Field Notes

Latest Version of the Healthy Eating Index Covers Toddler Diet Quality

In four articles in the Journal of Nutrition and Dietetics, published by Elsevier, leading nutrition experts describe and evaluate the latest versions of the Healthy Eating Index (HEI), issued to correspond to the 2020–2025 Dietary Guidelines for Americans (DGA). For the first time, there are two new HEIs, one for children and adults 2 years and older, and one for young children aged 12 through 23 months.

The Call to Action of the ninth edition of the DGA is “Make Every Bite Count.” These guidelines form the basis of nutrition policy for the United States Government and the foundation of all federal nutrition guidance. Developed to measure alignment with the evidence-based DGA, the HEI is a tool designed to measure diet quality—that is, how closely an eating pattern or mix of foods matches the recommendations in the DGA.

Four articles were written by the HEI team, through a collaboration between the US Department of Health and Human Services, National Cancer Institute, and the USDA Food and Nutrition Service.

Jill Reedy, PhD, MPH, RDN, a chief at the Risk Factor Assessment Branch of the National Cancer Institute, explains: “For the first time, the current DGA (2020–2025) includes a USDA Dietary Pattern for toddlers aged 12 through 23 months. The HEI has a long and robust history of evolving to align with the state of the science. The development of the HEI-Toddlers-2020 is a clear example of this and answers the call by the 2020 Dietary Guidelines Advisory Committee to ‘develop a dietary pattern scoring system, such as the Healthy Eating Index (HEI), for infants and children from birth to 24 months, considering findings from this report and future dietary guidance.’”

Reflecting the current DGA, the HEI articles cover the two separate indices: the HEI-2020 and the new HEI-Toddlers-2020. In addition to an introductory editorial, they include one article that highlights the HEI-2020 that was updated for children and adults (ie, 2 years and older), two articles on the new HEI-Toddlers-2020 that was developed and evaluated for toddlers 12 through 23 months, and an overarching article that discusses the continuity, considerations, and future directions for diet quality throughout the lifespan. They contribute to the growing literature on dietary patterns, toddler nutrition, and the healthy eating trajectory.

Both the HEI-Toddlers-2020 and the HEI-2020 have 13 components, each of which reflects an important aspect of diet quality. Nine components focus on adequacy (foods we should eat enough of to get the nutrients we need and for overall good health), and four components focus on moderation (dietary components that should be limited or consumed in small amounts). 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.

HEI-Toddlers-2020 and HEI-2020 radar plots including total scores for each age group are shown in the figure below. Total HEI scores across the lifespan are suboptimal with the highest scores being for young children aged 12 through 23 months (HEI-Toddlers-2020 Total Score 63.4) and adults aged 60 and older (HEI-2020 Total Score 59.5).

The HEI-Toddlers-2020, like HEI-2020, has 13 components reflecting all constituents of dietary intake, except for human milk or infant formula. Healthful dietary patterns for toddlers have unique considerations reflected in the scoring standards for added sugars and saturated fats, notably:

· a recommendation to avoid added sugars (the guidance for those aged 2 and older suggests limiting added sugars to less than 10% of kcal per day) and

· no recommendation to limit saturated fats to less than 10% of energy intake (the guidance for those aged 2 and older recommends limiting saturated fats to less than 10% of energy intake).

Kirsten A. Herrick, PhD, MSc, program director at the National Cancer Institute, and lead author of a contribution on the future directions of the HEI, comments: “The scientific evidence base may continue to evolve and lead to further refinement for tailored recommendations within the birth to 24 months age group, across the lifespan, and to other potential age groupings based on developmental milestones and other concepts about health over time.”

TusaRebecca Pannucci, PhD, MPH, RDN, branch chief at the USDA Food and Nutrition Service, and lead author of a contribution on the development of the HEI-Toddlers-2020, says: “The 2020–2025 edition of the DGA was the first to include comprehensive recommendations for dietary patterns in the second year of life and was the key driver in informing the creation of the HEI-Toddlers-2020. We recognize, as the DGA emphasizes, ‘every bite counts,’ and every shift toward a healthful dietary pattern should be acknowledged.”

Marissa M. Shams-White, PhD, MSTOM, MS, MPH, program director at the National Cancer Institute and lead author of a contribution on the review and update process for HEI 2020-2025, adds: “The HEI is used widely in different types of research, particularly as the concept of dietary patterns has grown and continues to evolve. There’s continued encouragement for research efforts to add to the scientific evidence base on dietary patterns and help address further methodological questions, including examining needs specific to each life stage and considerations for bridging across them."

The DGA was first published in 1980 and is updated every five years, leading to changes in emphasis and quantification. The DGA provides advice to consumers on what to eat and drink to meet nutrient needs, promote health, and prevent disease. The Dietary Guidelines Advisory Committee drafts a report about the guidelines for a professional audience, including policymakers, health care providers, nutrition educators, and federal nutrition program operators. A new HEI is issued to correspond to each new edition of the guidelines and to reflect these changes.

— Source: Elsevier

 

High Pregnancy Weight Gain Tied to Higher Risk of Later Death

Pregnant people who gained more than the now-recommended amount of weight had a higher risk of death from heart disease or diabetes in the decades that followed, according to new analysis of 50 years of data published in The Lancet and led by researchers from the Perelman School of Medicine at the University of Pennsylvania. The group studied a large national data set that stretched from when a person gave birth through the next five decades, assessing mortality rates to show the potential long-term effects of weight gain in pregnancy. Higher risk of death was found for all weight groups studied—including those defined as underweight, normal weight, or overweight before their pregnancies—but no increase in risk was uncovered among those who had been obese.

“We hope that this work leads to greater efforts to identify new, effective, and safe ways to support pregnant people in achieving a healthy weight gain,” says lead study author, Stefanie Hinkle, PhD, an assistant professor of epidemiology and obstetrics and gynecology at Penn. “We showed that gaining weight during pregnancy within the current guidelines may protect against possible negative impacts much later in life, and this builds upon evidence of the short-term benefits for both maternal health and the health of the baby.”

As in their previous work showing links between complications in pregnancy and higher death rates in the following years, Hinkle and her colleagues—who included members of Penn’s departments of biostatistics, epidemiology and informatics, and obstetrics and gynecology, as well as the Intramural Research Program of the National Institute of Child Health and Human Development—examined data from the Collaborative Perinatal Project. This project catalogued data from a racially diverse cohort of people who gave birth in the 1950s or 1960s and linked their records to mortality data that ran through 2016, approximately 50 years later. The researchers analyzed information from more than 45,000 people that included their BMIs, weight changes over pregnancy, and compared these data to modern recommendations. Those numbers were then linked first to deaths of any cause, then to deaths by cardiovascular- or diabetes-related causes.

Modern recommendations for weight gain during pregnancy were set in 2009 and are linked directly to a person’s weight at the start of their pregnancy. They range from 28 to 40 lbs for people considered “underweight” by BMI standards to 11 to 20 lbs for those considered “obese.” In the present day, almost one-half of those who are pregnant gain more weight than recommended.

Approximately 39% of the people in the cohort had died by 2016, and the death rate increased in correlation with prepregnancy BMI—those with the lowest BMI died at a lower rate than those with the highest BMI.

Among those who were “underweight” before pregnancy but gained more than the (now) recommended amount of weight, the risk of death related to heart disease climbed by 8%. Among those considered to be of “normal” weight before their pregnancy (which was roughly two-thirds of the cohort), all-cause mortality rose by 9% when they gained more weight than recommended, with their risk of heart disease-related death climbing by 20%. Finally, those considered “overweight” had a 12% increased risk of dying if they gained more weight than is now recommended, with a 12% increase in their risk of diabetes-related death.

The study found no correlation between high weight gain during pregnancy and subsequent deaths among those in the obese range. While their study wasn’t designed to look into that specific point, Hinkle says that it’s possible this group’s already-elevated death rate could have had a bearing on this finding.

Weight gain during pregnancy doesn’t happen in a vacuum, as health care access, nutrition, and stress all can play a significant factor in it. But now that they have a better picture of the long-term risks associated with unhealthy gains, Hinkle and her colleagues hope to find more that will help address the issue.

“We are committed to delving deeper into the various factors that can affect pregnant individuals' ability to achieve healthy weight gain during pregnancy,” Hinkle says. “Our team is dedicated to exploring the social, structural, biological, and individual aspects that play a role in this process.”

This study was funded by the Intramural Research Program of the Eunice Kennedy Shriver National Institutes of Child Health and Human Development.

— Source: Perelman School of Medicine at the University of Pennsylvania