Evaluation of the Healthy Eating Index-Toddlers-2020

Two a Priori Dietary Indices among Young Children in the Children's Healthy Living (CHL) Trial: Validation and Association with Health Outcomes

BACKGROUND

Children's diets affect multiple health outcomes. Dietary indices are a useful tool for quantifying the quality of the overall diet, but their performance may differ among children of different ages and in understudied populations.

OBJECTIVES

This analysis aimed to validate 2 dietary indices and examine their associations with physical body measures among 2-8-y-old children of the United States-Affiliated Pacific region.

METHODS

Data were collected on children (n = 2359) from 5 jurisdictions of the children's healthy living randomized control trial in independent cross-sectional cluster samples over 3-time points. Anthropometric measurements were taken, and dietary intakes were ascertained from 2 d of dietary records completed by caregivers. The Healthy Eating Index (HEI)-2020 and dietary approaches to stop hypertension (DASH) scores were calculated using a simple scoring algorithm, their construct validity and performance were evaluated, and associations with nutrient intake, body measures, and obesity status were examined using covariate-adjusted means and unconditional logistic regression.

RESULTS

We observed a wide range of variation in DASH (9-38 points) and HEI-2020 (10-94.7 points), clear separation of mean component scores by quintile of the total score, and multiple dimensions for each index. Significant trends in polyunsaturated and saturated fat were observed from the lowest to the highest quintile of HEI-2020 (12% higher and 21% reduction, respectively) but not for DASH. Significant differences by quintile of DASH and HEI-2020 were found for mean body mass index z-score among 6-8-y-olds and for waist circumference among boys and 6-8-y-olds. The odds of obesity exhibited statistically significant downward trends across quintiles of HEI-2020 among all participants and in all sexes and age groups, and across quintiles of DASH among all participants, boys and 6-8-y-olds.

CONCLUSIONS

We found that HEI-2020 is a better measure of dietary intake than DASH in this population of 2-8-y-old children of the United States-Affiliated Pacific region.

Association of household food insecurity with diet quality in a nationally representative sample of United States toddlers: a cross-sectional study

BACKGROUND

Although previous research has shown that food insecurity adversely affects diet quality in adults, this relationship is less consistently observed in children. However, studies in children have focused on those aged 2 y or older and the association of food insecurity with diet quality in children aged 12-23 mo is unclear.

OBJECTIVES

The objective was to determine the association of household food insecurity with diet quality, as indicated by Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020), in United States children aged 12-23 mo.

METHODS

The study used a cross-sectional design based on data from 2013-2014, 2015-2016, and 2017-March 2020 survey cycles of National Health and Nutrition Examination Survey. The primary sample included 708 children aged 12-23 mo with 1) complete data on food security, assessed via the United States Food Security Survey Module (USFSSM); 2) ≥1 d of reliable 24-h dietary recall data; and 3) reported energy intake from complementary foods/beverages (that is, foods and beverages other than human milk or infant formula). On the basis of responses to USFSSM, households were classified as food secure or food insecure. Proxies, typically parents, reported child's dietary intake. Diet quality was assessed using the HEI-Toddlers-2020. Linear regression analyses examined the association of household food security status with HEI-Toddlers-2020 total and component scores, adjusted for demographic characteristics.

RESULTS

Household food insecurity was significantly associated with lower HEI-Toddlers-2020 total score (estimate = -3.78; standard error = 1.06; P = 0.0007), as well as lower component scores for whole fruits (estimate = -0.56; standard error = 0.18; P = 0.003), and whole grains (estimate = -0.85; standard error = 0.35; P = 0.02).

CONCLUSIONS

The association of household food insecurity with lower diet quality in this study suggests that toddlers may not be shielded from household food shortages. Although consumption of certain food groups, such as whole grains, was inadequate in the overall sample of United States toddlers, food insecurity could exacerbate suboptimal intake of whole grains. Interventions to improve diet quality of young children must account for household food insecurity.

Measuring Dietary Quality Among Toddlers in the Feeding Infants and Toddlers Study, 2016, Using the New Healthy Eating Index-Toddlers-2020

BACKGROUND

Child diet can influence risk for obesity and other related noncommunicable diseases. Few studies have used the Healthy Eating Index (HEI)-Toddlers-2020 to assess diet quality among toddlers (children aged 12 to 23.9 months).

OBJECTIVE

The aim of this study was to examine diet quality among toddlers participating in the Feeding Infants and Toddlers Study, 2016, and determine differences by sociodemographic characteristics. Caregiver perception of how their toddler's diet aligns with HEI-Toddlers-2020 diet quality scores was also assessed.

DESIGN

This cross-sectional study used 24-hour dietary records collected in 2016.

PARTICIPANTS AND SETTING

Data were collected on toddlers ages 12 to 23.9 months (N = 1133) participating in the Feeding Infants and Toddlers Study, 2016.

MAIN OUTCOME MEASURES

Diet quality was assessed using the HEI-Toddlers-2020.

STATISTICAL ANALYSES PERFORMED

The population ratio method was used for all analyses using weighted data to estimate HEI-Toddlers-2020 scores overall and within subgroups. To determine significant differences of the HEI-Toddlers-2020 score between subgroups, pairwise t tests were used. Statistical significance at P < .05 was used as a cutoff for all 2-sided P values.

RESULTS

Average HEI-Toddlers-2020 score among toddlers ages 12 to 23.9 months participating in the Feeding Infants and Toddlers Study, 2016, was 71.2 out of a possible 100. Total scores (mean, standard error) varied by race and ethnicity with Hispanic toddlers having higher scores compared with non-Hispanic White toddlers (76.4 ± 2.5 vs 69.0 ± 1.2; P = .03) and by federal poverty level with those >200% of the poverty level having higher scores compared with those <100% of the poverty level (74.7 ± 1.5 vs 67.0 ± 2.6; P = .01).

CONCLUSIONS

Opportunities for improvement in dietary intake were identified using the new HEI-Toddlers-2020 to assess diet quality among children ages 12 to 23.9 months. Scores were indicative of toddlers consuming excess added sugars and lower-than-recommended amounts of seafood and plant proteins, greens and beans, whole grains, and vegetables. Interventions to improve diet quality in toddlers may benefit from focusing on foods children should eat more of along with foods to consume in moderation.

Efficacy of a 24-month behavioral intervention focused on sugary beverage reduction for Latino mother-infant dyads: evidence from a randomized controlled trial

BACKGROUND

Childhood obesity disproportionately impacts marginalized and under-resourced communities, particularly Latinos. Although consumption of sugar-sweetened beverages and juices (SSBJs) in infancy is linked to increased obesity, few early-life interventions have targeted SSBJ reduction.

OBJECTIVES

To determine the efficacy of a culturally tailored home intervention for reducing SSBJ intake and obesity risk in Latino mothers and infants.

METHODS

Mother-infant dyads (N = 210) were randomly assigned to 1 of 3 interventions for 2 years: 1) general health education (Control); 2) SSBJ intake reduction education (Intervention); 3) intervention plus home water delivery (Intervention + Water Delivery). Trained interventionists delivered education sessions 2 days/month during year 1 and 1 day/month during year 2. Mixed-effects models were used to examine changes in sugar consumption and weight-related outcomes over time by group for mothers and infants separately.

RESULTS

The mean prepregnancy BMI for mothers was 28.1 ± 5.6 kg/m2. Mothers receiving Intervention + Water Delivery demonstrated significantly greater reductions in consumption of free sugars from beverages from baseline to 12 months compared to the other 2 groups, where free sugars are total sugars except lactose (B: -7.98 g; 95% CI: (-13.96 g, -2.00 g), P = 0.009, PFDR= 0.036). However, this effect was not apparent in year 2. Group differences for infant sugar consumption followed a similar pattern but were smaller and nonsignificant. Weight-related outcomes were not significantly associated with treatment group for mothers or infants.

CONCLUSIONS

This intervention, combined with home delivery of bottled water, was effective in reducing sugar consumption from beverages for Latina mothers by roughly 8 g/day in the first year after childbirth. However, this effect was not maintained and was not significant for infants. More comprehensive and sustained strategies are likely needed to maintain efficacy and improve outcomes related to weight or body composition, particularly for infants. This trial was registered at clinicaltrials.gov as NCT03141346.

Association between the healthy eating index 2020 and heart failure among the U.S. middle-aged and older adults from NHANES 2005-2020: a cross-sectional study

Objective

This study aims to shed light on the correlation between Healthy Eating Index-2020 (HEI-2020) and heart failure (HF) in American adults aged 50 or above.

Methods

Data were from the National Health and Nutrition Examination Survey 2005-2020, encompassing 13,105 participants with an age of 50 or above. HEI-2020 score was utilized for rating the dietary quality. The link of HEI-2020 to HF was assessed via logistic regression, restricted cubic splines (RCS), generalized additive models (GAM), weighted quantile sum (WQS) regression, as well as quantile g-computation (Qgcomp) models.

Results

A negative association between HEI-2020 and HF risk was uncovered in middle-aged and older Americans (OR = 0.99, 95% CI: 0.98-1.00, p = 0.006). The highest quartile (Q4) exhibited a markedly lower HF risk than the lowest quartile (Q1) (OR = 0.70, 95% CI: 0.55-0.89, p = 0.004). RCS and GAM analyses demonstrated a linear dose-response relationship between HEI-2020 and HF. Finally, WQS regression and Qgcomp models revealed a beneficial combined influence of 13 dietary components on HF risk, with dairy and whole fruits emerging as the most influential.

Conclusion

Elevated HEI-2020 scores are linked to decreased HF risks among Americans aged 50 or above, suggesting that adherence to the Dietary Guidelines for Americans can mitigate HF risk.

Trends in Toddler Diet Quality in the United States: 1999 to 2018

BACKGROUND AND OBJECTIVES

Diet quality has improved over time for US adults and youth aged ≥2 years. Trends over time and disparities in the diet quality of toddlers 12 through 23 months old have not been documented. Our objective was to investigate the direction and magnitude of toddler diet quality trends from 1999 to 2018 overall and by household socioeconomic status.

METHODS

This serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data was performed with 2541 toddlers from 10 NHANES cycles from 1999 to 2018. Dietary intake was measured by NHANES study staff using proxy-reported 24-hour recalls. Healthy Eating Index-Toddlers-2020 total scores (0-100 points, higher scores indicate healthier diets) and component scores were calculated from the 24-hour dietary recalls using the population ratio method. Multivariable linear regression was used to evaluate the association between time in years (measured as the midpoint of each NHANES cycle) and diet quality.

RESULTS

Toddler diet quality improved significantly from 1999 to 2018 (P < .001), from 63.7 points on average in 1999-2000 to 67.7 points in 2017-2018. A significant positive linear trend in total diet quality was observed for all socioeconomic status groups (P < .05). Several dietary component scores improved, as follows: Whole Fruits (P < .001), Whole Grains (P = .016), Fatty Acids (P = .002), Refined Grains (P = .009), and Added Sugars (P < .001). Scores did not significantly change for Total Fruit, Total Vegetables, Greens and Beans, Dairy, Total Protein Foods, Seafood and Plant Proteins, Sodium, or Saturated Fats.

CONCLUSIONS

From 1999 to 2018, toddler diet quality improved significantly, but mean scores still fell short of dietary guidance.

Association of the Healthy Dietary Index 2020 and its components with chronic respiratory disease among U.S. adults

Background

Chronic respiratory disease is an important public health problem in the United States and globally. Diet, an important part of a healthy lifestyle, is also relevant to chronic respiratory health. We aimed to explore the relationship between overall dietary quality and the risk of chronic respiratory disease (CRD), include chronic bronchitis (CB), emphysema and asthma.

Method

A total of 4,499 United States adults were extracted from the National Health and Nutrition Examination Survey (NHANES) in 2017-2018. Diet quality was assessed using 2 day, 24 h dietary recall data and quantified as the Healthy Diet Index (HEI)-2020 score. Binary logistic regression models, restricted cubic splines (RCS) and generalized additive modeling (GAM), the weighted quartile sum (WQS) and qgcom models were used to assess the relationship between HEI-2020 scores and risk of CB, emphysema and asthma.

Results

High HEI-2020 scores are associated with low risk of chronic respiratory disease (CB: 0.98, 0.97-0.99; emphysema: 0.98, 0.97-0.99; asthma: 0.98, 0.97-0.99) and consistent results across different dietary variable categorization (Tertile: CB: 0.58, 0.42-0.81; asthma: 0.51, 0.35-0.74; Quartile: CB: 0.57, 0.34-0.97; asthma: 0.56, 0.36-0.86) and different weighting models. Negative dose-response relationship between dietary quality and risk of chronic respiratory disease also shown in RCS and GAM models. The WQS and qgcom models also showed a healthy mixing effect of dietary components on respiratory disease, with high-quality proteins, vegetables, and fruits making the heaviest contributions.

Conclusion

Higher HEI-2020 scores were associated with lower risk of CB, emphysema, and asthma. Following Dietary Guidelines for Americans 2020-2025 could support enhanced respiratory health.

Poor diet quality is associated with biochemical parameters of protein nutritional status after Roux-en-Y gastric bypass

OBJECTIVE

To assess diet quality and its association with body and biochemical parameters in patients who underwent Roux-en-Y gastric bypass (RYGB).

METHODS

Prospective observational study with individuals of both sexes subjected to RYGB. Body composition, biochemical parameters, and diet quality were assessed before and six months after RYGB. Diet quality was assessed by the Healthy Eating Index (HEI). Data were analyzed by the paired t-test or Wilcoxon signed-rank test, with a significance level of 5%. Spearman's correlation and simple linear regression were performed between variables.

RESULTS

The final sample included 34 patients. Their diet was classified as poor before and 6 mo after RYGB. BMI, fat mass, fat-free mass, waist perimeter, serum total protein, transthyretin, alpha-1-acid glycoprotein, and C-reactive protein decreased significantly (P < 0.05). Variations in the HEI score and caloric intake were associated with serum albumin and transthyretin (P < 0.05).

CONCLUSION

Poor diet quality was present before and six months after RYGB, and the study data suggest that poor diet quality is associated to a risk of loss of lean body mass and visceral protein six months after RYGB.

Dietary Patterns and Health: Insights From NESR Systematic Reviews to Inform the Dietary Guidelines for Americans

This perspective article shares unique insights from the extensive experience of the US Department of Agriculture Nutrition Evidence Systematic Review branch in conducting systematic reviews on dietary patterns and health outcomes to inform the Dietary Guidelines for Americans. Methodological approaches for reviewing dietary patterns research are described, including approaches to operationalizing definitions and analyzing labeled dietary patterns. The review also describes techniques for synthesizing dietary patterns research across life stages in systematic reviews that inform food-based, federal dietary guidance. Current research activities and recommendations for how to improve or address gaps in dietary patterns research in the future are also discussed.

Development of the Healthy Eating Index-Toddlers-2020

The Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020) is a measure for assessing how well a set of foods aligns with new guidance in the Dietary Guidelines for Americans, 2020-2025 (DGA) for toddlers aged 12 through 23 months. This new tool was developed using consistent features and the guiding principles of the HEI. The HEI-Toddlers-2020, like HEI-2020, has 13 components reflecting all constituents of dietary intake, except for human milk or infant formula. These components include the following: Total Fruits, Whole Fruits, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, Seafood and Plant Proteins, Fatty Acids, Refined Grains, Sodium, Added Sugars, and Saturated Fats. Healthy dietary patterns for toddlers have unique considerations reflected in the scoring standards for Added Sugars and Saturated Fats. Toddlers have lower energy intake relative to high nutrient needs and added sugars should be avoided. Another distinctive difference is that there is no recommendation to limit saturated fats to <10% of energy intake in this age group; however, saturated fats cannot be unlimited without displacing the energy available to achieve other food group and subgroup goals. Calculations using the HEI-Toddlers-2020, like the HEI-2020, result in a total score and a set of individual component scores that reveal a dietary pattern. The release of a HEI-Toddlers-2020 will enable assessment of diet quality that aligns with the DGA and support additional methodological research to examine needs specific to each life stage and how to model trajectories of healthy dietary patterns.

Continuity, Considerations, and Future Directions for the Healthy Eating Index-Toddlers-2020

The Dietary Guidelines for Americans, 2020-2025 includes guidance for infants and toddlers aged birth to 24 months. To assess alignment with this new guidance, the Healthy Eating Index (HEI)-Toddlers-2020 was developed for toddlers 12 through 23 months old. This monograph focuses on the continuity, considerations, and future directions of this new index for toddlers in the context of evolving dietary guidance. There is considerable continuity between the HEI-Toddlers-2020 and previous versions of the HEI. The same process, guiding principles, and features (with caveats) are repeated in the new index. However, there are unique considerations for measurement, analysis, and interpretation for the HEI-Toddlers-2020 that this article addresses, while identifying future directions for the HEI-Toddlers-2020. The continued evolution of dietary guidance for infants, toddlers, and young children will provide additional opportunities for index-based metrics: considering inclusion of multidimensional layers in dietary patterns, defining a healthy eating trajectory, bridging healthy eating across different life stages, and communicating the constructs of balance among dietary constituents.

Healthy Eating Index-2020: Review and Update Process to Reflect the Dietary Guidelines for Americans,2020-2025

The purpose of this review is to share the process for reviewing, updating, and developing the most recent version of the Healthy Eating Index-2020 (HEI-2020) for ages 2 and older, following the release of the Dietary Guidelines for Americans (DGA), 2020-2025. The overall review process included: 1) gathering information from the updated DGA, experts, and federal stakeholders; 2) considering substantive changes and needs for new development, keeping in mind the HEI's key features and guiding principles, the US Department of Agriculture's Dietary Patterns that serve as the foundation for the HEI, and scoring considerations; and 3) completing evaluation analyses, including the examination of content validity. The review process led to the development of the HEI-2020; a separate HEI-Toddlers-2020 was developed for ages 12 through 23 months. The 13 components and scoring standards of the HEI-2020 fully align with the HEI-2015, although the index was renamed to clarify that it aligned with the most recent 2020-2025 DGA. As the evidence informing the DGA continues to evolve, various aspects of the HEI may need to evolve in the future as well. Further methodological research is encouraged to add to the scientific evidence base on dietary patterns, to examine needs specific to each life stage, and to model optimal trajectories of healthy dietary patterns over the lifespan.