Dietary Intake Mendelian Randomization: Assessment and Development of Methods for Instrument Selection and Robust Inference.

Background: Mendelian randomization (MR) uses genetic instruments (GI) to infer causality between exposures, like dietary intake, and health outcomes. Almost all MR of dietary intake use the full set of genome-wide significant (GWS) variants in the GI, and therefore, causal estimates are likely biased by variants that act indirectly on diet. Objective: First, we performed an assessment of the diet MR literature to evaluate the applications and approaches common in the field. Second, using conventional two-sample MR techniques with GWS variants, we evaluated whether MR could detect expected associations between six diet-health relationships supported by existing nutrition science literature. Third, we developed and tested methods for refining the GI using filtering and mediation-based approaches. Methods: Studies that performed MR of foods or beverages on any health outcome were identified in PubMed. We recorded how the GI was created, what dietary intake traits were studied, how the exclusion restriction assumption was evaluated, and what sensitivity tests were performed. We tested if conventional MR methods could detect established diet-health relationships by selecting a biomarker and disease outcome for each dietary trait (six positive controls total). This included oily fish intake on triglycerides (TG) and cardiovascular disease (CVD), alcohol intake on alanine aminotransferase (ALT) and liver cirrhosis, and white vs whole grain or brown bread on LDL cholesterol (LDL-C) and CVD. To refine the GI to better estimate the direct effect of diet by removing or accounting for the indirect effects of confounders, we tested two phenome-wide association study (PheWAS) based GI filtering approaches and a mediation approach via multivariable MR (MVMR). Causal inferences were estimated by the inverse variance weighted (IVW) and weighted median (WM) estimators and by MR-CAUSE. Results: There is a strong and rapidly expanding interest in applying MR to dietary intake exposures (178 studies identified with 76 published in 2024). Existing studies showed a wide range of methodological rigor, especially with respect to GI specificity, which raised concerns whether MR using GWS GIs can adequately evaluate diet-health relationships. In empirical testing, conventional two-sample MR methods on GWS GIs only identified the relationships between oily fish on TG and white vs whole grain or brown bread on LDL-C using the WM estimator, whereas no relationships were identified by the IVW estimator. Filtering the GI improved the ability to detect the expectation for diet-biomarker pairs (IVW, oily fish on TG: β=-0.12 [95% CI -0.18 to -0.054]; IVW, white vs whole grain or brown bread on LDL-C: β = 0.11 [95% CI 0.058 to 0.16]) but not diet-disease pairs. MR-CAUSE identified the only diet-disease association - white vs. whole grain or brown bread on CVD (γ=0.17 [95% credible interval, 0.09 to 0.25]). Furthermore, MR-CAUSE found that many diet-health relationships were impacted by confounding. We evaluated which traits contributed to confounding via the PheWAS results and found that body composition traits were the most prevalent confounders. The PheWAS output was used to prioritize traits for MVMR and rescued the expected direct effect of alcohol on ALT (β= 0.028 [95% CI 0.017 to 0.039]). Conclusion: MR studies of diet's causal role in health have flooded the literature; however, our inconsistent associations with positive and negative controls using multiple tests and filtering methods signal a need for caution. More thoughtful curation of the GI is critical to reduce confounding due to health and environmental factors when evaluating the causal effect of diet on health.