Changes in Toddler Diet Quality Between 12 and 24 Months Using the HEI-Toddlers-2020: A Secondary Analysis of a Prospective Cohort.

BACKGROUND

Taste preferences and eating habits develop in the first two years of life and often persist over time, influencing the risk of obesity, cardiovascular disease, and other chronic conditions. Although diet quality is known to decline from early childhood to adolescence, less is known about how dietary patterns evolve during toddlerhood.

OBJECTIVE

The aim of this study was to assess toddler diet quality using the Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020) and characterize longitudinal shifts in dietary components and patterns between 12 and 24 months of age.

DESIGN

This was a secondary analysis of children in a prospective cohort. Dietary recalls were collected at 12 and 24 months. HEI-Toddlers-2020 scores quantified diet quality, and dietary patterns were derived using principal component analysis (PCA).

PARTICIPANTS/

SETTING

Of the 254 children enrolled in the Growth and Adiposity in Newborns Study (GAINS) cohort in Kansas City, KS, 88 were excluded due to incomplete and/or invalid dietary data, yielding a final analytic sample of 166 children. Data were collected from November 2017-August 2022.

MAIN OUTCOME MEASURES: Diet quality was assessed using the HEI-Toddlers-2020 total and component scores. Emerging dietary patterns and shifts over time were identified.

STATISTICAL ANALYSES PERFORMED: Paired t-tests and Wilcoxon signed-rank tests assessed changes in HEI scores with effect sizes expressed as the correlation coefficient r. Radar plots visually depicted diet quality changes. PCA with varimax rotation identified dietary patterns, and paired t-tests evaluated changes in pattern adherence over time.

RESULTS

Mean HEI-Toddlers-2020 scores decreased from 59.8 at 12 months to 57.1 at 24 months (p=0.03; d=0.17), but the difference was not significant after FDR adjustment. Total HEI scores were below recommended levels at both time points. Component-level changes included decreased intake of total vegetables (p<0.001, r=0.33), and increased intake of refined grains (p=0.01, r=0.21) and added sugars (p<0.001, r=0.62). PCA at 12 months identified four dietary patterns: (PC1) high unsaturated fat, low dairy/saturated fat; (PC2) vegetable and plant protein; (PC3) fruit-rich, low added sugars; and (PC4) low whole grain, high refined grain and sodium. From 12 to 24 months, mean adherence scores decreased for PC1 (mean difference: -0.66, p<0.001), PC2 (mean difference: -0.40, p=0.02), and PC3 (mean difference: -0.61, p<0.001), and increased for PC4 (mean difference: 0.38, p=0.002).

CONCLUSIONS

Toddler diet quality was below recommendations at both 12 and 24 months. Modest changes over time reflected a consistent directional shift in dietary components and patterns, including reduced vegetable intake and increased consumption of refined grains and added sugars, suggesting early emergence of less healthful dietary patterns rather than a large decline in overall diet quality. Findings underscore the importance of early dietary interventions to support healthy eating trajectories.