Dietary and Complementary Feeding Practices of US Infants, 6 to 12 Months: A Narrative Review of the Federal Nutrition Monitoring Data

Complementary foods and beverages (CFBs) are key components of an infant's diet in the second 6 months of life. This article summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFBs sometime before 6 months. The primary mode of feeding (ie, human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFBs is associated with the timing of introduction and types of CFBs reported. FMF infants (42%) are more likely to be introduced to CFBs before 4 months compared with HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed, including fruit, grains, dairy, proteins, and solid fats. Compared with HMF infants of the same age, FMF infants consume more total energy (845 vs 631 kcal) and protein (22 vs 12 g) from all sources, and more energy (345 vs 204 kcal) and protein (11 vs 6 g) from CFBs alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs 7%), zinc (54% vs <3%), and protein (27% vs <3%). FMF infants are more likely to have an early introduction (<12 months) to fruit juice (45% vs 20%) and cow's milk (36% vs 24%). Registered dietitian nutritionists and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could refine findings from this analysis.

Frequency of Eating in the US Population: A Narrative Review of the 2020 Dietary Guidelines Advisory Committee Report

Background

A person's daily nutrient intake and overall nutritional status are determined by a complex interplay of the types and amounts of foods ingested in combination with the timing and frequency of eating.

Objectives

The aim was to summarize frequency of eating occasion data examined by the 2020 Dietary Guidelines Advisory Committee, the macronutrient contributions they provide, and meal frequency relative to dietary quality among the US population (≥2 y), with a focus on sex, age, race/Hispanic origin, and income.

Methods

Demographic and 24-h recall data from the 2013-2016 NHANES were examined. An eating occasion was defined as "any ingestive event (e.g., solid food, beverage, water) that is either energy yielding or non-energy yielding"; all eating occasions were further divided into discrete meals and snacks. Frequency of meals and snacks was defined as "the number of daily EOs [eating occasions]," respectively. Diet quality was assessed via the Healthy Eating Index (HEI)-2015.

Results

Most Americans consume 2 (28%) to 3 (64%) meals on a given day and >90% consume 2 to 3 snacks on that day. Adult, Hispanic, and non-Hispanic Black and lower-income (<131% family poverty-to-income ratio) Americans had a lower frequency of eating than children or adolescents, non-Hispanic White, and non-Hispanic Asian Americans and higher-income Americans, respectively. Americans who reported 3 meals on a given day consumed a diet higher in dietary quality than Americans who consumed 2 meals on a given day (HEI-2015: 61.0 vs. 55.0), regardless of population subgroup.

Conclusions

The frequency of the types of eating occasions differs according to age, race and Hispanic origin, and income. Dietary quality is associated with the number of meals consumed. Healthy dietary patterns can be constructed in a variety of ways to suit different life stages, cultural practices, and income levels; improved diet quality and careful consideration of nutrient density when planning meals are warranted.

Measuring Diet Quality Across the Lifespan: Introducing the New Healthy Eating Index-Toddlers-2020 and Healthy Eating Index-2020

Objectives

Researchers at the National Cancer Institute (NCI) and the U.S. Department of Agriculture (USDA) collaborated to update the Healthy Eating Index (HEI) based on the 2020–2025 Dietary Guidelines for Americans (DGA).

Methods

The USDA's Dietary Patterns serve as the foundation for the HEI and provide standards to assess alignment with the DGA. Given that these dietary patterns for Americans 2 years and older remained virtually unchanged from the 2015–2020 DGA and there were no major changes in key recommendations, the components and scoring for HEI-2020 align fully with HEI-2015. However, guidance and distinct dietary patterns were introduced for toddlers ages 12–23 months (700–1,000 calories). Thus, a new index, HEI-Toddlers-2020, was developed and evaluated. Sensitivity analyses examined standards based on key recommendations rather than dietary patterns for Added Sugars and Sodium, compared the two sets of 1,000 calorie standards for Whole Grains and Refined Grains, and evaluated varying considerations with fat-specific constructs, as Saturated Fat is not restricted for children under 2 years.

Results

The 13 components for HEI-Toddlers-2020 are the same as those in HEI-2020. However, the standards and scoring approach for HEI-Toddlers-2020 have key differences and highlight the focused guidance for this age group. The standards for all maximum scores—except Added Sugars and Sodium—are based on the least-restrictive profiles from the dietary patterns (Added Sugars and Sodium draw on the key recommendations). The standards for minimum scores for Total Fruit, Whole Fruit, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, and Seafood and Plant Proteins are zero; for other components—Fatty Acids, Refined Grains, Sodium, Added Sugars, and Saturated Fats—standards are set at the 15^th (Fatty Acids) or 85^th (all others) percentiles of 1-day intake distributions from the 2007–2018 National Health and Nutrition Examination Survey.

Conclusions

The new HEI-Toddlers-2020 and updated HEI-2020 can be used to assess diet quality beginning at age 12 months. The consistency in component approach enables optimal bridging, and further research will inform how the indices can be used in conjunction to assess diet quality across the lifespan.

Funding Sources

None.

Development of Food Pattern Recommendations for Infants and Toddlers 6-24 Months of Age to Support the Dietary Guidelines for Americans, 2020-2025

BACKGROUND

Developing food-based dietary guidelines (FBDGs) for infants and toddlers is a complex task that few countries have attempted.

OBJECTIVES

Our objectives are to describe the process of food pattern modeling (FPM) conducted to develop FBDGs for the Dietary Guidelines for Americans, 2020-2025 for infants 6 to <12 mo and toddlers 12 to <24 mo of age, as well as the implications of the results and areas needing further work.

METHODS

The US 2020 Dietary Guidelines Advisory Committee, with the support of federal staff, conducted FPM analyses using 5 steps: 1) identified energy intake targets; 2) established nutritional goals; 3) identified food groupings and expected amounts, using 3 options for the amount of energy from human milk in each age interval; 4) estimated expected nutrient intakes for each scenario, based on nutrient-dense representative foods; and 5) evaluated expected nutrient intakes against nutritional goals.

RESULTS

For human milk-fed infants (and toddlers), example combinations of complementary foods and beverages were developed that come close to meeting almost all nutrient recommendations if iron-fortified infant cereals are included at 6 to <12 mo of age. These combinations would also be suitable for formula-fed infants. For toddlers not fed human milk, 2 patterns were developed: the Healthy US-Style Pattern and the Healthy Vegetarian Pattern (a lacto-ovo vegetarian pattern). Achieving nutrient recommendations left virtually no remaining energy for added sugars.

CONCLUSIONS

It is challenging to meet all nutrient needs during these age intervals. Added sugars should be avoided for infants and toddlers <2 y of age. Further work is needed to 1) establish a reference human milk composition profile, 2) update and strengthen the DRI values for these age groups, and 3) use optimization modeling, in combination with FPM, to identify combinations of foods that meet all nutritional goals.

Healthy Eating Index Protocol: Review, Update, and Development Process to Reflect Dietary Guidance Across the Lifespan

Objectives

The Healthy Eating Index (HEI) is a measure of diet quality, independent of quantity, that can be used to assess alignment with the Dietary Guidelines for Americans (DGAs), which are the basis of nutrition policy for the United States (US) government and the foundation of all federal nutrition guidance. The recently released 2020–2025 DGAs include recommendations for infants and toddlers for the first time, and necessitate a review, update, and development process of the HEI to reflect healthy eating across the lifespan.

Methods

Since 2005, researchers at the HHS National Cancer Institute (NCI) and the USDA Center for Nutrition Policy and Promotion have collaborated to revise the HEI based on updates to the DGAs, and the HEI-2015 is the most recent iteration. The process includes: 1) gathering information from dietary guidelines, experts, and federal stakeholders; 2) considering substantive changes and needs for new development; and 3) completing validation analyses.

Results

Updates to the HEI have aimed to maintain stability, reflecting the consistency of recommendations over time. A guiding principle is to only make changes to the HEI that have a strong rationale. With no significant changes in the USDA Dietary Patterns, few changes are anticipated for the HEI for 2 years and older; instead, the emphasis for the update process is focusing on considerations for an index for infants and toddlers under 2 years. Additionally, the Scientific Report of the 2020 Dietary Guidelines Advisory Committee identified the development of a scoring system (such as the HEI) for infants and toddlers as a research recommendation, because comparisons of diet quality using the HEI have thus far only been possible for Americans 2 years and older. The HEI review, update, and development process aims to consider analyses with distributions of HEI scores across the lifespan with nationally representative data and diverse cohorts.

Conclusions

The HEI is a valuable tool for research that can be used in nutrition interventions, epidemiology, and consumer nutrition education programs. The timely release of a new HEI will enable application across the lifespan and support additional methodological research to examine needs specific to each life stage and how to model optimal trajectories of healthy dietary patterns.

Funding Sources

None.

A Proposed Framework for Identifying Nutrients and Food Components of Public Health Relevance in the Dietary Guidelines for Americans

BACKGROUND

Identification of nutrients of public health concern has been a hallmark of the Dietary Guidelines for Americans (DGA); however, a formal systematic process for identifying them has not been published.

OBJECTIVES

We aimed to propose a framework for identifying "nutrients or food components" (NFCs) of public health relevance to inform the DGA.

METHODS

The proposed framework consists of 1) defining terminology; 2) establishing quantitative thresholds to identify NFCs; and 3) examining national data. The proposed framework utilizes available data from 3 key data sources or "prongs": 1) dietary intakes; 2) biological endpoints; and 3) clinical health consequences such as prevalence of health conditions, directly or indirectly through validated surrogate markers.

RESULTS

In identifying potential NFCs of public health concern, the 2020 DGA Committee developed a decision-tree framework with suggestions for combining the 3 prongs. The identified NFCs of public health concern for Americans ≥1 y old included fiber, calcium (≥2 y old), vitamin D, and potassium for low intakes and sodium, added sugars, and saturated fats (≥2 y old) for high intakes that were associated with adverse health consequences. Iron was identified among infants ages 6-12 mo fed human milk. For reproductive-aged and pregnant females, iron (all trimesters) and folate (first trimester) were identified for low intake, based on dietary and biomarker data (iron) or the severity of the consequence (folic acid and neural tube defects). Among pregnant women, low iodine was of potential public health concern based on biomarker data. Other NFCs that were underconsumed, overconsumed, and pose special challenges were identified across the life course.

CONCLUSIONS

The proposed decision-tree framework was intended to streamline and add transparency to the work of this and future Dietary Guidelines Advisory Committees to identify NFCs that need to be encouraged or discouraged in order to help reduce risk of chronic disease and promote health and energy balance in the population.

Usage of the Healthy Eating Index-2015 (HEI-2015) (P13-031-19)

Objectives

With each iteration of the Dietary Guidelines for Americans (DGA) since 2005, scientists from the U.S. Department of Agriculture and the National Cancer Institute (NCI) have updated and released a Healthy Eating Index (HEI) to measure alignment with federal dietary guidance. The HEI-2015, which includes the 13 dietary components emphasized in the 2015–2020 DGA, was released in April 2017, and details about its development, evaluation, and applications were published in September 2018. Examination of research using the HEI-2015 and resources designed to facilitate its application are critical for researchers who study dietary quality and dietary patterns and can inform key stakeholders and scientists participating in the ongoing refinement of the index and its supporting resources.

Methods

To evaluate use of resources related to the HEI-2015, we reviewed Adobe Analytics reports on the NCI HEI-2015 webpages, the main website containing background and detailed information about the application HEI-2015. We searched PubMed and Google Scholar abstracts to determine the number publications (including abstracts, poster presentations, and dissertations) that used the HEI-2015.

Results

In 2017–18, there were 87,130 page views of the NCI HEI webpages, of which 9244 were unique visitors to the HEI-2015 homepage. There were 3946 unique visitors to the “Calculating HEI Scores” webpage and 2502 unique visitors to the “SAS code” page. As of January 2019, there were 35 peer-reviewed publications utilizing the HEI-2015. A Google Scholar search yielded 20 abstracts, poster presentations, and dissertations that utilized the HEI-2015.

Conclusions

Usage of the latest iteration of the Healthy Eating Index, HEI 2015, has been growing in the only 20 months since its release in 2017. Publications using it include a range of topics, such as economic research, epidemiology, surveillance, and sustainability. Given the relatively small number of publications, abstracts or posters that have used the HEI-2015, and the large number of unique visitors to the HEI website, especially the SAS code webpage, many more applications of the HEI-2015 are anticipated in the near future.

Funding Sources

None.