Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Nutrition and Health (including climate and ecological aspects)

Assessment of the Dutch Healthy Diet index 2015 in the Lifelines cohort study at baseline



Dietary indices are useful measures to investigate associations between dietary intake and disease development. The Dutch Healthy Diet index 2015 (DHD2015-index), a measure of diet quality, assesses adherence to the 2015 Dutch dietary guidelines. We assessed the DHD2015-index in the Lifelines cohort study, and compared calculations from basic and detailed dietary intake data.


Dietary intake was assessed with a specially developed Food Frequency Questionnaire (FFQ) called Flower-FFQ, which consists of one main questionnaire (heart-FFQ), which asks for intakes of major food groups, and three complementary questionnaires (petal-FFQs), which ask for detailed information on food types within major food groups of the heart-FFQ. The DHD2015-index was assessed using data from the total Flower-FFQ (for 56,982 participants), and using data from the heart-FFQ only (for 129,030 participants). Agreement between the two indices was assessed with correlation and cross-classification.


The median (25th−75th percentile) DHD2015-index score was 70 (60–80) for men and 76 (65–86) for women based on the Flower-FFQ, and 68 (58–78) for men and 73 (63–83) for women based on the heart-FFQ. The Kendall’s tau-b correlation coefficient between the two scores was 0.66. Cross-classification into quartiles of the DHD2015-index showed that 59–60% of participants were classified in the same quartile, 37% in the adjacent, and 4% in the non-adjacent.


Dietary data from the Flower-FFQ provide the most optimal information to assess the DHD2015-index. However, the DHD2015-index from the heart-FFQ showed good agreement with the index from the Flower-FFQ of ranking participants according to diet quality, and can be used when the DHD2015 index from the Flower-FFQ is not available.

Your institute does not have access to this article

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1

Data availability

Data may be obtained from a third party and are not publicly available. Researchers can apply to use the Lifelines data used in this study. More information about how to request Lifelines data and the conditions of use can be found on their website (


  1. Satija A, Yu E, Willett WC, Hu FB. Understanding nutritional epidemiology and its role in policy. Adv Nutr. 2015;6:5–18.

    Article  Google Scholar 

  2. Scholtens S, Smidt N, Swertz MA, Bakker SJ, Dotinga A, Vonk JM, et al. Cohort Profile: LifeLines, a three-generation cohort study and biobank. Int J Epidemiol. 2015;44:1172–80.

    Article  Google Scholar 

  3. Sijtsma A, Rienks J, van der Harst P, Navis G, Rosmalen JGM, Dotinga A. Cohort Profile Update: Lifelines, a three-generation cohort study and biobank. Int J Epidemiol. 2021; online ahead of print.

  4. Baart AM, Brouwer-Brolsma EM, Perenboom CWM, de Vries JHM, Feskens EJM. Dietary Intake in the Lifelines Cohort Study: Baseline Results from the Flower Food Frequency Questionnaire among 59,982 Participants. Nutrients. 2021;14:48.

    Article  Google Scholar 

  5. Brouwer-Brolsma EM, Perenboom C, Sluik D, van de Wiel A, Geelen A, Feskens EJM, et al. Development and external validation of the “Flower-FFQ”: A food frequency questionnaire designed for the Lifelines Cohort Study. Public Health Nutr. 2022;25:225–36.

    Google Scholar 

  6. Jacobs DR Jr, Tapsell LC. Food, not nutrients, is the fundamental unit in nutrition. Nutr Rev. 2007;65:439–50.

    PubMed  Google Scholar 

  7. Jacobs DR, Tapsell LC. Food synergy: The key to a healthy diet. Proc Nutr Soc. 2013;72:200–6.

    Article  Google Scholar 

  8. Hu FB. Dietary pattern analysis: A new direction in nutritional epidemiology. Curr Opin Lipido. 2002;13:3–9.

    CAS  Article  Google Scholar 

  9. Fransen HP, Ocke MC. Indices of diet quality. Curr Opin Clin Nutr Metab Care. 2008;11:559–65.

    Article  Google Scholar 

  10. Arvaniti F, Panagiotakos DB. Healthy indexes in public health practice and research: a review. Crit Rev Food Sci Nutr. 2008;48:317–27.

    Article  Google Scholar 

  11. Looman M, Feskens EJ, de Rijk M, Meijboom S, Biesbroek S, Temme EH, et al. Development and evaluation of the Dutch Healthy Diet index 2015. Public Health Nutr. 2017;20:2289–99.

    Article  Google Scholar 

  12. Health Council of the Netherlands. Dutch dietary guidelines 2015. Health Council of the Netherlands. 2015.

  13. Kromhout D, Spaaij CJ, de Goede J, Weggemans RM. The 2015 Dutch food-based dietary guidelines. Eur J Clin Nutr. 2016;70:869–78.

    CAS  Article  Google Scholar 

  14. NEVO-tabel, Dutch Food Composition Table 2011 / version 3. RIVM, the Netherlands. 2011.

  15. Willett W Nutritional Epidemiology. 3rd ed. New York: Oxford University Press. 2013.

  16. Rhee JJ, Sampson L, Cho E, Hughes MD, Hu FB, Willett WC. Comparison of methods to account for implausible reporting of energy intake in epidemiologic studies. Am J Epidemiol. 2015;181:225–33.

    Article  Google Scholar 

  17. de Rijk MG, Slotegraaf AI, Brouwer-Brolsma EM, Perenboom CWM, Feskens EJM, de Vries JHM. Development and evaluation of a diet quality screener to assess adherence to the Dutch food-based dietary guidelines. Br J Nutr. 2021:1–11.

  18. Brink E, van Rossum C, Postma-Smeets A, Stafleu A, Wolvers D, van Dooren C, et al. Development of healthy and sustainable food-based dietary guidelines for the Netherlands. Public Health Nutr. 2019;22:2419–35.

    Article  Google Scholar 

  19. Rossum CTM, Fransen HP, Verkaik-Kloosterman J, Buurma-Rethans EJM. Ocké MC Dutch National Food Consumption Survey 2007-2010: Diet of Children Aged 7 to 69 Years. RIVM, the Netherlands. 2011.

  20. Vart P, Gansevoort RT, Coresh J, Reijneveld SA, Bultmann U. Socioeconomic measures and CKD in the United States and The Netherlands. Clin J Am Soc Nephrol. 2013;8:1685–93.

    Article  Google Scholar 

  21. Wendel-Vos GC, Schuit AJ, Saris WH, Kromhout D. Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity. J Clin Epidemiol. 2003;56:1163–9.

    Article  Google Scholar 

  22. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr, Tudor-Locke C, et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43:1575–81.

    Article  Google Scholar 

  23. Lombard MJ, Steyn NP, Charlton KE, Senekal M. Application and interpretation of multiple statistical tests to evaluate validity of dietary intake assessment methods. Nutr J. 2015;14:40.

    Article  Google Scholar 

  24. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10.

    CAS  Article  Google Scholar 

  25. Imamura F, Micha R, Khatibzadeh S, Fahimi S, Shi P, Powles J, et al. Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment. Lancet Glob Health 2015;3:e132–42.

    Article  Google Scholar 

  26. Trijsburg L, Geelen A, Hollman PC, Hulshof PJ, Feskens EJ, Van’t Veer P, et al. BMI was found to be a consistent determinant related to misreporting of energy, protein and potassium intake using self-report and duplicate portion methods. Public Health Nutr. 2017;20:598–607.

    Article  Google Scholar 

  27. Naska A, Lagiou A, Lagiou P. Dietary assessment methods in epidemiological research: current state of the art and future prospects. F1000Res. 2017;6:926.

    Article  Google Scholar 

  28. Goldbohm RA, van ‘t Veer P, van den Brandt PA, van ‘t Hof MA, Brants HA, Sturmans F. et al. Reproducibility of a food frequency questionnaire and stability of dietary habits determined from five annually repeated measurements. Eur J Clin Nutr. 1995;49:420–9.

    CAS  PubMed  Google Scholar 

  29. Siebelink E, Geelen A, de Vries JH. Self-reported energy intake by FFQ compared with actual energy intake to maintain body weight in 516 adults. Br J Nutr. 2011;106:274–81.

    CAS  Article  Google Scholar 

  30. Streppel MT, de Vries JH, Meijboom S, Beekman M, de Craen AJ, Slagboom PE, et al. Relative validity of the food frequency questionnaire used to assess dietary intake in the Leiden Longevity Study. Nutr J. 2013;12:75.

    Article  Google Scholar 

Download references


The authors wish to acknowledge the services of the Lifelines Cohort Study, the contributing research centers delivering data to Lifelines and all study participants.


The Lifelines initiative has been made possible by subsidy from the Dutch Ministry of Health, Welfare and Sport, the Dutch Ministry of Economic Affairs, the University Medical Center Groningen (UMCG), Groningen University and the Provinces in the North of the Netherlands (Drenthe, Friesland, Groningen)

Author information

Authors and Affiliations



AMB conceived the study. EMBB and JHMV developed the Flower FFQ for the Lifelines cohort study. AMB analyzed the data, all authors interpreted the results. AMB wrote the manuscript, all authors critically reviewed it. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to A. Mireille Baart.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The Lifelines study is conducted according to the principles of the Declaration of Helsinki and according to the research code of the University Medical Center Groningen (UMCG). The Lifelines study is approved by the medical ethical committee of the UMCG, The Netherlands. All participants gave written informed consent.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information


Supplementary table 1. Participant characteristics across quartiles of the DHD2015-index based on the heart-FFQ (n=129,030)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Baart, A.M., Brouwer-Brolsma, E.M., de Jong, H.B.T. et al. Assessment of the Dutch Healthy Diet index 2015 in the Lifelines cohort study at baseline. Eur J Clin Nutr (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI:


Quick links