D
EVALUATING POTENTIAL BENEFITS AND RISKS OF THE REVISED FOOD PACKAGES

Three of the six criteria guiding the development of the revised WIC food packages focused on nutrient and food intakes. Specifically, the committee aimed to develop WIC food packages that would (1) reduce the prevalence of inadequate nutrient intakes and of excessive nutrient intakes, (2) lead to dietary patterns that are consistent with the Dietary Guidelines for Americans for individuals two years and older,1 and (3) contribute to dietary patterns that are consistent with dietary guidance for infants and children younger than 2 years of age.

This appendix summarizes the results from an evaluation of the potential nutrient benefits and risks for the WIC target population associated with the revised WIC food packages. Potential benefits are characterized as reductions in the prevalence of inadequate nutrient intake and reductions in the prevalence of excessive nutrient intake. Potential risks are characterized as increases in the prevalence of inadequate intake, increases in the prevalence of excessive nutrient intake, and any departures from consistency with the Dietary Guidelines and dietary guidance for those younger than 2 years of age. Chapter 6How the Revised Food Packages Meet the Criteria Specified—addresses ways in which the revised packages provide

1  

Failure to meet the Dietary Guidelines for Americans was identified as a nutrition risk criteria for the WIC program (IOM, 1996).



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WIC Food Packages: Time for a Change D EVALUATING POTENTIAL BENEFITS AND RISKS OF THE REVISED FOOD PACKAGES Three of the six criteria guiding the development of the revised WIC food packages focused on nutrient and food intakes. Specifically, the committee aimed to develop WIC food packages that would (1) reduce the prevalence of inadequate nutrient intakes and of excessive nutrient intakes, (2) lead to dietary patterns that are consistent with the Dietary Guidelines for Americans for individuals two years and older,1 and (3) contribute to dietary patterns that are consistent with dietary guidance for infants and children younger than 2 years of age. This appendix summarizes the results from an evaluation of the potential nutrient benefits and risks for the WIC target population associated with the revised WIC food packages. Potential benefits are characterized as reductions in the prevalence of inadequate nutrient intake and reductions in the prevalence of excessive nutrient intake. Potential risks are characterized as increases in the prevalence of inadequate intake, increases in the prevalence of excessive nutrient intake, and any departures from consistency with the Dietary Guidelines and dietary guidance for those younger than 2 years of age. Chapter 6—How the Revised Food Packages Meet the Criteria Specified—addresses ways in which the revised packages provide 1   Failure to meet the Dietary Guidelines for Americans was identified as a nutrition risk criteria for the WIC program (IOM, 1996).

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WIC Food Packages: Time for a Change potential benefits through improved consistency with the Dietary Guidelines and dietary guidance for those younger than 2 years of age. This is not a complete assessment of risk and benefits in that it is not feasible to estimate what long-term health benefits and risks would be associated with a change in specific foods offered in the WIC program. Assuming that the recommendations in this report are adopted at the federal level, those benefits and risks would depend upon many factors, including the following: The extent to which the WIC state agencies allow local agencies to prescribe the maximum amounts of food in the revised food packages; The extent to which the WIC state agencies incorporate more allowed choices in the food package offerings; The success of approaches to nutrition education that address the revised food packages; The extent of redemption of the WIC food instruments for the revised packages; Whether the entire amount of food in the package is consumed by the WIC participant; and The association of consuming those foods with long-term health benefits. Notably, the committee used current dietary guidance from the Dietary Guidelines and Dietary Reference Intakes (DRIs) when redesigning the food packages, and these sources incorporate information on reduced risk of chronic diseases into their dietary guidance. The Dietary Guidelines for Americans 2005 “provide science-based advice [for people two years and older] to promote health and to reduce risk for chronic diseases through diet and physical activity” (DHHS/USDA, 2005, p. 1). The DRIs are intended to minimize the risk of nutrient inadequacy (including both classical deficiency states and the reduction of the risk of chronic disease and disorders) or nutrient excess and are intended to be applied to the healthy general population in the United States and Canada (IOM, 1997). Thus, the more closely that diets adhere to current dietary guidance, the greater the likelihood that they will result in long-term health benefits. METHODS FOR EVALUATING NUTRITIONAL BENEFITS AND RISKS The method for evaluating nutritional benefits and risks associated with changes in the WIC food packages is a modification of the risk assess-

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WIC Food Packages: Time for a Change ment method first outlined by the National Research Council in 1983 (NRC, 1983). In risk assessment, hazard identification is followed by dose-response assessment and exposure assessment before the results are combined in risk characterization. In risk assessment, the term hazard identification refers to the characterization of potential adverse effects on human health and the conditions necessary to elicit those effects. Inadequate nutrition can be characterized for specific nutrients as either inadequate intake or excessive intake that increases the risk of poor health outcomes, i.e., the risk of hazards. Detailed discussions of the possible hazards associated with poor dietary choices and inadequate nutrient intake are available in the DRI reports (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a). Concerns about excessive intake of some nutrients (e.g., excessive preformed vitamin A intake and excessive intake of food energy) arise because of potential toxicity or potential for unhealthy body weight gain, respectively, in the examples given. In risk assessment, dose-response assessment describes how changes in dose (in this case, changes in the intake of nutrients) influence the likelihood of a hazard being realized (that is, the likelihood of changes in health status). It is outside the scope of this report to discuss changes in health status. Therefore, for the analysis presented in this report, there is no formal assessment of changes in the number or severity of health effects due to changes in intake. That is, there is no formal dose-response assessment describing the likelihood of changes in health status. This report focuses on dietary inadequacy or excess as the hazard, rather than on changes in health status. In risk assessment, exposure assessment seeks to predict the change in exposure. In this case, exposure assessment for each WIC population addresses the changes in usual nutrient intake distributions that result from changes in individual intakes that are based on the changes in the nutrients provided by the revised food packages. As the final step in risk assessment, risk characterization reflects the integration of the previous three steps in order to help inform decision makers about quantitative levels of risk to human health status under different scenarios. This report contains a modified risk characterization because the committee was able to consider only dietary status (that is, the risk of inadequate intake and the risk of excessive intake), not health status. In summary, this evaluation of nutritional benefits and risks brings together information from (1) the assessment of inadequate nutrition (hazard identification), (2) considerations of the influence of potential changes in nutrients provided in the food packages on either inadequate intake or

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WIC Food Packages: Time for a Change excessive intake (a modified dose-response assessment), and (3) prediction of changes in usual intakes of nutrients (exposure assessment) to provide a quantitative description (that is, a modified risk characterization) of the potential change in nutritional status of the WIC population as the result of the recommended changes in the WIC food packages. Nutrient Intake The committee conducted a detailed evaluation to compare potential benefits and risks for the WIC participant subpopulations resulting from proposed changes in the food packages. Potential benefits are characterized as reductions in the prevalences of nutrient inadequacy or nutrient excess. Potential risks are characterized as increases in the prevalences of nutrient inadequacy or increases in the risk of excessive nutrient intakes. The committee’s analysis applied the framework proposed by the IOM Subcommittee on the Interpretation and Uses of the DRIs (IOM, 2003a). This framework considers improving the distribution of usual nutrient intakes as the ultimate goal of a group planning activity such as changing the WIC food packages. Specifically, the goal is to achieve usual nutrient intake distributions with an acceptably low prevalence of inadequate intakes and a low prevalence of excessive intakes. Changes in the contents of a WIC food package alter the nutrient profile of the package and thus the amounts of nutrients offered to WIC participants. (See Tables C-5A through C-5C for comparison of current and revised food packages with regard to priority nutrients offered.) Increases in nutrient intakes that lead to reductions in the prevalence of inadequacy are considered as benefits of the revised WIC food packages, as are decreased intakes of nutrients of concern for excessive intake. In contrast, reductions in nutrient intakes that lead to increases in the prevalence of inadequate intake are considered as risks of the revised food package. In addition, increases in nutrient intakes that increase the prevalence of excessive intakes also are considered to be a risk of the revised food package. Because foods contain many different nutrient components and because package changes address many different attributes, a change in the types and amounts of foods in a package has the potential of having both positive effects (that is, benefits) and negative effects (that is, risks) on the nutrient profile. Importantly, at this point, it is not possible to estimate the precise impact of any food package changes on nutrient intakes. The WIC program

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WIC Food Packages: Time for a Change can control only what is offered to participants, not what they actually consume. Some WIC participants consume a larger amount of a specific nutrient than is offered in their current food package. For example, such individuals consume the foods from the WIC food packages plus foods from the family resources, making their total intake of a nutrient greater than that offered in the food package. In contract, some WIC participants consume less of a specific nutrient than is provided by the maximum food package for their category. There are several reasons why estimated nutrient intakes may be less than nutrients offered through WIC food packages, including: Less than the maximum allowance of food may be prescribed for a WIC participant, and less food may be redeemed than prescribed (e.g., a participant does not use all her food instruments in a month); WIC foods may be shared with other people or discarded; and Food intakes may be underreported or misreported. With the revised WIC food packages, consumption patterns may change, leading to changes in both the shape and position of usual nutrient intake distributions. The major challenge in estimating the benefits and risks of changes in the WIC food packages is to predict what the usual nutrient intake distributions would be after the changes in the WIC food packages are implemented. Ultimately, evidence of the benefits and risks will come from data collection and analyses that occur after changes in the WIC food packages have been implemented. Nonetheless, the committee considered several approaches to predicting the changes in the usual intake distributions resulting from the change in the WIC food packages. The Delta Approach The first, and most straightforward, approach (the delta approach) was based on a starting assumption that any changes in the WIC food packages would be reflected solely in the nutrient intake by the individual WIC participant (i.e., infant, child, woman). Thus, the analysis of benefits and risks would start with the existing distribution of usual nutrient intake of WIC participants (which presumably reflects the existing intrahousehold allocation of WIC food packages). Then, for each package and each nutrient, the difference between the nutrient content of the revised WIC food package minus that of the corresponding current package is added to the previously estimated usual intakes of WIC participants. A shortcoming of this approach is that it ignores the reality that individuals do not always consume what is offered to them. Indeed, much of

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WIC Food Packages: Time for a Change the nutrient inadequacy reported in Chapter 2—Nutrient and Food Priorities—results from the fact that individuals do not consume all of the food offered in the current WIC food packages. For example, the mean amount of calcium offered in the maximum allowance for the non-breastfeeding postpartum food package is 1,199 mg per day, but the mean calcium intake by these women is 668 mg per day. In fact, even the 90th percentile of usual calcium intake by non-breastfeeding postpartum women (930 mg/d) is less than the amount offered by the maximum allowance in the current food package. Given that the mean intake of calcium is less than the amount currently offered, it is not reasonable to assume that a change in the amount of calcium offered through a revised WIC food package will lead to the same quantitative change in mean intake. Results of analyses with this approach are reported in Tables D-1A through D-1C at the end of this appendix; because of the concerns in the application of the delta approach, the consideration of risks and benefits of the revised food packages will focus on results from the committee’s second approach to predicting changes in population intake of nutrients—the proportional approach. The Proportional Approach The committee adopted a second approach (the proportional approach), with the following steps. For each usual intake, calculate the ratio of the intake to the amount offered in the current WIC food package. For example, at a usual calcium intake of 670 mg per day, the ratio is (670)/(1,200), or 0.56, indicating that at this intake, a non-breastfeeding postpartum woman would consume an average of 56 percent of the calcium offered in the WIC food package. If usual intake is less than the amount offered, the change in the amount offered is multiplied by this ratio to predict changes in the intake. Continuing with the calcium example, if the amount offered is reduced by 200 mg per day, the reduction in usual intake above is assumed to be (0.56) × (200 mg/d) = 112 mg/d. In contrast, under the delta approach, the reduction would be 200 mg per day, regardless of current usual intake of calcium. (In fact, the delta approach could lead to prediction of negative intakes.) If usual intake exceeds the amount offered, changes in the amount offered are simply added to usual intakes. Several assumptions are associated with the proportional approach. First, it assumes that the ratio of intake to the amount offered is the same

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WIC Food Packages: Time for a Change before and after the change in the WIC food package. Since many of the changes proposed are expected to increase the consumption of WIC foods, this assumption is not likely to hold. On the other hand, this assumption appears to be better than the assumption that any difference in what is offered leads to a difference in what is consumed, even for those who are not consuming much of what is offered in the first place. In addition, until usual intake data are available after the change in WIC food package, using information on current consumption patterns provides a reasonable starting point. A second key assumption is that individuals who consume more of a nutrient than is currently offered in the WIC food package will change their consumption by the extent of change in the amount offered by the revised food package relative to the current package. This approach does not account for certain food purchasing and consumption practices. For example, if more of a food is offered in the revised package, a participant may decrease the amount of that food (or of another food) that is bought with her own money but eat the same amount of the food. Similarly, if the amount of an offered food is reduced, the participant may buy more of that food and eat a similar amount. In the absence of data a priori on what changes in intake will result from changes in the food package, the assumption that consumption will change by a proportion of the difference between the current and revised package is a starting assumption. APPLICATION OF METHODS The WIC food packages are intended to supplement the diet of specific groups of low-income women, infants, and children. The potential risks and benefits of this intervention can be evaluated in several ways. As detailed in this report, the committee examined how the current and revised packages correspond with the Dietary Guidelines. The committee also evaluated the degree of inadequacy or excess nutrient intake predicted to occur in the participant subpopulations with the current and revised packages. Other benefits of the revised packages, such as the increased variety of foods available and the incentives for breastfeeding, are not quantified. Reliable data were not available to assess intakes of trans fatty acids; however, the amount of trans fatty acids in the current and proposed food packages were estimated and are included in the Appendix C—Nutrient Profiles. The current and revised WIC food packages contain insignificant amounts of industrial trans fats—the source of trans fat deemed to be of concern by the Dietary Guidelines Advisory Committee (DHHS/USDA, 2004).

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WIC Food Packages: Time for a Change Nutrient Intake Profiles Changing the mix of foods offered in the WIC food packages leads to complex changes in the nutrients available to WIC participants. Efforts to address specific priority nutrients are challenging because foods contain many different components. The committee characterized the effect of revised food packages in two ways. First, the change in nutrient content of packages was calculated. This measure can be estimated quite well; the only important assumptions are the choices of foods when options are presented (see Chapter 4—Revised Food Packages) (See details in Appendix D—Cost Calculations.). Next, predicted changes in nutrient intake were developed. The values of the predicted percentage inadequate or of the predicted changes in mean intake of a nutrient are subject to considerable uncertainty because of lack of knowledge of the consumption patterns and practices that will occur. Nonetheless, this approach provides useful insight into the possible benefits and risks of changes in the packages. The committee characterized changes in nutrients available in each package and estimated how these changes would influence predicted nutrient intake. Tables detailing changes in predicted intake of more than 30 micro- and macronutrients plus cholesterol and food energy for each of the current and revised WIC food packages are in Appendix C—Nutrient Profiles. Here in Appendix D the focus is on the specific food components identified as priorities in Chapter 2—Nutrient and Food Priorities—because of concern about either inadequate or excessive intakes. For priority nutrients with inadequate intakes for WIC subpopulations (e.g., calcium, vitamin E, fiber), Table D-1A presents current and predicted mean intakes, and current and predicted percentages with inadequate intakes, if applicable. Similar information is presented in Table D-1B for nutrients of concern with regard to excessive intake (e.g., sodium, preformed vitamin A, food energy), but this table shows current and predicted percentages with intakes greater than the Tolerable Upper Intake Level (UL) or Acceptable Macronutrient Distribution Range (AMDR). Comparisons for nutrients to limit in the diet (i.e., saturated fat and cholesterol) are shown in Table D-1C. Formula-Fed Infants Younger Than One Year of Age For formula-fed infants younger than one year of age, the committee identified nutrients of concern with regard to excessive intake, and the proposed changes to Food Packages I and II address these nutrients. The only nutrient with a change in intake in the non-desired direction is pre-

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WIC Food Packages: Time for a Change formed vitamin A in Food Package I; for this nutrient, the percentage of infants 4 through 5 months of age with intakes greater than the UL (600 mcg retinol/d) is predicted to increase by approximately 10 percentage points (Table D-1B). The committee increased the maximum allowance of formula for formula-fed infants in this age range to address their increased nutritional needs. The composition of formula makes it impossible to increase formula intake without increasing the intake of preformed vitamin A. In Food Package II-FF, for formula-fed infants ages 6 through 11 months, the percentage of the population above the UL for preformed vitamin A is predicted to decrease by 13.6 percentage points (Table D-1B). Children 1 Year of Age Children one year of age (12–23 mo of age), served by Food Package IV-A, are predicted to show improvement in almost all food components. The substantial increase in predicted intake of fiber (Table D-1A), decreases in the predicted percentage of the population with inadequate intake of vitamin E (Table D-1A), and the predicted reductions in intakes of sodium and food energy are all benefits of the revised food package (Table D-1B). The only priority nutrients with predicted changes in the non-desired direction are potassium, with an estimated 8 percent decrease in mean intake (Table D-1A), and zinc, with an increase in the percentage of the population above the 7 mg UL (Table D-1B). The committee has minimal concern regarding excessive intake of zinc because of the basis for setting the UL (IOM, 2001). The method used to set the ULs for zinc resulted in relatively narrow margins between the UL and the Recommended Dietary Allowance (RDA); the ULs are approximately 2.4 times the RDAs for children (IOM, 2001). There has been no evidence of adverse effects from ingestion of zinc as naturally occurring in food (IOM, 2001; Brown et al., 2004a). However, zinc is used as a fortificant in some foods that are commonly consumed by children (e.g., breakfast cereal). Further study is needed of the contribution of the zinc in such food products to possible overconsumption of zinc. Children 2 Through 4 Years of Age The revised Food Package IV-B serves children 2 through 4 years of age. The revised food package has many predicted benefits including sharp increases in intake of vitamin E and fiber (Table D-1A) and reductions in the consumption of sodium, food energy, saturated fat, and cholesterol (Tables D-1B and D-1C). Two nutrients have predicted changes in intake in the non-desired direction; mean predicted intake of potassium decreases by

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WIC Food Packages: Time for a Change 7 percent (Table D-1A) and the fraction of the population with predicted zinc intakes greater than the zinc UL increases (Table D-1B). Adolescent and Adult Women A major aim of the WIC program is supporting the nutrition of pregnant, lactating and non-breastfeeding postpartum women. Chapter 2—Nutrient and Food Priorities—and Appendix A—Nutrient Intake of WIC Subgroups—detail the many apparent nutrient intake inadequacies and excesses in these subpopulations. The committee proposed substantial revisions to Food Packages V through VII to address this situation. Food Package V—Pregnant Women and Partially Breastfeeding Women—The revised Food Package V leads to decreases in the predicted percentages of the population with inadequate intake for most of the priority nutrients, with particularly large benefits for magnesium, vitamin E, vitamin B6, and folate (Table D-1A). Other benefits include predicted increases in the intake of fiber and potassium (Table D-1A) and decreases in sodium, total fat, saturated fat, and cholesterol (Tables D-1B and D-1C). Two nutrients have changes in the non-desired direction; the predicted mean intake of calcium decreases slightly because of a reduction in the amount of milk and milk products in the package, and the predicted percentage of the population with inadequate intake of vitamin C increases by 11 percentage points (Table D-1A). The amount of calcium offered in the food package, however, exceeds the Adequate Intake (AI) for calcium. Food Package VI—Non-Breastfeeding Postpartum Women—Other than a predicted decrease in calcium and a predicted increase in the percentage with inadequate vitamin C intake, the revised Food Package VI makes progress toward addressing the priority nutrients identified by the committee (Table D-1A). For example, there is a reduction in the percentage with inadequate intake of iron, magnesium, vitamin E, vitamin A, fiber, potassium, vitamin B6 and folate (Table D-1A). Intake of sodium, food energy, total fat, saturated fat, and cholesterol all decrease, as intended (Tables D-1B and D-1C). Food Package VII—Fully Breastfeeding Women—The revised Food Package VII is intended both to enhance maternal nutrition in support of breastfeeding and (combined with changes in other packages) to provide an incentive for breastfeeding. The package addresses very well the priority nutrients for this group, with increased predicted mean intakes of calcium,

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WIC Food Packages: Time for a Change potassium, and fiber, and predicted decreases in the percentages with inadequate intakes of iron, magnesium, vitamin E, vitamin B6, and folate (Table D-1A). Again, intakes of sodium, food energy, total fat, saturated fat, and cholesterol are all predicted to decrease (Tables D-1B and D-1C). There is a small increase in the percentage of the population predicted to have an inadequate intake of vitamin A (Table D-1A). For vitamin C, the analysis predicts an increase in the percentage of the population with inadequate intake (Table D-1A). CAVEATS AND OTHER POTENTIAL BENEFITS AND RISKS Because of the uncertainties and assumptions associated with predicting the usual intake distributions that would result from changes in the WIC food package, the estimates of changes in the prevalence of inadequacy and in the risk of excessive intakes are uncertain. Although the quantitative predictions are uncertain, the direction of the change is likely to be robust. The committee urges that the quantitative results of the benefit and risk analysis be interpreted with caution. In addition, given the importance of assessing the benefits and risks of the revised WIC food packages, the committee recommends that USDA conduct pilot studies and randomized, controlled trials to estimate the changes in the usual nutrient intake distribution and the resulting changes in the prevalence of inadequacy and excessive intakes (see Chapter 7—Recommendations for Implementation and Evaluation). Non-Quantified Benefits and Risks Among the benefits and risks that are not amenable to quantification are the following. The first two benefits listed and the first risk listed would affect the accuracy of the predictions of the prevalence of inadequate or excess nutrient intake presented in Tables D-1A and D-1B. Benefits Increased choice of foods, if adopted, may increase the consumption of WIC foods by the participants in whole or in part. Participants who choose the additional options might consume all or consume somewhat more of the food in the package (possibly sharing the remainder with other household members). More food instruments may be redeemed, and less food may be discarded (or possibly given away). In these cases, the estimated prevalence of inadequacy may decrease and mean intakes of certain nutrients having an AI may increase more than predicted in Table D-1A.

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WIC Food Packages: Time for a Change SUMMARY In summary, the revised food packages lead to improvements in nutritional adequacy in almost all cases under the assumptions used in these analyses. In addition, food components identified as priorities because of possible excess consumption are almost always reduced. The committee anticipates that the set of revised food packages will provide a clear net benefit to WIC participants. The following is a list of tables presented in this appendix. Table D-1   Comparison of Current and Revised Food Packages     A   Nutrients of Concern with Regard to Inadequate Intake,   304 B   Nutrients of Concern with Regard to Excessive Intake,   308 C   Nutrients of Concern to Limit in the Diet,   312

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WIC Food Packages: Time for a Change TABLE D-1A Comparison of Current and Revised Food Packages: Nutrients of Concern with Regard to Inadequate Intake     Current Food Package, Usual Intakea Participant Category and Priority Nutrient EAR or AI* Mean Infants, 6–11.9 mo, breast-fed Food Package No. Current II Iron, mg/d 6.9 10.0 Zinc, mg/d 2.5 2.5 WIC Children, 1–1.9 y Food Package No. Current IV Iron, mg/d 3.0 11.9 Potassium, mg/d 3,000* 2,029 Vitamin E, mg ATE/dc 5.0 5.3 Fiber, g/d 19* 8.0 WIC Children, 2–4.9 yd Food Package No. Current IV Iron, mg/d 3.0 / 4.1 13.6 Potassium, mg/d 3,000* / 3,800* 2,211 Vitamin E, mg ATE/dc 5.0 / 6.0 6.0 Fiber, g/d 19* / 25* 10.9 Pregnant women and lactating women, 14–44 ye Food Package No. Current V Calcium, mg/d 1,000* – 1,300* 956 Iron, mg/d 6.5–23.0 16.5 Magnesium, mg/d 255–335 291 Potassium, mg/d 4,700* – 5,100* 2,909 Vitamin E, mg ATE/dc 12 / 16 8.3 Fiber, g/d 28* – 29* 17.7 Vitamin A, mcg RAE/d 530–900 902 Vitamin C, mg/d 66–100 134 Vitamin D, mcg/d 5.0* N/A Vitamin B6, mg/d 1.6–1.7 2.0 Folate, mcg DFE/d) 450–520 570

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WIC Food Packages: Time for a Change Revised Food Package, Predicted Usual Intakeb Current Food Packagea Revised Food Packageb Mean 25th Percentile Median 75th Predicted %Inadequate Percentile %Inadequate Revised II-BF Current II Revised II-BF 10.9 5.5 9.5 14.7 39.5 34.0 4.0 2.5 3.9 5.2 60.3 25.4 Revised IV-A Current IV Revised IV-A 13.2 9.4 12.4 16.2 1.6 0.9 1,885 1,506 1,827 2,195 — — 8.0 5.5 7.2 9.7 55.3 18.5 12.3 10.3 12.3 14.4 — — Revised IV-B Current IV Revised IV-B 15.0 11.9 14.6 17.6 0.4 0.1 2,078 1,651 2,022 2,438 — — 8.7 6.4 8.1 10.5 47.0 11.4 15.4 12.9 15.1 17.6 — — Revised V Current V Revised V 934 721 902 1,113 — — 19.3 15.6 18.5 22.2 7.5 3.4 349 292 341 398 49.4 20.3 3,052 2,548 3,005 3,506 — — 14.3 11.2 14.4 16.9 94.4 43.6 25.6 21.0 24.8 29.2 — — 1,041 741 987 1,277 31.2 20.2 119 63 97 154 32.7 43.5 — — — — — — 2.4 1.9 2.3 2.8 34.0 11.9 633 469 606 761 41.5 29.2

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WIC Food Packages: Time for a Change     Current Food Package, Usual Intakea Participant Category and Priority Nutrient EAR or AI* Mean Non-breastfeeding postpartum women, 14–44 y Food Package No. Current VI Calcium, mg/d 1,000* – 1,300* 668 Iron, mg/d 7.9–8.1 13.7 Magnesium, mg/d 255–300 213 Potassium, mg/d 4,700* 2,086 Vitamin E, mg ATE/dc 12 6.9 Fiber, g/d 25* – 26* 12.2 Vitamin A, mcg RAE/d 485–500 556 Vitamin C, mg/d 56–60 79 Vitamin D, mcg/d 5.0* N/A Vitamin B6, mg/d 1.0–1.1 1.4 Folate, mcg DFE/dc 320–330 482 Lactating women, 14–44 ye Food Package No. Current VII Revised VII Calcium, mg/d 1,000* – 1,300* 956 Iron, mg/d 6.5–7.0 16.5 Magnesium, mg/d 255–300 291 Potassium, mg/d 5,100* 2,909 Vitamin E, mg ATE/dc 16.0 8.3 Fiber, g/d 29* 17.7 Vitamin A, mcg RAE/d 885–900 902 Vitamin C, mg/d 96–100 134 Vitamin D, mcg/d 5.0* N/A Vitamin B6, mg/d 1.7 2.0 Folate, mcg DFE/dc 450 570 See notes for Tables D-1A through D-1C following Table D-1C.

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WIC Food Packages: Time for a Change Revised Food Package, Predicted Usual Intakeb Current Food Packagea Revised Food Packageb Mean 25th Percentile Median 75th Percentile %Inadequate Predicted %Inadequate Revised VI Current VI Revised VI       593 466 570 694 — — 16.0 14.6 16.0 17.4 9.5 4.6 246 216 243 273 87.5 66.0 2,156 1,859 2,129 2,424 — — 12.5 11.0 12.6 14.1 99.8 40.4 18.6 15.6 18.0 21.0 — — 655 488 633 797 44.1 26.9 77 47 69 98 42.2 47.1 — — — — — — 1.7 1.5 1.7 2.0 17.1 2.4 543 434 530 633 12.0 5.0 Current VII Revised VII         984 760 952 1,173 — — 18.7 14.8 18.0 21.6 7.5 4.2 330 273 322 379 49.4 29.1 2,909 2,404 2,861 3,361 — — 13.4 10.2 13.0 16.4 94.4 54.3 22.9 18.4 22.1 26.6 — — 881 589 812 1,098 31.2 35.7 107 55 85 137 32.7 51.9 — — — — — — 2.3 1.8 2.2 2.7 34.0 15.8 601 438 570 726 41.5 35.5

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WIC Food Packages: Time for a Change TABLE D-1B Comparison of Current and Revised Food Packages: Nutrients of Concern with Regard to Excessive Intake     Current Food Package, Usual Intakea Participant Category and Priority Nutrient UL, Mean EER, or AMDR† Mean WIC Infants, 0–3.9 mo, formula-fed Food Package No. CurrentI Zinc, mg/d 4.0 6.1 Preformed vitamin A, mcg/d 600 581 Food energy, kcal/d 555f 673 WIC Infants, 4–5.9 mo, formula-fed Food Package No. Current II Zinc, mg/d 4.0 7.0 Preformed vitamin A, mcg/d 600 626 Food energy, kcal/d 623f 802 WIC Infants, 6–11.9 mo, formula-fed Food Package No. Current II Zinc, mg/d 5.0 7.2 Preformed vitamin A, mcg/d 600 618 Food energy, kcal/d 754f 992 WIC Children, 1–1.9 y Food Package No. Current IV Zinc, mg/d 7.0 7.8 Sodium, mg/d 1,500 1,816 Preformed vitamin A, mcg/d 600 495 Food energy, kcal/d 942f 1,288 WIC Children, 2–4.9 yd Food Package No. Current IV Zinc, mg/d 7.0 / 12.0 9.1 Sodium, mg/d 1,500 / 1,900 2,519 Preformed vitamin A, mcg/d 600 / 900 513 Food energy, kcal/d 1,282f 1,585 Pregnant women and lactating women, 14–44 ye Food Package No. Current V Sodium, mg/d 2,300 3,330 Food energy, kcal/d 2,46f 2,115 Total fat, g/d na 76.7 Total fat, % of food energy 25–35†, <19 y 20–35†, ≥ 19 y` } 32.3

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WIC Food Packages: Time for a Change Revised Food Package, Predicted Usual Intakeb Current Food Packagea Revised Food Packageb Mean 25th Percentile Median 75th Percentile %>UL or %>AMDR Predicted %>UL or %>AMDR Revised I-FF-A Current I Revised I-FF-A 6.1 4.6 5.8 7.2 86.0 86.0 581 445 547 677 38.3 38.3 673 523 635 778 — — Revised I-FF-B Current II Revised I-FF-B 6.1 4.9 5.9 7.1 96.8 91.5 666 573 660 752 56.3 68.0 721 602 704 820 — — Revised II-FF Current II Revised II-FF 6.2 4.9 6.0 7.4 87.6 72.3 530 358 470 644 42.7 29.5 877 705 853 1,021 — — Revised IV-A Current IV Revised IV-A 8.7 6.6 8.3 10.3 55.7 68.8 1,733 1,217 1,641 2,145 63.5 58.4 304 207 270 350 25.0 5.1 1,248 1,026 1,222 1,441 — — Revised IV-B Current IV Revised IV-B 10.3 8.3 10.0 11.9 58.1 72.6 2,440 1,949 2,363 2,851 92.8 90.1 405 291 358 449 16.1 7.2 1,460 1,188 1,429 1,697 — — Revised V Current V Revised V 3,241 2,850 3,218 3,606 97.2 95.8 2,082 1,762 2,054 2,372 — — 68.8 56.6 67.7 79.9 — — 27.2 24.6 27.1 29.6 24.5 1.4

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WIC Food Packages: Time for a Change     Current Food Package, Usual Intakea Participant Category and Priority Nutrient UL, Mean EER, or AMDR† Mean Non-breastfeeding postpartum women, 14–44 y Food Package No. Current VI Sodium, mg/d 2,300 2,912 Food energy, kcal/d 2,163f 1,774 Total fat, g/d na 66.1 Total fat, % of food energy 25–35†, <19 y 20–35†, ≥ 19 y } 33.1 Lactating women, 14–44 ye Food Package No. Current VII Sodium, mg/d 2,300 3,330 Food energy, kcal/d 2,465f 2,115 Total fat, g/d na 76.7 Total fat, % of food energy 25–35†, <19 y 20–35†, ≥ 19 y } 32.3 See notes for Tables D-1A through D-1C following Table D-1C.

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WIC Food Packages: Time for a Change Revised Food Package, Predicted Usual Intakeb Current Food Packagea Revised Food Packageb Mean 25th Percentile Median 75th Percentile %>UL or %>AMDR Predicted %>UL or %>AMDR Revised VI Current VI Revised VI 2,646 2,319 2,623 2,948 90.7 76.4 1,674 1,442 1,654 1,885 — — 57.4 51.4 57.0 62.9 — — 24.6 23.8 24.6 25.4 4.9 <0.1 Revised VII Current VII Revised VII 3,267 2,877 3,245 3,633 97.2 96.3 2,037 1,717 2,009 2,327 — — 67.4 55.1 66.3 78.4 — — 27.6 25.3 27.5 29.8 24.5 1.6

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WIC Food Packages: Time for a Change TABLE D-1C Comparison of Current and Revised Food Packages: Nutrients of Concern to Limit in the Diet     Current Food Package, Usual Intakea Participant Category and Priority Nutrient Dietary Guidance Mean WIC Children, 2–4.9 y Food Package No. Current IV Saturated fat, g/d na 22.2 Saturated fat, % of food energy <10 12.5 Cholesterol, mg/d <300 216 Pregnant women and lactating women, 14–44 ye Food Package No. Current V Saturated fat, g/d na 27.5 Saturated fat, % of food energy <10 11.7 Cholesterol, mg/d <300 271 Non-breastfeeding postpartum women, 14–44 y Food Package No. Current VI Saturated fat, g/d na 22.9 Saturated fat, % of food energy <10 11.3 Cholesterol, mg/d <300 219 Lactating women, 14–44 ye Food Package No. Current VII Saturated fat, g/d na 27.5 Saturated fat, % of food energy <10 11.7 Cholesterol, mg/d <300 271 NOTES FOR TABLES D-1A THROUGH D-1C: AI = Adequate Intake, used when necessary, indicated by an asterisk (*); AMDR = Acceptable Macronutrient Distribution Range, indicated by a dagger (†); AT = (alpha)-tocopherol; ATE = (alpha)-tocopherol equivalents; DFE = dietary folate equivalents; EAR = Estimated Average Requirement, used when available; EER = Estimated Energy Requirement; kcal = kilocalories; na = not applicable; N/A = not available, intake data were not available for vitamin D; RAE = retinol activity equivalents; UL = Tolerable Upper Intake Level; %Inadequate = percentage with inadequate intakes as estimated from percentage with usual intake less than EAR; %>AMDR = percentage with usual intake greater than AMDR; %>UL = percentage with usual intake greater than UL. aObserved usual intakes were calculated using 1994–1996 and 1998 CSFII data. bMean intakes were predicted from the observed mean intakes by adding the difference between the current food package and the revised food package as appropriate for the individual’s age and life stage, using the proportional method described in the text. cFor discussion of important issues regarding differences between the Dietary Reference Intake (DRI) and dietary intake data in the units used for vitamin E and folate, please see the section Data Set—Nutrients Examined in Appendix A—Nutrient Intake of WIC Subgroups.

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WIC Food Packages: Time for a Change Revised Food Package, Predicted Usual Intakeb Current Food Packagea Revised Food Packageb Mean 25th Percentile Median 75th Percentile % Following Dietary Guidance Predicted % Following Dietary Guidance Revised IV-B Current IV Revised IV-B 14.7 10.3 14.1 18.4 — — 6.8 6.0 6.7 7.4 9.0 99.0 93 67 84 104 87.8 99.6 Revised V Current V Revised V 20.4 15.4 19.9 24.8 — — 6.4 5.7 6.4 7.1 19.1 99.8 127 86 107 152 67.6 97.5 Revised VI Current VI Revised VI 15.8 12.4 15.5 18.9 — — 6.0 5.7 6.0 6.3 3.8 >99.9 89 71 84 100 92.0 >99.9 Revised VII Current VII Revised VII 20.6 15.6 20.0 25.0 — — 8.0 7.1 7.9 8.8 19.1 94.2 207 156 193 242 67.6 88.9 dValues are for children ages 2–3.9 y and children age 4 y, respectively. eBecause of sample size limitations, the analysis sample combined all pregnant women and all lactating women. Thus, the current mean intakes and current prevalence values (i.e., %Inadequate; %>AMDR; %>UL) are identical for any categories containing pregnant women or lactating women (i.e., recipients of current Food Packages V and VII). fMean EER (kcal/d) (Table D-1B) was calculated based on CSFII data (FSRG, 2000) using the method described in the DRI report (IOM, 2002/2005). For additional detail, see Appendix C—Nutrient Intakes of WIC Subgroups. DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (FSRG, 2000). EARs, AIs, ULs, and AMDRs are from the DRI reports (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a). Dietary guidance in Table D-1C is from the American Heart Association (AHA, 2004) and the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005).