Longitudinal Diet Quality Trajectories Suggest Targets for Diet Improvement in Early Childhood

Published:October 24, 2020DOI:



      There is little information about how diet quality evolves in early childhood, whether children exhibit varying diet quality trajectories, or which components of diet quality should be targeted for intervention.


      The goal of this study was to identify and evaluate trajectories of dietary quality in young children.


      This was a secondary analysis of an observational, longitudinal cohort study of non-Hispanic African American or White children and their parents from racially concordant households with 4 years of follow-up (up to 13 study visits). Data on mother, infant feeding, and body mass index were assessed at baseline. Diet was evaluated using 3-day diaries at each visit.


      Of 372 children enrolled, 349 children had at least 3 study visits with dietary data for this analysis. Participants were enrolled at age 3 years between March 2001 and August 2002 in Cincinnati, OH. Final study visits were conducted between February 2005 and June 2006.

      Main outcome measure

      The main outcome measure was the total Healthy Eating Index 2005 (HEI-2005) score and HEI-2005 component scores.

      Statistical analyses

      Diet quality trajectories were modeled using group-based modeling techniques.


      The total HEI-2005 score was low at age 3 years (mean ± standard error = 55.1 ± 0.4 of maximum 100 points) and remained stable to age 7 years (mean ± standard error = 54.0 ± 0.6; P = 0.08 for trend). Five HEI-2005 trajectory groups were identified, of which 1 declined and 1 improved over time. HEI-2005 component scores, except milk intake and meat/beans scores, differed significantly (all, P ≤ 0.02) among trajectory groups at age 3 years, and most differences were maintained at age 7 years. Total vegetables, dark green and orange vegetables and legumes, and whole grains component scores were low for all trajectory groups. Whole fruit; total fruit; saturated fat; and calories from solid fats, alcoholic beverages, and added sugars (SoFAAS) were highly variable among trajectory groups. Children in the lowest diet quality trajectory group were less likely to be breastfed and more likely to have been regular consumers of soft drinks (e.g., powdered drink mixes, sport drinks, or soda pop) before age 3 years.


      Young childhood diet quality was low at age 3 years and remained stable to age 7 years. Improving intake of vegetables and whole grains is needed for all children. Focused attention regarding increasing fruit intake and reducing SoFAAS may be needed for families at increased risk for low overall diet quality.


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        • Zive M.M.
        • Berry C.C.
        • Sallis J.F.
        • Frank G.C.
        • Nader P.R.
        Tracking dietary intake in white and Mexican-American children from age 4 to 12 years.
        J Am Diet Assoc. 2002; 102: 683-689
        • Mannino M.L.
        • Lee Y.
        • Mitchell D.C.
        • Smiciklas-Wright H.
        • Birch L.L.
        The quality of girls' diets declines and tracks across middle childhood.
        Int J Behav Nutr Phys Act. 2004; 1: 5
        • Madruga S.W.
        • Araujo C.L.
        • Bertoldi A.D.
        • Neutzling M.B.
        Tracking of dietary patterns from childhood to adolescence.
        Rev Saude Publica. 2012; 46: 376-386
        • Saavedra J.M.
        • Deming D.
        • Dattilo A.
        • Reidy K.
        Lessons from the feeding infants and toddlers study in North America: What children eat, and implications for obesity prevention.
        Ann Nutr Metab. 2013; 62: 27-36
        • Reidy K.C.
        • Deming D.M.
        • Briefel R.R.
        • Fox M.K.
        • Saavedra J.M.
        • Eldridge A.L.
        Early development of dietary patterns: Transitions in the contribution of food groups to total enery—Feeding Infants and Toddlers Study, 2008.
        BMC Nutr. 2017; 3: 1-14
        • Northstone K.
        • Emmett P.M.
        A comparison of methods to assess changes in dietary patterns from pregnancy to 4 years post-partum obtained using principal components analysis.
        Br J Nutr. 2008; 99: 1099-1106
        • Knol L.L.
        • Haughton B.
        • Fitzhugh E.C.
        Dietary patterns of young, low-income US children.
        J Am Diet Assoc. 2005; 105: 1765-1773
        • Lioret S.
        • Betoko A.
        • Forhan A.
        • et al.
        Dietary patterns track from infancy to preschool age: Cross-sectional and longitudinal perspectives.
        J Nutr. 2015; 145: 775-782
        • US Department of Agriculture, US Department of Health and Human Services
        Dietary Guidelines for Americans; 2005.
        US Department of Agriculture, Washington, DC2005
        • US Department of Agriculture, US Department of Health and Human Services
        Dietary Guidelines for Americans 2010. 7th ed. Washington, DC: US Department of Agriculture; 2010.
        7th ed. US Department of Agriculture, Washington, DC2010
      1. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans, 2015-2020. 8th ed. Washington, DC: US Department of Agriculture; 2015.

        • Guenther P.M.
        • Casavale K.O.
        • Reedy J.
        • et al.
        Update of the Healthy Eating Index: HEI-2010.
        J Acad Nutr Diet. 2013; 113: 569-580
        • Guenther P.M.
        • Reedy J.
        • Krebs-Smith S.M.
        Development of the Healthy Eating Index-2005.
        J Am Diet Assoc. 2008; 108: 1896-1901
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Scaglioni S.
        • De Cosmi V.
        • Ciappolino V.
        • Parazzini F.
        • Brambilla P.
        • Agostoni C.
        Factors influencing children's eating behaviours.
        Nutrients. 2018; 10: 706
        • Burdette H.L.
        • Whitaker R.C.
        • Hall W.C.
        • Daniels S.R.
        Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age.
        Am J Clin Nutr. 2006; 83: 550-558
        • Woo J.G.
        • Sucharew H.
        • Su W.
        • Khoury P.R.
        • Daniels S.R.
        • Kalkwarf H.J.
        Infant weight and length growth trajectories modeled using superimposition by translation and rotation are differentially associated with body composition components at 3 and 7 years of age.
        J Pediatr. 2018; 196: 182-188.e181
        • Wosje K.S.
        • Khoury P.R.
        • Claytor R.P.
        • et al.
        Dietary patterns associated with fat and bone mass in young children.
        Am J Clin Nutr. 2010; 92: 294-303
        • USDA Food and Nutrition Service. Special
        Supplemental Nutrition Program for Women, Infants, and Children (WIC). Accessed August 19, 2020.
        • Baughcum A.E.
        • Powers S.W.
        • Johnson S.B.
        • et al.
        Maternal feeding practices and beliefs and their relationships to overweight in early childhood.
        J Dev Behav Pediatr. 2001; 22: 391-408
        • Burdette H.L.
        • Whitaker R.C.
        • Hall W.C.
        • Daniels S.R.
        Maternal infant-feeding style and children's adiposity at 5 years of age.
        Arch Pediatr Adolesc Med. 2006; 160: 513-520
        • Wosje K.S.
        • Khoury P.R.
        • Claytor R.P.
        • Copeland K.A.
        • Kalkwarf H.J.
        • Daniels S.R.
        Adiposity and TV viewing are related to less bone accrual in young children.
        J Pediatr. 2009; 154: 79-85.e72
        • Schakel S.F.
        Maintaining a nutrient database in a changing marketplace: Keeping pace with changing food products—A research perspective.
        J Food Comp Anal. 2001; 14: 315-322
        • Schakel S.F.
        • Buzzard I.M.
        • Gebhardt S.E.
        Procedures for estimating nutrient values for food composition databases.
        J Food Comp and Anal. 1997; 10: 102-114
        • Schakel S.F.
        • Sievert Y.A.
        • Buzzard I.M.
        Sources of data for developing and maintaining a nutrient database.
        J Am Diet Assoc. 1988; 88: 1268-1271
      2. Nutrition Data System for Research, version 4.03. Nutrition Coordinating Center, Minneapolis, MN2000
      3. Nutrition Data System for Research, version 4.04. Nutrition Coordinating Center, Minneapolis, MN2001
      4. Nutrition Data System for Research, version 4.05. Nutrition Coordinating Center, Minneapolis, MN2002
      5. Nutrition Data System for Research, version 4.06. Nutrition Coordinating Center, Minneapolis, MN2003
      6. Nutrition Data System for Research, version 5.0. Nutrition Coordinating Center, Minneapolis, MN2004
      7. Nutrition Data System for Research, version 2005. Nutrition Coordinating Center, Minneapolis, MN2005
      8. Nutrition Data System for Research, version 2006. Nutrition Coordinating Center, Minneapolis, MN2006
      9. Nutrition Data System for Research, version 2015. Nutrition Coordinating Center, Minneapolis, MN2015
        • Ludwig D.A.
        • Landy D.C.
        • Kurtz J.M.
        • Miller T.L.
        Ludwig DA, Landy DC, Kurtz JM, Miller TL. Using SAS to expand the applicationof standard measures and guide statistical explorations: Creating Healthy Eating Index scores using Nutrition Data System for research output. Paper presented at: SAS Global Forum 2013; April 28-May 1, 2013; San Francisco, CA. Accessed September 23, 2020.
        • Kirkpatrick S.I.
        • Reedy J.
        • Krebs-Smith S.M.
        • et al.
        Applications of the Healthy Eating Index for surveillance, epidemiology, and intervention research: Considerations and caveats.
        J Acad Nutr Diet. 2018; 118: 1603-1621
        • Jones B.L.
        • Nagin D.S.
        • Roeder K.
        A SAS procedure based on mixture models for estimating developmental trajectories.
        Sociol Methods Res. 2001; 29: 374-393
        • Jones B.L.
        • Nagin D.S.
        Advances in group-based trajectory modeling and an SAS procedure for estimating them.
        Sociol Methods Res. 2007; 35: 542-571
        • Banfield E.C.
        • Liu Y.
        • Davis J.S.
        • Chang S.
        • Frazier-Wood A.C.
        Poor adherence to US dietary guidelines for children and adolescents in the National Health and Nutrition Examination Survey population.
        J Acad Nutr Diet. 2016; 116: 21-27
        • Rauber F.
        • Hoffman D.J.
        • Vitolo M.R.
        Diet quality from pre-school to school age in Brazilian children: A 4-year follow-up in a randomised control study.
        Br J Nutr. 2014; 111: 499-505
        • Jun S.
        • Catellier D.J.
        • Eldridge A.L.
        • Dwyer J.T.
        • Eicher-Miller H.A.
        • Bailey R.L.
        Usual nutrient intakes from the diets of US Children by WIC participation and income: Findings from the Feeding Infants and Toddlers Study (FITS) 2016.
        J Nutr. 2018; 148: 1567S-1574S
        • Ahluwalia N.
        • Herrick K.A.
        • Rossen L.M.
        • et al.
        Usual nutrient intakes of US infants and toddlers generally meet or exceed Dietary Reference Intakes: Findings from NHANES 2009-2012.
        Am J Clin Nutr. 2016; 104: 1167-1174
        • Eldridge A.L.
        • Catellier D.J.
        • Hampton J.C.
        • Dwyer J.T.
        • Bailey R.L.
        Trends in mean nutrient intakes of US infants, toddlers, and young children from 3 feeding infants and toddlers studies (FITS).
        J Nutr. 2019; 149: 1230-1237
        • Woo J.G.
        • Guerrero M.L.
        • Ruiz-Palacios G.M.
        • et al.
        Specific infant feeding practices do not consistently explain variation in anthropometry at age 1 year in urban United States, Mexico, and China cohorts.
        J Nutr. 2013; 143: 166-174
        • Woo J.G.
        • Herbers P.M.
        • McMahon R.J.
        • et al.
        Longitudinal development of infant complementary diet diversity in 3 international cohorts.
        J Pediatr. 2015; 167: 969-974.e961
        • Emmett P.M.
        • Jones L.R.
        Diet, growth, and obesity development throughout childhood in the Avon Longitudinal Study of Parents and Children.
        Nutr Rev. 2015; 73: 175-206
        • Au L.E.
        • Gurzo K.
        • Paolicelli C.
        • Whaley S.E.
        • Weinfield N.S.
        • Ritchie L.D.
        Diet quality of US infants and toddlers 7-24 months old in the WIC Infant and Toddler Feeding Practices Study-2.
        J Nutr. 2018; 148: 1786-1793
        • Hamner H.C.
        • Moore L.V.
        Dietary quality among children from 6 months to 4 years, NHANES 2011-2016.
        Am J Clin Nutr. 2020; 111: 61-69
        • Veugelers P.J.
        • Fitzgerald A.L.
        • Johnston E.
        Dietary intake and risk factors for poor diet quality among children in Nova Scotia.
        Can J Public Health. 2005; 96: 212-216
        • Worsley A.
        Nutrition knowledge and food consumption: Can nutrition knowledge change food behaviour?.
        Asia Pac J Clin Nutr. 2002; 11: S579-S585
        • Tester J.M.
        • Leung C.W.
        • Crawford P.B.
        Revised WIC food package and children's diet quality.
        Pediatrics. 2016; 137e20153557
        • Collins L.J.
        • Lacy K.E.
        • Campbell K.J.
        • McNaughton S.A.
        The predictors of diet quality among Australian children aged 3.5 years.
        J Acad Nutr Diet. 2016; 116: 1114-1126.e1112
        • Rose C.M.
        • Birch L.L.
        • Savage J.S.
        Dietary patterns in infancy are associated with child diet and weight outcomes at 6 years.
        Int J Obes (Lond). 2017; 41: 783-788
        • Woo J.G.
        • Martin L.J.
        Does breastfeeding protect against childhood obesity? Moving beyond observational evidence.
        Curr Obes Rep. 2015; 4: 207-216
        • Beauchamp G.K.
        • Mennella J.A.
        Flavor perception in human infants: Development and functional significance.
        Digestion. 2011; 83: 1-6
        • Birch L.L.
        • Fisher J.O.
        Development of eating behaviors among children and adolescents.
        Pediatrics. 1998; 101: 539-549
        • Mennella J.A.
        • Beauchamp G.K.
        Flavor experiences during formula feeding are related to preferences during childhood.
        Early Hum Dev. 2002; 68: 71-82
        • Leung C.W.
        • DiMatteo S.G.
        • Gosliner W.A.
        • Ritchie L.D.
        Sugar-sweetened beverage and water intake in relation to diet quality in U.S. children.
        Am J Prev Med. 2018; 54: 394-402
        • Laster L.E.
        • Lovelady C.A.
        • West D.G.
        • et al.
        Diet quality of overweight and obese mothers and their preschool children.
        J Acad Nutr Diet. 2013; 113: 1476-1483
        • Saldiva S.R.
        • Venancio S.I.
        • de Santana A.C.
        • da Silva Castro A.L.
        • Escuder M.M.
        • Giugliani E.R.
        The consumption of unhealthy foods by Brazilian children is influenced by their mother's educational level.
        Nutr J. 2014; 13: 33
        • de Hoog M.L.
        • Kleinman K.P.
        • Gillman M.W.
        • Vrijkotte T.G.
        • van Eijsden M.
        • Taveras E.M.
        Racial/ethnic and immigrant differences in early childhood diet quality.
        Public Health Nutr. 2014; 17: 1308-1317
        • Hiza H.A.
        • Casavale K.O.
        • Guenther P.M.
        • Davis C.A.
        Diet quality of Americans differs by age, sex, race/ethnicity, income, and education level.
        J Acad Nutr Diet. 2013; 113: 297-306
        • Ruder E.H.
        • Lohse B.
        • Mitchell D.C.
        • Cunningham-Sabo L.
        Parent food and eating behavior assessments predict targeted Healthy Eating Index components.
        J Nutr Educ Behav. 2019; 51: 711-718
        • Hedrick V.E.
        • Davy B.M.
        • You W.
        • Porter K.J.
        • Estabrooks P.A.
        • Zoellner J.M.
        Dietary quality changes in response to a sugar-sweetened beverage-reduction intervention: Results from the Talking Health randomized controlled clinical trial.
        Am J Clin Nutr. 2017; 105: 824-833


      J. G. Woo is a professor, Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.


      K. Reynolds is a medical student, University of Cincinnati College of Medicine, Cincinnati, OH.


      S. Summer is a clinical research manager, Clinical Translational Research Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.


      P. R. Khoury is a senior biostatistician, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.


      S. R. Daniels is a professor and chair, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.


      H. J. Kalkwarf is a professor, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.