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Dietary Assessment Tools in WIC

Each state WIC agency uses its own standardized tools to collect dietary data. One of the committee’s approaches was to review these tools to identify potential candidates for widespread use in eligibility determination related to failure to meet Dietary Guidelines or inadequate diet. Since dietary data collection tools are used for several purposes in WIC, this chapter briefly describes the uses that go beyond establishing dietary risk for eligibility purposes. It also summarizes the committee’s findings about the types of tools that are in use for women and children, as well as the criteria that are applied in establishing eligibility.

PURPOSES OF DIETARY DATA COLLECTION

Dietary intake data are collected in WIC for three main purposes: (1) for determining dietary risk for eligibility purposes as discussed in Chapter 1, (2) as a starting place for nutrition education, and (3) for tailoring food packages. Because of the second and third uses, the dietary intake of a WIC applicant generally is assessed even if the applicant has already met eligibility requirements through other nutrition risk criteria. In fact, in 1998, 86 percent of state agencies had policies requiring that dietary information be obtained from all participants (Bartlett et al., 2000). Time constraints within the WIC program necessitate that the selected tools used provide information needed for all three uses.



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Dietary Risk Assessment in the WIC Program 2 Dietary Assessment Tools in WIC Each state WIC agency uses its own standardized tools to collect dietary data. One of the committee’s approaches was to review these tools to identify potential candidates for widespread use in eligibility determination related to failure to meet Dietary Guidelines or inadequate diet. Since dietary data collection tools are used for several purposes in WIC, this chapter briefly describes the uses that go beyond establishing dietary risk for eligibility purposes. It also summarizes the committee’s findings about the types of tools that are in use for women and children, as well as the criteria that are applied in establishing eligibility. PURPOSES OF DIETARY DATA COLLECTION Dietary intake data are collected in WIC for three main purposes: (1) for determining dietary risk for eligibility purposes as discussed in Chapter 1, (2) as a starting place for nutrition education, and (3) for tailoring food packages. Because of the second and third uses, the dietary intake of a WIC applicant generally is assessed even if the applicant has already met eligibility requirements through other nutrition risk criteria. In fact, in 1998, 86 percent of state agencies had policies requiring that dietary information be obtained from all participants (Bartlett et al., 2000). Time constraints within the WIC program necessitate that the selected tools used provide information needed for all three uses.

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Dietary Risk Assessment in the WIC Program Nutrition Education and Counseling Federal regulations require nutrition education to be offered to each participant at least twice in each certification period (generally about 6 months). There are two broad goals of WIC nutrition education: (1) “to stress the relationship between proper nutrition and good health, with special emphasis on the nutritional needs of the program’s target populations; and (2) to assist individuals at nutritional risk in achieving a positive change in food habits, resulting in improved nutritional status and the prevention of nutrition related problems” (Fox et al., 1998). The forms of education vary widely among agencies and types of participants. Frequently reported methods include individual counseling, group discussions, written materials, use of food models, food demonstrations, and video or slide show presentations (Bartlett et al., 2000). Education may be provided by a competent professional authority (CPA), who may be a professional or a paraprofessional staff member who has received basic training. Most education for high-risk individuals is provided by professional nutritionists. Nutrition education topics vary among types of participants and sites. Examples of commonly covered topics include the Food Guide Pyramid, diet for pregnancy, breastfeeding, and strategies to prevent or manage overweight. An individual’s self-described eating habits or patterns, in any form, can often be helpful to the CPA when choosing a starting place for nutrition education. Discussions of usual intake may help to establish rapport and also can uncover participant eating practices, disorders, or concerns to which WIC staff can respond appropriately with education or referral. Food Package Tailoring WIC participants receive supplemental food packages or instruments (vouchers or checks to be redeemed in retail grocery stores) in order to increase their intake of selected nutrients. Seven food packages are available for WIC participants: two for infants (age dependent); one for children 1–4 years of age; one for pregnant and breastfeeding women; one for postpartum, nonbreastfeeding women; an enhanced package for breastfeeding women; and specially tailored packages for women or children with special needs. The foods that make up the different packages are high in one or more nutrients that historically have been low in the diets of the program’s low-income target population (i.e., protein, calcium, iron, and vitamins A and C). The foods provided include ironfortified infant formula and infant and adult cereal, vitamin C-rich fruit and vegetable juices, eggs, milk, cheese, peanut butter, dried beans or peas, tuna fish, and carrots. Approximately 98 percent of state WIC agencies adjust the contents of food packages to accommodate a participant’s particular nutritional needs or preferences (Bartlett et al., 2000). Examples of the types of tailoring that are

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Dietary Risk Assessment in the WIC Program TABLE 2-1 Nutritionally Related Food Package Tailoring Practices of WIC State Agencies Tailoring Practice Percent of State Agencies Specific forms of formula are specified (ready-to-feed or powdered) 93 A specific form of food is specified for the convenience of the participant (powdered milk, juice concentrate) 82 Type of milk is specified (to reduce fat, lactose, or calories) 77 Amounts of certain food types are reduced (to meet age-related needs) 55 Amounts of certain food types are reduced (to reduce calories or nutrient intake for weight control) 49 Type of cheese is specified (to reduce fat) 28 Other methods (e.g., adjustment for food allergies) 25 Quantity of eggs is reduced (to reduce cholesterol) 19 Amounts of milk or juice are reduced 15 Type of cereal is specified (to reduce sucrose) 11   SOURCE: Bartlett et al. (2000). made and the percentages of state agencies that practice each type of tailoring can be found in Table 2-1. The types of information useful for tailoring food packages include food allergies and intolerances, weight status, the availability of refrigeration or cooking appliances, and individual preferences within groups of nutrient-rich foods. DIETARY ASSESSMENT TOOLS CURRENTLY USED BY WIC PROGRAMS Most state and local WIC agencies may choose from more than one approved type of dietary assessment tool, depending on the circumstances. In 1998, 82 percent of states reported the use of 24-hour recalls and 80 percent reported the use of food frequency checklists (Bartlett et al., 2000). Other tools included dietary records (7 percent), computer-assisted analysis (8 percent), and other methods such as a diet history or questionnaires on feeding and eating practices (2 percent) (Bartlett et al., 2000). In preparation for this study, the Nutrition Section of the National Association of WIC Directors asked each of the 88 state WIC agencies to submit current dietary assessment tools. A total of 54 agencies (43 states, 2 territories, and 9 Indian Tribal Organizations) responded to the request. Some agencies sent comprehensive explanations regarding the methods used to assess dietary risk; others

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Dietary Risk Assessment in the WIC Program sent only the tools being used. The tools varied in style from a blank box in which an individual could write her recollection of what was eaten the previous day to a four-page food frequency questionnaire that would allow a computer-generated summary of the dietary analysis. State agencies used one of at least two different methods to categorize children: separate forms for infants and children ages 0–12 months, 12–24 months, and 2–5 years, or separate forms only for infants 0–12 months and children 1–5 years of age. Sixty-nine percent of the tools were designed to be self-administered, and 26 percent appeared to be interviewer-driven. The method of administration of the remaining 5 percent could not be determined. Although a few states used methods with a published research base, most used tools developed or adapted by state WIC agencies; they did not provide information about the validation of these tools. Although not specifically requested to submit the forms used for the ethnic groups served, many states did so, suggesting that many were attempting to meet the needs of their diverse populations. Twenty-four-hour recalls capture a snapshot of an individual’s diet over a 24-hour period. The procedures for obtaining 24-hour recalls can vary greatly. While a research-quality diet recall usually requires an interview of at least 20 minutes (Thompson and Byers, 1994; see Chapter 5), WIC time constraints generally preclude assessments of this length or intensity. The WIC tools used for collecting 24-hour recall data also vary considerably. For example, in Colorado, individuals are asked to write down everything eaten on a “typical” day. Other states (e.g., Florida) ask applicants to record all foods and beverages eaten the previous day and to mark an item indicating whether or not the day had been typical of eating habits. Staff in Arizona, using a similar recall method, then shade in the number of servings on a pyramid picture. Yet, in other states, recalls are interviewer-driven. Wyoming, among many states, stresses open-ended questions and the use of food models, measuring cups, and utensils to establish portion sizes typically consumed. Food frequency questionnaires can vary greatly in design and number of food items, and those used by WIC vary greatly from state to state. Research-quality food frequency questionnaires that are intended to assess overall food or nutrient intake generally have 50 or more food items (see Chapter 5). Pennsylvania uses a 25-item questionnaire that categorizes foods into groups and obtains a daily number of servings from the five food groups of the Food Guide Pyramid (USDA, 1992, see Figure 2-1) by an unspecified method. Vermont uses a 39-item questionnaire and a simple arithmetic process to estimate the number of servings from the five Pyramid food groups. North Dakota uses an 84-item questionnaire and a simple computer program to produce a similar estimate. Some states use portion sizes in their questionnaires; others do not.

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Dietary Risk Assessment in the WIC Program FIGURE 2-1 USDA Food Guide Pyramid. SOURCE: USDA (1992). In 1998, six state agencies reported using dietary records or food diaries (Bartlett et al., 2000). However, of states submitting assessment tools in 2000, including two states (North Carolina and West Virginia) that had reported using food records or diaries in 1998, none supplied tools that used this method. As shown in Chapter 5, diet histories ordinarily obtain data such as usual meal patterns and food intake. The information about dietary assessment tools provided by the states to the U.S. Department of Agriculture suggests that a consistent definition of diet history is not used. In 1998, only one state, Indiana, reported using a diet history (Bartlett et al., 2000); but in 2000, nine states submitted tools labeled as “Diet History.” Other tools labeled as “24-Hour Recall” actually appear to resemble modified diet histories. For example, several states used 24-hour recalls and then followed-up with questions regarding how typical the day had been and if not typical, what would be more typical? Some administered both a 24-hour recall and a short food-frequency questionnaire, which, when combined, are similar to a diet history. Depending on the participant responses and subsequent level of questioning, it can be difficult to classify assessment tools as one type or another. Forty-six percent of states included some type of behavioral questions, but in most cases, it could not be determined whether the response would contribute in any way to the eligibility determination. Many tools included questions regarding physical activity, and some had questions to gain insight into food safety practices. A few forms also had questions that would indicate to staff

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Dietary Risk Assessment in the WIC Program whether the individual was at risk for food insecurity. States tended to use similar versions of the same tool for the different categories of participants. An earlier examination of WIC dietary assessment tools included a checklist for dietary data collection instruments—primarily for food frequency questionnaires (Gardner et al., 1991). The committee noted that some of the WIC tools had many or most of the desirable characteristics identified in that list, but the list does not encompass all the key points presented in Chapter 4 of this report. ELIGIBILITY CRITERIA IN USE Review of the tools indicated that criteria used to establish dietary risk of women and children most often relate to the recommended numbers of servings from the Food Guide Pyramid. That is, the data obtained about food intake is converted to an estimated number of servings per day from the grains, fruit, vegetable, dairy, and meat and beans groups. (For more information about the Pyramid, see Chapter 3.) Few states provided information about the method used to assign combination or mixed foods to food groups. Cut-off points to determine “at dietary risk” status vary greatly among the state WIC agencies. This variation occurs in the specification of the minimum number of servings from each food group and the number of deficiencies needed to establish dietary risk. For example, Arizona and Georgia use nine as the minimum number of servings from the grain group for pregnant women, whereas Illinois, Texas, and Delaware set the minimum number at six servings. In Arizona, if a participant falls short by only one serving in one food group, he or she qualifies as being at risk. In contrast, Texas not only requires deficiencies in three food groups before an individual qualifies as having an inadequate dietary pattern, but to make the criterion even more stringent, assigns only one deficiency if the person consumes at least some of the required servings from a food group.1 For example, a pregnant women who consumes two out of the recommended six grain servings would be given a rating of only one deficiency. This woman would not have qualified based on the criterion for inadequate diet in Texas. Ironically, if this woman lived in Arizona, she would have been considered to be at dietary risk even if she had consumed an additional six servings (for a total of eight) from the bread group. 1   Except for the fruits and vegetables food group. Within this food group, the lack of either a vitamin A-rich food or a vitamin C-rich food counts as a deficiency even if five fruits and vegetables are consumed.

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Dietary Risk Assessment in the WIC Program SUMMARY Tools for determining eligibility based on dietary risk also need to be useful for nutrition education and tailoring of the food package. Different WIC state agencies use many variations of 24-hour recalls and food frequency questionnaires. Similarly, the agencies use different criteria to identify dietary risk, but nearly all are based on the Food Guide Pyramid. After viewing the many variations of dietary assessment tools, it became apparent to the committee that the following needed review: the Dietary Guidelines and its embedded Food Guide Pyramid (Chapter 3), research on 24-hour recalls and food frequency questionnaires (Chapter 5), methods of physical activity assessment (Chapter 6), and approaches dealing with specific behaviors (Chapter 7).

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