WIC Nutrition Risk Criteria A Scientific Assessment (1996) / Chapter Skim
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4 ANTHROPOMETRIC RISK CRITERIA
4 ANTHROPOMETRIC RISK CRITERIA
Pages 67-148
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From page 67... ...
Then, it covers anthropometric criteria used for pregnant or postpartum women, followed by risk criteria used for infants and children. For each risk criterion, available information is provided about the prevalence of the condition in the population eligible for participation in the WIC program, use of each criterion as an indicator of risk and a predictor of benefit, and cutoff points in use in WIC programs nationwide.
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From page 68... ...
68 WIC NUTRITION RISK CRITERIA TABLE 4-1 Summary of Anthropometric Risk Criteria in the WIC Program and Use by States States Using Postpartum Women Pregnant Women Lactating Nonlactating Infants Children Women Prepregnancy 54 18 15 underweight Low maternal 53 weight gain Maternal weight 33 loss during pregnancy Prepregnancy 53 17 12 overweight High gestational 37 38 15 weight gain Maternal short 0 1 1 stature Postpartum 43 43 underweight Postpartum 42 39 overweight Infants and Children Low birth weight 53 8 Small for - 10 gestational age Short stature - 48 50 Underweight 53 52 Low head 7 circumference Large for gestational age Overweight Failure to thrive . 14 53 49 30 27 NOTE: Dashes indicate criterion was not used for that subgroup.
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From page 69... ...
All the anthropometric measurements covered in this chapter are practical and can be obtained with reliability in the WIC program setting with adequate training of personnel, periodic quality assurance reviews, and use of appropriate equipment that is calibrated regularly.
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From page 70... ...
111~ BAA~_~% ~ ~^ ~ ^~ ^~=~ ~^~ ~ ~ r TABLE 4-2 Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Pregnant and Postpartum Women Postpartum Women Pregnant Women Lactating Nonlactating Risk Criterion . Prepregnancy underweight Low maternal weight gain Maternal weight loss during pregnancy Prepregnancy overweight High gestational weight gain Maternal short stature Postpartum underweight Postpartum overweight Abnormal postpartum weight ?
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From page 71... ...
In a study of about 600 WIC program participants in California who were followed through two consecutive pregnancies, the most important factor predicting a low prepregnancy weight-for-height at the beginning of the second pregnancy was low prepregnancy weight in the first pregnancy (Caan et al., 1987~. As household size increased, the risk of prepregnancy underweight decreased.
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From page 72... ...
Prepregnancy Underweight as an Indicator of Nutrition and Health Benefit Data from several food supplementation trials have demonstrated that intervention to improve nutrition can increase birth weight in underweight women (Edozien et al., 1979; IOM, 1990~. Two evaluations of the Missouri WIC program separately examined the impact of WIC program participation in underweight women.
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From page 73... ...
Therefore, the committee recommends use of maternal prepregnancy underweight as a nutrition risk criterion for pregnant women by the WIC program, with a cutoff value of 90 percent of IBW or a BMI less than 19.8. The committee recommends discontinuation of the use of maternal prepregnancy underweight as a nutrition risk criterion for postpartum women by the WIC program.
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From page 74... ...
Prevalence of and Factors Associated with Low Maternal Weight Gain The published literature consistently shows that maternal weight gain is highly variable. A low gestational weight gain occurs most commonly among women with a high prepregnancy BMI, especially those who are obese (IOM, 19909.
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From page 75... ...
concluded that low maternal weight gain during the second and third trimester is a determinant of fetal growth, and that low maternal gain is associated with smaller average birth weights and an increased risk of delivering an infant with fetal growth restriction. Studies published since that report confirm this finding (Hickey et al., 1993; Parker and Abrams, 1992; Scholl et al., 1990a)
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From page 76... ...
and infants who are SGA (Abrams and Newman, 1991~; others do not agree (Dawes and Grudzinskas, 1991b; Petitti et al., 1991~. A recent study of almost 3,000 white women concluded that, after controlling for total maternal weight gain and other factors, a low gestational weight gain during the second trimester was associated with decreased birth weight (Abrams and Selvin, 19959.
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From page 77... ...
However, Susser's review of data from the Dutch famine and supplementation trials concluded that dietary influences on birth weight appear to bypass gestational weight gain (Susser, 1991~. Of the three WIC program evaluations that have reported on the program's impact on maternal weight gain, two suggest a positive effect.
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From page 78... ...
suggested that WIC supplemented mothers consumed more energy and gained more weight; although birth weight was not improved overall, fetal head circumference was greater. Of special note Is the s~gn~cant finding In this study that WIC program participation reversed initial low maternal weight gain identified at the time of the first visit to the WIC program.
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From page 79... ...
There is both empirical evidence and a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of low maternal weight gain as a nutrition risk criterion for pregnant women by the WIC program, with the IOM cutoff values of <0.9 kg/month in nonobese women and < 0.45 kg/month in obese women.
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From page 80... ...
Weight loss may indicate underlying dietary or health practices or health or social conditions that could be improved by the supplemental food, nutrition education, and referrals provided by the WIC program. Use of Maternal Weight Loss During Pregnancy as a Nutrition Risk Criterion in the WIC Setting Of the 33 state WIC agencies that reported using weight loss as a nutrition risk criterion (see Table 4-1)
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From page 81... ...
In a study of about 600 WIC program participants in California who were followed through two consecutive pregnancies, the following characteristics were significantly associated with increased risk of beginning the second pregnancy with a high maternal prepregnancy weight-for-height (> 120 percent of IBW) : high prepregnancy weight-for-height during the first pregnancy, high birth weight of the first infant, and large number of individuals in the household.
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From page 82... ...
However, in the Collaborative Perinatal Project, Naeye (1990) found obese women to be at increased risk for preterm delivery and for higher perinatal mortality rates.
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From page 83... ...
However, a study in California comparing women participating in the WIC program who received food supplementation during two consecutive pregnancies found that women who received supplementation for 5 to 7 months postpartum had half the risk of being overweight of those who received supplementation only briefly (Caan et al., 19879. Although the study was observational rather than experimental, it was very well designed.
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From page 84... ...
Therefore, the committee recommends use of prepregnancy overweight as a nutrition risk criterion for pregnant and postpartum women by the WIC program, with the cutoff values of BMI greater than 26. To improve potential for benefit from WIC program participation, the committee recommends research on culturally appropriate methods of effective intervention for obese women.
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From page 85... ...
High Gestational Weight Gain as an Indicator of Nutrition and Health Risk Very high gestational weight gain is associated with increased rates of high birth weight or macrosomia (Cogswell et al., 1995; IOM, 1990~. In adolescents, high maternal weight gain at 16 weeks of gestation or later was associated with a doubled risk of macrosomia (Scholl et al., 1990b)
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From page 86... ...
There is a theoretical basis and limited empirical evidence for benefit from WIC program participation. Therefore, the committee recommends use of high maternal weight gain as a nutrition risk criterion for pregnant and postpartum women by the WIC program, with the IOM cutoff values of greater than 3 kg per month during pregnancy and the BMI-specific upper limits for total weight gain for postpartum women.
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From page 87... ...
, but other investigators report that the relationship of maternal height and birth weight is mediated through maternal weight (Krasovec and Anderson, 19919. Women with short stature are at increased risk of delivering infants who are SGA or growth-retarded (Abrams and Newman, 1991; Kramer, 1987b; Wen et al., 1990~.
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From page 88... ...
Also, because short stature is associated with an increased risk of cephalopelvic disproportion, the benefits of increased birth weight must be counterbalanced against the potential for increased morbidity to mother and infant caused by difficulties during labor and delivery. Use of Maternal Short Stature as a Nutrition Risk Criterion in the WIC Program In 1992, no state WIC agency used maternal short stature as a nutrition risk criterion for pregnant women (see Table 4-1~.
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From page 89... ...
Thus, until there is evidence that the adverse outcomes associated with short stature can be alleviated through intervention during pregnancy, the committee does not recommend that maternal short stature be used as a nutrition risk criterion for pregnant women by the WIC program. Nonetheless, evaluating short stature among women has clinical utility for both assessment for increased risk of poor intrauterine growth and individualizing maternal weight gain recommendations (short pregnant women are advised to gain at the lower end of the recommended weight gain range [IOM, 1990~.
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From page 90... ...
and psychological conditions that impair appetite or food behaviors, including eating disorders and depression. Postpartum Underweight as an Indicator of Nutrition and Health Risk Low maternal weight-for-height during the postpartum period is of concern because it may indicate poor energy stores or the lack of replenishment of maternal nutrient stores that were mobilized during pregnancy.
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From page 91... ...
No studies have been reported addressing the efficacy of postpartum interventions to improve the maternal or infant health or nutrition specifically in underweight postpartum women and their infants living in the United States. However, a well-designed evaluation of the postpartum component of the WIC program suggests that the provision of WIC program benefits during the postpartum period is associated with better maternal and infant health (Caan et al., 19874.
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From page 92... ...
Therefore, the committee recommends use of maternal postpartum underweight as a nutrition risk criterion for postpartum women by the WIC program, with the IOM cutoff value of a BMI of 19. It also recommends research to determine the most valid postpartum cutoff points for lactating and nonlactating women.
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From page 93... ...
Results from studies of postpartum weight retention vary according to study population, the follow-up periods after delivery, and definitions or observations of infant feeding practices. Methodologic problems include bias from inaccurate recall of prepregnancy weight, failure to adjust for the expected increase in body weight with age, and lack of information on energy intake and exercise patterns.
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From page 94... ...
who participated in a South Carolina WIC program concluded that the most important variables in predicting postpartum weight loss were prepregnancy weight, prenatal weight gain, parity, and prenatal exercise. After these factors were controlled, race predicted that black women retained 6.4 pounds more than white women.
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From page 95... ...
The WIC program's assessment and follow-up of women's weight during the postpartum period may provide the only possibility of intervention, because in contrast to the intensive monitoring of health status that occurs during pregnancy, most women receive relatively little medical care during the postpartum period. Use of Postpartum Overweight as a Nutrition Risk Criterion in the WIC Setting In 1992, most of the agencies that used postpartum overweight as a risk criterion for breastteeding and nonlactating women (see Table 4-1)
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From page 96... ...
Abnormal Postpartum Weight Change as an Indicator of Health and Nutrition Benefit No studies have examined the possible health benefits of intervening for women with high rates of weight loss or gain after delivery. Common sense suggests that when a rapid weight loss or gain over a short period of time is observed in a postpartum woman, additional assessments of maternal health and psychological, social, and economic status are warranted to determine the cause and that the food and/or nutrition education provided by the WIC program can help remedy the problem.
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From page 97... ...
Therefore, the committee recommends discontinuation of use of abnormal postpartum weight change as a nutrition risk criterion for postpartum women by the WIC program. ANTHROPOMETRIC RISK CRITERIA FOR INFANTS AND CHILDREN A summary of anthropometric risk criteria as predictors of risk and benefit for infants and children appears in Table 4-3.
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From page 98... ...
. LBW is caused by a short gestational period, intrauterine growth retardation (IUGR)
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From page 99... ...
Little information is available on potential benefits relative to different WIC program components and different types of LBW. Use of LBW as a Nutrition Risk in the WIC Setting Low birth weight was used as a nutrition risk criterion for infants by 53 state WIC agencies in 1992 (see Table 4-1~.
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From page 100... ...
Therefore, the committee recommends use of LBW as a nutrition risk criterion for infants and children by the WIC program, with the conventional cutoff value of less than 2,500 g. However, priority should be given to using the SGA and prematurity criteria (see subsequent section and "Prematurity" in Chapter 5)
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From page 101... ...
The consistently positive, although sometimes modest, effect of food supplementation and the negative effect of increased energy needs during pregnancy on birth weight have been demonstrated both in developing countries and in low-income populations of industrialized countries (Adair and Pollitt, 1985; Chavez and Martinez, 1980; Habicht and Yarbrough, 1980; Kramer, 1993; Lechtig and Klein, 1981; Prentice et al., 1983; Rush et al., 1988c)
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From page 102... ...
. The results showed that, in both blacks and whites, disproportionate infants with lower birth weights had a higher risk of mortality.
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From page 103... ...
Use of SGA as a Nutrition Risk Criterion in the WIC Setting Of the 10 state WIC agencies using the small for gestational age nutrition risk criterion in 1992 (USDA, 1994) (see Table 4-1)
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From page 104... ...
Therefore, the committee recommends the use of SGA as a nutrition risk criterion for infants and children by the WIC program, with a cutoff value of less than the 10th percentile because it includes full-term infants who are SGA with birth weights of greater than 2,500 g. In addition, the committee recommends further studies to relate body proportionality to risks and also to potential benefits from interventions.
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From page 105... ...
This indicates the importance of offering interventions that combine both food and health components. The impact of inadequate food and frequent episodes of infectious disease on short stature is especially pronounced in the first few years of life.
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From page 106... ...
. The fact that some of the variation in birth weight and subsequent infant linear growth is determined by maternal health and nutrition status indicates the importance of targeting interventions to pregnant women and mothers.
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From page 107... ...
Short Stature as an Indicator of Nutrition and Health Benefit The effects of food supplementation on the stature of malnourished infants and children have been mixed. A review of more than 200 supplementary feeding programs in developing countries concluded that the effect of supplementation on nutrition status, as assessed by growth performance, was surprisingly small (Beaton and Ghassemi, 1982~.
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From page 108... ...
after 6 to 11 months of program participation. However, because short stature was used as a criterion for eligibility for participation in the WIC Program.
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From page 109... ...
There is clear evidence that short stature that resulted from malnutrition may respond to appropriate health and nutrition interventions Therefore, the committee recommends use of short stature as a nutrition risk criterion for infants and children by the WIC program, with a cutoff value of below the 5th percentile.
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From page 110... ...
During the entire period of infancy and childhood, birth weight has a strong influence on weight-for-height values. Infants with lower
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From page 111... ...
Thus, even mild to moderate malnutrition, the kind more commonly seen in low-income populations in industrialized countries, is of concern. Underweight is also a poor correlate of short stature at either an individual or a population level (Gorstein et al., 1994; Haaga, 1986; Victora, 1992)
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From page 112... ...
Review of some of the early food supplementation studies reveals that, in general, supplementary feeding, when given in adequate amounts to malnourished infants, had a positive effect on weights-for-height (Habicht and Butz, 1979; Rivera, 1988~. No significant improvement in weight was found when there was no clear evidence of dietary improvement.
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From page 113... ...
(CDC, 1978~. Participation in the WIC program had no significant impact on weight but had a positive effect on weight-for-height for infants and children who had participated in the program either prenatally or within 3 months of birth (Rush et al., 1986~.
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From page 114... ...
There is indirect evidence from supplementation trials that underweight infants and children can benefit from participation in the WIC program. Therefore, the committee recommends the use of underweight as a nutrition risk criterion for infants and children, with a cutoff value of the 5th percentile.
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From page 115... ...
who have larger head circumferences, infants with very low birth weights (< 1.5 kg) who have a smaller head circumference have more motor abnormalities at 12 months of age (Simon et al., 1993)
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From page 116... ...
. Use of LHC as a Nutrition Risk Criterion in the WIC Setting Few state WIC agencies presently use low head circumference as a nutrition risk criterion (USDA, 1994)
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From page 117... ...
Therefore, the committee recommends use of LHC as a nutrition risk criterion for infants by the WIC program, with a cutoff value of below the 5th percentile of increments in head circumference for age (Roche and Himes, 1980~. Large for Gestational Age Large for gestational age (LGA)
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From page 118... ...
LGA infants may benefit from the WIC program in the same ways that other newborns do: support from promoting breastieeding and healthy infant feeding practices, the provision of nutrient-dense supplemental foods to the mother or formula for the infants, and health referrals from the program to detect or treat medical complications that may accompany LGA. Use of the LGA as a Nutrition Risk Criterion in the WIC Setting For the 14 state WIC agencies using high birth weight as a risk criterion for determining WIC program eligibility for infants in 1992, cutoff points ranged from 4,000 to 5,000 g, and the median cutoff point was 4,500 g (USDA, 19949.
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From page 119... ...
and total fat intake (Gazzaniga and Burns, 1993~. After adjusting for energy intake, resting energy expenditure, and physical activity, the percentage of body fat correlated positively with intake of total, saturated, monounsaturated, and polyunsaturated fatty acids and negatively with carbohydrate and total energy.
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From page 120... ...
, total energy expenditure and metabolizable energy intake were measured by the doubly labeled water method and by indirect calorimetry at 3 months of age. Total energy expenditure was about 20 percent lower in the infants who became overweight by the age of 1 year than in the infants who did not.
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From page 121... ...
has recommended that dietary energy restriction not be used as a means to induce weight loss in infants and children. Overweight as an Indicator of Nutrition and Health Benefit Inasmuch as obesity during infancy and childhood is related to obesity during adulthood and adult obesity is associated with a number of adverse health consequences, it is assumed but not verified that treatment of excess adiposity in young children will be more effective than treatment of adiposity in
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From page 122... ...
Therefore, the committee recommends the use of overweight as a nutrition risk criterion for infants and children in the WIC program, with a cutoff value at above the 95th percentile of NCHS-CDC references.
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From page 123... ...
Anthropometric assessment in the WIC program may identify the need for referral for the diagnosis and treatment of FIT of any origin. Nonorganic failure to thrive is a medical term for poor growth without apparent medical cause.
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From page 124... ...
The committee recommends the use of slow growth as a nutrition risk criterion for infants and children, with a cutoff value of below the 3rd percentile of change in weight, stature, or head circumference for age (Roche and Himes, 1980~.
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From page 125... ...
For example, it is important to understand whether WIC program participation increases maternal weight gain and thus birth weight,
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From page 127... ...
127 in=, ~o=, ~(.4-, ooo ~ooo C)
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From page 128... ...
7. Examine the benefits of the WIC program relative to individual anthropometric criteria.
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From page 129... ...
1995. Maternal weight gain pattern and birth weight.
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From page 130... ...
1966. Birth weight, gestational age, and pregnancy outcome with special reference to high birth weight-low gestational age infant.
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From page 131... ...
1993. The Heterogeneity of Low Birth Weight as it Relates to the BlackWhite Gap in Birthweight Specific Neonatal Mortality.
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From page 132... ...
1993. Maternal weight-loss patterns during prolonged lactation.
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From page 133... ...
1992. Maternal weight, weight gain during pregnancy and pregnancy outcomes.
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From page 134... ...
1989. Maternal weight loss associated with hyperemesis gravidarum: A predictor of fetal outcome.
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From page 135... ...
1993. Prenatal weight gain, term birth weight, and fetal growth retardation among highrisk multiparous black and white women.
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From page 136... ...
1992. Excessive maternal weight and pregnancy outcome.
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From page 137... ...
1994. Classroom behavior of very low birth weight elementary school children.
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From page 138... ...
1981. Prenatal nutrition and birth weight: Is there a causal association?
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From page 139... ...
1995. Low birth weight not a black-and-white issue.
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From page 140... ...
1985. The contribution of low birth weight to infant mortality and childhood mortality.
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From page 141... ...
1992. Maternal pregravid weight, age and smoking status as risk factors for low birth weight births.
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From page 142... ...
1990. Cocaine and the risk of low birth weight.
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From page 143... ...
1995. Prevalence of low birth weight and preterm delivery in relation to the interval between pregnancies among white and black women.
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From page 144... ...
1991. Maternal weight gain, diet and infant birth weight: Correlations during adolescent pregnancy.
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From page 145... ...
1991. Maternal weight gain, infant birth weight and diet: Causal sequences.
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From page 146... ...
1993. Malaria and low birth weight in Central Sudan.
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From page 147... ...
1992. Effect of fat and fat-free mass deposition during pregnancy on birth weight.
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From page 148... ...
1995. Influence of maternal anthropometric status and birth weight on the risk of cesarean delivery.
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