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

Abstract

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.

FIGURE 1

HEI-Toddlers total score among US toddlers 12 through 23 months old in the NHANES 1999 to 2018. HEI-Toddlers total scores range from 0 to 100 points, with higher scores indicating better diet quality. The mean scores in this figure were generated by using the NCI’s population ratio method, the recommended analytic method for mean scores for population-level nutrition monitoring. The P value for linear trend test is for scores generated using the simple scoring method, followed by a linear regression model that treated time as a continuous variable using the midpoint of each NHANES cycle, as follows: β = 0.28 (SE: 0.061) P < .001. In a sensitivity analysis with the 2011 to 2012 cycle excluded, β = 0.24 (SE: 0.063) and P < .001.

FIGURE 2

HEI-Toddlers component scores for 1999–2000 versus 2017–2018 TNHANES cycles scored using the population ratio method, the recommended analytic method for mean scores for nutrition monitoring. On the radar plots, each component score is plotted as a percentage of its maximum points. The outer edge of the “wheel” represents 100% of the maximum score for that component; the center represents 0% of the maximum score for that component. Therefore, a plot with many points along the edge of the wheel indicates better diet quality than plots with few points along the outer edge. Additional information on how to construct or interpret HEI radar plots can be found on the NCI Web site: https://epi.grants.cancer.gov/hei/interpret-visualize-hei-scores.html.

FIGURE 3

HEI-Toddlers component scores for NHANES 1999 to 2018 scored using the population ratio method, the recommended analytic method for mean scores for nutrition monitoring. Adequacy components are dietary components to eat more of for good health; high scores reflect high intakes. Adequacy components are scored out of 5 points for paired food groupings (ie, Total Fruits and Whole Fruits, Total Vegetables and Greens and Beans, Total Protein Foods and Seafood and Plant Proteins); all other adequacy components are scored out of 10 points. Moderation components are dietary components of which to eat less for good health; high scores reflect low intakes. All moderation components are scored out of 10 points.

FIGURE 4

Rate of change in HEI-Toddlers component score points for adequacy and moderation components calculated using the population ratio method.

FIGURE 5

HEI-Toddlers total score by SES and NHANES cycle. Symbols indicate covariate-adjusted means from the simple scoring method. Low SES is defined as toddlers with caregivers with <12 years educational attainment and a PIR <1.30; high SES is defined as toddlers with caregivers with >12 years of education attainment and a PIR ≥3.5; and all other respondents not missing caregiver educational attainment or PIR data were classified as medium SES. P values are from linear trend tests stratified by SES group, as follows: high SES P = .039; low SES P = .037; medium SES P < .001.