The quality of young children's diets

Most young children have diets that need to be improved. This is of concern because poor eating habits in young children may impair their growth and development and serve as the foundation for poor eating habits when they become adults. Poor eating habits, as well as inactivity among American children, are key factors that influence the degree to which children over the past decades have been overweight. Recent data show that 13 percent of American children 6 to 11 years old are overweight, compared with 4 percent in the 1960's (National Center for Health Statistics, 2002). Overweight children are at risk for cardiovascular diseases, Type II diabetes, and other serious health problems; thus, information on their diet is critical in helping nutrition and health professionals develop strategies for healthier children.

To assess the dietary status of Americans and monitor changes in these patterns, the U.S. Department of Agriculture's (USDA) Center for Nutrition Policy and Promotion (CNPP) developed the Healthy Eating Index (HEI) and first computed the Index by using 1989 data. The HEI is a summary measure of the overall quality of people's diets (broadly defined in terms of adequacy, moderation, and variety). The Index consists of scores for consumption of the recommended number of servings of each of the five major food groups of the Food Guide Pyramid, intake of total fat and saturated fat (as a percentage of calories), intake of cholesterol and sodium, and a measure of dietary variety. Computed on a regular basis, the HEI is the only index issued by the Federal Government that gauges overall quality of the population's diet.

This article presents the HEI for young children (age 2 to 9) for 1994-96/98--the most recent years for which nationally representative food intake data are available to compute the Index. The HEI is calculated for these children because they were the only subpopulation on which food intake data were collected in 1998.

Components of the Healthy Eating Index

The HEI provides an overall picture of the types and quantities of foods people eat, their compliance with specific dietary recommendations, and the variety in their diets. The total Index score is the sum of 10 dietary components, representing various aspects of a healthful diet, which are weighted equally (fig. 1). The maximum overall HEI score is 100.

* Components 1-5 measure the degree to which a person's diet conforms to the serving recommendations for the five major food groups of the USDA Food Guide Pyramid: grains (bread, cereal, rice, and pasta), vegetables, fruits, milk (milk, yogurt, and cheese), and meat (meat, poultry, fish, dry beans, eggs, and nuts).

* Component 6 measures total fat consumption as a percentage of total food energy (calorie) intake.

* Component 7 measures saturated fat consumption as a percentage of total food energy intake.

* Component 8 measures total cholesterol intake.

* Component 9 measures total sodium intake.

* Component 10 measures the variety in a person's diet.

An HEI score over 80 implies a "good" diet; a score between 51 and 80, a diet that "needs improvement"; and a score less than 51, a "poor" diet. (1) The HEI does not include a component for overconsumption of food. However, meeting the Food Guide Pyramid serving recommendations and dietary recommendations regarding fat and cholesterol typically should prevent overconsumption. People with a high HEI score have been found to have a low body mass index (BMI); conversely, people with a low HEI score have been found to have a high BMI (an indication of being overweight) (U.S. Department of Agriculture [USDA], 1995).

Food Group Components of the USDA Food Guide Pyramid

The USDA Food Guide Pyramid translates recommendations from the Dietary Guidelines for Americans into groups and amounts of foods people can eat to achieve a healthful diet (Dietary Guidelines Advisory Committee, 2000). The recommended number of Food Guide Pyramid servings depends on a person's caloric requirement. In developing the HEI, CNPP used serving recommendations from the Food Guide Pyramid for various age/gender groups. Pyramid serving recommendations for 1,600, 2,200, and 2,800 calories were used to interpolate serving recommendations for age/gender groups of children not described in the Pyramid. For grains, the recommended servings ranged from 6 to 7.8, depending on the child's age; for vegetables, 3 to 3.7; for fruits, 2 to 2.7; for milk, 2 for all age groups; and for meat, 2 to 2.3 servings.

A maximum score of 10 was assigned to each of the five food group components of the HEI. Children whose diets met or exceeded the recommended number of servings for a food group received the maximum score of 10 points. For example, if a child's diet met serving recommendations for the fruit group, then his or her diet was awarded 10 points. For each of the five major food groups, a score of zero was assigned to the respective components if a child did not consume any item from the food group. Intermediate scores were computed proportionately to the number of servings consumed. For example, if the serving recommendation for a food group was four and a child consumed two servings, the component score was 5 points. Similarly, if three servings were consumed, a score of 7.5 was assigned.

The Recommended Energy Allowance (REA) for children 2 to 3 years of age is less than 1,600 kilocalories (National Research Council, 1989b). The recommended number of servings was kept at the minimal serving level for these children, but the serving size was scaled downward to be proportionate with their recommendations for food energy. This approach is consistent with Food Guide Pyramid guidance. (2)

To compute the scores for each of the five major food groups, CNPP used serving definitions that were intended to be as consistent as possible with the concepts and definitions described in the Food Guide Pyramid (USDA, 1996). These serving definitions reflect consistency with the underlying rationale in terms of nutrient contributions from each of the five major food groups and are also consistent with the Pyramid concept of defining servings in common household measures and easily recognizable units. The servings calculated for the HEI were based on the Pyramid servings database developed by the USDA's Agricultural Research Service.

When calculating the HEI, USDA researchers needed to assign the foods in mixtures, in the appropriate amounts, to their constituent food groups. Pizza, for example, can make significant contributions to several food groups, including grains, vegetables, milk, and meat. The approach used was a straightforward extension of the one used to estimate serving sizes. Commodity compositions of foods were identified; then commodities were assigned to appropriate food groups based on the gram/serving size factors that were calculated. Dry beans and peas were first assigned to the meat group if the recommendations for meat servings were not met, after which they were assigned to the vegetable group.

Fat and Saturated Fat Components

CNPP examined Index scores for fat and saturated fat intakes, that is, intake as a proportion of total food energy expressed as kilocalories. Total fat intake of 30 percent or less of total calories in a day was assigned a maximum score of 10 points, a percentage based on the recommendations of the 2000 edition of the Dietary Guidelines for Americans. Fat intake equal to, or greater than, 45 percent of total calories in a day was assigned a score of zero; intake between 30 and 45 percent was scored proportionately.

Saturated fat intake of less than 10 percent of total calories in a day was assigned a maximum score of 10 points. This percentage is also based on the recommendations of the 2000 edition of the Dietary Guidelines for Americans. Saturated fat intake equal to, or greater than, 15 percent of total calories in a day was assigned a score of zero; intake between 10 and 15 percent was scored proportionately. The upper limit percentages for fat (45 percent) and saturated fat (15 percent) were based on consultation with nutrition researchers and exploration of the distribution of the consumption of these components.

Cholesterol Component

The score for cholesterol was based on the amount consumed in milligrams per day, with an assigned score of 10 points when daily cholesterol intake was 300 milligrams (mg) or less. This amount is based on recommendations of the Committee on Diet and Health of the National Research Council and represents a consensus of experts in foods and nutrition, medicine, epidemiology, public health, and related fields (National Research Council, 1989a). A score of zero was assigned when daily intake reached a level of 450 mg or more, and intake between 300 and 450 mg was scored proportionately. The upper limit for cholesterol intake was based on consultation with nutrition researchers and exploration of the distribution of the consumption of this component.

Sodium Component

The score for sodium was based on the amount consumed in milligrams per day. A score of 10 points was assigned when daily sodium intake was 2,400 mg or less--the amount based on recommendations of the Committee on Diet and Health of the National Research Council (National Research Council, 1989a). Daily intake of 4,800 mg or more received zero points, and intake between 2,400 and 4,800 mg was scored proportionately. Sodium intake, however, does not include salt added to a meal at the table. The upper limit for sodium intake was based on consultation with nutrition researchers and exploration of the consumption distribution of this component.

Variety Component

The Dietary Guidelines, the Food Guide Pyramid, and the National Research Council's diet and health report all stress the importance of variety in a diet. There is no consensus, however, on how to quantify variety. Thus, dietary variety was assessed by totaling the number of different foods in a day that a child ate that were in amounts sufficient to contribute at least one-half of a serving in a food group. Food mixtures were separated into their food ingredients and assigned to the appropriate food category. Foods that differed only by preparation method were grouped together and counted as one type of food. For example, baked, fried, or boiled potatoes were counted once. Different types of a food were considered to be a different food. For example, each type of fish--mackerel, tuna, and trout--was considered to be a different food.

A maximum variety score of 10 points was assigned if a child consumed, in a day, at least half a serving each of eight or more different types of foods. A score of zero was assigned if three or fewer different foods were consumed in a day by a child. Intermediate scores were computed proportionately. These upper and lower limit amounts to gauge food variety were based on consultation with nutrition researchers. (3)

Data Used to Calculate the Healthy Eating Index

USDA's Supplemental Children' s Survey of the 1994-96/98 Continuing Survey of Food Intakes by Individuals (CSFII) provides information on children's consumption of foods and nutrients and information about their demographic and socioeconomic characteristics. CNPP used these data to compute the HEI for children age 2 to 9. For the 1994-96/98 CSFII, dietary intakes of children were collected on 2 nonconsecutive days. Data on children's food intake were collected from the parent and/or caregiver (including daycare providers, babysitters, and teachers) through an in-person interview using the 24-hour dietary recall method. The survey was designed to be representative of the U.S. population of children living in households. Weights were used to ensure that the sample was representative of all U.S. children.

The HEI was computed for children with complete food intake records for the first day of the survey: this allows for comparisons across the years. Prior research has indicated that food intake data based on 1 day provide reliable measures of usual intakes of groups of people (Basiotis et al., 1987). The final sample size was 7,177 children.

Results

Few Children Had Good Diets

Most young children (81 percent) had diets that needed improvement or were poor (fig. 2). Less than one-fifth (19 percent) of children had good diets. Although most children had diets that needed improvement, most children met the Recommended Dietary Allowance (RDA) for many essential nutrients (USDA, 1999). However, unlike the HEI, the RDAs do not assess recommended food servings, fat intake, or food variety.

Children's scores were best on the cholesterol component: 82 percent of children met the cholesterol recommendation (fig. 3). For each of the other nine HEI components, less than half of the children met the recommendations. Children had the lowest score on the meat component: only 18 percent met the meat recommendation. The result for the meat component may seem surprising given this food group includes meat alternates such as peanut butter and eggs. Only 22 percent of children met the vegetable recommendation, 29 percent met the saturated fat recommendation, and 33 percent met the fruit recommendation. Hence, there is much room for improvement in children's diets for most HEI components.

Overall Diet Quality Varied by Sociodemographic Characteristics

The quality of children's diets varied significantly based on their sociodemographic characteristics: age, gender, household income, food stamp receipt, food sufficiency, and residency (table 1).

Compared with their respective counterparts, younger children, boys, and children living in suburban areas had a better diet. Over one-third (34 percent) of children age 2 to 3 had a good diet; whereas, only 16 percent of 4- to 6-year-olds and 13 percent of 7- to 9-year-olds had a good diet. Twenty percent of boys versus 18 percent of girls had a good diet, and 21 percent of suburban children, compared with 16 percent of their nonmetro counterparts, had intakes that resulted in having a good diet.

Family resources were associated with the quality of children's diets. Children had worse diets if they were in households (1) with a low income (defined as before-tax income below 130 percent of the poverty threshold), (2) that received food stamps, and (3) who categorized themselves as food insufficient (defined as sometimes or often not having enough food to eat). Sixteen percent of children in low-income households and 16 percent in house-holds receiving food stamps had a good diet, compared with 20 percent of children in non-low-income households and 20 percent of children in house-holds not receiving food stamps. Eighteen percent of children in food-insufficient households had a poor diet, compared with 8 percent of children in food-sufficient households. These results indicate that financial resources and diet quality have a positive relationship. There was no significant difference in overall diet quality among children based on their race, ethnicity, and household type (dual-headed vs. single-headed).

Obtaining the Maximum Score on the HEI Components Also Varied by Sociodemographic Characteristics

A significantly greater percentage of children age 2 to 3, compared with children age 7 to 9, obtained the maximum score (meaning they met the dietary recommendation) for grains (54 vs. 31 percent), vegetables (31 vs. 20 percent), fruits (57 vs. 20 percent), meat (28 vs. 16 percent), sodium (64 vs. 33 percent), and variety (50 vs. 41 percent) (table 2). The milk component was the only one for which a significantly greater percentage of children age 7 to 9, compared with children age 2 to 3, met the dietary recommendation (49 vs. 44 percent).

A significantly greater percentage of boys than girls met the dietary recommendation for grains (40 vs. 32 percent), milk (49 vs. 44 percent), and meat (21 vs. 16 percent). A significantly higher percentage of girls than boys met the dietary recommendation for cholesterol (85 vs. 79 percent) and sodium (52 vs. 43 percent).

Although there was no significant difference in overall diet quality among children by race, ethnicity, and household type, there were significant differences in the percentage of children obtaining a maximum score on the various HEI components by these characteristics. A significantly greater percentage of non-White children than White children met the dietary recommendation for vegetables (25 vs. 20 percent) and meat (24 vs. 16 percent). A lower percentage of nonWhite children than White children met the dietary recommendation for milk (40 vs. 49 percent), saturated fat (26 vs. 30 percent), and cholesterol (78 vs. 83 percent). The higher prevalence of lactose intolerance among non-White children is likely the reason fewer of these children met the milk recommendation.

By ethnicity, a significantly lower percentage of Hispanic than non-Hispanic children met the cholesterol recommendation (73 vs. 83 percent). By household type, a greater percentage of children in dual-headed households than single-headed households met the dietary recommendation for fat (39 vs. 32 percent), saturated fat (31 vs. 23 percent), cholesterol (83 vs. 78 percent), and sodium (48 vs. 43 percent). A lower percentage of children in dual-headed households than single-headed households met the dietary recommendation for vegetables (21 vs. 26 percent) and meat (17 vs. 25 percent).

As for children in low-income households, compared with children in non-low-income households, a significantly lower percentage met the dietary recommendation for fruits (30 vs. 35 percent), fat (31 vs. 40 percent), saturated fat (22 vs. 32 percent), and cholesterol (75 vs. 85 percent). A higher percentage of children in low-income households met the dietary recommendation for meat (25 vs. 16 percent). Almost similar results were observed with children in households receiving food stamps, compared with children in households not receiving food stamps. This was expected because only low-income families qualify for food stamps.

By food sufficiency, the only significant difference between children in food insufficient households and food sufficient households was in terms of cholesterol. Fewer children in food insufficient households, compared with their counterparts, met the cholesterol recommendation (70 vs. 82 percent). By residency, a significantly greater percentage of children residing in suburbs obtained a maximum score for grains, fruits, fat, saturated fat, and variety than did their counterparts in central cities or nonmetro areas.

Conclusion

As indicated by the HEI, the diets of most young children (age 2 to 9) need substantial improvement to meet dietary recommendations--children are not eating according to the Dietary Guidelines for Americans and the Food Guide Pyramid.

The HEI was first computed by using 1989 food consumption data. It is, therefore, possible to compare the scores for children age 2 to 9 in 1989 and 1994-96/98. Although the method of calculating the milk and variety component scores of the HEI has changed between the two periods, comparisons based on average scores may be made. The overall HEI score for young children has not changed significantly between the two periods--about 70 points in both periods--indicating a diet that needs improvement.

Nutrition promotion activities need to focus on improving the quality of children's diets. It is important for children to eat healthfully to ensure adequate growth and development as well as to help lay the foundation for healthful eating behaviors throughout life. Encouraging these behaviors needs to be a shared responsibility--where health professionals, families, and communities work together to make a difference in the quality of children's diets.

The Federal Government created the Dietary Guidelines for Americans, the Food Guide Pyramid, the Food Guide Pyramid for Young Children 2 to 6 Years Old, and the Nutrition Facts label. Using these tools, health professionals can help busy families--of diverse incomes and ethnic backgrounds--select foods for optimal nutrition and show them how to fit nutritious meals and snacks into hectic schedules. Likewise, health professionals can work with schools, parent associations, and community agencies to discuss nutrition issues and concerns and develop activities to best promote healthful eating by America's children.

Table 1. The quality of young children's diets, by sociodemographic
characteristics

Characteristic       Good diet    Diet needs improvement   Poor diet

                                         Percent
Age (years)
  2 - 3              [34.sup.a]         [60.sup.a]          [6.sup.a]
  4 - 6              [16.sup.b]         [74.sup.b]         [10.sup.b]
  7 - 9              [13.sup.c]         [78.sup.b]          [9.sup.b]

Gender
  Boy                [20.sup.a]         [70.sup.a]          10
  Girl               [18.sup.b]         [74.sup.b]           8

Race
  White               19                 73                  8
  Non-White           18                 72                 10

Ethnicity
  Hispanic            18                 74                  8
  Non-Hispanic        19                 72                  9

Household type
  Dual-headed         19                 73                  8
  Single-headed       18                 73                  9

Household income
  Low-income         [16.sup.a]          73                [11.sup.a]
  Non-low-income     [20.sup.b]          72                 [8.sup.b]

Food stamp receipt
  Yes                [16.sup.a]          73                 11
  No                 [20.sup.b]          72                  8

Food sufficiency
  Sufficient          19                 73                 [8.sup.a]
  Not sufficient      13                 69                [18.sup.b]

Residency
  Central city        19                 71                 10
  Suburb             [21.sup.a]          72                 [7.sup.a]
  Nonmetro           [16.sup.b]          73                [11.sup.b]

Note: Column percentages by characteristic with different superscripts
are significantly different at the .05 level.

Data source: Supplemental Children's Survey of the 1994-96/98
Continuing Survey of Food Intakes by Individuals.
Table 2. Young children meeting the dietary recommendation of the
Healthy Eating Index components, by sociodemographic
characteristics

                     Grains      Vegetables     Fruits        Milk

                                         Percent

Age (years)
  2 - 3            [54.sup.a]    [31.sup.a]   [57.sup.a]   [44.sup.a]
  4 - 6            [28.sup.b]    [17.sup.b]   [31.sup.b]   [45.sup.ab]
  7 - 9            [31.sup.b]    [20.sup.b]   [20.sup.c]   [49.sup.b]

Gender
  Boy              [40.sup.a]     22           34          [49.sup.a]
  Girl             [32.sup.b]     21           32          [44.sup.b]

Race
  White             37           [20.sup.a]    33          [49.sup.a]
  Non-White         34           [25.sup.b]    34          [40.sup.b]

Ethnicity
  Hispanic          32            26           37           48
  Non-Hispanic      36            21           33           46

Household type
  Dual-headed       36           [21.sup.a]    34           47
  Single-headed     33           [26.sup.b]    31           44

Household income
  Low-income        33            23          [30.sup.a]    45
  Non-low-income    37            21          [35.sup.b]    47

Food stamp
    receipt
  Yes               34            23           31           44
  No                36            21           34           47

Food sufficiency
  Sufficient        36            22           33           46
  Not sufficient    35            17           31           47

Residency
  Central city     [36.sup.ab]    21          [34.sup.a]    45
  Suburb           [37.sup.a]     21          [37.sup.a]    48
  Nonmetro         [32.sup.b]     26          [24.sup.b]    43

                                             Saturated
                      Meat         Fat          fat

                                 Percent

Age (years)
  2 - 3            [28.sup.a]    40           28
  4 - 6            [14.sup.b]    38           28
  7 - 9            [16.sup.b]    36           30

Gender
  Boy              [21.sup.a]    37           27
  Girl             [16.sup.b]    38           31

Race
  White            [16.sup.a]    38          [30.sup.a]
  Non-White        [24.sup.b]    36          [26.sup.b]

Ethnicity
  Hispanic          20           34           28
  Non-Hispanic      18           38           29

Household type
  Dual-headed      [17.sup.a]   [39.sup.a]   [31.sup.a]
  Single-headed    [25.sup.b]   [32.sup.b]   [23.sup.b]

Household income
  Low-income       [25.sup.a]   [31.sup.a]   [22.sup.a]
  Non-low-income   [16.sup.b]   [40.sup.b]   [32.sup.b]

Food stamp
    receipt
  Yes              [27.sup.a]   [31.sup.a]   [20.sup.a]
  No               [17.sup.b]   [39.sup.b]   [31.sup.b]

Food sufficiency
  Sufficient        18           38           29
  Not sufficient    22           28           22

Residency
  Central city      19          [36.sup.a]   [28.sup.a]
  Suburb            17          [42.sup.b]   [32.sup.b]
  Nonmetro          21          [29.sup.c]   [25.sup.a]

                   Cholesterol     Sodium       Variety

                                   Percent

Age (years)
  2 - 3             83           [64.sup.a]   [50.sup.a]
  4 - 6             82           [50.sup.b]   [40.sup.b]
  7 - 9             80           [33.sup.c]   [41.sup.b]

Gender
  Boy              [79.sup.a]    [43.sup.a]    44
  Girl             [85.sup.b]    [52.sup.b]    42

Race
  White            [83.sup.a]     48           43
  Non-White        [78.sup.b]     45           43

Ethnicity
  Hispanic         [73.sup.a]     54           46
  Non-Hispanic     [83.sup.b]     47           43

Household type
  Dual-headed      [83.sup.a]    [48.sup.a]    43
  Single-headed    [78.sup.b]    [43.sup.b]    43

Household income
  Low-income       [75.sup.a]     45           40
  Non-low-income   [85.sup.b]     48           44

Food stamp
    receipt
  Yes              [74.sup.a]    [42.sup.a]    43
  No               [83.sup.b]    [48.sup.b]    43

Food sufficiency
  Sufficient       [82.sup.a]     47           43
  Not sufficient   [70.sup.b]     56           35

Residency
  Central city      81            46          [43.sup.ab]
  Suburb            83            48          [45.sup.a]
  Nonmetro          82            46          [38.sup.b]

Note: Column percentages by characteristic with different superscripts
are significantly different at the .05 level.

Data source: Supplemental Children's Survey of the 1994-96/98
Continuing Survey of Food Intakes by Individuals.
Figure 1. Components of the Healthy Eating Index

Component 6 measures total fat         Total Fat
consumption as a percentage of
total food energy intake.

Component 7 measures saturated fat     Saturated Fat
consumption as a percentage of total
food energy intake.

Component 8 measures total             Cholesterol
cholesterol intake.

Component 9 measures total             Sodium
sodium intake.

Component 10 examines the              Variety
variety in a person's diet.

Components 1-5                         Food Guide
measure the degree to which a          Pyramid
person's diet conforms to USDA's
Food Guide Pyramid serving
recommendations for the grains,
vegetables, fruits, milk, and meat
food groups.

Note: Table made from pie chart.
Figure 2. The quality of young children's diets

Good diet                19%
Diet needs improvement   72%
Poor diet                 9%

Data source: Supplemental Children's Survey of the 1994-96/98
Continuing Survey of Food Intakes by Individuals.

Note: Table made from pie chart.
Figure 3. Percentage of young children meeting the dietary
recommendation of the Healthy Eating Index components

Grains          36
Vegetables      22
Fruits          33
Milk            46
Meat            18
Fat             37
Saturated fat   29
Cholesterol     82
Sodium          47
Variety         43

Data source: Supplemental Children's Survey of the 1994-96/98
Continuing Survey of Food Intakes by Individuals.

Note: Table made from bar graph.

(1) In the initial HEI work, and in consultation with nutrition experts, Kennedy et al. (1995) developed this scoring system.

(2) For more details on determination of Food Guide Pyramid serving definitions, estimation of food group serving requirements by age and gender, and design alternatives, the reader is referred to the 1994-96 HEI administrative report for the entire population (USDA, 1998).

(3) For more details on the coding structure used to compute the variety component of the HEI, the reader is referred to the 1994-96 HEI administrative report (USDA, 1998).

References

Basiotis, P.P., Welsh, S.O., Cronin, F.J., Kelsay, J.L., & Mertz, W. (1987). Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. Journal of Nutrition 117(9):1638-1641.

Dietary Guidelines Advisory Committee. (2000). Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2000. U.S. Department of Agriculture, Agricultural Research Service.

Kennedy, E.T., Ohls, J., Carlson, S., & Fleming, K. (1995). The Healthy Eating Index: Design and applications. Journal of the American Dietetic Association 95(10):1103-1108.

National Center for Health Statistics, Center for Disease Control and Prevention. (n.d.). Prevalence of overweight among children and adolescents: United States, 1999. Retrieved January 15, 2002, from www.cdc.gov/nchs/products/pubs/pubd/ hestats/overwght99.htm

National Research Council, Committee on Diet and Health, Food and Nutrition Board. (1989a). Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press.

National Research Council, Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board. (1989b). Recommended Dietary Allowances (10th ed.). Washington, DC: National Academy Press.

U.S. Department of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Food Surveys Research Group. (1999). Food and Nutrient Intakes by Children, 1994-96, 1998. Table Set 17.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. (1995). The Healthy Eating Index. CNPP-1.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. (1996). The Food Guide Pyramid. Home and Garden Bulletin Number 252.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. (1998). The Healthy Eating Index, 1994-96. CNPP-5.

Mark Lino, PhD
P. Peter Basiotis, PhD
Shirley A. Gerrior, PhD
Andrea Carlson, PhD

U.S. Department of Agriculture
Center for Nutrition Policy and Promotion

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