{
  "abstract": "BackgroundIn three national surveys, no cross-national ranking of diet-attributable metabolic burden was identified: the apparent ordering moved with the definition of the outcome and with the validity of the dietary index. Both were tested.\n\nSubjects/MethodsWe harmonised individual-participant data from national surveys in the USA (NHANES 2017-2018), Korea (KNHANES 2015-2021) and Mexico (ENSANUT 2018-2019); 56,365 adults in total, recovered Mexican blood-pressure data from the raw files, and defined metabolic syndrome (MetS) with a common five-component ATP III rule. We estimated survey-weighted sex-specific associations of the energy-adjusted Dietary Inflammatory Index (E-DII) with MetS, country-specific population-attributable fractions (PAFs) on a common counterfactual scale, and the E-DIIs correlation with log high-sensitivity C-reactive protein (hsCRP). A quantitative bias analysis examined whether validity differences could reverse the country ordering.\n\nResultsThe E-DII-MetS association was larger in women (USA OR 1.23, 95% CI 0.98-1.55; Korea 1.078, 1.028-1.132; Mexico 1.074, 0.992-1.163; interaction P=0.080) but disappeared without blood pressure in the outcome (pooled 1.065, 0.982-1.155; P=0.13). Female PAFs were 15.0%, 7.6% and 3.8%; no pairwise difference was distinguishable (all P[≥]0.23). E-DII validity was 0.137 in US women versus 0.040 in Korean women (P=2.0x10-4); the validity ratio was 0.29, correction reversed the observed ordering, and its interval straddled the reversal threshold.\n\nConclusionsNeither the direction nor the magnitude of cross-national differences in diet-attributable MetS burden was identified; the ordering was bounded by outcome definition and by index validity. Cross-national burden comparisons require local validation of both.",
  "abstract_shown": true,
  "affiliations": [
    "Ningbo City College of Vocational Technology"
  ],
  "article_type": "PUBLISHAHEADOFPRINT",
  "arxiv": null,
  "author_total": 2,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "S. Huang"
    },
    {
      "name": "X. Wang"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/5da07h0berm0w.bib",
  "cited_by": 1,
  "doi": "10.64898/2026.07.25.26358918",
  "fulltext_url": "https://www.medrxiv.org/content/10.64898/2026.07.25.26358918v3.full",
  "id": "5da07h0berm0w",
  "issns": [],
  "landing_url": "https://www.medrxiv.org/content/10.64898/2026.07.25.26358918v3",
  "language": null,
  "licence": "CC-BY-NC",
  "licence_label": "CC BY-NC",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "medrxiv",
      "epidemiology"
    ],
    [
      "openalex",
      "2739|Nutritional Studies and Diet"
    ]
  ],
  "openalex": "W7171647656",
  "pdf_url": "https://www.medrxiv.org/content/10.64898/2026.07.25.26358918v3.full.pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-07-25",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/5da07h0berm0w.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:21:21Z",
      "native_id": "10.64898/2026.07.25.26358918",
      "source": "medrxiv",
      "url": "https://www.medrxiv.org/content/10.64898/2026.07.25.26358918v3"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "medrxiv:epidemiology",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Outcome definition and index validity in cross-national comparisons of diet-attributable metabolic burden",
  "title_text": "Outcome definition and index validity in cross-national comparisons of diet-attributable metabolic burden",
  "type": "preprint",
  "updated_at": "2026-10-30T12:21:21Z",
  "url": "https://research.draconitic.com/paper/5da07h0berm0w",
  "venue": "medRxiv",
  "versions": []
}