National Academies Press: OpenBook

WIC Food Packages: Time for a Change (2006)

Chapter: 2 Nutrient and Food Priorities for the WIC Food Packages

« Previous: 1 Introduction and Background
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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-

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient 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 CNutrient Intake of WIC Subgroups.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient 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

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 SetNutrients Examined in Appendix CNutrient 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 CNutrient 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 CNutrient Intake of WIC Subgroups—for details of the methodology.)

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient 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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient 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 CNutrient 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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient 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-

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 CNutrient Intake of WIC Subgroups.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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-

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

ing Survey of Food Intakes by Individuals [CSFII]) do not include nutrients from dietary supplements and thus may overestimate the true prevalence of inadequacy and underestimate the prevalence of excessive intake levels. Second, the differences between mean EER and mean food energy intakes for the women suggest that some women were underreporting intakes. If food energy intakes were less than actual energy expenditures for specific subgroups, then individuals could not maintain their body weight, and these subgroups would then experience weight loss. Given the increase in the prevalence of overweight and obesity, however, underreporting of food intakes is the likely explanation for the difference between mean EER and mean food energy intakes.

Given the likely underreporting of food energy intakes by adolescents and adults in general (Mertz et al., 1991; Johansson et al., 1998; Schoeller, 2002), an important question is the extent to which the prevalence of inadequacy for micronutrients was overestimated in these analyses for adolescent and adult women in the WIC population. The answer depends on the extent of underreporting and the correlation between food energy intake and micronutrient intakes. Nonetheless, given the very high prevalence of inadequacy for some micronutrients—vitamin E and magnesium in particular—and the low intakes of calcium, it is unlikely that underreporting of food intakes could explain fully the apparent inadequacies in the intakes of these nutrients.

For WIC children, mean food energy intakes were considerably larger than the mean EER for low-income children 1 through 4 years of age. Although the increasing prevalence of overweight and obesity among children is consistent with an excess of food energy intakes over requirements, the magnitude of the difference between mean intake and mean EER suggests that parents or caregivers overreported food intakes of children. To the extent that caregivers overreport the food intakes of children (Devaney et al., 2004), the rates of inadequate nutrient intakes in this report are underestimates.

Estimates of Requirements

Although the committee used the DRIs as nutrient standards when redesigning the WIC packages, it was recognized that it would not be possible for a supplemental food package to raise intakes of all priority nutrients to a level that would reduce the prevalence of inadequacy to a very low percentage. This was particularly true for nutrients, such as vitamin E, for which the prevalence of inadequacy was identified as being very high.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Vitamin E—Estimates of dietary intakes of vitamin E were inadequate for large proportions of the population in the data sample, with the prevalence of inadequacy ranging from about 50 percent among children to more than 90 percent among women. Other recent studies also reported inadequate dietary intakes of vitamin E in young children (Devaney et al., 2004), school age children (Suitor and Gleason, 2002), adolescents (Suitor and Gleason, 2002), and adults (Maras et al., 2004). Vitamin E intakes were inadequate even when dietary supplements were included in the analysis (Devaney et al., 2004). Although clinical vitamin E deficiency is rare, low dietary intake of vitamin E may increase the long-term risk of cardiovascular disease (Knekt et al., 1994; Kushi et al., 1996; Iannuzzi et al., 2002; Ford et al., 2003). The committee is aware that the current vitamin E requirements are considered high by some. Nonetheless, the Dietary Guidelines Advisory Committee accepted the DRIs for vitamin E (DHHS/USDA, 2004); the Dietary Guidelines state that vitamin E may be a nutrient of concern because of low intake (DHHS/USDA, 2005); and federal nutrition assistance programs such as WIC are required to follow the Dietary Guidelines recommendations (U.S. Congress, Pub. L. No. 101-445, 1990). Therefore, vitamin E was considered a priority nutrient for WIC women and children.

Other nutrients also have requirement estimates that are difficult to achieve on a population level (for example, magnesium requirements for adults, the AIs for fiber for children, and AIs for potassium for children and women). If functional consequences of the reported low intakes of such nutrients are not observed, further evaluation of these requirement estimates may be appropriate.

Estimates of Upper Levels

The committee recognized that it would not be feasible to revise the food packages in ways that would substantially reduce the prevalence of excessive intakes for all nutrients with a UL. The zinc and vitamin A ULs for infants and children are particularly problematic because high proportions of the population exceed these ULs. If adverse effects of these reported high intakes are not observed, further evaluation of these ULs may be appropriate in future revisions of the DRIs.

Zinc—Substantial proportions of non-breastfed WIC infants and of WIC children had estimated usual intakes above the UL for zinc, indicating a possible risk of adverse effects. Zinc intakes above the UL have been observed in other analyses (Arsenault and Brown, 2003). The method used to set the ULs for zinc resulted in relatively narrow margins between the UL and the Recommended Dietary Allowance (RDA) or AI; the ULs are 1.7–2.0 times the AI or RDA for infants and 2.3–2.4 times the RDAs for

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

children (IOM, 2001).2 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 added to infant formula and some infant cereal and is also 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 the possible overconsumption of zinc.

Vitamin A—Additionally, substantial proportions of non-breastfed WIC infants and of WIC children had estimated usual intakes above the UL for preformed vitamin A, indicating a possible risk of adverse effects. The method used to set the ULs for retinol resulted in relatively narrow margins between the UL and the RDA or AI for vitamin A; the ULs are 1.2–1.5 times the AIs for infants and 2.0–2.3 times the RDAs for children (IOM, 2001).3 Although certain animal-derived food sources of preformed vitamin A can contribute to hypervitaminosis A, toxicity is rare without a supplemental source of retinol (IOM, 2001). Preformed vitamin A is used in infant formula and is also used as a fortificant in some foods that are commonly consumed by children (e.g., fortified milk products and breakfast cereals). Further study is needed of the contribution of the preformed vitamin A in such food products to possible overconsumption of vitamin A.

Priority Nutrients

While the discussion and caveats above suggest caution in interpreting the results presented in this report, concerns persist about dietary inadequacies and excesses. Based on the detailed analyses results, the following nutrients are considered high priority.

  • WIC Infants Under 1 Year of Age, Non-Breastfed—No nutrients were identified with a high risk of inadequacy. Priority nutrients related to risk of excessive intakes in non-breastfed infants are zinc, preformed vitamin A, and food energy.

2  

For infants, the AI is 2 mg zinc per day for ages 0 through 5 months, and the RDA is 3 mg zinc per day for ages 6 through 11 months; the ULs are 4 and 5 mg zinc per day for ages 0 through 5 months and 6 through 11 months, respectively (IOM, 2001). For children, the RDAs are 3 and 5 mg zinc per day for ages 1 through 3 years and 4 years, respectively; the ULs are 7 and 12 mg zinc per day for ages 1 through 3 years and 4 years, respectively (IOM, 2001).

3  

For infants, the AIs are equivalent to 400 and 500 mcg retinol per day for ages 0 through 5 months and 6 through 11 months, respectively; the UL is 600 mcg retinol per day for all infants (IOM, 2001). For children, the RDAs are equivalent to 300 and 400 mcg retinol per day for ages 1 through 3 years and 4 years, respectively; the ULs are 600 and 900 mcg retinol per day for ages 1 through 3 years and 4 years, respectively (IOM, 2001).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
  • Breast-Fed Infants 6 Through 11 Months—Priority nutrients identified as lacking in the diets of the breast-fed infants six months and older are iron and zinc.

  • WIC Children 1 Through 4 Years of Age—Priority nutrients identified as lacking in the diets of young children are vitamin E, fiber, and potassium. Nutrients that may be excessive in the diets of young children are zinc, preformed vitamin A, sodium, food energy, and saturated fat.

  • Pregnant, Lactating, and Non-Breastfeeding Postpartum Women—Priority nutrients identified as lacking are calcium, magnesium, vitamin E, potassium, and fiber. Nutrients with more moderate, but still high, levels of inadequacy are vitamins A, C, and B6, and folate. Nutrients with lower levels of inadequacy are iron, zinc, thiamin, niacin, and protein. Sodium intakes and saturated fat intakes (the latter expressed as a percentage of food energy intakes) are excessive in the diets of pregnant, lactating, and non-breastfeeding postpartum women.

NUTRITION-RELATED HEALTH PRIORITIES

In addition to analyses of nutrient adequacy, a comprehensive examination of nutrition priorities needs to consider nutrition-related health risks. For this analysis of nutrition-related health risks, the committee reviewed epidemiological evidence on body weight status, micronutrients of special concern during reproduction and early childhood, food allergies, and selected environmental risks to the health of women, infants, and children.

Overweight and Obesity

Data from the National Health and Nutrition Examination Survey (NHANES) and Pediatric Nutrition Surveillance System document a substantial increase in the prevalence of overweight and obesity among children and among women of reproductive age (Kuczmarski et al., 1994; Ogden et al., 2002; Flegal et al., 2002). Among nonpregnant women 20 to 39 years of age, 28 percent are obese (Flegal et al., 2002), and overweight and obesity are more common among most minority and low-income groups (Hedley et al., 2004). Among children 6 to 11 years of age, the prevalence of overweight increased from 4 percent in 1965 to 15 percent in 1999–2000 (Ogden et al., 2002). Among children 2 through 5 years in 1999–2000, 10 percent were overweight (Ogden et al., 2002).

The increasing prevalence of overweight and obesity suggests the need to monitor energy intakes and energy expenditure (Koplan and Dietz, 1999; IOM, 2002/2005).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Iron-Deficiency Anemia

Recent data from NHANES suggest that, despite declines in the prevalence of iron deficiency, this deficiency remains a nutrition-related health risk for both children and women of reproductive age. Additionally, reduction of iron deficiency is a goal of Healthy People 2010 (DHHS, 2000a). Although the prevalence of inadequacy of iron intake by WIC subgroups was lower than that for most nutrients examined (see previous section), a large body of literature suggests that WIC foods contribute to the adequacy of iron intake among low-income women, infants, and children (Yip et al., 1987; Rush et al., 1988c, 1988d; Batten et al., 1990; Rose et al., 1998; Pehrsson et al., 2001; Sherry et al., 2001; Siega-Riz et al., 2004). Because of considerable evidence of the role of the WIC program in reducing iron-deficiency anemia, as well as the important role that iron status plays in child growth and cognitive development, iron remains a priority nutrient, both in terms of the need to increase intakes in some subgroups (e.g., older infants fully breast-fed) and in terms of the importance of maintaining adequate intakes in other subgroups (e.g., infants fed iron-fortified formula).

Folate and Birth Defects

Well-designed studies have documented the relationship between low maternal folate stores and birth defects such as the neural tube defects of spina bifida and anencephaly (Daly et al., 1995). Randomized, controlled clinical trials have shown a protective effect of folic acid in the periconceptional stage (MRC Vitamin Study Research Group, 1991; Czeizel and Dudas, 1992; Czeizel et al., 1994). In response to this information, enriched grain products are required to be fortified with folic acid. Despite the fortification of grain products and a resulting decline in the prevalence of neural tube defects over the last decade (Honein et al., 2001; Mathews et al., 2002; Williams et al., 2002; CDC, 2004f), disparities in folate intake persist (CDC, 2004f), and many women are unaware of the connection between folate intake and birth outcomes (March of Dimes Birth Defects Foundation, 2004). Only 40 percent of women of childbearing age report taking a multivitamin containing folic acid on a regular basis (CDC, 2004h; March of Dimes Birth Defects Foundation, 2004). Despite numerous public health messages targeted to women of reproductive age, a low percentage of women in this age group use a multivitamin supplement or other measures that may contribute to optimal folate status (March of Dimes Birth Defects Foundation, 2003, 2004).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Other Nutrition-Related Health Risks

The committee identified several other nutrition-related health risks and outcomes in its review of epidemiological evidence.

  • Vitamin D and Bone Health—Recent evidence suggests that vitamin D deficiency may be re-emerging as a health concern, especially for population subgroups in regions with seasonal variation in exposure to sunlight (Kreiter et al., 2000). Despite some controversy about the actual prevalence and public health significance of vitamin D deficiency,4 a calcium- and vitamin D-rich diet is important during periods of peak bone mass accretion (Raisz, 1999; Curran and Barness, 2000; Branca and Vatueña, 2001; New, 2001; Calvo and Whiting, 2003). The Dietary Guidelines note the importance of dietary sources of vitamin D for the elderly, persons with dark skin, and those with insufficient exposure to ultraviolet B radiation (DHHS/USDA, 2005). Recommendations from the American Academy of Pediatrics note the importance of vitamin D supplementation of breast-fed infants (AAP, 2005).

  • Zinc and Breast-Fed Infants 6 Through 11 Months—Chemical analyses of breast milk at various stages of lactation indicate that at 6 through 11 months postpartum, the zinc (and iron) content of breast milk alone is not sufficient for older infants (Krebs, 2000; Dewey, 2001; Krebs and Westcott, 2002). Thus, the content and bioavailability of zinc (and iron) in complementary foods become very important for fully breast-fed infants.

  • Calcium Intake and Lead Exposure—Studies of calcium intakes and exposure to lead suggest that adequate calcium intake has an added benefit of decreasing blood lead levels in pregnant women and lactating women (Hertz-Picciotto et al., 2000; Hernandez-Avila et al., 2003).

  • Dioxins—Dioxins are low-level environmental contaminants, but their presence in animal feed, food and water resources for animals in the wild (e.g., fish), and the human food supply is widespread. Because dioxins have a variety of potential toxic effects, including developmental effects on

4  

There is recent evidence that vitamin D intakes are inadequate for adolescent and adult women of reproductive age (Moore et al., 2004). However, vitamin D intakes appeared adequate for children ages 1 to 8 years (Moore et al., 2004), indicating that vitamin D intakes are likely to be adequate among children in these age groups on a population basis. Nevertheless, vitamin D deficiency has been reported in population subgroups or the whole population in regions with seasonal variation in exposure to sunlight (Daaboul et al., 1997; Lawson and Thomas, 1999; Lawson et al., 1999; Kreiter et al., 2000; Dawodu et al., 2003). Thus, whether inadequate intakes of vitamin D are a public health concern remains controversial.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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 4Revised 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

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
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 CNutrient 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.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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).

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

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.

Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 46
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 47
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 48
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 49
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 50
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 51
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 52
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 53
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 54
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 55
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 56
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 57
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 58
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 59
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 60
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 61
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 62
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 63
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 64
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 65
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 66
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 67
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 68
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 69
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 70
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 71
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 72
Suggested Citation:"2 Nutrient and Food Priorities for the WIC Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Page 73
Next: 3 Process Used for Revising the WIC Food Packages »
WIC Food Packages: Time for a Change Get This Book
×
Buy Paperback | $64.00 Buy Ebook | $49.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

The Special Supplemental Nutrition Program for Women, Infants, and Children (the WIC program) has promoted the health of low-income families for more than 30 years by providing nutrition education, supplemental food, and other valuable services. The program reaches millions of families every year, is one of the largest nutrition programs in the United States, and is an important investment in the nation’s health. The U.S. Department of Agriculture charged the Institute of Medicine with creating a committee to evaluate the WIC food packages (the list of specific foods WIC participants obtain each month). The goal of the study was to improve the quality of the diet of WIC participants while also promoting a healthy body weight that will reduce the risk of chronic diseases. The committee concluded that it is time for a change in the WIC food packages and the book provides details on the proposed new food packages, summarizes how the proposed packages differ from current packages, and discusses the rationale for the proposed packages.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!