Evaluation of the Healthy Eating Index-Toddlers-2020

Background: With the addition of new guidance for children from birth to 24 months in the Dietary Guidelines for Americans, 2020-2025 (DGA), a Healthy Eating Index (HEI) was developed for toddlers.

Objective: To evaluate the psychometric properties of the HEI-Toddlers-2020, 5 analyses relevant to construct and concurrent validity and 2 related to reliability were examined.

Design: Twenty-four-hour diet recall data from the cross-sectional National Health and Nutrition Examination Survey (2011-2018) were used. In addition, exemplary menus were analyzed.

Participants/setting: The main analytic sample included toddlers aged 12 through 23 months (n = 838), with additional analyses of toddlers aged 12 through 35 months (n = 1,717) from the United States. Included participants had valid diet recalls and available weight-for-age data.

Main outcome measures: Outcomes measures included HEI-Toddlers-2020 total and component scores on menus, population distributions, and correlations.

Statistical analyses: HEI total and component scores were calculated using menus from the American Academy of Pediatrics and Healthy Eating Research. Score means and distributions were estimated using a Markov Chain Monte Carlo approach with National Health and Nutrition Examination Survey data (2011-2018). Principal component analysis explored dimensions and Pearson correlations examined components, energy, and Cronbach α. In addition, HEI-Toddlers-2020 and HEI-2020 scores were compared for identical intakes at age 24 months.

Results: For validity, exemplary menus received high scores with the HEI-Toddlers-2020. The mean ± SE total HEI-Toddlers-2020 score for toddlers aged 12 through 23 months was 62.9 ± 0.78 and ranged from 40.1 to 84.4 (1^st to 99^th percentile). Correlation between diet quality and diet quantity was low (-0.15); the scree plot revealed multiple factors. In addition, total scores for identical intakes were approximately 1.5 points higher for HEI-Toddlers-2020 compared with HEI-2020 (difference range for component scores, -4.97 to 4.89). For reliability, most of the intercorrelations among components were low to moderate (0 to 0.49), with a few exceptions among related components. Cronbach α was .48. These results indicate that the index is multidimensional, with no single component driving the total score, and no unnecessary components that are highly correlated with another component.

Conclusions: The results demonstrated evidence supportive of validity and reliability. The HEI-Toddlers-2020 can be used to assess alignment with the DGA for toddlers.