WIC Nutrition Risk Criteria A Scientific Assessment (1996) / Chapter Skim
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6 DIETARY RISK CRITERIA
6 DIETARY RISK CRITERIA
Pages 251-294
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From page 251... ...
~. In general, dietary risk criteria are used to certify pregnant and breastfeeding women and infants at nutrition risk as demonstrated by inadequate dietary pattern under priority IV, children under priority V, and nonbreastfeeding postpartum women under priority VI.
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A list of the risk criteria used by state WIC agencies appears in Table 6-1. A summary of broad cate TABLE 6-1 Summary of Broad Dietary Risk Criteria in the WIC Program and Use by States Risk Criterion Inappropriate dietary patterns Excessive consumption of sugar, 11 fat, or sodium States Using'' Pregnant Women .
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? ash Risk Criteriona Inappropriate diet Inappropriate infant feedings Caffeine intake Pica Inadequate diet Food insecurity Risk Benefit Risk Benefit Risk Benefit ?
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Prevalence of Dietary Patterns That Fail to Meet Dietary Guidelines for Americans Information about dietary patterns of low-income women and children has been obtained using data from the second National Health and Nutrition Examination Survey (NHANES II) , a nationally representative sample of individuals surveyed from 1976 to 1980 (USDA, 1987~.
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Dietary Patterns That Fail to Meet Dietary Guidelines for Americans as an Indicator of Nutrition and Health Risk Women. Dietary patterns that fail to meet Dietary Guidelines may provide lower than recommended amounts of essential nutrients.
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Both indicate that adequate energy intake, nutrient intake, and growth are quite possible with fat intakes at or slightly below 30 percent of total calories provided that low-fat dairy products are included in the diet. Children with high serum cholesterol concentrations tend to continue to have high concentrations as adults (Lauer and Clarke, 1990~.
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Tools and Cutoff Points to Assess Dietary Patterns That Fail to Meet the Dietary Guidelines for Americans In the WIC program, data on dietary patterns are usually derived from brief 24-hour recalls or questions about the frequency of intake of food groups (Gardner et al., 1991~. It is relatively easy to hand-tally numbers of servings from food groups, to compare the results with the recommended number of servings, and to use the results in nutrition education tailored to WIC program participants.
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Therefore, the committee recommends use of failure to meet Dietary Guidelines as a nutrition risk criterion. The committee believes that any cutoff points would be arbitrary.
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When the definition is restricted vegan diets, the prevalence is probably quite low. Vegetarian Diets as an Indicator of Nutrition and Health Risk Liberal vegetarian diets that include dairy products and eggs are generally high in essential nutrients and unlikely to pose health risks.
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Highly Restrictive Diets as an Indicator of Nutrition and Health Risk Highly restrictive diets severely limit nutrient intake, may interfere with growth if taken regularly, and, if very low in calories, may lead to a number of adverse physiological effects. Highly restrictive diets pose particular risks during pregnancy and lactation (IOM, 1990, 1991~.
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Inappropriate Infant Feeding Infant feeding practices include breastteeding habits, the type of formula or milk fed, and the timing and contents of the supplemental foods and fluids introduced. The Committee on Nutrition of the American Academy of Pediatrics (CN-AAP)
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Market research data collected by Ross Laboratories during the early 1980s showed that of the infants ages 8 to 13 months consuming cow milk, 42 percent were fed reduced-fat milk (Fomon, 1987~. Data were not available on the prevalence of other inappropriate infant feeding practices.
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Other examples of inappropriate infant feeding practices include improper dilution of formula, feeding of sugar-based beverages (e.g., fruit flavored
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Infrequent breastfeeding as the sole source of nutrients can lead to serious undernutrition and dehydration. Inappropriate Infant Feeding as an Indicator of Nutrition and Health Benefit Although the evidence is indirect, by and large it suggests that educational efforts and food supplementation can improve infant feeding practices.
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The potential for benefit from participation in the WIC program is expected to be good based on theoretical and indirect empirical evidence. Therefore, the committee recommends use of selected inappropriate infant feeding practices as risk criteria for use by all states, as listed in Table 6-3.
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267 o ~ Cal ~ Ct ._ sin ~ c., o v: 0 5 3 ._ .
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The potential to benefit from participation in the WIC program is expected to be high based on theoretical evidence. Therefore, the committee recommends use of the nutrition risk criterion inappropriate use of nursing bottle by state WIC programs.
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See the section "Dietary Patterns that Fail to Meet Dietary Guidelines for Americans" in this chapter and "Central Nervous System Disorders" in Chapter 5. Excessive Caffeine Intake Caffeine is a plant alkaloid found in coffee, tea, cocoa, cola beverages and some other soft drinks, chocolate, and over-the-counter medications including cold tablets, allergy and analgesic preparations, appetite suppressants, and stimulants (Dalvi, 1986; Watkinson and Fried, 1985~.
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Recommendation for Excessive Caffeine Because of lack of evidence of nutrition risk, the committee recommends discontinuation of use of excessive caffeine intake as nutrition risk criterion by state WIC agencies. Pica Pica is a perceived craving for and ingestion of nonfood items, including, but not limited to, clay, starch (laundry and cornstarch)
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From page 271... ...
The strongest and most persistent association of nutrition risk with pica is anemia in women. There has been a long debate over the direction of the association: whether anemia predisposes a woman to pica (Crosby, 1982; Keith et al., 1968, 1970)
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The risk of pica for women is less well documented. The committee recommends use of pica as a nutrition risk criterion for children by all state WIC programs and for pregnant women in areas where the prevalence is high enough to justify it.
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, using 1986 data from the Continuing Survey of Food Intake by Individuals (CSFII) , examined the prevalence of nutrient intake below 70 percent of the RDA (averaged over 4 days of data collected over a l-year period)
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Long-term deficiency of vitamin BE intake by a lactating woman can lead to vitamin BE deficiency in the infant (see the section "Vegetarian Diets"~. Inadequate Diet as an Indicator of Nutrition and Health Benefit A major goal of the WIC program is to improve the quality and sufficiency of diets consumed by low-income pregnant, postpartum, and breastfeeding women, infants, and children who are at nutrition risk.
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Recently, FFQs have been developed that can provide computer-generated estimates of nutrient intakes and then compare them to the RDAs (Jacobson et al., 1990; USDA, 1994~. Either a 24-hour recall of food intake or a food frequency questionnaire (FFQ)
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Foodirequency assessments. Food frequency questionnaires or interviews theoretically provide relatively stable estimates of usual intakes because they cover an extended period: in the WIC program this is typically the previous week or month.
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On the basis of that work, the authors recommended further research to develop appropriate food frequency questionnaires or methods of administration for Hispanic women. For children, they recommended further development and validation of a brief set of questions for assessing appropriate dietary intakes (USDA, 19943.
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If the usual intake of any of the nutrients targeted by the WIC program is truly low, there is also no doubt that the WIC program's food package and nutrition education would result in a nutrition and health benefit. However, the assessment tools currently in use for identifying usual nutrient intakes have very low yield.
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Research is urgently needed to develop practical and valid assessment tools for the identification of inadequate diets. FOOD INSECURITY Definition of Food Insecurity The term food security was first used in the international development literature in the 1960s.
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among children ages 3 to 5 years in households with incomes less than 130 percent of the federal poverty level versus those in households with incomes higher than that cutoff. Prevalence of Food Insecurity The prevalence of food insecurity is assumed to be high based on the income eligibility criteria for WIC participation.
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From page 281... ...
The 1989-1991 CSFII showed somewhat lower total energy intakes and a higher proportion of dietary energy from fat in children from less food-secure households (Kennedy and Goldberg, 1995~. Aside from the direct linkages of food insecurity with poor diet and poor nutrition status, food insecurity likely leads to preventable non-nutrition-related health risks.
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l Recommendations for Food Insecurity Food insecurity presents risks of malnutrition and unhealthful dietary patterns in both the present and the future. Furthermore, food insecurity can be considered a concern in its own right.
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Since the whole-diet approach to assessment focuses attention on diet in relation to health and provides a basis for nutrition education, use of diet recalls or food frequency questionnaires is recommended for this purpose. Given the limitations of the methods used for the assessment of dietary risks, research efforts should be undertaken to develop, refine, and validate practical assessment tools that can be used to detect inappropriate diet, inadequate diet, andfood insecurity in the context of the WIC program.
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1995. A brief, telephone-administered food frequency questionnaire can be useful for surveillance of dietary fat intakes.
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1990. Food and nutrient intake of 6- to 12month old infants fed formula or cow milk: A summary of four national surveys.
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1993. Reproducibility and validity of food intake measurements from a semiquantitative food frequency questionnaire.
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1994. Characterizing nutrient intakes of children by sociodemographic factors.
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1993. A diet history questionnaire ranks nutrient intakes in middleaged and older men and women similarly to multiple food records.
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1994. Energy and Macronutrient Intakes of Persons Ages 2 Months and Over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-1991.
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1991. Macronutrient intake in relation to nutritional standards.
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1992. Consistency of the Willett semiquantitative food frequency questionnaire and 24-hour dietary recalls in estimating nutrient intakes of preschool children.
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1989. A comparison of food frequency and diet recall methods in studies of nutrient intake of low-income pregnant women.
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1985. Reproducibility and validity of a semiquantitative food frequency questionnaire.
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