The quality of diets among US children has been slowly improving during the last decade and a half, according to data from the National Health and Nutritional Examination Survey (NHANES) that were published in JAMA.

The estimated proportion of children with poor-quality diet significantly decreased from 76.8% to 56.1% from 1999 to 2016, whereas the estimated proportion of children with intermediate-quality diet significantly increased from 23.2% to 43.7%, noted the investigators. Despite these improvements, more than half of children in America still eat a poor-quality diet, as defined by <40% adherence to the American Heart Association (AHA) healthy diet, they said.

To investigate the eating habits of children, the investigation used data across 9 cycles of NHANES, including children aged 2 to 19 years who completed at least 1 valid 24-hour diet recall in which respondents reported all foods and beverages consumed during the previous 24 hours (midnight to midnight). Survey participants aged ≥12 years completed the dietary intervention on their own; proxy-assisted interviews were conducted for children aged 6 to 11 years, and proxy respondents reported diets for children aged ≤5 years or for those who could not self-report.

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The primary outcomes were the mean consumption of dietary components and proportion meeting targets of the AHA 200 continuous diet score (based on total fruits and vegetables, whole grains, fish and shellfish, sugar-sweetened beverages, and sodium). AHA secondary scores were also evaluated (nuts, seeds, and legumes; processed meat and saturated fat), as were the Healthy Eating Index (HEI-2015) score and other food groups and nutrients linked to major health outcomes and of current policy or general public interest.

For calculating AHA diet scores, intake of each dietary component was scored from 0 to 10 (beneficial components) and from 10 to 0 (harmful components). Poor diet was defined as <40% adherence, intermediate as 40% to 79.9% adherence, and ideal as at least 80% adherence. Higher diet scores indicate a better diet quality.

Trends in diet quality and intake of major food groups and nutrients were evaluated by age (2-5, 6-11, and 12-19 years), sex, race/ethnicity, parental education levels, family income, and household food security status. A total of 31,420 youth (mean age, 10.6 years; 49.1% female) who completed at least 1 valid 24-hour diet recall were included in the analysis, including 20,193 (64.3%) who also provided a second recall. From 1999 to 2016, the proportion of non-Hispanic white youth decreased from 59.6% to 50.6%, whereas the proportion of Mexican American youth increased from 11.0% to 16.3%.

From 1999 to 2016, estimated overall dietary quality improved, whether based on the AHA primary score, AHA secondary score, or HEI-2015 score. The estimated mean primary AHA score significantly increased from 14.8 to 18.8 out of 50 (an improvement of 27.0%), the estimated mean secondary AHA score significantly increased from 29.2 to 33.0 out of 80 (an improvement of 13%), and the estimated mean HEI-2015 score significantly increased from 44.6 to 49.6 out of 100 (an improvement of 11.2%).

Statistically significant changes were found among individual components of the diet scores: From 1999 to 2016, the estimated mean consumption of sugar-sweetened beverages significantly decreased from 2.0 to 1.0 servings per day. The estimated mean consumption of whole grains significantly increased from 0.46 to 0.95 servings per day, total fruits and vegetables from 1.62 to 1.81 servings per day, poultry from 0.28 to 0.36 servings per day, and eggs from 0.25 to 0.39 servings per day. The estimated mean consumption of sodium increased from 3166 mg/d to 3326 mg/d. Intakes of processed meat, refined grains, nuts and seeds, and fish and shellfish did not significantly change.

From 1999 to 2016, significant improvements in diet quality were observed among all subgroups, but with mostly persistent or increasing differences based on mean dietary scores or proportions having poor, intermediate, or ideal diet quality. The estimated proportion of youth having poor diet quality in 2015 to 2016 was 39.8% for ages 2 to 5 years, 52.5% for ages 6 to 11 years, and 66.6% for ages 12 to 19 years.

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“The findings support the need for rigorous evaluation of national and community strategies to improve diet quality to identify the most influential actions,” the authors concluded.


Liu J, Rehm CD, Onopa J, Mozaffarian D. Trends in diet quality among youth in the United States, 1999-2016. JAMA. 323(12):1161-1174.