C
NUTRIENT INTAKE OF WIC SUBGROUPS

This appendix presents the details of the final analyses the committee conducted to identify priority nutrients to consider in revising the WIC food packages. Using the Dietary Reference Intakes (DRIs) and the methods described by the Institute of Medicine (IOM, 2000a) to assess nutrient adequacy, the committee assessed the nutrient adequacy of the diets of categorical WIC subgroups—WIC infants under 1 year of age, WIC children 1 through 4 years of age, and pregnant, lactating, and non-breast-feeding postpartum women. Chapter 2Nutrient and Food Priorities—of this report presents a summary of the results. The first section of this appendix describes the DRIs and then discusses how to use them in assessing nutrient adequacy. The next section describes the data set used in the analyses, and the final section includes tables with the detailed analysis results. For a discussion and interpretation of the results, see Chapter 2 of this report.

The results presented in this appendix and summarized in Chapter 2Nutrient and Food Priorities—update the results of similar analyses conducted by the committee for its first report, Proposed Criteria for Selecting the WIC Food Packages: A Preliminary Report of the Committee to Review the WIC Food Packages (IOM, 2004b). Based on comments received on that report and on initial analyses conducted in response to those comments, the committee expanded the set of nutrients examined and defined the WIC subgroups to correspond more closely to those served by the WIC program. The priority nutrients identified by the two analyses are essentially the same, but the specific results of the analyses differ.



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WIC Food Packages: Time for a Change C NUTRIENT INTAKE OF WIC SUBGROUPS This appendix presents the details of the final analyses the committee conducted to identify priority nutrients to consider in revising the WIC food packages. Using the Dietary Reference Intakes (DRIs) and the methods described by the Institute of Medicine (IOM, 2000a) to assess nutrient adequacy, the committee assessed the nutrient adequacy of the diets of categorical WIC subgroups—WIC infants under 1 year of age, WIC children 1 through 4 years of age, and pregnant, lactating, and non-breast-feeding postpartum women. Chapter 2—Nutrient and Food Priorities—of this report presents a summary of the results. The first section of this appendix describes the DRIs and then discusses how to use them in assessing nutrient adequacy. The next section describes the data set used in the analyses, and the final section includes tables with the detailed analysis results. For a discussion and interpretation of the results, see Chapter 2 of this report. The results presented in this appendix and summarized in Chapter 2—Nutrient and Food Priorities—update the results of similar analyses conducted by the committee for its first report, Proposed Criteria for Selecting the WIC Food Packages: A Preliminary Report of the Committee to Review the WIC Food Packages (IOM, 2004b). Based on comments received on that report and on initial analyses conducted in response to those comments, the committee expanded the set of nutrients examined and defined the WIC subgroups to correspond more closely to those served by the WIC program. The priority nutrients identified by the two analyses are essentially the same, but the specific results of the analyses differ.

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WIC Food Packages: Time for a Change DIETARY REFERENCE INTAKES (IOM, 1997–2005) Over the past decade, knowledge of nutrient requirements has increased substantially, resulting in a set of new dietary reference standards called the Dietary Reference Intakes (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a). The DRIs replace the earlier Recommended Dietary Allowances and are the appropriate standards to use in determining whether diets are nutritionally adequate without being excessive. The DRIs for micronutrients include four reference standards—the Estimated Average Requirement, the Recommended Dietary Allowance, the Adequate Intake, and the Tolerable Upper Intake Level (IOM, 2003a)—as follows. Estimated Average Requirement (EAR) is the usual intake level that is estimated to meet the requirement of half the healthy individuals in a life stage and gender group. At this level of intake, the other half of the healthy individuals in the specified group would not have their needs met. Recommended Dietary Allowance (RDA) is the usual intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a particular age and gender group (97.5 percent of the individuals in a group). If the distribution of requirements in the group is assumed to be normal, the RDA can be derived as the EAR plus two standard deviations of requirements. Adequate Intake (AI)—When information is not sufficient to determine an EAR (and, thus, an RDA), then an AI is set for the nutrient. The AI is a recommended average daily nutrient intake level based on experimen-tally derived intake levels or approximations of observed mean nutrient intakes by a group (or groups) of apparently healthy people who are maintaining a defined nutritional state or criterion of adequacy. Tolerable Upper Intake Level (UL)—Many nutrients have a UL, which is the highest level of usual nutrient intake that is likely to pose no risks of adverse health effects to individuals in the specified life stage group. As intake increases above the UL, the risk of adverse effects increases. The absence of a UL does not imply that the nutrient does not have a tolerable upper intake level, but, rather, that the available evidence at this times does not permit its estimation. Three of the four DRIs—the EAR, AI, and UL—are appropriate to use in assessing the nutrient intakes of population subgroups. The RDA, however, should not be used in assessing group intakes. Tables F-1A and F-1B in Appendix F—Supplementary Information—present the DRIs for the micronutrients examined in the assessment of the nutrient adequacy of the diets of WIC-eligible population subgroups.

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WIC Food Packages: Time for a Change TABLE C-1 Acceptable Macronutrient Distribution Ranges   Range (percentage of food energy intake) Macronutrient Children, 1–3 y Children, 4 y Women, 13–44 y Protein 5–20 10–30 10–35 Carbohydrate 45–65 45–65 45–65 Fat 30–40 25–35 20–35 DATA SOURCE: DRI report (IOM, 2002/2005). For macronutrients, a somewhat different set of DRIs has been developed (IOM, 2002/2005). In the case of food energy, dietary requirements are expressed in terms of Estimated Energy Requirements (EERs). An adult EER is defined as the dietary energy intake needed to maintain energy balance in a healthy adult of a given age, gender, body weight, height, and level of physical activity. In children, the EER is defined as the sum of the dietary energy intake predicted to maintain energy balance for an individual’s age, body weight, height, and activity level, plus an allowance for normal growth and development. For fat, protein, and carbohydrate, the DRIs include Acceptable Macronutrient Distribution Ranges (AMDRs) for intakes as a percentage of energy intakes (Table C-1). Tables F-1C and F-1D in Appendix F—Supplementary Information—present the DRIs for macronutrients and subcategories (e.g., saturated fat) examined in the assessment of the diets of WIC-eligible population subgroups. In addition to micronutrients and macronutrients, other nutrients and dietary components have DRIs. Potassium and fiber have AIs, and sodium has an AI for infants under 1 year of age and a UL for children and older adults. Current dietary guidance is that the percentage of food energy intake from added sugars not exceed 25 percent (IOM, 2002/2005). The Dietary Guidelines recommend food energy intake from saturated fat not exceed 10 percent and that the daily intake of cholesterol not exceed 300 milligrams (DHHS/USDA, 2005). USING THE DRIS TO ASSESS NUTRIENT ADEQUACY To assess the nutrient adequacy of WIC-eligible subgroups, three questions are important. What are the characteristics of the usual nutrient intake distributions?

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WIC Food Packages: Time for a Change What proportion of the subgroup is at risk of inadequate usual intake? What proportion is at risk of excessive intake levels? What are the characteristics of the usual nutrient intake distributions? In order to describe the characteristics of the usual intake distribution, and to use the DRIs in assessing diets, one needs information on the distribution of usual nutrient intakes. The usual intake of a nutrient is defined as the long-term average intake of the nutrient by the individual (NRC, 1986; Beaton, 1994; IOM, 2000a). Usual intake is not observed; rather, dietary recalls provide data on observed nutrient intakes over some specified period of time. Even discounting errors related to the dietary recall data and its analysis, observed daily intake measures usual intake with error. That is, nutrient intake varies from day to day within an individual. This day-to-day variability is “noise”—the individual-to-individual variability in usual nutrient intake provides the needed information. Because for most nutrients, the day-to-day variability in intakes can be larger than the individual-to-individual variability, it is very important to “remove” the effect of this additional variability when estimating the distribution of usual intakes (Beaton et al., 1979). The National Research Council (NRC, 1986) proposed a simple additive measurement error model that permits adjusting the data for the presence of the day-to-day variability in intakes. The NRC model assumes that the observed daily intake for an individual can be expressed as a deviation from the individual’s usual intake. Subsequently, researchers at Iowa State University (ISU) developed and modified approaches that permit estimating the usual intake distributions with a higher degree of accuracy. This method, proposed by Nusser et al., (1996), is known as the ISU method for estimating usual nutrient intake distributions, and is now widely used by the nutrition community (see, for example, Carriquiry, 1999; IOM, 2000a). Software packages are available that produce estimates of the mean and variance of usual intake in the group, as well as estimates of any percentile of interest. Importantly, these software packages produce estimates of the usual intake distributions of groups and are not appropriate for estimation of the usual intake of individuals. What proportion of the subgroup has inadequate usual intake? Assessing the prevalence of nutrient inadequacy in a group requires estimating the proportion of individuals in the group whose usual intakes of a nutrient do not meet requirements. For most nutrients with an EAR, the committee used the EAR cut-point method to estimate the prevalence of

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WIC Food Packages: Time for a Change inadequacy among categorical WIC subgroups. The EAR cut-point method involves estimating the proportion of individuals in a group whose usual nutrient intakes are less than the EAR. Under certain assumptions, the proportion with usual intakes less than the EAR is an estimate of the proportion of a group whose usual intakes do not meet requirements (Beaton, 1994; Carriquiry, 1999; IOM, 2000a). Given the available information about the distribution of requirements for most nutrients, it appears that the underlying assumptions of the EAR cut-point method hold for most nutrients except iron in premenopausal women and energy. To assess iron adequacy, the probability approach proposed in the National Research Council report (1986) was used. With this approach, a probability model, based on the requirement distribution for iron, was used to estimate the probability of inadequacy at each level of usual iron intake. When more than one EAR applied to a WIC subgroup (e.g., because the age range of the subgroup did not match an age range of the DRIs), the analytic approach to estimating the percentage with usual intakes involved (1) dividing observed intakes by the EAR, (2) adjusting the ratio using the usual intake adjustment software, and (3) estimating the percentage with the ratio less than 1. This approach was used for low-income children ages 1 through 4 years, vitamin C for smokers and nonsmokers, and, in some cases, for low-income pregnant and lactating women. In the case of energy, the reference value used is the Estimated Energy Requirement (EER). Since populations in balance should have usual intake and EER distributions with roughly equal mean values, the analysis compares the mean usual intake of food energy with the mean EER for each subgroup to examine energy adequacy. In addition, for protein, carbohydrate, and fat, tables present (1) the usual distributions of intake as a percentage of observed energy intake and (2) estimates of the proportion outside the AMDR. For nutrients without an EAR—that is, for nutrients with an AI—usual intake distributions are presented and mean intakes are compared with the AI. Importantly, however, limited inferences can be made regarding the prevalence of inadequacy for nutrients with an AI. If mean intake levels are equal to or exceed the AI, it is likely that the prevalence of inadequacy is low; but if mean intakes are less than the AI, no conclusions can be drawn about the prevalence of inadequacy (IOM, 2000a). What proportion is at risk of excessive intake levels? The proportion with usual intakes exceeding the UL is an estimate of the proportion of each subgroup at risk of excessive intake levels. Because ULs have not been established for all nutrients, this question can be ad-

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WIC Food Packages: Time for a Change dressed only for those nutrients with ULs. Because the data used in the analysis do not include intakes from supplements, the assessment of the risk of excessive intake was limited to considering nutrient intake from foods. This means that the committee could not assess the risk of excessive intake for those nutrients whose ULs refer to intakes from supplements only, and the assessment of risk is incomplete to the extent that subgroup members took nutrient supplements. The committee estimated the proportion at risk of excessive intake levels for calcium; iron; zinc; vitamins A, B6, and C; and folate (folic acid). Risk of excessive intake levels for magnesium and vitamin E were not assessed. DATA SET The primary data set used in this analysis is the 1994–1996 and 1998 Continuing Survey of Food Intakes by Individuals (CSFII). The 1994–1996 CSFII provides information on food and nutrient intake over two non-consecutive days for 16,103 individuals of all ages and gender, and of a variety of income levels, racial and ethnic groups, and sociodemographic characteristics. The three-year survey was designed so that the information collected on any one year would constitute a nationally representative sample of individuals of all ages. The samples were selected using stratified, clustered multistage sampling procedures, with an oversampling of low-income individuals. Food intake data were collected using 24-hour dietary recall questionnaires, which included information on the type and amounts of all foods consumed by individuals over two non-consecutive days. In addition, the survey provides sociodemographic information, including income and participation in food assistance programs. The 1998 Supplemental Children’s Survey was designed to be a one-time supplement to the 1994–1996 CSFII, using the same design and survey methodology of the CSFII. Dietary intake data were collected from 5,559 infants and children aged 0 through 9 years over two non-consecutive days between November 1997 and October 1998. The sample was designed to be a stand-alone, nationally representative sample of children in that age range; also, however, it could be combined with the dietary information collected for infants and children up to nine years of age in the 1994–1996 CSFII. Combining the data from the Supplemental Children’s Survey sample and the 1994–1996 CSFII provides a large sample of children for the committee’s analysis.

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WIC Food Packages: Time for a Change Analysis Sample1 The analysis sample includes respondents from the CSFII 1994–1996 and 1998 who completed 24-hour dietary recalls and were in one of the following categorical subgroups. WIC Infants, Non-Breastfed, Less Than One Year of Age—The analysis sample included WIC infants 0 through 3 months of age [sample size (n) = 152], WIC infants 4 through 5 months of age (n = 104), and WIC infants 6 through 11 months of age (n = 275). Because data are not available on the quantity of breast milk consumed, breast-fed infants were excluded from most analyses of nutrient intake. Infants, Breast-Fed, 6 Through 11 Months of Age (n = 143)—Because of concerns about the adequacy of iron and zinc intakes of older breast-fed infants, the committee assessed the adequacy of these nutrients for breast-fed infants 6 through 11 months of age. (Since the iron and zinc content of breast milk is very low for older breast-fed infants, the absence of data on the quantity of breast milk consumed does not affect the analysis of iron and zinc adequacy.) Because of small sample sizes for WIC (or low-income) breast-fed infants 6 through 11 months of age, the analysis examined all breast-fed infants in this age group. WIC Children, 1 Through 4 Years of Age—The analysis sample included WIC children one year of age (n = 287), and WIC children 2 through 4 years of age (n = 872). Pregnant Women and Lactating Women, Ages 14 Through 44 Years (n = 123)—This analysis sample included all pregnant women and all lactating women combined, regardless of participation in the WIC program; otherwise the samples would have been too small to analyze meaningfully. Women, Non-Breastfeeding, up to One Year Postpartum, Ages 14 Through 44 Years (n = 105)—Because of small sample sizes for non-breastfeeding women up to six months postpartum and low-income non-breastfeeding women up to one year postpartum, the analysis included all low-income and high-income non-breastfeeding women up to one year postpartum. 1   In all of the analyses of the CSFII data, including the C-SIDE estimation procedures, the appropriate (one-day) weights were used to statistically allow for the complex design of the data set (that is, the appropriate weights were used to statistically allow the data set to be representative of the national population).

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WIC Food Packages: Time for a Change Nutrients Examined The nutrients and dietary components examined include: Nutrients currently targeted by the WIC program—calcium, iron, vitamin A, vitamin C, and protein; Macronutrients—food energy and the percentage of food energy from protein, carbohydrate, and fat; and Other nutrients and dietary components considered of public health significance—selenium, magnesium, phosphorus, sodium, potassium, vitamin E, thiamin, riboflavin, niacin, vitamin B6, vitamin B12, folate, fiber, and cholesterol; also saturated fat and added sugars as a percentage of food energy intake. An important issue is to ensure that comparable units for each nutrient are used among the various resources used. Specific issues arise regarding the units for vitamin E, niacin and folate. Vitamin E—The DRIs report vitamin E as AT [(alpha)-tocopherol]. Thus, the EARs for vitamin E apply only to RRR-(alpha)-tocopherol, the form of (alpha)-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms, a portion of the (alpha)-tocopherol used in fortified foods and dietary supplements. Analysis of dietary intake (CSFII) was based on data in which the units for reporting vitamin E were ATE [(alpha)-tocopherol equivalents which include the contribution of eight naturally occurring tocopherols]. Because of the differences in the units between the intake data and the EARs, the estimated prevalences of inadequacy of vitamin E intakes in this report are likely to be underestimates. Niacin—Analysis of dietary intake of niacin was based solely on preformed niacin; however, the EAR is based on niacin equivalents (which allows for some conversion of the amino acid tryptophan to niacin). Thus, the estimated prevalence of inadequacy of niacin intakes is likely to be an overestimate. Folate in Dietary Folate Equivalents—The DRIs report folate as microgram DFE (Dietary Folate Equivalents). Dietary intake data (CSFII) reports folate in micrograms. For this report, the amount of folate was calculated by applying the nutrient values from the Food and Nutrient Database for Dietary Studies (FSRG, 2004) to the CSFII folate data. The CSFII data included some food codes not included in the FNDDS; for those food codes the committee applied conversions developed by USDA’s Center for Nutrition Policy and Promotion (CNPP database received from Tracy Von Ins, OANE, FNS, USDA, October, 2004) to obtain the total amount of folate (as microgram DFE) consumed per day for all foods eaten. The values of “folate as dietary folate equivalents” were compared to the EARs.

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WIC Food Packages: Time for a Change Folate as Folic Acid—The UL for folate applies only to folic acid, the form of folate used in fortification and supplementation. For estimates of intake used in comparison to the UL for folate, the variable folic acid was obtained from the nutrient data, calculated by applying the nutrient values from the FNDDS Nutrient Values file (FSRG, 2004) to the amount of food eaten. This represents folate from fortification only. The committee was not able to obtain folic acid data for all foods because the CSFII data included some food codes not included in the FNDDS; the conversion database developed by CNPP did not contain folic acid values. The net effect of this small amount of missing data is to slightly underestimate the percentage with dietary intakes above the UL. The following is a list of the data tables presented in this appendix. Table C-2   Usual Intake Distributions of Selected Micronutrients and Electrolytes:     A   WIC Infants, 0 Through 3 Months, Non-Breastfed,   274 B   WIC Infants, 4 Through 5 Months, Non-Breastfed,   275 C   WIC Infants, 6 Through 11 Months, Breast-Fed and Non-Breastfed,   276 D   WIC Children, 12 Through 23 Months,   277 E   WIC Children, 2 Through 4 Years,   278 F   Adolescent and Adult Women, Pregnant or Lactating,   280 G   Adolescent and Adult Women, Non-Breastfeeding Postpartum,   282 Table C-3   Usual Intake Distributions of Selected Macronutrients (Cholesterol and Fiber)     A   WIC Infants, 0 Through 3 Months, Non-Breastfed,   284 B   WIC Infants, 4 Through 5 Months, Non-Breastfed,   284 C   WIC Infants, 6 Through 11 Months, Non-Breastfed,   285 D   WIC Children, 12 Through 23 Months,   285 E   WIC Children, 2 Through 4 Years,   286 F   Adolescent and Adult Women, Pregnant or Lactating,   287 G   Adolescent and Adult Women, Non-Breastfeeding Postpartum,   288 Table C-4   Usual Intakes and Percentages with Reported Usual Intakes of Macronutrients and Added Sugars Outside Dietary Guidance,   289

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WIC Food Packages: Time for a Change TABLE C-2A Usual Intake Distributions of Selected Micronutrients and Electrolytes: WIC Infants, 0 Through 3 Months, Non-Breastfed     Intake Distribution (percentiles and mean) Nutrient Units (per day) 10th 25th Median Mean 75th 90th AI* UL %>UL Calcium mg 350 430 530 562 660 810 210* ND — Iron mg 7.5 9.5 11.8 12.7 14.8 18.8 0.27* 40 0.2 Zinc mg 3.7 4.6 5.8 6.1 7.2 8.7 2* 4 86.0 Selenium mcg 10 12 16 17 19 24 15* 45 0.3 Magnesium mg 38 47 59 63 74 94 30* naa — Phosphorus mg 217 269 343 368 437 547 100* ND — Sodium mg 129 158 200 216 256 323 120* ND — Potassium mg 470 560 690 736 860 1,060 400* ND — Vitamin A mcg RAE 362 440 550 586 692 854 400* — — Vitamin A, preformed mcg 367 445 547 581 677 833   600 38.3 Vitamin Eb mg 6.5 8.2 10.2 11.1 12.9 16.4 4* ND — Vitamin C mg 44 55 71 78 93 121 40* ND — Thiamin mg 0.36 0.44 0.55 0.60 0.70 0.90 0.2* ND — Riboflavin mg 0.53 0.66 0.84 0.92 1.08 1.39 0.3* ND — Niacinb mg 4.5 5.4 6.8 7.5 8.7 11.3 2* nac — Folateb mcg DFE 95 123 158 166 200 246 65* ND — Vitamin B6 mg 0.26 0.32 0.40 0.42 0.50 0.61 0.1* ND — Vitamin B12 mcg 1.14 1.40 1.76 1.92 2.24 2.87 0.4* ND — NOTES FOR TABLE C-2A: Analysis sample was data for non-breastfed infants from birth through 3.9 mo of age participating in the WIC program at the time of the survey (n = 152). See additional notes for Tables C-2A through C-2G following Table C-2G.

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WIC Food Packages: Time for a Change TABLE C-2B Usual Intake Distributions of Selected Micronutrients and Electrolytes: WIC Infants, 4 Through 5 Months, Non-Breastfed     Intake Distribution (percentiles and mean) Nutrient Units (per day) 10th 25th Median Mean 75th 90th AI* UL %>UL Calcium mg 467 562 665 675 776 893 210* ND — Iron mg 10.6 13.1 16.1 16.7 19.5 23.5 0.27* 40 0.3 Zinc mg 4.9 5.9 6.9 7.0 8.1 9.3 2* 4 96.8 Selenium mcg 14 17 20 20 23 27 15* 45 <0.1 Magnesium mg 62 72 85 87 100 115 30* naa — Phosphorus mg 309 370 447 456 532 616 100* ND — Sodium mg 179 206 242 247 282 323 120* ND — Potassium mg 730 830 960 974 1,100 1,250 400* ND — Vitamin A mcg RAE 536 606 687 693 773 859 400* — — Vitamin A, preformed mcg 453 533 620 626 712 806   600 56.3 Vitamin Eb mg 8.8 10.1 12.2 12.6 14.7 16.9 4* ND — Vitamin C mg 78 93 115 124 145 181 40* ND — Thiamin mg 0.52 0.64 0.80 0.84 1.00 1.22 0.2* ND — Riboflavin mg 0.81 0.96 1.15 1.19 1.38 1.61 0.3* ND —Niac inb mg 6.8 8.2 10.0 10.5 12.1 14.7 2* nac — Folateb mcg DFE 137 163 194 196 227 258 65* ND — Vitamin B6 mg 0.41 0.46 0.53 0.53 0.60 0.67 0.1* ND — Vitamin B12 mcg 1.40 1.71 2.06 2.07 2.43 2.76 0.4* ND — NOTES FOR TABLE C-2B: Analysis sample was data for non-breastfed infants 4–5.9 mo of age participating in the WIC program at the time of the survey (n = 104). See additional notes for Tables C-2A through C-2G following Table C-2G.

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WIC Food Packages: Time for a Change TABLE C-2F Usual Intake Distributions of Selected Micronutrients and Electrolytes: Adolescent and Adult Women, Pregnant or Lactating     Intake Distribution (percentiles and mean) Nutrient Units (per day) 10th 25th Median Mean 75th 90th Calcium mg 590 740 920 956 1,140 1,360 Iron mg 10.8 12.8 15.6 16.5 19.2 23.6 Zinc mg 8.6 9.9 11.4 11.7 13.2 15.1 Selenium mcg 71 84 99 103 117 139 Magnesium mg 196 234 282 291 339 398 Phosphorus mg 964 1,137 1,343 1,359 1,564 1,775 Sodium mg 2,630 2,940 3,310 3,330 3,690 4,060 Potassium mg 2,030 2,410 2,860 2,909 3,360 3,850 Vitamin A mcg RAE 444 605 834 902 1,124 1,446 Vitamin A, preformed mcg 299 405 552 589 732 926 Vitamin Eb mg 4.9 6.1 7.8 8.3 9.9 12.3 Vitamin C mg 49 75 116 134 173 242 Thiamin mg 1.08 1.31 1.60 1.67 1.96 2.34 Riboflavin mg 1.43 1.73 2.12 2.19 2.57 3.04 Niacinb mg 14.5 17.5 21.1 21.8 25.3 29.9 Folateb mcg DFE 322 411 535 570 691 863 Folic acidb,d mcg — — — — — — Vitamin B6 mg 1.20 1.49 1.88 1.95 2.33 2.81 Vitamin B12 mcg 3.05 3.75 4.63 4.79 5.66 6.74 NOTES FOR TABLE C-2F: Analysis sample was data for pregnant or lactating adolescent and adult women ages 14–44 y (n = 123). Because of sample size limitations, the analysis sample combined all pregnant women and all lactating women. The DRIs shown in the table are for women ages 19–30 y of age only; however, the analysis was conducted on the entire sample. See additional notes for Tables C-2A through C-2G following Table C-2G.

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WIC Food Packages: Time for a Change EAR or AI* (19–30 y) UL (19–30 y) Pregnant Lactating % Inadeq Pregnant Lactating %>UL 1,000* 1,000* — 2,500 2,500 <0.1 22 6.5 7.5 45 45 0.1 9.5 10.4 23.8 40 40 <0.1 49 59 1.4 400 400 <0.1 290 255 49.4 naa naa — 580 580 0.4 3,500 4,000 <0.1 1,500* 1,500* — 2,300 2,300 97.2 4,700* 5,100* — ND ND — 550 900 31.2 ND ND —     — 3,000 3,000 <0.1 12 16 94.4 1,000 1,000 <0.1 70 100 32.7 2,000 2,000 <0.1 1.2 1.2 17.2 ND ND — 1.2 1.3 3.8 ND ND — 14 13 8.1 nac nac — 520 450 41.5 — — —     — 1,000 1,000 <0.1 1.6 1.7 34.0 100 100 <0.1 2.2 2.4 1.5 ND ND —

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WIC Food Packages: Time for a Change TABLE C-2G Usual Intake Distributions of Selected Micronutrients and Electrolytes: Adolescent and Adult Women, Non-Breastfeeding Postpartum     Intake Distribution (percentiles and mean) Nutrient Units (per day) 10th 25th Median Mean 75th 90th Calcium mg 430 530 640 668 780 930 Iron mg 11.1 12.2 13.6 13.7 15.0 16.4 Zinc mg 9.2 9.4 9.7 9.7 10.0 10.2 Selenium mcg 72.2 79.0 87.0 87.8 95.8 104.4 Magnesium mg 161 183 210 213 240 269 Phosphorus mg 832 925 1,034 1,042 1,151 1,263 Sodium mg 2,320 2,580 2,890 2,912 3,220 3,540 Potassium mg 1,570 1,790 2,060 2,086 2,350 2,630 Vitamin A mcg RAE 316 406 528 556 675 831 Vitamin A, preformed mcg 195 264 361 388 482 615 Vitamin Eb mg 5.2 5.9 6.8 6.9 7.8 8.7 Vitamin C mg 34 49 72 79 101 135 Thiamin mg 1.03 1.18 1.36 1.38 1.57 1.77 Riboflavin mg 1.15 1.34 1.57 1.60 1.83 2.10 Niacinb mg 13.0 15.2 17.9 18.1 20.7 23.7 Folateb mcg DFE 312 377 463 482 566 675 Folic acidb,d mcg — — — — — — Vitamin B6 mg 1.01 1.17 1.37 1.39 1.59 1.80 Vitamin B12 mcg 2.20 3.10 4.60 5.48 6.80 9.90 NOTES FOR TABLE C-2G: Analysis sample was data for non-breastfeeding postpartum adolescent and adult women ages 14–44 y (n = 105). See additional notes for Tables C-2A through C-2G following this table. NOTES FOR TABLES C-2A THROUGH C-2G: AI = Adequate Intake, used when EAR could not be determined, indicated by an asterisk (*); DFE = dietary folate equivalents; EAR = Estimated Average Requirement; na = not applicable; ND = not determined, EAR could not be determined or UL not determined due to lack of data of adverse effects; RAE = retinol activity equivalents; RE = retinol equivalents; UL = Tolerable Upper Intake Level; %>UL, percentage with usual intake greater than UL; % Inadeq = percentage with inadequate intakes as estimated from percentage with usual intake less than EAR. aThe UL for magnesium represents intake from pharmacological agents only and does not include intake from food and water. bFor discussion of important issues regarding differences between the DRI and dietary intake data in the units used for vitamin E, niacin, and folate, please see the section Data Set—Nutrients Examined—here in Appendix C.

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WIC Food Packages: Time for a Change EAR or AI* (19–30 y) UL (19–30 y) Pregnant Lactating % Inadeq Pregnant Lactating %>UL 1,300* 1,000* — 2.5 2.5 <0.1 7.9 8.1 9.5 45 45 <0.1 7.3 6.8 <0.1 34 40 <0.1 45 45 <0.1 400 400 <0.1 300 265 87.5 naa naa   1,055 580 0.7 4,000 4,000 <0.1 1,500* 1,500* — 2.3 2.3 90.7 4,700* 4,700* — ND ND — 485 500 44.1 ND ND —     — 2,800 3,000 <0.1 12 12 99.8 800 1,000 <0.1 56 60 42.2 1,800 2,000 <0.1 0.9 0.9 3.2 ND ND — 0.9 0.9 1.2 ND ND — 11 11 3.3 nac nac — 330 320 12.0 — — —     — 800 1,000 <0.1 1 1.1 17.1 80 100 <0.1 2 2 6.6 ND ND — cThe UL for niacin represents intake of free niacin likely to be ingested only in supplements or fortified foods. dFor folic acid, the form of folate used in food fortification, the intake distribution could not be calculated because available dietary intake data were incomplete. For detailed explanation, please see the section Data Set—Nutrients Examined—here in Appendix C. eValues are for children ages 2–3.9 y and children age 4 y, respectively. For this analyses, the intake of each child was compared to the age-appropriate DRI. DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (FSRG, 2000); data set does not include intake from dietary supplements (e.g., multivitamin and mineral preparations). Intake distributions were calculated using C-SIDE (ISU, 1997).

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WIC Food Packages: Time for a Change TABLE C-3A Usual Intake Distributions of Selected Macronutrients: WIC Infants, 0 Through 3 Months, Non-Breastfed     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 437 523 635 673 778 951 EERa kcal/d 406 468 559 555 640 687 Protein g/d 9.4 11.4 14.1 14.9 17.6 21.5   % of energy 8 8 9 9 9 10 Carbohydrate g/d 47 57 71 75 87 106   % of energy 41 43 44 44 46 48 Fat, total g/d 22 27 33 35 40 49   % of energy 43 45 47 46 48 49 Saturated fatty acids g/d 9 11 13 14 16 20   % of energy 16 18 19 19 20 21 NOTES FOR TABLE C-3A: Analysis sample was data for non-breastfed infants from birth through 3.9 mo of age participating in the WIC program at the time of the survey (n = 152). See additional notes for Tables C-3A through C-3G following Table C-3G. TABLE C-3B Usual Intake Distributions of Macronutrients and Fiber: WIC Infants, 4 Through 5 Months, Non-Breastfed     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 603 684 786 802 903 1,021 EERa kcal/d 471 541 614 623 675 765 Protein g/d 12.6 14.9 17.5 17.8 20.3 23.2   % of energy 8 8 9 9 9 10 Carbohydrate g/d 73 83 96 98 111 126   % of energy 43 46 48 49 52 57 Fat, total g/d 28 33 38 38 44 49   % of energy 37 40 42 42 45 47 Saturated fatty acids g/d 11 13 15 15 17 20   % of energy 14 16 17 17 18 19 Fiber g/d <1 <1 1 2 3 5 NOTES FOR TABLE C-3B: Analysis sample was data for non-breastfed infants 4–5.9 mo of age participating in the WIC program at the time of the survey (n = 104). See additional notes for Tables C-3A through C-3G following Table C-3G.

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WIC Food Packages: Time for a Change TABLE C-3C Usual Intake Distributions of Macronutrients, Cholesterol, and Fiber: WIC Infants, 6 Through 11 Months, Non-Breastfed     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 691 821 970 992 1,137 1,319 EERa kcal/d 570 641 740 754 854 958 Proteinb g/d 15.9 19.7 24.9 26.7 31.8 39.9   % of energy 8 9 10 11 12 13 Carbohydrate g/d 91 107 128 131 151 176   % of energy 47 50 53 54 57 60 Fat, total g/d 27 33 40 40 47 55   % of energy 30 34 37 36 40 43 Saturated fatty acids g/d 11 13 16 16 19 22   % of energy 11 13 15 14 16 18 Cholesterol mg/d 13 23 47 71 92 160 Fiber g/d 2 3 5 5 6 8 bFor protein, 0.6% of WIC infants ages 6–11.9 mo had inadequate intakes. NOTES FOR TABLE C-3C: Analysis sample was data for non-breastfed infants 6–11.9 mo of age participating in the WIC program at the time of the survey (n = 275). See additional notes for Tables C-3A through C-3G following Table C-3G. TABLE C-3D Usual Intake Distributions of Macronutrients, Cholesterol, and Fiber: WIC Children, 12 Through 23 Months     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 901 1,065 1,262 1,288 1,482 1,708 EERa kcal/d 729 827 935 942 1,050 1,165 Proteinb g/d 32 38 46 48 56 66   % of energy 12 13 15 15 16 18 Carbohydrate g/d 115 137 164 168 194 226   % of energy 46 49 53 53 57 61 Fat, total g/d 32 39 48 49 58 68   % of energy 28 31 33 33 36 39 Saturated fatty acids g/d 14 17 21 21 25 30   % of energy 11 13 15 15 17 18 Cholesterol mg/d 97 130 176 192 238 309 Fiber g/d 4 6 8 8 10 12 bFor protein, <0.1% of WIC children ages 1–1.9 y had inadequate intakes. NOTES FOR TABLE C-3D: Analysis sample was data for non-breastfed children 12–23.9 months of age participating in the WIC program at the time of the survey (n = 287). See additional notes for Tables C-3A through C-3G following Table C-3G.

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WIC Food Packages: Time for a Change TABLE C-3E Usual Intake Distributions of Macronutrients, Cholesterol, and Fiber: WIC Children, 2 Through 4 Years     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 1,112 1,312 1,553 1,585 1,822 2,095 EERa-Low Active kcal/d 1,000 1,146 1,285 1,282 1,412 1,545 EERa-Active kcal/d 1,019 1,207 1,411 1,389 1,567 1,700 Proteinb g/d 40 47 56 57 67 77   % of energy 13 14 15 15 16 17 Carbohydrate g/d 146 173 208 213 247 286   % of energy 48 51 54 54 57 60 Added sugars g/d 6 8 12 13 17 21   % of energy 7 9 12 13 16 20 Fat, total g/d 39 47 57 58 68 80   % of energy 28 30 33 33 35 38 Saturated fatty acidsc g/d 15 18 22 22 26 30   % of energy 10 11 13 13 14 15 Cholesterold mg/d 134 165 206 216 257 311 Fiber g/d 7 8 11 11 13 16 bFor protein, <0.1% of WIC children ages 2–4.9 y had inadequate intakes. cFor saturated fatty acids, 9% of WIC children ages 2–4.9 y had intakes that followed dietary guidance to limit to less than 10% of food energy intake. dFor cholesterol, 88% of WIC children ages 2–4.9 y had intakes that followed dietary guidance to limit intake to less than 300 mg per day. NOTES FOR TABLE C-3E: Analysis sample was data for children 2–4.9 y of age participating in the WIC program at the time of the survey (n = 872). See additional notes for Tables C-3A through C-3G following Table C-3G.

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WIC Food Packages: Time for a Change TABLE C-3F Usual Intake Distributions of Macronutrients, Cholesterol, and Fiber: Adolescent and Adult Women, Pregnant or Lactating     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 1,557 1,798 2,088 2,115 2,403 2,707 EERa-Low Active kcal/d 2,279 2,355 2,451 2,465 2,560 2,671 Proteinb g/d 58 68 79 79 90 102   % of energy 14 15 16 16 16 17 Carbohydrate g/d 199 235 279 285 328 378   % of energy 49 51 54 54 56 59 Added sugars g/d 10 14 20 22 27 35   % of energy 8 11 15 16 19 24 Fat, total g/d 55 64 76 77 88 99   % of energy 28 30 32 32 35 37 Saturated fatty acidsc g/d 19 23 27 27 32 37   % of energy 9 10 12 12 13 14 Cholesterold mg/d 173 210 260 271 320 385 Fiber g/d 10 13 17 18 21 26 bFor protein, 17% of pregnant and lactating women had inadequate intakes. cFor saturated fatty acids, 19% of pregnant and lactating women had intakes that followed dietary guidance to limit to less than 10% of food energy intake. dFor cholesterol, 68% of pregnant and lactating women had intakes that followed dietary guidance to limit intake to less than 300 mg per day. NOTES FOR TABLE C-3F: Analysis sample was data for pregnant or lactating adolescent and adult women ages 14–44 y (n = 123). Because of sample size limitations, the analysis sample combined all pregnant women and all lactating women. See additional notes for Tables C-3A through C-3G following Table C-3G.

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WIC Food Packages: Time for a Change TABLE C-3G Usual Intake Distributions of Macronutrients, Cholesterol, and Fiber: Adolescent and Adult Women, Non-Breastfeeding Postpartum     Intake Distribution (percentiles and mean) Nutrient Units 10th 25th Median Mean 75th 90th Food energy kcal/d 1,363 1,540 1,754 1,774 1,986 2,210 EERa-Low Active kcal/d 1,988 2,058 2,148 2,163 2,253 2,359 Proteinb g/d 50 57 64 65 72 80   % of energy 12 14 15 15 16 18 Carbohydrate g/d 159 189 226 229 266 305   % of energy 47 49 52 52 55 57 Added sugars g/d 8 13 19 21 27 36   % of energy 8 12 17 18 24 30 Fat, total g/d 55 60 66 66 72 77   % of energy 32 32 33 33 34 35 Saturated fatty acidsc g/d 17 20 23 23 26 29   % of energy 10 11 11 11 12 12 Cholesterold mg/d 152 179 213 219 253 292 Fiber g/d 7 9 12 12 15 18 bFor protein, 4% of non-breastfeeding postpartum women had inadequate intakes. cFor saturated fatty acids, 4% of non-breastfeeding postpartum women had intakes that followed dietary guidance to limit to less than 10% of food energy intake. dFor cholesterol, 92% of non-breastfeeding postpartum women had intakes that followed dietary guidance to limit intake to less than 300 mg per day. NOTES FOR TABLE C-3G: Analysis sample was data for non-breastfeeding postpartum adolescent and adult women ages 14–44 y (n = 105). See additional notes for Tables C-3A through C-3G following this table. NOTES FOR TABLES C-3A THROUGH C-3G: EER = Estimated Energy Requirement; kcal = kilocalories. aMean EER (kcal/d) was calculated based on CSFII data (FSRG, 2000) using the method described in the DRI report (IOM, 2002/2005). For pregnant women, EER calculations assumed the second trimester. For lactating women, EER calculations assumed the first 6 month period postpartum. DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (FSRG, 2000); data set does not include intake from dietary supplements (e.g., multivitamin and mineral preparations). Intake distributions were calculated using C-SIDE (ISU, 1997).

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WIC Food Packages: Time for a Change TABLE C-4 Usual Intakes and Percentages with Reported Usual Intakes of Macronutrients and Added Sugars Outside Dietary Guidance   Participant Category Nutrient (Dietary Guidance) WIC Children, 1–1.9 y (n = 287) WIC Children, 2–4.9 y (n = 872) Pregnant Women and Lactating Women (n = 123) Non-Breastfeeding Postpartum Women (n = 105) Protein (AMDR†a as percentage of food energy) (5–20†) (5–20†, 2–3.9 y) (10–30†, 4–4.9 y) (10–30†, <19 y) (10–35†, ≥ 19 y) (10–35†) Mean usual intake (g/d) 48 57 79 65 %<AMDR <0.1 0.5 <0.1 0.3 %>AMDR 1.5 1.0 <0.1 <0.1 Carbohydrate, total (AMDR†a as percentage of food energy) (45–65†) (45–65†) (45–65†) (45–65†) Mean usual intake (g/d) 168 213 285 229 %<AMDR 7.5 2.0 1.5 4.8 %>AMDR 2.8 1.1 0.2 0.1 Added Sugars (<25% of food energy) Mean usual intake (g/d) — 13 22 21 %>25% of energy na 2.9 7.3 20.4 Fat, total (AMDR†a as percentage of food energy) (30–40†) (30–40†, 2–3.9 y) (25–35†, 4–4.9 y) (25–35†, <19 y) (20–35†, ≥ 19 y) (25–35†, <19 y) (20–35†, ≥ 19 y) Mean usual intake (g/d) 49 58 77 66 %<AMDR 20.8 18.1 0.2 <0.1 %>AMDR 5.5 10.4 24.5 4.9

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WIC Food Packages: Time for a Change   Participant Category Nutrient (Dietary Guidance) WIC Children, 1–1.9 y (n = 287) WIC Children, 2–4.9 y (n = 872) Pregnant Women and Lactating Women (n = 123) Non-Breastfeeding Postpartum Women (n = 105) Fat, saturated (<10% of food energy)b Mean usual intake (g/d) 21 22 27 23 %>10% of energy na 91.0 80.9 96.2 aAMDRs are presented as a range of intakes expressed as percentage of food energy intake (IOM, 2002/2005). For this analyses, the intake of each individual was compared to the age-appropriate AMDR. bThe dietary guidance in this table for saturated fat is a part of the Dietary Guidelines for Americans (DHHS/USDA, 2005). The Dietary Reference Intake (DRI) guidance for saturated fat is to consume amounts as low as possible while consuming a nutritionally adequate diet (IOM, 2002/2005). NOTES: This table is similar to Table 2-5; more detail is presented here in Appendix C. AMDR = Acceptable Macronutrient Distribution Range indicated by a dagger (†); n = sample size; na = not applicable; %<AMDR, percentage with usual intake less than AMDR; %>AMDR, p ercentage with usual intake greater than AMDR. DATA SOURCES: Intake data were obtained from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (FSRG, 2000). All young children were non-breastfed. Usual intake distributions were calculated using C-SIDE (ISU, 1997). AMDRs and dietary guidance for added sugars were obtained from the DRI report (IOM, 2002/2005). Dietary guidance for saturated fat was obtained from the Dietary Guidelines (DHHS/USDA, 2005) (see note b).