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Original Investigation
March 24/31, 2020

Trends in Diet Quality Among Youth in the United States, 1999-2016

Author Affiliations
  • 1Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
  • 2Office of Community and Population Health, Montefiore Medical Center, Bronx, New York
  • 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
JAMA. 2020;323(12):1161-1174. doi:10.1001/jama.2020.0878
Key Points

Question  What was the quality of diets among youth in the United States and how did it change between 1999 and 2016?

Findings  In this serial cross-sectional analysis of nationally representative data from 31 420 youth, diet quality modestly improved from 1999-2000 to 2015-2016 based on validated dietary quality scores. The estimated proportion of children with poor-quality diet significantly decreased (from 76.8% to 56.1%), the estimated proportion with intermediate quality diet significantly increased (from 23.2% to 43.7%), and the estimated proportion with an ideal quality significantly increased but remained low (from 0.07% to 0.25%).

Meaning  From 1999 to 2016, the estimated overall diet quality of US youth modestly improved, but more than half of children still had poor-quality diets.


Importance  Prior studies of dietary trends among US youth have evaluated major macronutrients or only a few foods or have used older data.

Objective  To characterize trends in diet quality among US youth.

Design, Setting, and Participants  Serial cross-sectional investigation using 24-hour dietary recalls from youth aged 2 to 19 years from 9 National Health and Nutrition Examination Survey (NHANES) cycles (1999-2016).

Exposures  Calendar year and population sociodemographic characteristics.

Main Outcomes and Measures  The primary outcomes were the survey-weighted, energy-adjusted mean consumption of dietary components and proportion meeting targets of the American Heart Association (AHA) 2020 continuous diet score (range, 0-50; based on total fruits and vegetables, whole grains, fish and shellfish, sugar-sweetened beverages, and sodium). Additional outcomes were the AHA secondary score (range, 0-80; adding nuts, seeds, and legumes; processed meat; and saturated fat) and Healthy Eating Index (HEI) 2015 score (range, 0-100). Poor diet was defined as less than 40% adherence (scores, <20 for primary and <32 for secondary AHA scores); intermediate as 40% to 79.9% adherence (scores, 20-39.9 and 32-63.9, respectively); and ideal, as at least 80% adherence (scores, ≥40 and ≥64, respectively). Higher diet scores indicate better diet quality; a minimal clinically important difference has not been quantified.

Results  Of 31 420 youth aged 2 to 19 years included, the mean age was 10.6 years; 49.1% were female. From 1999 to 2016, the estimated AHA primary diet score significantly increased from 14.8 (95% CI, 14.1-15.4) to 18.8 (95% CI, 18.1-19.6) (27.0% improvement), the estimated AHA secondary diet score from 29.2 (95% CI, 28.1-30.4) to 33.0 (95% CI, 32.0-33.9) (13.0% improvement), and the estimated HEI-2015 score from 44.6 (95% CI, 43.5-45.8) to 49.6 (95% CI, 48.5-50.8) (11.2% improvement) (P < .001 for trend for each). Based on the AHA primary diet score, the estimated proportion of youth with poor diets significantly declined from 76.8% (95% CI, 72.9%-80.2%) to 56.1% (95% CI, 51.4%-60.7%) and with intermediate diets significantly increased from 23.2% (95% CI, 19.8%-26.9%) to 43.7% (95% CI, 39.1%-48.3%) (P < .001 for trend for each). The estimated proportion meeting ideal quality significantly increased but remained low, from 0.07% (95% CI, 0.01%-0.49%) to 0.25% (95% CI, 0.10%-0.62%) (P = .03 for trend). Persistent dietary variations were identified across multiple sociodemographic groups. The estimated proportion of youth with a poor diet in 2015-2016 was 39.8% (95% CI, 35.1%-44.5%) for ages 2 to 5 years (unweighted n = 666), 52.5% (95% CI, 46.4%-58.5%) for ages 6 to 11 years (unweighted n = 1040), and 66.6% (95% CI, 61.4%-71.4%) for ages 12 to 19 years (unweighted n = 1195), with persistent differences across levels of parental education, household income, and household food security status.

Conclusions and Relevance  Based on serial NHANES surveys from 1999 to 2016, the estimated overall diet quality of US youth showed modest improvement, but more than half of youth still had poor-quality diets.