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WIC Nutrition Risk Criteria: A Scientific Assessment
Committee on Scientific Evaluation of WIC Nutrition Risk Criteria
Food and Nutrition Board
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
1996
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NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
This study was supported under contract no. 59-3198-3-044 from the Food and Nutrition Service, U.S. Department of Agriculture.
Library of Congress Catalog Card No. 95-72317
International Standard Book Number 0-309-05385-4
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Washington, D.C. metropolitan area) or visit the online bookstore at http://www.nas.edu/nap/online/.
Copyright 1996 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
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Committee on Scientific Evaluation of WIC Nutrition Risk Criteria
RICHARD E. BEHRMAN (Chair),*
Center for the Future of Children, David and Lucile Packard Foundation, Los Altos, California
BARBARA ABRAMS,
School of Public Health, University of California, Berkeley
A. SUE BROWN (through February 1995),
Commission on Health Care Finance, Government of the District of Columbia, Washington, D.C.
MARY ELLEN COLLINS,
Brigham and Women's Hospital, Boston, Massachusetts
CATHERINE COWELL,
School of Public Health, Columbia University, New York, New York
BARBARA DEVANEY,
Mathematica Policy Research, Inc., Plainsboro, New Jersey
LEON GORDIS,*
School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland
JEAN-PIERRE HABICHT,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
K. MICHAEL HAMBIDGE,
Center for Human Nutrition, University of Colorado Health Sciences Center, Denver
GAIL G. HARRISON,
School of Public Health, University of California, Los Angeles
JEAN YAVIS JONES,
Congressional Research Service, Library of Congress, Washington, D.C.
ROY M. PITKIN,*
School of Medicine, University of California, Los Angeles
ERNESTO POLLITT,
Department of Pediatrics, University of California, Davis
KATHLEEN M. RASMUSSEN,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
EARNESTINE WILLIS,
MACC Fund Research Center and Department of Pediatrics, Medical College of Wisconsin, Milwaukee
Staff
ROBERT EARL, Study Director (through November 1995)
CAROL WEST SUITOR, Study Director (beginning November 1995)
SANDRA A. SCHLICKER, Senior Program Officer (beginning November 1995)
SHEILA A. MOATS, Research Associate
KIMBERLY M. BREWER, Research Assistant (beginning September 1995)
GERALDINE KENNEDO, Project Assistant
*
Member, Institute of Medicine
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Food and Nutrition Board
CUTBERTO GARZA (Chair),
Division of Nutritional Sciences, Cornell University, Ithaca, New York
JOHN W. ERDMAN, JR. (Vice Chair),
Division of Nutritional Sciences, College of Agriculture, University of Illinois, Urbana
PERRY L. ADKISSON,
† Department of Entomology, Texas A&M University, College Station
LINDSAY H. ALLEN,
Department of Nutrition, University of California, Davis
DENNIS M. BIER,
USDA Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
FERGUS M. CLYDESDALE,
Department of Food Science and Nutrition, University of Massachusetts, Amherst
MICHAEL P. DOYLE,
Center for Food Safety and Quality Enhancement, University of Georgia, Griffin
JOHANNA T. DWYER,
Frances Stern Nutrition Center, New England Medical Center, Boston, Massachusetts
SCOTT M. GRUNDY,
Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas
K. MICHAEL HAMBIDGE,
Center for Human Nutrition, University of Colorado Health Sciences Center, Denver
JANET C. KING,
* USDA Western Human Nutrition Research Center, Presidio of San Francisco, California
SANFORD A. MILLER,
Graduate Studies and Biological Sciences, University of Texas Health Science Center, San Antonio
ALFRED SOMMER,
* School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
STEVE L. TAYLOR (Ex officio),
Food Processing Center, University of Nebraska, Lincoln
VERNON R. YOUNG,
† Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge
*
Member, Institute of Medicine
†
Member, National Academy of Sciences
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Staff
ALLISON A. YATES, Director (beginning July 1994)
CATHERINE E. WOTEKI, Director (through December 1993)
BERNADETTE M. MARRIOTT, Associate Director and Interim Director (through June 30, 1994)
GAIL SPEARS, Administrative Assistant (beginning September 1994)
MARCIA S. LEWIS, Administrative Assistant (through August 1994)
JAMAINE L. TINKER, Financial Associate
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Acknowledgments
This report represents the collaborative efforts of many individuals, particularly the study committee and staff whose names appear at the beginning of this document. Completion of this study was a complex task and it required substantial dedication and effort by all those who participated in its completion.
The committee wishes to acknowledge the assistance of the National Association of WIC Directors (NAWD) for furnishing volumes of information about nutrition risk criteria in use in state WIC programs. NAWD's president during the majority of the study, Alice Lenihan, was particularly helpful and supportive. The committee wants to express their appreciation of the input received from the entire WIC community, too numerous to mention by name, through public meetings, site visits, additional information about nutrition risk criteria, and informal communications.
Drs. Robert Kuczmarski and Anne Looker of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, made presentations to the committee on upcoming data from the third National Health and Nutrition Examination Survey and revision of NCHS infant and child growth charts. Dr. Tiefu Shen of the Division of Nutritional Sciences, Cornell University, and Cyn O'Malley and Suzan Carmichael of the School of Public Health, University of California, Berkeley, provided substantial assistance with the development of the chapter on anthropometric risk criteria.
This report was sponsored by the Food and Consumer Service, U.S. Department of Agriculture (USDA). Without their vision for the need to undertake this scientific assessment, this report would not have become a reality. The committee acknowledges their commitment to the WIC program
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and their support of this project, particularly the support of project officers Jay Hirschman and Dr. Janet Tognetti Schiller. In addition, the committee recognizes other major informational contributions of several USDA staff: Donna Hines, Julie Kresge, Michele Lawler, Elaine Lynn, and Debra Whitford.
The committee also wishes to express its appreciation to the staff of the Food and Nutrition Board of the Institute of Medicine, whose tireless efforts on our behalf were so critical to the committee's deliberations and the production of this report. Our appreciation goes to Robert Earl, who provided administrative support to the committee. The committee is especially grateful for the substantial efforts of Dr. Carol Suitor, who, with the assistance of Dr. Sandra Schlicker and Kim Brewer, worked closely with committee members to complete the analysis and finalize the report. The efforts of Sheila Moats, Geraldine Kennedo, Susan Knasiak, and Dr. Allison Yates on behalf of the committee are also deserving of our heartfelt thanks.
RICHARD E. BEHRMAN, Chair
Committee on Scientific Evaluation of WIC Nutrition Risk Criteria
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Contents
SUMMARY
1
Committee Process and Structure of the Report
3
Principles of Nutrition Risk Assessment
5
General Conclusions
7
Recommendations for Specific Nutrition Risk Criteria
9
Recommendations for Future Research and Action
20
1
OVERVIEW
23
Charge to the Committee
24
The WIC Program
25
Overview of the Report and the Committee Process
34
References
38
2
POVERTY AND NUTRITION RISK
41
Definition of Poverty
41
Prevalence of Poverty
43
Poverty and Nutrition Risk for Women
43
Poverty and Nutrition Risk for Infants and Children
45
Effects of WIC Program Participation
47
References
49
3
PRINCIPLES UNDERLYING THE NUTRITION RISK CRITERIA FOR WIC ELIGIBILITY
53
Principles of Nutrition Risk Assessment
53
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WIC Nutrition Risk Criteria
60
Priority System of the WIC Program
60
Summary and Implications
63
References
65
4
ANTHROPOMETRIC RISK CRITERIA
67
Use of Anthropometric Measures in the WIC Program
67
Maternal Anthropometric Risk Criteria
70
Prepregnancy Underweight
70
Low Maternal Weight Gain
73
Maternal Weight Loss During Pregnancy
79
Prepregnancy Overweight
80
High Gestational Weight Gain
84
Maternal Short Stature
87
Postpartum Underweight
89
Postpartum Overweight
92
Abnormal Postpartum Weight Change
96
Anthropometric Risk Criteria for Infants and Children
97
Low Birth Weight
97
Small for Gestational Age
100
Short Stature
104
Underweight
110
Low Head Circumference
114
Large for Gestational Age
117
Overweight
118
Slow Growth
123
Summary and Conclusions
125
References
128
5
BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA
149
Criteria Related to Nutrient Deficiencies
154
Anemia
154
Failure to Thrive and Other Nutrient Deficiency Disease
159
Medical Conditions Applicable to the Entire WIC Population
166
Gastrointestinal Disorders
166
Diabetes Mellitus
169
Thyroid Disorders
170
Chronic Hypertension
172
Renal Disease
174
Cancer
175
Central Nervous System Disorders
177
Genetic and Congenital Disorders
179
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Inborn Errors of Metabolism
181
Chronic or Recurrent Infections
183
HIV Infection and AIDS
185
Recent Major Surgery, Trauma, Burns, or Severe Acute Infections
188
Other Medical Conditions
190
Conditions Related to the Intake of Specific Foods
192
Food Allergies
192
Food Intolerances
194
Conditions Specific to Pregnancy
195
Pregnancy at a Young Age
195
Pregnancy Age Older Than 35 Years
197
Closely Spaced Pregnancies
197
High Parity
200
History of Preterm Delivery
204
History of Postterm Delivery
206
History of Low Birth Weight
206
History of Neonatal Loss
207
History of Previous Birth of an Infant with a Congenital or Birth Defect
207
Lack of Prenatal Care
208
Multifetal Gestation
210
Fetal Growth Restriction
211
Preeclampsia and Eclampsia
213
Placental Abnormalities
214
Conditions Specific to Infants and/or Children
215
Prematurity
215
Hypoglycemia
217
Potentially Toxic Substances
218
Long-Term Drug-Nutrient Interactions or Misuse of Medications
218
Maternal Smoking
220
Alcohol and Illegal Drug Use
226
Lead Poisoning
229
Summary
232
References
233
6
DIETARY RISK CRITERIA
251
Inappropriate Dietary Patterns
253
Dietary Patterns That Fail to Meet Dietary Guidelines for Americans
253
Vegetarian Diets
259
Highly Restrictive Diets
260
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Inappropriate Infant Feeding
261
Inappropriate Use of Nursing Bottle
265
Inappropriate Diets in Children
268
Excessive Caffeine Intake
269
Pica
270
Inadequate Diet
272
Food Insecurity
279
Definition of Food Insecurity
279
Summary
283
References
283
7
PREDISPOSING NUTRITION RISK CRITERIA
295
Homelessness
297
Migrancy
304
Passive Smoking
309
Low Level of Maternal Education and Illiteracy
311
Maternal Depression
314
Battering
317
Child Abuse or Neglect
319
Child of a Young Caregiver
321
Child of a Mentally Retarded Parent
323
Summary
325
References
325
8
CONCLUSIONS AND RECOMMENDATIONS
335
General Conclusions
336
Recommendations for Specific Nutrition Risk Criteria
337
Recommendations for Future Research and Action
350
APPENDIXES
A
Participants at the First Public Meeting, May 19, 1994
353
B
Participants at the Second Public Meeting, September 19–20, 1994
355
C
WIC Program: Common Nutritional Risk Criteria
357
D
Definitions of Yield and Sensitivity of Cutoff Points for Nutrition Risk
359
E
Biographical Sketches
361
ACRONYMS
371
INDEX OF RISK CRITERIA
373
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List of Tables and Figures
TABLES
S-1
Nutrition Risk Criteria and Committee Recommendations for the Specific WIC Population, by Category of Nutrition Risk,
10
1-1
WIC Program Participation by Subgroup and Federal Costs, 1974–1993,
35
3-1
Nutrition Risk Criteria Defined by WIC Program Regulations,
61
3-2
The WIC Priority System,
62
4-1
Summary of Anthropometric Risk Criteria in the WIC Program and Use by States,
68
4-2
Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Pregnant and Postpartum Women,
70
4-3
Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Infants and Children,
98
4-4
Summary of Anthropometric Risk Criteria and Committee Recommendations for the Specific WIC Population,
126
5-1
Summary of Biochemical and Other Medical Risk Criteria in the WIC Program and Use by States,
150
5-2
Summary of Broad Categories of Biochemical and Other Medical Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,
153
5-3
Cutoff Points for Anemia Used in the WIC Program and Recommended Cutoff Points from the Centers for Disease Control and Prevention and the Institute of Medicine for Women, Infants, and Children,
158
5-4
Summary of Medical Risk Criteria and Committee Recommendations for the Specific WIC Population,
160
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6-1
Summary of Broad Dietary Risk Criteria in the WIC Program and Use by States,
252
6-2
Summary of Broad Dietary Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,
253
6-3
Summary of Broad Dietary Risk Criteria and Committee Recommendations for the Specific WIC Population,
266
7-1
Summary of Predisposing Risk Criteria in the WIC Program and Use by States,
296
7-2
Summary of Predisposing Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,
297
7-3
Summary of Dietary Risk Criteria and Committee Recommendations for the Specific WIC Population,
298
8-1
Nutrition of Risk Criteria and Committee Recommendations for the Specific WIC Population, by Category of Nutrition Risk,
338
8-2
Committee Recommendations for Changes in Risk Criteria,
347
FIGURES
S-1
WIC program components, services, benefits, and projected outcomes,
2
1-1
WIC program components, services, benefits, and projected outcomes,
26