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Nutrition in acute and chronic diseases

Mediators of dietary diversity score (DDS) on NAFLD in Iranian adults: a structural equation modeling study



The current study examines the association between the Dietary Diversity Score (DDS) and nonalcoholic fatty liver disease (NAFLD) in Iranian adults using structural equation modeling (SEM).


A sample of 3220 adults from the Amol Cohort Study was recruited for this cross-sectional study. Dietary acid load (DAL) and DDS were calculated using the data obtained from a validated food frequency questionnaire. Anthropometric parameters, blood pressure, biochemical measurements, and liver ultrasonography were evaluated according to standard protocols.


DDS was neither directly nor indirectly associated with a greater prevalence of NAFLD. In the second model (DDS sub-scores model), the association of DAL with NAFLD was fully mediated through waist circumference (WC) (of DAL to WC: β = 0.14, P < 0.0001, and of WC to NAFLD: β = 0.50, P < 0.001). Vegetable and fruit diversity scores had a significant negative indirect relationship with NAFLD prevalence through DAL (β = −0.06, P = 0.001, β = −0.10, P < 0.001, respectively). Meat diversity score was positively associated with NAFLD prevalence in a full mediational process through DAL (β = 0.12, P < 0.001). The SEM fit indices suggested a reasonably adequate fit of the data to the DDS model (Χ2/df = 4.76, GFI = 0.98, AGFI = 0.97, IFI = 0.97, CFI = 0.97, RMSEA = 0.03, and SRMR = 0.02) and its sub-scores model (Χ2/df = 4.72, GFI = 0.98, AGFI = 0.97, IFI = 0.95, CFI = 0.95, RMSEA = 0.03, and SRMR = 0.02).


Meat diversity and lack of vegetable and fruit diversity were indirectly associated with NAFLD prevalence through DAL and WC mediators. Interventions for NAFLD may be more successful if they target a lower intake of animal protein sources and dietary diversity, particularly vegetable and fruit diversity.

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Fig. 1: Study flowchart.
Fig. 2: Hypothesized model in which DAL and WC as mediating variables relate socio-demographic variables and DDS to NAFLD.
Fig. 3: Final structural model of relationship between DDS and NAFLD.
Fig. 4: Final structural model of relationship between DDS sub groups and NAFLD.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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We greatly appreciate the participants, healthcare executives in public health centers in Amol, and the GILDRC staff (, without whom the study would not have been possible.


This research was conducted by a grant from the research council of Iran University of Medical Sciences of Iran (IUMS) (grant NO: 99–2–30–19054).

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Authors and Affiliations



FZ, MK, AHF, MN, MRM, and AD were responsible for the study concept and design. AD and NM had full access to all data and took responsibility for the integrity of the data and the accuracy of the data analysis. MM, FST, and AA were involved in data collection. AD, NM, CC, and SC analyzed and interpreted the data. MH and AD wrote the initial draft of the manuscript. All authors revised the manuscript critically for important intellectual content and approved the final manuscript. FZ is the guarantor and takes responsibility for the paper as a whole.

Corresponding author

Correspondence to Farhad Zamani.

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The authors declare no competing interests.

Ethics approval

The current study was conducted according to the guidelines laid down in the Declaration of Helsinki, and procedures involving human subjects/patients were approved by the Iran University of Medical Sciences (IUMS) ethical committee (No. IR.IUMS.REC.1399.1393). Written informed consent was obtained from all participants prior to the study.

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Doustmohammadian, A., Amirkalali, B., Gholizadeh, E. et al. Mediators of dietary diversity score (DDS) on NAFLD in Iranian adults: a structural equation modeling study. Eur J Clin Nutr (2022).

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