2
NUTRIENT AND FOOD PRIORITIES FOR THE WIC FOOD PACKAGES

The first step in revising the WIC food packages is identification of the nutrients and food groups of highest priority, either because of potential inadequacies or excesses. The committee considered the following types of evidence to identify priority nutrients and foods: (1) results from an analysis of the estimated nutrient adequacy of the diets of categorical WIC subgroups (i.e., women, infants, and children); (2) published evidence of nutrient inadequacy or excess, based on physiological or biochemical data; and (3) published data from analyses of foods consumed relative to new recommendations contained in the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005) and relative to dietary guidance for children under 2 years of age. This chapter summarizes nutrient and food priorities that the committee took into account when redesigning the WIC food packages with the goal of improving the nutrition of WIC participants.

NUTRIENT PRIORITIES

Assessing nutrient adequacy involves determining the extent to which the diets of WIC-income-eligible subgroups meet nutrient requirements without being excessive. This task involves using the new dietary reference values called the Dietary Reference Intakes (DRIs) (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a) and the methods recently published by the Institute of Medicine (IOM, 2000a) to assess the nutrient adequacy of the reported diets of WIC subgroups. To date, no published studies have reported such analyses. Therefore, the committee conducted analyses applying the DRIs and the recommended methods to assess the nutrient ad-



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WIC Food Packages: Time for a Change 2 NUTRIENT AND FOOD PRIORITIES FOR THE WIC FOOD PACKAGES The first step in revising the WIC food packages is identification of the nutrients and food groups of highest priority, either because of potential inadequacies or excesses. The committee considered the following types of evidence to identify priority nutrients and foods: (1) results from an analysis of the estimated nutrient adequacy of the diets of categorical WIC subgroups (i.e., women, infants, and children); (2) published evidence of nutrient inadequacy or excess, based on physiological or biochemical data; and (3) published data from analyses of foods consumed relative to new recommendations contained in the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005) and relative to dietary guidance for children under 2 years of age. This chapter summarizes nutrient and food priorities that the committee took into account when redesigning the WIC food packages with the goal of improving the nutrition of WIC participants. NUTRIENT PRIORITIES Assessing nutrient adequacy involves determining the extent to which the diets of WIC-income-eligible subgroups meet nutrient requirements without being excessive. This task involves using the new dietary reference values called the Dietary Reference Intakes (DRIs) (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a) and the methods recently published by the Institute of Medicine (IOM, 2000a) to assess the nutrient adequacy of the reported diets of WIC subgroups. To date, no published studies have reported such analyses. Therefore, the committee conducted analyses applying the DRIs and the recommended methods to assess the nutrient ad-

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WIC Food Packages: Time for a Change equacy of the diets of WIC subgroups—WIC infants under 1 year of age, WIC children 1 through 4 years of age, and pregnant, lactating, and non-breastfeeding postpartum women.1 To guide the committee in recommending specific changes in the food packages, the committee conducted analyses to determine nutrients of concern: (1) nutrients of concern regarding inadequate intakes as defined by intakes below the Estimated Average Requirement (EAR); and (2) nutrients of concern regarding excessive intakes as defined by intakes above the Tolerable Upper Intake Level (UL). This chapter summarizes the analysis results. Details on the methods and results of the analysis of nutrient adequacy are provided in Appendix C—Nutrient Intake of WIC Subgroups. Estimated Adequacy of Micronutrient Usual Intakes Overall, fully formula-fed WIC infants had adequate intakes of micronutrients and macronutrients. For three nutrients—iron, zinc, and protein—precise estimates of inadequacy can be calculated. These results show a low prevalence of inadequacy for formula-fed WIC infants 6 through 11 months but a higher prevalence of inadequacy for iron and zinc for breast-fed infants (Table 2-1). The results for breast-fed infants (WIC and non-WIC breast-fed infants combined because of small sample sizes) indicate 40 percent of breast-fed infants 6 through 11 months had inadequate iron intakes and 60 percent had inadequate zinc intakes (Table 2-1). WIC children have adequate intakes of all micronutrients except vitamin E, while the diets of pregnant, lactating, and non-breastfeeding postpartum women have high levels of inadequacy for a number of nutrients (Table 2-2). The micronutrients with the highest prevalence of inadequacy were magnesium and vitamin E. For vitamin E, the estimated prevalence of inadequacy exceeded 90 percent for pregnant and lactating women and was almost 100 percent for non-breastfeeding postpartum women. More than 40 percent of pregnant and lactating women had inadequate folate intakes. About one-third of pregnant and lactating women had inadequate intakes of vitamins A, C, and B6. An even higher percentage of non-breastfeeding postpartum women had inadequate intakes of vitamins A and C (more than 40 percent). The prevalence of inadequate intake of vitamin B6 was twice as high for pregnant and lactating women as for non-breastfeeding postpartum women. 1   Due to sample size limitations in the data set from the Continuing Survey of Food Intakes by Individuals (CSFII), the analyses of nutrient adequacy used all pregnant and lactating women (14 through 44 years of age) and all non-breastfeeding women (14 through 44 years of age) up to one year postpartum. In contrast, the analyses for infants and children used only infants and children receiving WIC benefits. For details on sample size, see Appendix C—Nutrient Intake of WIC Subgroups.

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WIC Food Packages: Time for a Change TABLE 2-1 Estimated Prevalence of Inadequacy of Selected Micronutrients and Protein Using Usual Intakes, Infants Nutrient Estimated Prevalence of Inadequacy (percentage) WIC Infants, Non-Breastfed, 6–11.9 mo (n = 275) Breast-Fed Infants, 6–11.9 moa (n = 143) Iron 1.7 39.5 Zinc 0.3 60.3 Protein 0.6 — aBecause of the lack of data on the quantity of breast milk consumed by breast-fed infants 6–11.9 mo of age, protein adequacy could not be assessed. Iron and zinc adequacy could be assessed, since breast milk consumed by these older breast-fed infants has little iron and zinc content. NOTES: n = sample size. Details of these analyses are provided in Tables C-2C and C-3C in Appendix C—Nutrient Intake of WIC Subgroups. Further analyses of non-breastfed infants ages 0–3.9 mo and 4–5.9 mo are provided in Tables C-2A and C-3A (0–3.9 mo) and Tables C-2B and C-3B (4–5.9 mo). DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (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). Estimated Average Requirements used in the analysis were from the Dietary Reference Intake reports (IOM, 2001, 2002/2005). Zinc, thiamin, and niacin appear to be inadequate in the diets of a substantial proportion of pregnant and lactating women. Almost one-quarter had inadequate zinc intakes, 17 percent had inadequate thiamin intakes, and 8 percent had inadequate niacin intakes (based on intakes of preformed niacin). Interestingly, the prevalence of inadequate intake for non-breastfeeding postpartum women was only 12 percent for folate, 3 percent for thiamin and niacin, and virtually zero for zinc. For iron, 7.5 percent of pregnant and lactating women and 9.5 percent of non-breastfeeding postpartum women had inadequate usual intakes. The estimated prevalence of inadequate intake of selenium, phosphorus, and the remaining B vitamins (riboflavin and vitamin B12) was low (less than 7 percent) for pregnant, lactating, and non-breastfeeding postpartum women. Calcium, Potassium, and Fiber Usual Intakes Calcium intakes appear to be adequate for formula-fed WIC infants and WIC children but low for pregnant, lactating, and non-breastfeeding

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WIC Food Packages: Time for a Change TABLE 2-2 Estimated Prevalence of Inadequacy of Selected Micronutrients and Protein Using Usual Intakes, Children and Women Nutrient Estimated Prevalence of Inadequacy (percentage) WIC Children, 1–1.9 y (n = 287) WIC Children, 2–4.9 y (n = 872) Pregnant Women and Lactating Women, 14–44 y (n = 123) Non-Breastfeeding Postpartum Women, 14–44 y (n = 105) Iron 1.6 0.4 7.5 9.5 Zinc 0.2 0.1 24.1 <0.1 Selenium 0.3 <0.1 1.4 <0.1 Magnesium 0.1 0.5 49.4 87.5 Phosphorus 0.6 0.2 0.4 0.7 Vitamin A 0.5 0.4 31.2 44.1 Vitamin Ea 55.3 47.0 94.4 99.8 Vitamin C <0.1 <0.1 32.7 42.2 Thiamin 0.1 <0.1 17.2 3.2 Riboflavin <0.1 <0.1 3.8 1.2 Niacina 2.5 0.1 8.1 3.3 Vitamin B6 <0.1 <0.1 34.0 17.1 Vitamin B12 0.1 <0.1 1.5 6.6 Folatea 1.2 <0.1 41.5 12.0 Protein <0.1 <0.1 17.1 4.2 aFor discussion of important issues regarding differences between the Dietary Reference Intakes (DRIs) and dietary intake data in the units used for vitamin E, niacin and folate, please see the section Data Set—Nutrients Examined in Appendix C—Nutrient Intake of WIC Subgroups. NOTES: n = sample size. Details of these analyses are provided in Tables C-2D through C-2G and Tables C-3D through C-3G (protein), in Appendix C—Nutrient Intake of WIC Subgroups. DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (FSRG, 2000); data set does not include intake from dietary supplements (e.g., multivitamin and mineral preparations). All young children were non-breastfed. Intake distributions were calculated using C-SIDE (ISU, 1997). Estimated Average Requirements used in the analysis were from the DRI reports (IOM, 1997, 1998, 2000b, 2001, 2002/2005). postpartum women (Table 2-3). For WIC infants and children, mean calcium intakes exceeded the Adequate Intake (AI), while for women, mean calcium intakes were low, far below the AI in most cases. Although mean intakes below the AI do not necessarily imply nutrient inadequacy, when mean intakes are far below the AI, concerns about nutrient adequacy may arise. (See Appendix C—Nutrient Intake of WIC Subgroups—for details of the methodology.)

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WIC Food Packages: Time for a Change TABLE 2-3 Adequate Intakes and Mean Reported Usual Intakes of Calcium, Potassium, and Fiber Participant Category n Dietary Component Calcium (mg/d) Potassium (mg/d) Fiber (g/d) WIC Infants,a 0–3.9 mo 152   AI*   210* 400* ND   Mean usual intake   562 736 — WIC Infants,a 4–5.9 mo 104   AI*   210* 400* ND   Mean usual intake   675 974 — WIC Infants,a 6–11.9 mo 275   AI*   270* 700* ND   Mean usual intake   722 1,349 — WIC Children,a 1–1.9 y 287   AI*   500* 3,000* 19*   Mean usual intake   937 2,029 8 WIC Children, 2–4.9 y 872   AI*   500* / 800*b 3,000* / 3,800*b 19* / 25*b   Mean usual intake   833 2,211 11 Women, pregnant or lactating, 14–44 y 123   AI*   1,300* / 1,000*c 4,700* / 5,100*d 28* / 29*d   Mean usual intake   956 2,909 18 Women, non-breastfeeding postpartum, 14–44 y 105   AI*   1,300* / 1,000*c 4,700* 26* / 25*c   Mean usual intake   668 2,086 12 aBreast-fed infants and children were excluded from the analyses. bThe AIs refer to children 1–3 y of age and children 4 y of age, respectively. cThe AIs refer to women 14–18 y of age and 19–44 y of age, respectively. dThe AIs refer to pregnant women and lactating women, respectively. NOTES: AI = Adequate Intake, used when an Estimated Average Requirement could not be determined, indicated by a asterisk (*); n = sample size; ND = not determined. Details of these analyses are provided in Tables C-2A through C-2G (calcium and potassium) and Tables C-3A through C-3G (fiber) in Appendix C—Nutrient Intake of WIC Subgroups. DATA SOURCES: Intake data are from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (FSRG, 2000); data set does not include intake from dietary supplements (e.g., multivitamin and mineral preparations). All infants and young children were non-breastfed. AIs are from the Dietary Reference Intake reports (IOM, 1997, 2002/2005, 2005a). Intake distributions were calculated using C-SIDE (ISU, 1997).

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WIC Food Packages: Time for a Change Intakes of potassium and fiber were low for all subgroups one year of age or older. As with calcium, mean intakes were substantially less than the AI, raising concerns about inadequate intake levels. Usual Food Energy Intakes Both the mean and median reported usual intakes of food energy of WIC infants and children exceeded the comparable percentiles of the energy requirement distributions (Table 2-4). For WIC infants 0 through 3 months (excluding breast-fed infants), mean food energy intake (673 kilocalories per day) exceeded mean Estimated Energy Requirement (EER) (555 kilocalories per day) by 118 kilocalories per day, or by about 20 percent. For older WIC infants (ages 6 through 11 months), mean energy intake was greater than the mean EER by 238 kilocalories per day or 30 percent. For WIC children, mean energy intakes exceeded mean EERs by 346 kilocalories per day for children one year of age and by 303 kilocalories per day for children 2 through 4 years of age. The large magnitude of these differ- TABLE 2-4 Reported Usual Food Energy Intakes and Estimated Energy Requirements Participant Category n Usual Energy Intakes (kcal/d) Estimated Energy Requirement (kcal/d) Median Mean Median EER Mean EER WIC Infants, 0–3.9 mo 152 635 673 559 555 WIC Infants, 4–5.9 mo 104 786 802 614 623 WIC Infants, 6–11.9 mo 275 970 992 740 754 WIC Children, 1–1.9 y 287 1,262 1,288 935 942 WIC Children, 2–4.9 y 872 1,553 1,585 1,285a 1,282a Women, pregnant or lactating, 14–44 y 123 2,088 2,115 2,451a 2,465a Women, non-breastfeeding postpartum, 14–44 y 105 1,754 1,774 2,148a 2,163a aEER calculations assumed low active Physical Activity Level (IOM, 2002/2005). For additional detail, see Appendix C—Nutrient Intake of WIC Subgroups. NOTES: EER = Estimated Energy Requirement; kcal = kilocalories; n = sample size. Details of these analyses are provided in Tables C-3A through C-3G in Appendix C—Nutrient Intake of WIC Subgroups. DATA SOURCES: Intake data were obtained from 1994–1996 and 1998 Continuing Survey of Food Intake by Individuals (CSFII) (FSRG, 2000). All infants and young children were non-breastfed. EERs were calculated according to the Dietary Reference Intake report (IOM, 2002/2005). Intake distributions were calculated using C-SIDE (ISU, 1997).

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WIC Food Packages: Time for a Change ences would imply larger body weight gains than have been observed among infants and children, suggesting overreporting of food intakes for infants and children (see section on Discussion of Results). In contrast, reported intakes of food energy were less than the EER for pregnant, lactating, and non-breastfeeding postpartum women (Table 2-4). Mean reported food energy intake was 350 kilocalories per day less than the mean EER for pregnant and lactating women and 389 kilocalories per day less than the mean EER for non-breastfeeding postpartum women suggesting underreporting of food intakes for these subgroups (see section on Discussion of Results). Usual Intakes of Macronutrients and Added Sugars Many WIC children have reported usual fat intakes outside the Acceptable Macronutrient Distribution Range (AMDR) (Table 2-5). Interestingly, more WIC children were below the lower bound of the AMDR for total fat than were above the upper bound (21 percent below and 5 percent above for WIC children 1 year of age; 18 percent below and 10 percent above for WIC children 2 through 4 years of age). This suggests that excessive intake of total fat is not a concern in children. Saturated fat, however, is a nutrient of concern with regard to excessive intake; 91 percent of WIC children ages 2 through 4 years had saturated fat intakes above the recommended range of less than 10 percent of total food energy (Table 2-5). The estimate of the percentage of WIC children with intakes of added sugars exceeding 25 percent of food energy (the upper bound set in the DRI reports [IOM, 2002/2005]) was about 3 percent (Table 2-5). However, it is difficult to plan diets that provide recommended amounts of nutrients when added sugars provide such a high percentage of total calories (DHHS/USDA, 2004). (See also discussion of added sugars in the section on Food Priorities). Approximately 7 percent of pregnant and lactating women and 20 percent of non-breastfeeding postpartum women had intakes of added sugars greater than 25 percent of total food energy intake (Table 2-5). A substantial proportion of pregnant and lactating women had usual fat intakes outside the AMDR. Only a small proportion had usual fat intakes less than the lower bound of the AMDR (20 to 25 percent of food energy intakes), but almost a quarter had usual fat intakes exceeding the upper bound of the AMDR (35 percent of energy intakes) (Table 2-5). Saturated fat is a nutrient of concern with regard to excessive intake; 81 percent of pregnant and lactating women and 96 percent of non-breastfeeding postpartum women (Krauss et al., 1996) did not meet dietary guidance to limit saturated fat intake to less than 10 percent of total food energy intakes (AHA, 2004; DHHS/USDA, 2005).

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WIC Food Packages: Time for a Change TABLE 2-5 Percentage with Reported Usual Intakes of Macronutrients and Added Sugars Outside Dietary Guidance   Participant Category Nutrient WIC Children, 1–1.9 y (n = 287) WIC Children, 2–4.9 y (n = 872) Pregnant Women and Lactating Women, 14–44 y (n = 123) Non-Breastfeeding Postpartum Women, 14–44 y (n = 105) Protein %<AMDR <0.1 0.5 <0.1 0.3 %>AMDR 1.5 1.0 <0.1 <0.1 Carbohydrate, total %<AMDR 7.5 2.0 1.5 4.8 %>AMDR 2.8 1.1 0.2 0.1 Added Sugars %>25% of food energy na 2.9 7.3 20.4 Fat, total %<AMDR 20.8 18.1 0.2 <0.1 %>AMDR 5.5 10.4 24.5 4.9 Fat, saturateda %>10% of food energy na 91.0 80.9 96.2 aThe dietary guidance in this table for saturated fat is a part of the Dietary Guidelines for Americans (DHHS/USDA, 2005). The dietary guidance from the Dietary Reference Intake (DRI) reports for saturated fat is to consume amounts as low as possible while consuming a nutritionally adequate diet (IOM, 2002/2005). NOTES: AMDR = Acceptable Macronutrient Distribution Range; n = sample size; na = not applicable; %<AMDR, percentage with usual intake less than AMDR; %>AMDR, percentage with usual intake greater than AMDR. For details of these analyses, see Table C-4 in Appendix C—Nutrient Intake of WIC Subgroups. 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 a). Excessive Intake Levels In general, the risk of excessive nutrient intakes was low, less than 1 percent for most WIC subgroups (Tables 2-5 and 2-6). Some notable exceptions were: Intakes of sodium appeared excessive. More than 90 percent of WIC children 2 through 4 years and of pregnant, lactating, and non-

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WIC Food Packages: Time for a Change TABLE 2-6 Percentage with Reported Usual Intakes Above the Tolerable Upper Intake Level and Dietary Guidance   WIC Infants, Formula-Fed   0–3.9 mo (n = 152) 4–5.9 mo (n = 104) 6–11.9 mo (n = 275) Calcium (mg/d) UL ND ND ND %>UL — — — Iron (mg/d) UL 40 40 40 %>UL 0.2 0.3 0.3 Zinc (mg/d) UL 4 4 5 %>UL 86.0 96.8 87.6 Selenium (mcg/d) UL 45 45 60 %>UL 0.3 <0.1 5.1 Phosphorus (mg/d) UL ND ND ND %>UL — — — Sodium (mg/d) UL ND ND ND %>UL — — — Vitamin A (mcg/d) UL 600 600 600 %>UL 38.3 56.3 42.7 Vitamin C (mg/d) UL ND ND ND %>UL — — — Vitamin B6 (mg/d) UL ND ND ND %>UL — — — Cholesterol (mg/d) Guidance na na na %>Guidance — — — aUL for children 2–3.9 y / children 4–4.9 y. bUL for women 14–18 y / women 19–44 y. cUL for pregnant women 14–44 y / lactating women 14–44 y. NOTES: n = sample size; na = not applicable; ND = not determined, UL not determined due to lack of data of adverse effects; UL = Tolerable Upper Intake Level; %>Guidance = percentage with usual intake greater than the applicable dietary guidance (e.g., cholesterol intake should not exceed 300 mg/d); %>UL = percentage with usual intake greater than UL. Details of these analyses are provided in Tables C-2A through C-2G (micronutrients and sodium) and Tables C-3A through C-3G (cholesterol) in Appendix C—Nutrient Intake of WIC Subgroups.

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WIC Food Packages: Time for a Change WIC Children Women, 14–44 y 1–1.9 y (n = 287) 2–4.9 y (n = 872) Pregnant or Lactating (n = 123) Non-Breastfeeding Postpartum (n = 105) 2,500 2,500 2,500 2,500 0.1 <0.1 <0.1 <0.1 40 40 45 45 <0.1 <0.1 0.1 <0.1 7 7 / 12a 34 / 40b 34 / 40b 55.7 58.1 <0.1 <0.1 90 90 / 150a 400 400 4.0 9.1 <0.1 <0.1 3,000 3,000 3,500 / 4,000c 4,000 <0.1 <0.1 <0.1 <0.1 1,500 1,500 / 1,900a 2,300 2,300 63.5 92.8 97.2 90.7 600 600 / 900a 2,800 / 3,000b 2,800 / 3,000b 25.0 16.1 <0.1 <0.1 400 400 / 650a 1,800 / 2,000b 1,800 / 2,000b <0.1 <0.1 <0.1 <0.1 30 30 / 40a 80 / 100b 80 / 100b <0.1 <0.1 <0.1 <0.1 na <300 <300 <300 — 12.2 32.2 8.1 DATA SOURCES: Intake data were obtained 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) or sodium intake from table salt. All infants and young children were non-breastfed. The ULs were obtained from IOM (1997, 1998, 2000b, 2001, 2002/2005, 2005a). Intake distributions were calculated using C-SIDE (ISU, 1997). Dietary guidance for cholesterol is from the American Heart Association (AHA, 2004) and the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005).

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WIC Food Packages: Time for a Change breastfeeding postpartum women had usual sodium intakes above the UL. More than 60 percent of WIC children age one year had usual sodium intakes above the UL. It is noteworthy that the data set used for these analyses did not include dietary sodium added in the form of table salt. High proportions of formula-fed WIC infants and WIC children ages 1 through 4 years had estimated usual intakes of zinc and preformed vitamin A that exceeded the UL. Almost 90 percent of formula-fed WIC infants and more than half of WIC children had usual zinc intakes above the UL. About 38 percent of formula-fed WIC infants 0 through 3 months and even higher percentages of formula-fed older WIC infants had usual preformed vitamin A intakes above the UL. High percentages of WIC children also had usual intakes of preformed vitamin A above the UL. The values for preformed vitamin A in Table 2-6 are likely underestimates since the data set for these analyses did not include intake from dietary supplements. Sizeable proportions of subgroups have saturated fat intakes above the dietary guidance to consume less than 10 percent of total food energy as saturated fat: 91 percent of WIC children ages 2 through 4 years; 81 percent of pregnant and lactating women; and 96 percent of non-breastfeeding postpartum women. About one-third of pregnant and lactating women had usual cholesterol intakes that exceeded the recommended limit of 300 milligrams per day. Discussion of Results The results above provide a comprehensive analysis of the nutrient adequacy of the diets of WIC subgroups, focusing on the prevalence of inadequate nutrient intake, risk of excessive intake, and dietary imbalances in macronutrient intake. The results indicate inadequate intakes of a number of micronutrients, particularly vitamin E and magnesium; reported food energy intakes that differ from EERs; excessive intake of saturated fat (expressed as a percentage of total food energy intake); low intakes of calcium, potassium, and fiber; excessive intakes of sodium; and, for some groups, potentially excessive intakes of zinc and preformed vitamin A. The diets of WIC infants and children were more nutritionally adequate than those of adolescent and adult women (pregnant, lactating, and non-breastfeeding postpartum). Data Limitations In interpreting these results, several analytic issues should be noted. First, the dietary data used in the analysis (1994–1996 and 1998 Continu-

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WIC Food Packages: Time for a Change the fetus and infant, it is prudent to minimize their exposure whenever possible (ATSDR, 1998). Almost all current human exposure occurs through food, and the large majority of that through consumption of fat from animal sources (IOM, 2003b). A reduction in the consumption of fat from animal sources will reduce exposure to these toxicants. Methylmercury—Consumption of fish or shellfish is an important part of the diet of women and young children (NRC, 1989b). However, almost all fish and shellfish contain some methylmercury, an environmental contaminant that is hazardous to the fetus and to the nervous system of young children at excessive exposures (ATSDR, 1999; CFSAN, 2001; EPA/ FDA, 2004; CDC, 2004a). Certain types of fish and shellfish contain high levels of methylmercury. The FDA and EPA advise “women who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and eat fish and shellfish that are lower in mercury” (EPA/FDA, 2004). Summary of Nutrition-Related Health Priorities The review of nutrition-related health risks indicates several nutrient and food priorities for all WIC subgroups—obesity, poor iron status, and contamination of food with dioxin and methylmercury. Low folate intake is a concern for all women during their reproductive years because of its importance in preventing neural tube defects. Insufficient calcium intake for pregnant and breastfeeding women may be associated with potential lead toxicity for the fetus and infant. Low intake of vitamin D is a potential concern for women of reproductive age. Inadequate zinc intake is a concern for breast-fed infants 6 through 11 months of age. These nutrition-related health risks are summarized in Table 2-7. FOOD GROUP PRIORITIES To determine whether specific foods or types of food should receive priority in the redesign of WIC food packages, the committee reviewed information about dietary guidance, amounts of foods consumed by groups that potentially are eligible for the WIC program, and the amounts of foods in current WIC food packages. The assessment gave heavy weight to the federal requirement that the WIC program promote the Dietary Guidelines for Americans in carrying out its program (Pub. L. No. 101-445, U.S. Congress, 1990). To do this, the committee used the newly released the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005) as the source of dietary guidance for children ages two years and older and widely accepted dietary guidance from professional groups for children under 2 years of age. This section summarizes the results of the committee’s assessment.

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WIC Food Packages: Time for a Change TABLE 2-7 Summary of Nutrition-Related Health Risks Nutrient or Food Component Health Concern WIC Subgroup Vitamin D Low intake of vitamin D; poor bone health All women Fully breast-fed infants Folate Low intake of folate; birth defects persist All women Calcium Low intake of calcium; lead exposure persists Pregnant women and lactating women Iron Iron-deficiency anemia persists Women, infants, and children Zinc Low amount of zinc in breast milk after 6 mo postpartum Fully breast-fed infants, 6–11.9 mo Food energy Comorbidities of obesity Women, infants, and children Dioxins Developmental effects Women, infants, and children Methylmercury Adverse effects on nervous system Women, infants, and children Low-Income Children Ages 2 Through 4 Years and Women Using data from Pyramid Serving Data, (FSRG, 1999), Table 2-8 shows mean numbers of servings of foods from five basic food groups and for selected food subgroups. It also gives the mean number of teaspoons of added sugars consumed. To allow comparison of the means with the newly released dietary guidance, Table 2-8 also shows the daily amount specified in the revised USDA food pattern for 1,000 to 1,600 kilocalories (which covers the energy range for most young children) and the daily amount for the 2,000 kilocalories food pattern (which would meet the needs of many of the women served by the WIC program). The income level used—under 131 percent of the federal poverty level—is the level publicly available that is most representative of the WIC population (FSRG, 1999). Results are very similar to those for individuals of all incomes (FSRG, 1999) Children Ages 2 Through 4 Years The biggest shortfalls in reported intake were for food subgroups rather than major food groups, especially for whole grains and dark green leafy vegetables. Mean intakes of dark green leafy vegetables, deep yellow vegetables, and legumes were very low compared with the revised USDA pattern. These subgroups are rich in a number of the nutrients of concern identified above. Similarly, whole grains are a better source of fiber and

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WIC Food Packages: Time for a Change certain other nutrients than are refined grains, but mean intake of whole grains was less than one serving in a day. The Dietary Guidelines (DHHS/USDA, 2005) set no specific limits on added sugars but urge that intake be limited as needed to allow for the intake of essential nutrients without exceeding energy needs. The revised USDA food patterns specify teaspoons of sugar only as an example. Added sugars may improve the palatability of some food, and, in some cases, added sugars may lead to increased intake of foods (e.g., milk, breakfast cereal) that are excellent nutrient sources (Frary et al., 2004). However, the mean amount of added sugars consumed (about 1/3 cup) provides no essential nutrients while providing about 240 kilocalories. Based on this information, the committee determined that added sugars should be limited, but, as shown in Table 4-3 (Chapter 4—Revised Food Packages), it allows selected foods to contain small specified amounts of added sugars. Women in the Childbearing Years Among women, mean intake of whole grains was much lower than the three one ounce-equivalents recommended by the Dietary Guidelines (DHHS/USDA, 2005) (see Table 2-8). Intakes of dark green leafy vegetables, deep yellow vegetables, and cooked dry beans and peas were much lower than the amounts specified in the revised USDA pattern. Reported intakes from the dairy group also were much lower than the newly recommended three servings per day. Mean intake of added sugars by the teens (20 teaspoons) was somewhat greater than that by the women (17 teaspoons). Added sugars would provide about 320 and 270 kilocalories per day, respectively—more than is easily compatible with meeting recommended nutrient intakes without exceeding energy needs. Summary for Children Ages 2 Through 4 Years and Women in the Childbearing Years Examining the data in the light of the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005), the following concerns have been identified. Children—Intakes tend to be low in whole grains and in dark green leafy vegetables, deep yellow vegetables, and cooked dry beans and peas rather than vegetables in general. Women—Intakes tend to be low in whole grains, dark green leafy vegetables, deep yellow vegetables, cooked dry beans and peas, fruits, and milk and milk products. Overall—Intakes of whole grains, vegetable subgroups excluding

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WIC Food Packages: Time for a Change TABLE 2-8 Mean Numbers of Servings from Five Basic Food Groups with Selected Subgroups and Mean Teaspoons of Added Sugars Consumed by Selected Age Groups, Income Under 131 Percent of Federal Poverty Level Food Group and Food Subgroups Amount in Revised USDA 1,000–1,600 Kcal Pattern (daily or weekly) Mean Number of Servingsa Consumed Daily by Children Males, 2–5 y Females, 2–5 y Grains, total 3–6 oz equiv/db 6.3 6.0 Whole grain 3 oz equiv/dc 0.8 0.8 Vegetables, total 2–4/d 2.3 2.3 Dark green leafy 2–4/wk † 0.1 Deep yellow 1–3/wk 0.1 0.1 Dry beans/peas, cooked 1–5/wk 0.2 0.2 White potatoes }3–5/wk 1.0 1.0 Other starchy vegetables 0.2 0.2 Tomatoes }8–11/wk 0.4 0.3 Other vegetables 0.4 0.4 Fruits, total 2–3/d 1.9 1.8 Citrus, melons, berries — 0.7 0.8 Dairy, totald 2/d 1.8 1.8 Milk — 1.5 1.5 Yogurt — † † Cheese — 0.3 0.3 Meat and Alternativese 2–5 oz equiv/df 3.2 ‡ 3.0 ‡ Meat — 1.1 1.1 Poultry — 0.8 0.7 Fish — 0.1 0.2 Organ meat — †* †* Frankfurter/lunch meat — 0.7 0.6 Eggs — 0.4 0.3 Soybean products — †* †* Nuts and seeds — 0.1 0.1 Added Sugars 4–5 tsp/dg 13.9 14.0 aServings from each food group: fruits and vegetables, 1/2 cup or equivalent; grains, 1 oz dry or 1/2 cup cooked; dairy, 1 cup milk or equivalent; meat and meat alternatives, equivalent to 1 oz of lean meat. bFor the grain food group a 1 oz equiv is equal to: 1 slice of bread; 1 cup dry cereal; or 1/ 2 cup cooked rice, pasta, or cereal (USDA/DHHS, 1992). cThree whole grain one ounce-equivalents per day is the minimum amount specified by the Dietary Guidelines Advisory Committee regardless of the total number of servings of grain (DHHS/USDA, 2004). The Dietary Guidelines for Americans 2005 specifies a minimum of 3 whole grain one ounce-equivalents per day (DHHS/USDA, 2005); a general recommendation is also provided that at least half the total grain servings should be whole grain (DHHS/ USDA, 2005). The revised USDA food patterns specify that half the total number of servings of grain be whole grain. dIntakes include small amounts of miscellaneous dairy products, such as whey and nonfat sour cream, that are not included in the subgroups milk, yogurt, and cheese. eIntakes exclude dry beans and peas (i.e., legumes) because they were tabulated as vegetables. Dry beans and peas may be counted either as vegetables or in the meat group, but not both.

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WIC Food Packages: Time for a Change Amount in Revised USDA 2,000 Kcal Pattern (daily or weekly) Mean Number of Servingsa Consumed Daily by Women 12–19 y 20–39 y 6 oz equiv/db 6.3 5.4 3 oz equiv/dc 0.9 0.8 5/d 2.8 2.8 6/wk 0.1 0.1 4/wk 0.1 0.1 6/wk 0.2 0.2 } 6/wk 1.2 0.7 0.1 0.2 } ~2/d 0.5 0.4 0.7 1.0 4/d 1.1 1.2 — 0.6 0.6 3/d 1.4 1.1 — 0.9 0.7 — † † — 0.4 0.4 5.5 oz equiv/df 4.3 4.3 — 1.9 1.7 — 0.9 1.1 — 0.2 0.4 — †* †* — 0.8 0.6 — 0.4 0.4 — †* †* — 0.1 0.1 10–12 tsp/dg 22.6 18.7 fFor the meat and bean food group a 1 oz equiv is equal to: 1 oz of cooked lean meats, poultry, or fish; 1 egg; 1/4 cup cooked dry beans; or 1 tablespoon of peanut butter (DHHS/ USDA, 2004, 2005). gExample of how remaining (discretionary) calories might be distributed if a person consumes recommended amounts of foods in their fat-reduced, no added sugars forms. NOTES: † = value less than 0.05 but greater than 0; ‡ = recommended minimum number of servings is different for specific subgroups; * = statistical reliability is reduced due to small cell size; kcal = kilocalories; oz equiv = ounce equivalents; tsp = teaspoon. ~ indicates approximate amount. DATA SOURCES: Intake date were obtained from 1994–1996 Continuing Survey of Food Intakes by Individuals (CSFII) and are 2-day average intakes based on daily intakes (FSRG, 1999). Available sample size information may be found in the “Appendix A table” of this online report (FSRG, 1999). Daily amounts in revised USDA patterns were obtained from “Appendix A-2” of the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005, pg. 53).

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WIC Food Packages: Time for a Change potatoes and other starchy vegetables, fruits, milk and milk products, and meat are all lower than recommended on average. Data are not available on the extent to which fruit juice intake exceeds recommendations. Low-Income Children Younger Than 2 Years of Age To identify food-related priorities for infants and children younger than 2 years of age, the committee obtained descriptive information about their food intakes and examined the data in relation to objectives in Healthy People 2010 (DHHS, 2000a, 2000b) and to widely accepted dietary guidance from the American Academy of Pediatrics, the American Dietetic Association, and other selected sources (see Table 2-9). In 2002, reported breastfeeding rates for WIC participants were about 60 percent in the first week postpartum and 22 to 26 percent at six months (Abbott Laboratories, 2003; Li et al., 2005). These rates are substantially lower than the Healthy People 2010 (DHHS, 2000b) objectives of 75 percent in the early postpartum period and 50 percent at six months.5 Furthermore, rates for WIC participants are about 20 percentage points lower than the rates for non-WIC infants (Abbott Laboratories, 2003; Li et al., 2005). Much of the dietary guidance related to feeding infants and young children addresses when to introduce foods of different types and feeding a varied, healthful diet to toddlers (see Table 2-9). A study of WIC participants (Bayder et al., 1997) and the Feeding Infants and Toddler Study found that many infants are introduced to foods earlier than recommended. For example, almost 30 percent of infants were fed complementary foods before age four months (Briefel et al., 2004a), and almost 25 percent of infants ages 9 through 11 months were fed cow’s milk (Bayder et al., 1997; Briefel et al., 2004a). Fruit juice intake exceeded recommendations for about 60 percent of the children (Skinner et al., 2004), and non-juice fruit and vegetable consumption was low, with approximately 30 percent of infants and toddlers consuming no fruits or vegetables (Fox et al., 2004). The most common vegetable consumed by toddlers 15 months and older was fried potatoes (Fox et al., 2004). Most caregivers in the Feeding Infants and Toddlers Study reported offering a new food to infants or toddlers no more than 3 to 5 times before deciding that their infant or toddler disliked it (Carruth et al., 2004), whereas research suggests 8 to 15 exposures may be necessary for acceptance (Sullivan and Birch, 1994; Birch and Fisher, 1995). 5   Healthy People 2010 includes the breastfeeding objective of 25 percent of mothers breastfeeding at 12 months postpartum (DHHS, 2000b).

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WIC Food Packages: Time for a Change TABLE 2-9 Dietary Guidance for Infants and Children Under the Age of Two Years Breastfeeding Source Breastfeeding is the preferred method of infant feeding because of the nutritional value and health benefits of human milk. AAP, 2004, 2005 Encourage breastfeeding with exclusion of other foods until infants are around 6 months of age.a AAP, 2005; WHO, 2002 Continue breastfeeding for first year after birth. AAP, 2004, 2005 Continue breastfeeding into second year after birth if mutually desired by the mother and child. AAP, 1997, 2001b, 2004, 2005; Kleinman, 2000 Formula Feeding Source For infants who are not currently breastfeeding, use infant formula throughout the first year after birth. Kleinman, 2000; AAP, 2004, 2005 Infant formula used during the first year after birth should be iron-fortified. AAP, 1999, 2001b, 2004, 2005 Infants with specific medical conditions may require medical formula and this should be readily available through projects such as the WIC program. AAP, 2001b Feeding Other Foods to Infants and Young Children Source Introduce semisolid complementary foods gradually beginning around 6 months of age.a Kleinman, 2000; WHO, 2001a, 2002; AAP, 2005 Introduce single-ingredient complementary foods, one at a time for a several day trial. AAP, 2004 Introduce a variety of semisolid complementary foods throughout ages 6–12 mo. WHO, 2001a Encourage consumption of iron-rich complementary foods during ages 6–12 mo. AAP, 2001a, 2004, 2005 Avoid introducing fruit juice before 6 mo of age. 2001a, 2004 Kleinman, 2000; AAP, Limit intake of fruit juice to 4–6 fl oz/d for children ages 1–6 y. Kleinman, 2000; AAP, 2001a, 2004, 2005 Encourage children to eat whole fruits to meet their recommended daily fruit intake. AAP, 2001a, 2004

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WIC Food Packages: Time for a Change Delay the introduction of cow’s milk until the second year after birth. AAP, 1992a, 2004, 2005 Cow’s milk fed during the second year after birth (that is, ages 1–1.9 y) should be whole milk. AAP, 1992b, 1998 Developing Healthy Eating Patterns Source Provide children with repeated exposure to new foods to optimize acceptance and encourage development of eating habits that promote selection of a varied diet. ADA, 1999c, 2004 Prepare complementary foods without added sugars or salt (i.e., sodium). AAP, 2004 Promote healthy eating early in life. ADA, 1999c, 2004 Promoting Food Safety Source Avoid feeding hard, small, particulate foods up to age 2–3 y to reduce risk of choking. Kleinman, 2000; AAP, 2004 aThere is acknowledged disagreement among experts on the subject of timing of introduction of complementary foods (AAP, 2004, 2005). Many organizations that support maternal and child health currently recommend exclusive breastfeeding (i.e., feeding of no food or beverages other than breast milk with the exception of medications and vitamin or mineral supplements) for the first six months after birth (AAP, 1997; UNICEF, 1999; ACOG, 2000; AAFP, 2005; WHO, 2001b). The rationale for the recommendation to encourage breastfeeding with exclusion of other foods until infants are around six months of age is summarized in the following quotes from the most recent policy statement from the American Academy of Pediatrics (AAP, 2005). • “Exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months after birth and provides continuing protection against diarrhea and respiratory tract infection.” “There is a difference of opinion among AAP experts on this matter. The Section on Breastfeeding acknowledges that the Committee on Nutrition supports introduction of complementary foods between 4 and 6 months of age when safe and nutritious complementary foods are available.” • Regarding exclusive breastfeeding of infants—“Complementary foods rich in iron should be introduced gradually beginning around 6 months of age.” • Regarding exclusive breastfeeding of infants—“Introduction of complementary feedings before 6 months of age generally does not increase total caloric intake or rate of growth and only substitutes foods that lack the protective components of human milk.” DATA SOURCES: Dietary guidance is from: the American Academy of Pediatrics (AAP, 1992a, 1992b, 1997, 1998, 1999, 2001a, 2001b, 2004, 2005; Kleinman, 2000); the American Dietetic Association (ADA, 1999c, 2004); and the World Health Organization (WHO, 2001a, 2002).

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WIC Food Packages: Time for a Change Summary for Infants and Children Younger Than 2 Years of Age Examining the data in the light of Healthy People 2010 (DHHS, 2000a, 2000b) and dietary guidance from professional groups (see Table 2-9), the committee identified the following concerns: Breastfeeding rates are below the nationwide objectives. This affects the health both of mothers and infants. For many infants, complementary foods and beverages (juice and cow’s milk) are introduced earlier than recommended. For many infants and toddlers, fruit juice intake substantially exceeds recommendations. Most older infants and young toddlers have limited exposure to different fruits and vegetables. SUMMARY Based on the information presented above and documented in greater detail in Appendix C—Nutrient Intake of WIC Subgroups, the committee developed the following list of nutrient and food priorities (Table 2-10). Additional key points about food choices are the following: The dietary practices of most concern for the infants and toddlers younger than 2 years of age include the short duration of breastfeeding, excessive consumption of fruit juice, early introduction of solid food and cow’s milk, low consumption of fruits (other than juice) and vegetables, and infrequent exposure to new foods. Examination of foods in the current WIC packages shows that there is room for improvement to become more consistent with current dietary guidance.

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WIC Food Packages: Time for a Change TABLE 2-10 Nutrient and Food Group Priorities for Revision of the WIC Food Packages Participant Category Nutrients of Concern with Regard to Inadequate Intake Infants, younger than 1 y, non-breastfed No need identified to increase particular nutrients; maintain iron intakes and continue to provide a balanced set of essential nutrientsa Infants, 6–11.9 mo, breast-fed Increase intakes of: Iron and Zinc Children, 12–23.9 mo Increase intakes of: Iron, Potassium, Vitamin E, and Fiber Children, 2–4.9 y Increase intakes of: Iron, Potassium, Vitamin E, and Fiber Adolescent and adult women of reproductive age Give highest priority to increasing intakes of: Calcium, Iron, Magnesium, Potassium, Vitamin E, and Fiber   Also try to increase intakes of: Vitamin A, Vitamin C, Vitamin D, Vitamin B6, and Folate aIron intakes are apparently adequate for non-breastfed infants, probably due in part to provision of iron-fortified formula in the current WIC food packages. The committee recommends that the WIC program continue to provide iron-fortified formula to prevent iron-deficiency anemia. bThe Tolerable Upper Intake Level applies only to preformed vitamin A (i.e., retinol) ingested from the combined sources of animal-derived foods, fortified foods, and dietary supplements (IOM, 2001).

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WIC Food Packages: Time for a Change Priority Food Groups Nutrients of Concern with Regard to Excessive Intake Nutrients and Ingredients to Limit in the Diet na Decrease intakes of: Zinc, Vitamin A, preformed,b and Food energy   na     Increase intakes of a variety of nonstarchy vegetables. Decrease intakes of: Zinc, Vitamin A, preformed,b and Food energy   Increase intakes of whole grains, and a variety of nonstarchy vegetables. Decrease intakes of: Zinc, Sodium, Vitamin A, preformed,b and Food energy Limit intakes of: Saturated fat, Cholesterol, and Added sugars Increase intakes of whole grains, a variety of nonstarchy vegetables, fruit, and fat-reduced milk products. Decrease intakes of: Sodium, Food energy, and Total fat Limit intakes of: Saturated fat, Cholesterol, Trans fatty acids,c and Added sugars cTrans fatty acids have not specifically been identified as a hazard for infants and children, and thus are shown in the table as nutrients to limit only in the diets of adolescents and adults (IOM, 2002/2005). However, the dietary guidance to limit trans fatty acids from processed foods in the diet is presumed to apply to all individuals regardless of age. NOTE: na = not applicable.