intake was assessed with FFQs, food records and
24h-recalls [27].
ANTI-INFLAMMATORY DIET INDEX
It was shown that the DII was associated with CRP in
the USA, but not necessarily in other populations [29].
The eDII was specifically developed and validated in
US-based cohorts [23,24]. The Anti-Inflammatory Diet
Index (AIDI) was developed in 2018 specifically for
non-US populations: In a study of 3503 middle-aged
Swedish women, 20 FFQ-derived foods were correlated
with high-sensitivity-CRP (hs-CRP). Fifteen anti-
inflammatory and five pro-inflammatory foods in
relation with food-specific consumption cut-offs were
identified. When anti-inflammatory or pro-inflamma-
tory foods were consumed above or below an empiri-
cally specified cut-off, a point was given. The AIDI can
range from 0 (least anti-inflammatory) to 20 (most
anti-inflammatory). The scoring contrasts the other
indices, where higher scores indicate a rather pro-
inflammatory diet. Potential confounders such as
age, smoking, trunk fat mass, anti-inflammatory
drugs, hormone replacement and chronic diseases
were considered. High sensitivity analyses found asso-
ciations even with very low hs-CRP (< 3 mg/L) [29].
The AIDI is rapidly applicable and easy to calculate,
however, it was only validated among women of
middle age and with regard to hs-CRP only. The short
AIDI version (16 food groups) has recently been
applied in a Swedish cohort that found the AIDI to
be associated with all-cause and cancer mortality,
whereas identifying the strongest inverse associations
in current smokers [16].
EMPIRICAL INFLAMMATORY DIETARY
INDEX
All previous dietary indices were developed on the
basis of dietary intake data (mostly FFQ, 24h-recall)
and depend on cost- and time-consuming analyses.
In 2019, a novel eDII was developed [28 ]. It eval-
&&
uates the intake frequency of 16 food groups, with-
out the need for previous dietary assessments. It is
based on eight pro-inflammatory and eight anti-
inflammatory foods. They are mostly derived from
the eDII, with slight adaptations to East-Asian diets
(’pizza’ excluded, ‘eggs’ included). Whereas ‘fish’ is
considered pro-inflammatory in the eDII, it is
divided into ‘oily fish’ and ‘other fish’ in the eDII
to better account for its anti-inflammatory potential
&&
[28 ]. Similar to the DII, the intake frequency of
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each food group is scored either high (2), medium
(1) or low (0). Thus, the total score ranges from 16
to þ16, with a higher score indicating a rather pro-
inflammatory potential of the diet.
The eDII was validated in independent samples
against the inflammatory aging score and correlates
&&
with other healthy diet scores [28 ]. As the eDII is
only based on intake frequencies, it allows a quick
evaluation of an individual’s dietary inflammatory
potential. However, construct validation against
inflammatory biomarkers is still pending and the
lack of extensive dietary intake data may lead to a
loss of information and lack of comparability.
DIETARY INFLAMMATION SCORE AND
LIFESTYLE INFLAMMATION SCORE
Previous indices did not take the interactions of diet
and other lifestyle factors into account, although they
are considered to be important confounders
&&
[11,16,30 ]. To address this issue, a new tool was
&&
developed and validated in 2019 [31 ]. The Dietary
Inflammation Score (DIS) and Lifestyle Inflammation
Score (LIS) are based on an FFQ and lifestyle question-
naires. Nineteen food groups that contain bioactive
nutrients and are presumed to have an effect on
chronic inflammation in the literature are scored.
Frequency of intense physical activity, alcohol con-
sumption, smoking and body mass index are assessed
as additional lifestyle factors. Weighting of DIS and LIS
components was calculated, based on the strengths of
associations, of the components with inflammatory
biomarkers in the REGARDS cohort study. Further, the
authors compared the strengths of associations of the
DIS/LIS with the DII and eDII in three study popula-
tions. Those with the highest DIS, LIS, DII, eDII scores
(indicating a pro-inflammatory diet), compared to the
lowest scores, had higher odds of high CRP. The
authors found strong synergistic contributions of diet
&&
and lifestyle to inflammation [31 ].
All tools are displayed in Fig. 1 and with an
overview of strengths and weaknesses in Table 1.
CONSIDERATIONS OF ASSESSMENT
METHODS
Studying dietary patterns and their inflammatory
potential can be challenging due to the diversity in
dietary patterns, individual differences of inflamma-
tory responses and challenges in dietary intake
assessments.
Assessment of dietary intake
The foundation for most of the dietary indices is
dietary intake data that are usually derived from 24
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Assessment of nutritional and metabolic status
FIGURE 1. Graphical abstract-assessing the (anti)-inflammatory potential of diet, figure created with biorender.com.
h-recalls or FFQs. Although a certain reporting bias
cannot be avoided in neither of these instruments
[32], the use of the open method of 24 h-recalls
identifies as many foods as possible. It also includes
foods that are not commonly suggested in FFQs,
such as spices, which may have substantial effects
on inflammation and are therefore considered in
the DII food list [17,33]. However, the assessment of
dietary habits requires several 24 h-recalls [32]. Fur-
ther, a person might change the diet if a recall
is expected.
A FFQ consists of a predetermined list of selected
foods, which differs between studies and countries.
Therefore, DII food components in studies are also
variable [34]. Shivappa et al. recommended the use
of an open nutritional assessment to include as
many of the 45 food items as possible [17]. There
is, however, evidence that associations of dietary
patterns, such as in FFQs, highlight the effect of diet-
quality on inflammation better than evaluation of
single nutrients [4]. The FFQ is relatively cheap and
easy to use, but portion sizes are difficult to estimate
and the limited food lists can cause a loss of preci-
sion. To gain information on all the 45 nutrients
required for DII or ISD, the 24 h-recall seems to be
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the better option. The 24 h-recall more accurately
assesses the recent macro- and micronutrient intake
&
[35,36 ]. Whereas the FFQ rather evaluates long-
term dietary habits, the recent but more precise
snapshot given by the 24 h-recall might be prefera-
ble in conjunction with simultaneous biomarker
measurements. If feasible, one might use either both
methods [32] or average dietary data across two FFQs
to reduce within-subject variability [23]. Neverthe-
less, the software used for both dietary intake assess-
ments are based on country-specific databases,
which limits comparability between countries [37].
Assessment of biomarkers and confounders
A recent review emphasized the importance of the
time point of blood draws to investigate effects of
food intake on inflammation. It may be more accu-
rate to measure biomarkers in response to a dietary
&&
challenge to assess the actual effects of diets [30 ].
In addition, the choice of biomarkers may be rele-
vant. In a study with 20,823 adults, food groups
were associated with an inflammatory biomarker
score, but not with CRP alone [19]. It is known that
IL-6 and CRP follow a similar biochemical pattern.
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 Table 1. Dietary inflammatory indices: strengths and weaknesses
Dietary Dietary
Inflammatory Inflammatory
Index Index (DII)
Year of publication 2009, 2014
Based on Literature-derived, 45 foods
and nutrients, bioactive
components
Dietary assessment Possibility of using any dietary
&&
methods intake assessment [18 ]
such as 24h-recalls, FFQ,
food records
Recent Validation  Moli-sani study (n ¼ 20.823)
studies [19]
 Several population-specific
validation studies
[39,54,55]
Strengths  Widely established and
validated against six
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biomarkers and other health
&&
indices [18 ]
 Possibility of using any
dietary intake assessment
&&
[18 ]
 Growing body of DII-related
publications allows for
&&
comparisons [18 ]
 Can be applied in any
population: Global
reference population with
11 food consumption data
sets [17]
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Empirical Dietary Inflammatory
Inflammatory Score of the
Index (eDII) Diet (ISD)
2016 2018
Empirical-derived, 18 food Literature-derived, 28 food
groups groups
FFQ FFQ (quantitative,
semiquantitative), food
records, 24h-recall in
subsets
 Multiethnic U.S.-  See DII
population of  Applied in European
postmenopausal women Prospective Investigation
(n ¼ 31.472) [24] into Cancer study
(n ¼ 476.160) [27,56]
 Dietary patterns are  Aims to compensate for
easier to translate into limitations of the DII by
dietary modifying food groups
recommendations for  Study population’s mean
health promotion and standard deviations
 Can be calculated in a as reference population
standardized and (EPIC study) ! higher
reproducible manner internal validity
across populations  Minimizes measurement
error: linear regression
calibration uses 24h-
recall-data
Empirical Dietary
Inflammatory
Index (eDII)
2019
Literature-derived food groups,
empirical-derived index, 16
food groups
None
 Japanese Kashiba Silver
Agers Healthy Longevity
Study (n ¼ 168) and
nutritional epidemiologic
&&
study (n ¼ 1464) [28 ]
 Quick and easy to use,
suitable for screening
 Does not depend on dietary
intake assessments with
FFQ, 24h-recall
 Adapted to rather East-Asian
diets with modified food
groups
 Dietary patterns are easier to
translate into
recommendations
Dietary Inflammation
Anti-Inflammatory Diet Score (DIS)/Lifestyle
Index (AIDI) Inflammation Score (LIS)
2018 2019
Empirical-derived, Literature-derived food groups
20 food groups and empirically derived
scores, 19 food groups and
4 lifestyle characteristics
FFQ FFQ and lifestyle questionnaire
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 Cross-validated in the  Multiethnic U.S. Reasons for
Swedish Mammography Geographic and Racial
Cohort (SMC) study Differences in Stroke Study
(n ¼ 1751) and external (n ¼ 14.210) and two other
validated (n ¼ 1752) validation cohorts (n ¼ 423)
&&
[29] (n ¼ 173) [31 ]
 Applied in prospective
cohort study
(n ¼ 68.273) including
the SMC cohort [16]
MCO 240502
 Associations between the  Combined use of dietary and
AIDI and hs-CRP are lifestyle factors better
even present if CRP is accounts for interactive
low < 3 mg/L contributions to low-grade
 Easy to use, cut-offs for inflammation
scoring according to  Addresses limitations in
associations with studying associations of
biomarker CRP mixed dishes with
 Also tested with shorter inflammation biomarker
96-item-FFQ and only concentrations by
16 food groups [29] disaggregating mixed
 Dietary patterns are dishes into their component
easier to translate in parts using the My Pyramid
dietary Equivalents Database’
&&
recommendations for [31 ]
health promotion  Dietary patterns are easier to
translate in dietary
recommendations for health
promotion
Assessing the (anti)-inflammatory potential of diets Bahr et al.
 6
Table 1 (Continued)
Dietary Dietary Empirical Dietary Inflammatory Empirical Dietary Dietary Inflammation
Inflammatory Inflammatory Inflammatory Score of the Inflammatory Anti-Inflammatory Diet Score (DIS)/Lifestyle
Index Index (DII) Index (eDII) Diet (ISD) Index (eDII) Index (AIDI) Inflammation Score (LIS)

Weakness/  Potential overestimations:
considerations food items as a whole as
well as parts [57]
 Focus on single nutrients, no
dietary patterns
 Does not consider single  Compared to the DII, the
nutrients or food ISD did not use the
components global data base, which
 Developed and validated limits comparability with
&&
in cohorts of healthcare other studies [18 ]
 Not validated against
inflammatory biomarkers
 Limited comparability with
other dietary inflammatory
indices using established
 CRP is a rather un-  DIS and LIS components
specific biomarker for weightings are derived from
low-grade inflammation, a cross-sectional study !
composite of biomarkers Longitudinal investigations
may be more valid might show different results
&&
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 For DII calculations, one
should have access to
global data bases; the
energy-adjusted DII can only
workers !  Other DII weaknesses dietary intake assessments  Validated only in middle- [31 ]
transferability to other apply here as well  No detailed information aged women [29]  Above-mentioned cohort with
populations limited about the population in the  Unbalanced food groups largest sample size is a US
&&
 Requirements of publication [28 ] (15 anti-inflammatory, 5 population with future stroke

www.co-clinicalnutrition.com
be calculated with access to
global data bases
 FFQ is mostly used in studies
that cannot estimate all
components from the DII list
measuring inflammatory pro-inflammatory) cases (population may have
biomarkers, when derived from SMC study cardiovascular risk factors)
investigated study including middle aged ! validation in other
population differs from female patients only ! cohorts awaited
validation studies’ may not be applicable
&&
Assessment of nutritional and metabolic status

! unclear, what impact it populations [18 ] in other study

has, if not all 45 food items
can be assessed [57]
 Certain food groups such populations
as pizza or alcohol are  Biomarker assessment
not necessarily necessary if tested in
consumed in other other populations
MCO 240502

&&
countries [18 ], even
though a reduced
number of food groups
can be applied [58]

CRP, c-reactive protein; FFQ, Food Frequency Questionnaire

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Assessing the (anti)-inflammatory potential of diets Bahr et al.
However, studies investigating their relationship to
& &
diet are inconsistent [38 ]. For example, in a Japa-
nese validation study, the DII was associated with IL-
6, but not CRP, and associations were found only in
men [39]. A recent review argued that ‘This incon-
sistency may be due to the shorter half-life of IL-6, so
that CRP is likely to remain in the serum longer and
because IL-6 triggers the production of CRP by the
liver’ and recommends to look at a wider range of
&
biomarkers [38 ].
Other considerations may be, macronutrient
composition, that might also affect inflammation
&&
(e.g., carbohydrate-restricted diets) [30 ], which is
considered in the DII and ISD, but not in the other
indices. In addition, currently not evaluated inter-
mittent fasting periods, could influence inflamma-
tion, even though this may be mediated by weight
loss [40].
Body weight is suspected to mediate associations
between dietary inflammatory potential and bio-
&&
markers [23,30 ,41]. Thus, effects of dietary inter-
ventions on inflammatory biomarkers should be
controlled for weight loss. A major advantage of
the DIS/LIS is the inclusion of other relevant lifestyle
factors. The study by Byrd et al. showed that diet in
conjunction with certain lifestyle factors such as
physical activity, smoking, and BMI collectively
&&
contributes to chronic inflammation [31 ].
Assessment of dietary inflammatory potential
of food groups or nutrients
All dietary inflammatory indices are suitable to
assess the inflammatory potential of a person’s diet.
In case one wants to assess the inflammatory poten-
tial of nutrients or food groups, a reduced rank
regression can be applied (inflammatory biomarkers
as dependent variables and food group or nutrients
&&
as independent variables) [30 ].
POTENTIAL FUTURE INFLAMMATORY
FOOD COMPONENTS
The dietary inflammatory potential is a highly
dynamic research field and recent research high-
lights possibly relevant dietary factors that are cur-
rently not included in the described indices.
Salt and ultra-processed foods
Salt intake is generally difficult to assess. It is not
included in the food lists of the DII/ISD, although it
asks for single nutrients. However, a high salt diet
has been shown to upregulate pro-inflammatory
responses in healthy humans [42]. Furthermore,
high salt intake is associated with pro-inflammatory
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responses in children and adolescents [43] and may
favor autoimmune diseases [44 ,45]. To improve the
assessment of salt intake, 24 h-recalls and, were
applicable, interview techniques that sensitize to
salty foods might be used. FFQs should contain
foods with high salt content or questions for the
quantification of added salt [46].
Common high salt intake in the Western diet is
often associated with ultra-processed foods (UPF)
[47,48]. One study has demonstrated that high UPF
consumption increased the odds of displaying
inflammation almost twice, compared with the
lowest consumption [49]. There were also positive
associations between UPF and CRP [50]. The fact
that fish consumption was positively associated
with pro-inflammatory markers in the Tabung
study [23] emphasizes the role of processing. The
authors claim that this may be due to the fish
preparation methods (e.g., frying), possibly provid-
ing trans fats, which are not captured by the FFQ. In
the same study, tomatoes were positively associated
with pro-inflammatory markers, whereas pizza was
inversely associated. It was suggested that the
amount of the bioavailable tomato component
lycopene would be much higher in tomato paste
than in fresh tomatoes [23]. Current dietary assess-
ment tools do not inquire food processing or quality
and databases merely quantify macro- and micro-
&
nutrient contents [36 ]. Both DII and ISD do not
consider food processing, eDII, eDII and DIS only
consider processed meat, refined grains and the
AIDI additionally chips.
Omega-3- and omega-6-fatty acids
The DII lists omega-6-fatty acids, omega-3-fatty
acids and total polyunsaturated fatty acids, but does
not differentiate between the sources of omega fatty
acids. Omega fatty acids are either plant-derived or
animal-derived. In general, omega-6- and 3-fatty
acids are thought to primarily exert pro- and anti-
inflammatory effects, respectively. However, this
might be an oversimplification.
In some studies, the source of omega fatty acids
plays a role in health outcomes. A 16-year study with
521,120 participants found that total omega-3-fatty
acid intake, plant-derived omega-3 alpha-linolenic
acid and animal-derived omega-6 arachidonic acid
was associated with increased mortality. In contrast,
animal-derived omega-3-fatty acids and plant-
derived omega-6-fatty acids were associated with
lower mortality [51]. In addition, higher biomarkers
of animal-derived omega-3-fatty acids were associ-
ated with a lower risk of type 2 diabetes, whereas
biomarkers of the plant-derived omega-3-fatty acid
were not [52]. Low levels of animal-derived omega-
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Assessment of nutritional and metabolic status
3-fatty acids were also associated with a risk of
inflammatory disorders [53]. Based on this evidence,
it seems to be useful to inquire the source of dietary
omega fatty acids. This might help shed further light
on their intricate effects on inflammation.
Nutritional supplements
Although nutritional supplements might have a
major impact on the inflammatory status of an
individual, they are not sufficiently captured by
current indices. Some examples are the short-chain
fatty acid propionate, probiotics, selenium, fish cap-
sules, and vitamin D. Nutritional supplements
might be overlooked by the FFQ, which asks only
for specific ones and neglects dosages altogether. In
case of the 24 h-recall, supplements will be missed if
they have not been taken on the day prior to assess-
ment. In addition, most indices do not consider
supplements at all. The DIS is the only tool so far
that asks for specific supplements.
CONCLUSION AND PRACTICAL
IMPLICATIONS
Assessing a person’s diet with a dietary inflamma-
tory index provides valuable information about
their dietary habits and can detect areas for improve-
ment. The use of such indices further allows evalua-
tion of dietary inflammatory effects on health
outcomes, comparisons across populations, and
can serve as a surrogate for inflammatory biomarker
measurements. However, one major limitation is
the risk of bias in dietary intake assessments on
which most of these indices are based on. Even
the use of validated tools entails the risk of biases
due to incomplete memory, under- and over-report-
ing, and social desirability. Additionally, analysis
software differs between studies and countries.
The appropriateness of the used tool depends on
the specific aim. If the goal is to compare the
inflammatory potential of diets across populations,
the DII is the best choice, because it makes use of
global databases and is widely established. Further,
the DII is suitable for the estimation of anti-inflam-
matory effects of dietary interventions. If the aim is
to investigate associations of a population’s inflam-
matory potential of diet with certain health out-
comes, the ISD can be used as well.
The indices DIS/LIS, AIDI and eDII - in contrast
to the DII and ISD - focus on dietary patterns. The
eDII does not require extensive dietary intake data
and may be suitable for a quick screening, but a
biomarker-founded validation is still pending. The
AIDI needs to be validated in further populations
and against other biomarkers. If the interplay of diet
8 www.co-clinicalnutrition.com
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and lifestyle is the focus, the DIS/LIS could be the
first choice. However, validation in further popula-
tions is pending, too. Generally, empirical derived
dietary patterns such as eDII and AIDI are popula-
tion-specific, thus limiting the transferability of
indices. However, indices focusing on dietary pat-
terns generate results that are easier to translate into
dietary guidelines and health policies, which is a
major advantage.
Additional foods and dietary factors that seem to
influence inflammation, such as high salt intake
and UPF, might be considered in future instrument
developments.
Acknowledgements
We would like to thank Kristina Norman for her valuable
input on this work.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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