ABSTRACT: BACKGROUND:Identifying leading dietary determinants for cardiometabolic risk (CMR) factors is urgent for prioritizing interventions in children. We aimed to identify leading dietary determinants for the change in CMR and create a healthy diet score (HDS) to predict CMR in children. METHODS:We included 5676 children aged 6-13?years in the final analysis with physical examinations, blood tests, and diets assessed at baseline and one year later. CMR score (CMRS) was computed by summing Z-scores of waist circumference, an average of systolic and diastolic blood pressure (SBP and DBP), fasting glucose, high-density lipoprotein cholesterol (HDL-C, multiplying by -?1), and triglycerides. Machine learning was used to identify leading dietary determinants for CMR and an HDS was then computed. RESULTS:The nine leading predictors for CMRS were refined grains, seafood, fried foods, sugar-sweetened beverages, wheat, red meat other than pork, rice, fungi and algae, and roots and tubers with the contribution ranging from 3.9 to 19.6% of the total variance. Diets high in seafood, rice, and red meat other than pork but low in other six food groups were associated with a favorable change in CMRS. The HDS was computed based on these nine dietary factors. Children with HDS ?8 had a higher decrease in CMRS (? (95% CI): -?1.02 (-?1.31, -?0.73)), BMI (-?0.08 (-?0.16, -?0.00)), SBP (-?0.46 (-?0.58, -?0.34)), DBP (-?0.46 (-?0.58, -?0.34)), mean arterial pressure (-?0.50 (-?0.62, -?0.38)), fasting glucose (-?0.22 (-?0.32, -?0.11)), insulin (-?0.52 (-?0.71, -?0.32)), and HOMA-IR (-?0.55 (-?0.73, -?0.36)) compared to those with HDS ?3. Improved HDS during follow-up was associated with favorable changes in CMRS, BMI, percent body fat, SBP, DBP, mean arterial pressure, HDL-C, fasting glucose, insulin, and HOMA-IR. CONCLUSION:Diets high in seafood, rice, and red meat other than pork and low in refined grains, fried foods, sugar-sweetened beverages, and wheat are leading healthy dietary factors for metabolic health in children. HDS is strongly predictive of CMR factors.