Submitted to: Journal Of The American Dietetic Association
Publication Type: Other
Publication Acceptance Date: June 1, 2004
Publication Date: September 1, 2004
Citation: Nicklas, T. 2004. Assessing diet quality in children and adolescents. Journal of The American Dietetic Association. 104(9):1383-1384. Technical Abstract: Epidemiological studies of diet and chronic disease have traditionally focused on the relation between consumption of a single nutrient and chronic disease risk. However, most foods contain many nutrients, and intakes of one nutrient are often correlated with intakes of others. A limitation with the single-nutrient approach is that it does not allow for an assessment of nutrient interactions and their cumulative effect on health outcomes. Some investigators have attempted to relate the consumption of individual foods to chronic disease risk. However, diets are composed of many different foods that are usually consumed in combinations of foods and not solely by themselves. Epidemiological studies have shown that when researchers attempt to relate either a single nutrient or a specific food to health outcomes, the results have been modest at best. Moreover, the amount of variance that was explained in the health outcome was very small and of little public health significance. The single-food or the single-nutrient approach is rather simplistic and does not address the complexities of the human diet. The measurement of overall diet quality has been recommended as an alternative method to assess diet and health outcomes. In an attempt to measure how well Americans are meeting current dietary recommendations, the US Department of Agriculture developed a measure of overall diet quality--the Healthy Eating Index (HEI). The HEI is a 100-point diagnostic tool for measuring how well an individual's diet is in compliance with the Dietary Guidelines for Americans. The HEI is a measure of diet quality that is both food- and nutrient-based. A disadvantage of the HEI is that it has been used to rate the diets of all participants 2 years of age and older. Studies have shown that food choices are often influenced by sociodemographic variables such as age, sex, ethnicity, and socioeconomic status. Thus, it is unclear whether the HEI is successfully assessing eating habits that are reflective of children and adolescents. The study by Feskanich and colleagues is an attempt to modify the HEI to better address dietary issues that are specific to older children and adolescents. Thus,the investigators renamed the index the "Youth Healthy Eating Index" (YHEI). A major difference between the HEI and the YHEI is that the YHEI focuses more on healthy and unhealthy eating behaviors and food choices rather than direct calculation of nutrient intakes. Unlike the HEI, the YHEI focuses on foods high in trans-fatty acids and saturated fatty acids, high in added sugars, or low in fiber. Additional eating behaviors are considered and include multivitamin use, consumption of fried foods outside the home, consumption of visible animal fat, eating breakfast, and eating dinner with family members. Intuitively, it makes sense that these modifications to the HEI are reflective of behaviors in children and adolescents. However, the results showed that these additional eating behaviors in this cohort of children and adolescents contributed very little to the variation in the total score. Thus, it was concluded that these eating behaviors may be more useful in other populations that have more diverse eating behaviors. This further suggests that the use of a global diet quality index may not be appropriate for use with all Americans, and the index may need to be tailored to best fit the eating behaviors of specific age groups. Six components of the YHEI explained 85% of the variation in the total score, which included consumption of whole grains, fruit, soda and drinks, snack foods, dairy, and the meat ratio. In contrast, the HEI components did not contribute significantly and independently toward the total score in this age group. Although these results are interesting and suggest that measures of diet quality may need to be designed to address age-specific nutritional concerns, more studies are needed to confirm these findings, particularly in ethnically diverse samples of children and adolescents from varying socioeconomic backgrounds. Furthermore, additional work is needed to demonstrate the ability of such a measure to predict health outcomes. The development of a valid and reliable screening tool that assesses diet quality, particularly in children and adolescents, would be a valuable contribution to the dietetics profession. Many potential applications exist for such a screening tool: in nutrition education as a tool for teaching nutrition students a more tangible concept of diet quality, in community and clinical settings for teaching individuals ways they can improve the quality of their diet so that it meets the current Dietary Guidelines for Americans, and in research for looking at diet quality and health outcomes.