New healthy eating index tailored for toddlers promotes lifelong nutritional habits


In a recent study published in the Journal of the Academy of Nutrition and Dietetics, researchers explain the healthy eating index (HEI) for toddlers between 12 and 23 months of age, which reflects the guidelines and fundamental features of the Dietary Guidelines for Americans (DGA) in the United States.

Study: Development of the Healthy Eating Index-Toddlers-2020. Image Credit: Onjira Leibe /


The HEI is a qualitative measure of the DGA, which is revised every five years through the collaborative effort of the U.S. Health and Human Services (HHS) department, the Center for Nutrition Policy and Promotion at the U.S. Department of Agriculture (USDA), Food and Nutrition Services, and the National Cancer Institute (NCI).

Although the nutrition of infants and toddlers has gained considerable research interest in recent times, there have been very few diet quality scores for toddlers or infants, with only three existing from high-income countries. These include the Diet Quality Index Score, Toddler Diet Quality Index, and the Complementary Feeding Utility Index, which vary significantly in the included categories and scoring criteria, with some indices recommending food types not included in the DGA. The HEI-Toddlers-2020 was designed to measure the alignment of diet quality with the DGA recommendations for 2020-2025.

Major features

HEI is based on the dietary patterns recommended by the USDA, which include food and beverage recommendations for toddlers between the ages of one and two years who are no longer being fed infant formula or breastmilk.

HEI-based diet quality comparisons have only been conducted for children above the age of two years. Moreover, HEI-toddlers 2020 was developed using information from the DGA and through the collaborative efforts of federal stakeholders experienced in pediatric nutrition.

One of the aspects of the HEI for toddlers is that, as recommended by the DGA, the nutrient needs of toddlers should be met through primary foods and not dietary supplements. Dietary pattern recommendations for older infants still consist largely of infant formula or human milk, and complementary foods or beverages are not required for infants below the age of six months. As a result, HEI is not intended for infants and instead assesses the dietary quality of toddlers above the age of one year and below the age of two.

To allow the index to support the assessment of diet along a healthy trajectory through the lifespan of an individual, a guiding principle was added to allow the bridging of components between the HEI-Toddlers-2020 and HEI for those above the age of two years. Furthermore, while the components of HEI-Toddlers-2020 are the same as those for HEI-2020 for those above the age of two years, the standards and approach to scoring have some key differences.

Apart from the standard recommendations of adequacy and moderation, which include the foods that must be encouraged and avoided, respectively, HEI-Toddlers-2020 also offers more nuanced recommendations that are required for toddlers, such as the saturated fat content of the diet. The dietary recommendations for toddlers between the ages of 12 and 23 months are unique, as they have relatively high nutrient requirements for the rapid development and growth occurring during this stage.

Since toddlers’ calorific needs are much lower than their nutrient requirements, their diets have no room for added sugars. Furthermore, since preferences for tastes are formed when complementary foods are introduced into their diet, added sugars in toddler diets pose the risk of them developing a preference for sugary foods.

The calculation of scores is based on a weighted system, which results in a balance between all components of the dietary recommendations and aligns with the need for DGA recommendations to be considered in their entirety as equally important. The scoring is based on comparing the amount of a specific food component for every 1,000 calories to relevant established standards. HEI-Toddlers-2020 also includes adaptations for five components, including sodium, added sugars, whole grains, saturated fats, and refined grains.


HEI-Toddlers-2020 was designed based on the DGA 2020-2025 dietary recommendations for toddlers between the ages of one and two years. This index enables the assessment of diet quality based on the alignment of the dietary plans with the DGA recommendations.

Apart from the 13 components in the HEI for individuals above the age of two, the HEI for toddlers also includes adaptations of recommendations for added sugars, saturated fats, whole and refined grains, and sodium based on the nuanced requirements of toddlers undergoing rapid growth.

Journal reference:
  • Pannucci, T. E., Lerman, J., Herrick, K. A., et al. (2023). Development of the Healthy Eating Index-Toddlers-2020. Journal of the Academy of Nutrition and Dietetics. doi:10.1016/j.jand.2023.05.013

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