DIETARY RISK ASSESSMENT IN THE WIC PROGRAM

Committee on Dietary Risk Assessment in the WIC Program

Food and Nutrition Board

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, DC



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Dietary Risk Assessment in the WIC Program DIETARY RISK ASSESSMENT IN THE WIC PROGRAM Committee on Dietary Risk Assessment in the WIC Program Food and Nutrition Board INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, DC

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Dietary Risk Assessment in the WIC Program NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Food and Nutrition Service, U.S. Department of Agriculture. The views presented in this report are those of the Institute of Medicine Committee on Dietary Risk Assessment in the WIC Program and are not necessarily those of the funding agency. International Standard Book Number: 0-309-08284-6 Library of Congress Control Number: 2002100331 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s home page at www.nap.edu. The full text of this report is available at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2002 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Dietary Risk Assessment in the WIC Program Knowing is not enough; we must apply. Willing is not enough; we must do. —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Dietary Risk Assessment in the WIC Program THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chairman and vice chairman, respectively, of Research the National Council.

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Dietary Risk Assessment in the WIC Program COMMITTEE ON DIETARY RISK ASSESSMENT IN THE WIC PROGRAM VIRGINIA A. STALLINGS (chair), Division of Gastroenterology and Nutrition, The Children’s Hospital of Philadelphia, Pennsylvania TOM BARANOWSKI, Department of Pediatrics, Baylor College of Medicine, Houston, Texas RONETTE R. BRIEFEL, Mathematica Policy Research, Washington, D.C. YVONNE BRONNER, Public Health Program, Morgan State University, Baltimore, Maryland LAURA E. CAULFIELD, Department of International Health, Johns Hopkins University, Baltimore, Maryland EZRA C. DAVIDSON, JR., Department of Obstetrics and Gynecology, Charles R. Drew University of Medicine and Science, Los Angeles, California THERESA O. SCHOLL, Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey, Stratford, New Jersey CAROL W. SUITOR, Nutrition Consultant, Northfield, Vermont ROBERT C. WHITAKER, Division of General and Community Pediatrics, Children’s Hospital Medical Center, Cincinnati, Ohio Staff Romy Gunter-Nathan, Study Director Kimberly Stitzel, Research Associate Jaime Lanier, Project Assistant (until May 2001) Peter Keo, Project Assistant (after May 2001)

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Dietary Risk Assessment in the WIC Program FOOD AND NUTRITION BOARD CUTBERTO GARZA (chair), Division of Nutritional Science, Cornell University, Ithaca, New York ALFRED H. MERRILL, JR. (vice chair), School of Biology, Georgia Institute of Technology, Atlanta ROBERT M. RUSSELL (vice chair), Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts VIRGINIA A. STALLINGS (vice chair), Division of Gastroenterology and Nutrition, The Children’s Hospital of Philadelphia, Pennsylvania LARRY R. BEUCHAT, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, D.C. ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington A. CATHARINE ROSS, Department of Nutrition, The Pennsylvania State University, University Park BARBARA O. SCHNEEMAN, Department of Nutrition, University of California, Davis ROBERT E. SMITH, R.E. Smith Consulting, Inc., Newport, Vermont STEVE L. TAYLOR, Food Processing Center, University of Nebraska, Lincoln BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, The Pennsylvania State University, University Park Staff ALLISON A. YATES, Director LINDA D. MEYERS, Deputy Director GAIL E. SPEARS, Administrative Assistant GARY WALKER, Financial Associate

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Dietary Risk Assessment in the WIC Program Acknowledgments Sincere appreciation is extended to the many individuals and groups who were instrumental in the development of this report. First and foremost, many thanks are due to the committee members who volunteered countless hours to the research, deliberations, and preparation of the report. Their dedication to this project and to a stringent timeline was commendable, and the basis of our success. Many individuals volunteered significant time and effort to address and educate our committee members during the workshop and public meeting. Workshop speakers included Jean Anliker, PhD, RD, University of Maryland; Ann Barone, LDN, Rhode Island Department of Health; Gladys Block, PhD, University of California at Berkeley; Graham Colditz, MD, DrPH, Harvard University; Cutberto Garza, MD, PhD, Cornell University; Bob Greenstein, Center on Budget and Policy Priorities, Washington, D.C.; Jill Leppert, LD, RD, North Dakota State Department of Health; Kristin Marcoe, MBA, RD, U.S. Department of Agriculture; Lynn Parker, MS, RD, Food Research and Action Center, Washington, D.C.; Carol Rankin, MS, RD, LD, Mississippi Department of Health; Anna Maria Siega-Riz, PhD, University of North Carolina; Amy Subar, PhD, MPH, RD, National Cancer Institute; Valerie Tarasuk, PhD, University of Toronto; and Amanda Watkins, MD, RD, Arizona Department of Health Services. In addition, two organizations provided oral testimony to the committee during its public meeting: the National Association of WIC Directors and the Food and Nutrition Service, U.S. Department of Agriculture. Sincere thanks and appreciation are also extended to Barbara Ainsworth, PhD, University of South

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Dietary Risk Assessment in the WIC Program Carolina, for her valuable assistance as a consultant in the field of physical activity assessment. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Maxine Hayes, Washington State Department of Health Jules Hirsch, Rockefeller University Elvira Jarka, Health Resources and Services Administration Louise C. Masse, National Cancer Institute Esther Myers, American Dietetic Association Valerie Tarasuk, University of Toronto Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Gail Harrison, University of California, Los Angeles. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. It is apparent that many organizations and individuals from a variety of clinical and scientific backgrounds provided timely and essential support for this project. Yet we would have never succeeded without the efforts, skills, and grace that was provided in large measure by Romy Gunter-Nathan, MPH, RD, our study director for this project; Kimberly Stitzel, MS, RD, research associate; Geraldine Kennedo, project assistant; Jaime Lanier, project assistant; Peter Keo, project assistant; and Allison A. Yates, PhD, RD, director, Food and Nutrition Board, Institute of Medicine. Last, as chair, I express my sincere appreciation to each member of this committee for their extraordinary commitment to the project and the wonderful

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Dietary Risk Assessment in the WIC Program opportunity to work with them on this important task for the nutrition and policy community and for the women and children of the WIC population whose care we were asked to consider. Virginia A. Stallings, MD Chair, Committee on Dietary Risk Assessment in the WIC Program

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Dietary Risk Assessment in the WIC Program Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   13     The WIC Program,   14     Nutrition Risk Criteria,   15     Dietary Risk,   19     The Charge to the Committee and the Study Process,   22     Organization of the Report,   24 2   DIETARY ASSESSMENT TOOLS IN WIC   27     Purposes of Dietary Data Collection,   27     Dietary Assessment Tools Currently Used by WIC Programs,   29     Eligibility Criteria in Use,   32     Summary,   33 3   USING THE DIETARY GUIDELINES AS THE BASIS OF DIETARY RISK CRITERIA   35     The Dietary Guidelines, WIC, and National Goals,   35     Which Dietary Guidelines Should be Targeted,   36 4   FRAMEWORK FOR EVALUATING TOOLS TO ASSESS DIETARY RISK   49     Desirable Characteristics of an Assessment Tool,   49     Summary,   55

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Dietary Risk Assessment in the WIC Program 5   FOOD-BASED ASSESSMENT OF DIETARY INTAKE   57     A Focus on Usual Intake,   58     Overview of Research-Quality Dietary Methods for Estimating Food or Nutrient Intake,   60     Methods to Compare Food Intakes with the Dietary Guidelines,   79     Conclusions Regarding Food-Based Dietary Assessment Methods for Eligibility Determination,   83 6   ASSESSMENT OF PHYSICAL ACTIVITY   85     Challenges in Assessing Physical Activity,   85     Methods to Assess Physical Activity,   88     Conclusions Regarding the Role of Physical Activity Assessment for Eligibility Determination,   90     Recommendations for Future Research,   92 7   BEHAVIORAL INDICATORS OF DIET AND PHYSICAL ACTIVITY   93     The Concept of Behavioral Indicators,   94     Behavioral Indicators of Diet,   96     Behavioral Indicators of Physical Activity,   112     Conclusions Regarding the Use of Behavioral Indicators for Eligibility Determination,   114 8   EVIDENCE OF DIETARY RISK AMONG LOW-INCOME WOMEN AND CHILDREN   115     Nutritional Vulnerability of Groups Served by WIC,   115     Results from Relevant Dietary Intake Studies,   120     Associations of Food Intake with Income,   124     Summary of Evidence Suggesting Dietary Risk,   126 9   FINDINGS AND RECOMMENDATIONS   129     Findings,   129     Recommendation,   133     Concluding Remark,   135 10   REFERENCES   137     APPENDIXES     A   Allowed Nutrition Risk Criteria,   159 B   Workshop Agenda and Presentations,   163 C   Biographical Sketches,   165

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