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Dietary Risk Assessment in the WIC Program 3 Using the Dietary Guidelines as the Basis of Dietary Risk Criteria The Dietary Guidelines are an integral part of WIC, just as they are of every federal program concerned with food, nutrition, or health. This chapter addresses the potential for using the Dietary Guidelines as the basis of one or more dietary risk criteria for establishing eligibility for WIC. It covers relationships among the Dietary Guidelines, WIC, and major goals of Healthy People 2010 (HHS, 2000). Then it identifies the guidelines that the committee selected for special attention, advantages and disadvantages of failure to meet Dietary Guidelines as a risk criterion, and the rationale for the selection of guidelines for special attention. THE DIETARY GUIDELINES, WIC, AND NATIONAL GOALS The Dietary Guidelines are closely tied with the two major national goals presented in Healthy People 2010 (HHS, 2000): (1) increase quality and years of healthy life, and (2) eliminate health disparities. Following the Dietary Guidelines helps Americans meet both those goals. The goal to eliminate health disparities is especially relevant to the WIC population. For nearly every nutrition objective covered in Healthy People 2010, groups that are heavily represented in WIC have baseline levels that are less favorable than the average. For example, 8 percent of low-income children ages 5 years and younger were growth retarded in 1997 (compared with an expected 5 percent) (HHS, 2000). Similarly, 12 percent of low-income children (≤ 130 percent of poverty) ages 1 to 2 years had iron deficiency compared with 7 percent of children from families
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Dietary Risk Assessment in the WIC Program with incomes greater than 130 percent of poverty. Low-income people also are at increased risk for high levels of both morbidity and mortality associated with chronic diseases such as cardiovascular disease, diabetes, obesity, hypertension, and cancer (HHS, 2000). WHICH DIETARY GUIDELINES SHOULD BE TARGETED? A previous Institute of Medicine report recommended that failure to meet Dietary Guidelines be used as a criterion to establish dietary risk in WIC (IOM, 1996). Since a criterion consists of an indicator and a cut-off point, this means that the committee had to examine the Dietary Guidelines (USDA/HHS, 2000) for potential indicators and cut-off points. Recognizing that there are 10 guidelines, the committee addressed whether any of the 10 should be excluded from consideration—either because they are covered by other WIC nutritional risk criteria or because the guideline does not include a basis for setting a discrete, measurable cut-off point. The WIC Policy Memorandum 98-9, Nutrition Risk Criteria (FNB, 1998; see Appendix A), which presents the nutrition risk criteria currently allowed in WIC, those not allowed, and those in need of further review, was examined. Although criterion number 401, failure to meet Dietary Guidelines, is an allowed criterion, it has not been standardized across WIC state agencies. Instead, a state WIC agency may base the criterion used on the definitions currently in use by that agency. (This situation relates to the need for the study by this committee.) Summary of Guidelines Selected for Targeting Table 3-1 lists each of the 10 guidelines in abbreviated form, the committee’s decision regarding its relevance to the committee’s work, and the reason, in brief, for that decision. Further details are provided in the text that follows. Advantages and Disadvantages of Using the Dietary Guidelines to Establish Risk Criteria in WIC The principal advantage of the Dietary Guidelines as a basis for dietary risk criteria is that the guidelines were developed for Americans from all backgrounds as a means to promote health. There are several obstacles to developing criteria for failure to meet Dietary Guidelines: The Dietary Guidelines are not intended for use for children under age 2 years; this restriction eliminates the use of the Dietary Guidelines for approximately 44 percent of the WIC population (USDA/HHS, 2000).
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Dietary Risk Assessment in the WIC Program TABLE 3-1 Summary of the Committee’s Decision to Review a Dietary Guideline Topic in Detail for Use in Setting Dietary Risk Criteria Dietary Guideline Topic Consider Further Rationale Healthy weight No Both underweight and overweight are already approved indicators of nutrition risk under the category of Anthropometric for all program applicants (see Appendix A). The Dietary Guidelines provide no indicators useful for identifying individuals at high risk of becoming overweight or underweight. Physical activity Yes Strong relationship to weight and health, specific target activity levels are indicated (see Chapter 6). Food Guide Pyramid Yes Specific target food group intakes are indicated for different energy levels. It is strongly related to at least two other guidelines (grains and fruits/vegetables) and also to the fat and sugars guidelines. Grains Yesa Encompassed by the Pyramid guideline. Fruits and vegetables Yesa Encompassed by the Pyramid guideline. Food safety No Not readily operationalized into a criterion. Saturated fat, fat, and cholesterol Yesa Covered in part by the Pyramid guideline. Sugars No No quantitative recommendations. Salt No A specific amount of salt is mentioned only indirectly and is the same for all individuals. Estimation of salt intake is very time-consuming. Alcohol No Alcohol use is already an approved indicator of nutrition risk through the category of Clinical/Health/Medical (see Appendix A). a Initially considered, but encompassed under the Food Guide Pyramid so not pursued individually. Some of the guidelines (i.e., Healthy Weight and Alcohol) already are covered by approved nutritional risk criteria (see Table 3-1). For the guidelines that do not have cut-off points specified, the committee has no basis for setting a cut-off point.
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Dietary Risk Assessment in the WIC Program In the following sections, a brief discussion of each guideline and issues related to the development of a specific risk criterion for that guideline are presented. Rationale for the Selection of Guidelines to Target Aim for a Healthy Weight Background. The focus of this guideline is on avoiding undesirable weight gain or losing weight gradually, if needed, in order to achieve a healthy weight. The purpose is to help people be fit and reduce their risk for high blood pressure, high blood cholesterol, heart disease, stroke, diabetes, certain types of cancer, arthritis, and breathing problems. Although not covered in the Dietary Guidelines, a healthy weight also promotes favorable reproductive outcomes (Galtier-Dereure et al., 1995, 2000). The guidance provided focuses on building a healthy base by eating vegetables, fruits, and grains with little added fat or sugar, selecting sensible portion sizes, and engaging in regular physical activity. Issues Related to Setting a Dietary Risk Criterion. The Dietary Guidelines provide no clear basis for identifying intakes that are excessive or inadequate for maintaining a healthy weight. Since many elements are involved in achieving caloric balance, and since a small daily deficit or excess could lead to substantial weight change over time, it is not feasible to establish a practical and valid criterion concerning diet in relation to healthy weight. Be Physically Active Each Day Background. The specific physical activity recommendation in the Dietary Guidelines is to “aim to accumulate at least 30 minutes (adults) or 60 minutes (children) of moderate physical activity most days of the week, preferably daily.” Moderate activity is defined, for adults, as “any activity that requires about as much energy as walking two miles in 30 minutes.” Creating a separate guideline for physical activity was justified by the Dietary Guidelines Advisory Committee (2000) for the following reasons: the relationship between nutrition and physical activity goes beyond weight management; the health benefits of physical activity are extensive and intertwined with the health benefits of a healthful eating pattern; physical activity levels in the United States are lower than desirable; and people of all ages need to improve their physical activity levels regardless of their weight status.
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Dietary Risk Assessment in the WIC Program FIGURE 3-1 USDA Food Guide Pyramid. SOURCE: USDA (1992). Issues Related to Setting a Dietary Risk Criterion. As stated above, the guideline includes a minimum amount of activity that could be used to set a cutoff point for a criterion. Chapter 6 addresses this issue in detail. Let the Pyramid Guide Your Food Choices Background. Let the Pyramid guide your food choices replaces the guideline Eat a variety of foods from earlier editions of the Dietary Guidelines (Dietary Guidelines Advisory Committee, 2000). A major objective of the change was to use wording that would help ensure nutritional adequacy. The pyramid referred to in the guideline is the Food Guide Pyramid developed by the U.S. Department of Agriculture (USDA) (Figure 3-1). It provides concrete recommendations for the numbers of servings a person (ages 2 years or older) should consume from each of five basic food groups (grains, fruits, vegetables, milk products, and meat or beans) based on their energy needs (see Table 3-2). It also advises consumers to use fats, oils, and sweets sparingly. People who consume the recommended number of servings from each of the five basic groups in the Food Guide Pyramid are likely to have nutrient intakes that come close to the 1989 Recommended Dietary Allowances (NRC, 1989)—the intakes recommended at the time the Pyramid was developed (Cleveland, 1997)—rather
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Dietary Risk Assessment in the WIC Program TABLE 3-2 Recommended Number of Pyramid Servings by Physiologic Status/Energy Intake and Food Group Food Group Children Ages 2–3 y (≈ 1,300 kcal) Children Ages 4–6 y, Women (≈ 1,600 kcal) Moderately Active Women, Some Pregnant Women (≈ 1,800 kcal) Teen Girls; Active, Pregnant, or Lactating Women (≈ 2,200 kcal) Grains group, especially whole grain 6 6 7 9 Vegetable group 3 3 3.3 4 Fruit group 2 2 2.3 3 Milk group, preferably fat free or low fat 2a 2 or 3b 2 or 3b 2 or 3b Meat and beans group, preferably lean or low fat 2 2, for a total of 5 oz 2, for a total of 6 oz 2, for a total of 6 oz a Portion sizes are reduced for children ages 2–3 years, except for milk. b The number of servings from the milk group depends on age. Older children and teenagers (ages 9 to 18 years) need three servings daily. Women 19 years and older need two servings daily. During pregnancy and lactation, the recommended number of milk group servings is the same as for nonpregnant females of the same age. SOURCE: Adapted from USDA/HHS (2000). than the current Dietary Reference Intakes (DRIs) (IOM, 1997, 1998, 2000b, 2001). From its inception, the Food Guide Pyramid was intended to be a dynamic nutrition education tool that is based on the Dietary Guidelines and nutrient recommendations, foods commonly consumed by Americans, and data on the nutrient content of those foods (Cronin, 1987). It was designed to allow consumers to choose foods they enjoy from each food group. In concept, the Pyramid incorporates the Dietary Guidelines and promotes good health, and it provides guidance for achieving nutrient adequacy without using supplements or highly fortified foods. Its design aims for balance and moderation along with nutrient adequacy. Notably, many state WIC agencies use the Food Guide
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Dietary Risk Assessment in the WIC Program FIGURE 3-2 Children’s Food Guide Pyramid. SOURCE: Center for Nutrition Policy and Promotion (CNPP, 1999). Pyramid to set specifications for the failure to meet Dietary Guidelines indicator. The newer Children’s Food Guide Pyramid, which is for children ages 2 to 6 years and their caregivers, has the same five food groups as the original Pyramid, but it lists only one recommended number of servings for each food group (the minimum number specified in Figure 3-2, which assumes an energy intake of 1,600 kcal/day) (Davis et al., 1999). The Children’s Pyramid features nutritious foods commonly eaten by children and shows children engaged in active pursuits. Issues Related to Setting a Dietary Risk Criterion. Is the Food Guide Pyramid a good tool to use to determine if a person is meeting the Dietary Guidelines? In some ways it is, but it is more complex than it appears. Based on the premise that the recommended numbers of servings for different energy levels are the numbers consistent with meeting the Dietary Guidelines and nutrient recommendations, the committee agreed that a cut-off point for each food group should be determined from Table 3-2. In other words, cut-off points
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Dietary Risk Assessment in the WIC Program for numbers of servings should be based on a person’s estimated energy requirement and—for the milk group servings—a woman’s age. For example, three servings of vegetables daily would be the cut-off point for a woman needing 1,600 kcal/day, but four servings would be the cut-off point for a woman needing 2,200 kcal/day. Two milk groups servings per day would be the cut-off point for a woman age 19 years or older, regardless of whether she was pregnant, lactating, or postpartum nonlactating. The challenge to WIC personnel is obtaining a reasonably accurate estimation of the person’s energy requirement. An advantage of using the Pyramid guidelines is that grains, vegetables, and fruits form the base of the Pyramid, and this is consistent with the emphasis on those foods in the next two guidelines listed below. The Food Guide Pyramid does less well, however, in addressing other parts of the Dietary Guidelines. It does not address physical activity or food safety (the two new guidelines) or alcohol at all. While the newer Food Guide Pyramid for Children (Davis et al., 1999) makes a small reference to physical activity through pictures of children engaged in activity, the original Food Guide Pyramid figure contains no clear guidance concerning how individuals should aim for a healthy weight. Although the accompanying educational materials do specify minimum numbers of servings to consume from the five recommended basic food groups for different energy levels, they do not provide maximum numbers. However, if excessive intake from one food group led to too few servings from another food group, the latter problem could be identified by comparison with the minimum. Neither the original nor the children’s Pyramid provides a quantitative means to meet the other guidelines in the choose sensibly category—that is, guidelines for fat and cholesterol, sugars, and salt. Educational materials have been developed by USDA to support the Pyramid and provide this information, except for sugars (Shaw et al., 1996). Using the Pyramid as a guide is intended to replace the need to evaluate one’s diet on a nutrient-by-nutrient basis (Kennedy and Goldberg, 1995). Information is not available concerning how well the Pyramid provides for meeting revised recommended intake values that have been released in the DRI series (IOM, 1997, 1998, 2000b, 2001). Many of these new recommended intake values differ substantially from the ones used in developing the Pyramid before its release in 1992. The Pyramid has not been revised since its initial release—at least in part because the process of revising it would be complex and time-consuming (Shaw et al., 2000). Despite its limitations, the committee considered Let the Pyramid guide your food choices promising as a practical and comprehensive guideline to use as a basis for determining if a person is at dietary risk because of failure to meet Dietary Guidelines. Consequently, it examined evidence related to the validity, reliability, and practicality of food-based questionnaires to assess whether an individual meets the Dietary Guidelines (see Chapter 5).
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Dietary Risk Assessment in the WIC Program Eat a Variety of Grains Daily, Especially Whole Grains Background. This guideline emphasizes whole grains because many of the health benefits of grains have been linked with whole grains rather than with refined grains. Components of whole grains may help reduce risk of chronic diseases such as coronary heart disease and certain types of cancer (Dietary Guidelines Advisory Committee, 2000). Whole grains also help promote normal bowel function. Both refined and whole grains provide the base of a healthful diet since many good-tasting choices are available that are low in fat, added sweeteners, and salt. Issues Related to Setting a Dietary Risk Criterion. The text supporting this guideline is consistent with Food Guide Pyramid recommendations of at least six servings of grains per day (more for those with energy requirements greater than 1,600 kcal/day). The text also states “and include several servings of whole grain foods” and provides reasons for doing so, but it does not quantify the term “several.” A risk criterion covering this guideline would fit under the guideline Let the Pyramid guide your food choices; however, it is unclear whether a cut-off should be set for whole grains. Choose a Variety of Fruits and Vegetables Daily Background. A generous intake of a variety of fruits and vegetables may help reduce the risk of chronic diseases such as heart disease and certain kinds of cancer. It also helps promote normal bowel function. Fruits and vegetables as a group tend to be good to excellent sources of many vitamins and minerals, as well as fiber. However, variety is important since a fruit rich in some vitamins and minerals may be low in others. Likewise, another fruit may have a different nutrient pattern altogether. Issues Related to Setting a Dietary Risk Criterion. Again, the text supporting this guideline is consistent with Food Guide Pyramid recommendations: have a variety—including at least two servings of fruits and three servings of vegetables daily. It is unclear whether or how to translate “choose a variety” into a dietary risk criterion. The text advises consumers to choose dark-green leafy vegetables, orange fruits and vegetables, and cooked dry beans and peas often, but it does not specify frequency. Risk criteria covering the fruits and vegetable guideline would fit under the guideline Let the Pyramid guide your food choices. Keep Food Safe to Eat Background. Food safety is relevant to WIC’s target population because pregnant women, infants, and young children are at high risk for food-borne
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Dietary Risk Assessment in the WIC Program illness and the consequences of food-borne illness may be serious—even life-threatening. Risk is especially high for people with weakened immune systems, such as mothers or infants who are infected with human immunodeficiency virus, many of whom are served by WIC. Healthful eating depends on consuming food that is safe from harmful bacteria, viruses, parasites, and chemical contaminants. Although farmers, food producers, and food handlers in markets and eating establishments all play important roles in keeping food safe to eat, women and caregivers can take concrete steps to protect themselves and the infants and children in their care. Issues Related to Setting a Dietary Risk Criterion. Criteria pertaining to this guideline would need to focus on one or more of the seven subguidelines in the Dietary Guidelines: Clean. Wash hands and surfaces often. Separate. Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing. Cook. Cook foods to a safe temperature. Chill. Refrigerate perishable foods promptly. Check and follow the label. Serve safely. Keep hot foods hot and cold foods cold. When in doubt, throw it out. The supporting text in the Dietary Guidelines provides specifics that could be used to set numerous criteria, for example, criteria concerning handwashing, safe temperatures, and maximum times for holding foods at temperatures in the danger zone. However, operationalizing these behaviors for the purpose of determining WIC eligibility would be difficult. The guideline does not lend itself to a criterion-based reference. Moreover, the committee found no tested questionnaires or related research to use as a basis for considering food safety as an indicator of practices in the criterion category failure to meet Dietary Guidelines. Therefore, the committee discontinued consideration of this dietary guideline for setting a dietary risk criterion. Choose a Diet that is Low in Saturated Fat and Cholesterol and Moderate in Total Fat Background. Strong evidence indicates that high intakes of saturated fat and cholesterol contribute to the development of coronary heart disease. The contribution of fat to obesity and to other chronic diseases is less certain. Compared with earlier editions of the Dietary Guidelines, the latest edition places greater emphasis on lowering saturated fat intake. The text provides
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Dietary Risk Assessment in the WIC Program suggestions for doing this, covering sources of saturated fats and possible alternatives. The text places less emphasis on restricting total fat intake. Issues Related to Setting a Dietary Risk Criterion. The Dietary Guidelines specifies “no more than 30 percent of calories from total fat” and “less than 10 percent of calories from saturated fat” should be consumed in one day. Both the Dietary Guidelines and the Food Guide Pyramid specify an upper limit on total fat intake as a percentage of food energy for the day and suggest about 300 mg of cholesterol as a maximum average daily intake. However, only the Dietary Guidelines presents reasons why the percentage of energy from total fat should not be much below 30 percent. When the fruit or grain recommendation is not met, the percentage of energy from fat may become excessive (Krebs-Smith et al., 1997). The Pyramid guideline would only partially cover the fat guideline. Choose Beverages and Foods to Moderate Your Intake of Sugars Background. The guideline to moderate intake of sugars is intended to reduce risk of tooth decay and help avoid excess calories. The focus is on added sweeteners, not the sugars that occur naturally in fruit and milk products. Issues Related to Setting a Dietary Risk Criterion. The text accompanying the guideline provides no specific guidance regarding what quantity of sweeteners would be excessive. Rather, it encourages consumers to get most of their calories from grains, fruits, vegetables, low-fat or non-fat dairy products, and lean meats or meat substitutes. It warns against letting soft drinks or other sweets crowd out more nutritious foods. The Dietary Guidelines provide no quantitative basis for setting a dietary risk criterion based on intake of sweeteners. Consequently, the committee did not consider this guideline further in relation to setting dietary risk criteria. Choose and Prepare Foods with Less Salt Background. The principal intent of this guideline is reduction of the risk of hypertension (high blood pressure). The rate of hypertension is greater in low-income populations (32 percent) than in middle- or high-income populations (27 percent), and is greater in African-American individuals (40 percent) than in white individuals (27 percent) (HHS, 2000). Based on data from the 1988–1991 National Health and Nutrition Examination Survey, 39 to 68 percent of U.S. women ages 50 to 79 years have hypertension, as do 48 to 73 percent of African-American women (HHS, 2000). Issues Related to Setting a Dietary Risk Criterion. The Guideline does not state a specific cut-off point for salt or sodium. Rather, it refers to the Daily
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Dietary Risk Assessment in the WIC Program Value of 2,400 mg of sodium specified on Nutrition Facts Labels and mentions that the need for sodium is actually much less. A majority of the salt in U.S. diets comes from salt added during food processing or during preparation in a food establishment or at home. Thus, estimating the amount of salt provided by the foods consumed would require detailed information from food labels and from people involved in food preparation—along with information about the consumer’s addition of salt and salty seasonings. For these several reasons, the committee did not consider this guideline further for setting dietary risk criteria. If You Drink Alcoholic Beverages, Do So in Moderation Background. The text of Dietary Guidelines points out many adverse effects of excess alcohol intake and makes it clear that women under age 55 years are unlikely to benefit from alcohol consumption. It names groups that should not drink alcoholic beverages at all, including children, adolescents, and women who may become pregnant or who are pregnant. The concern for women who may become pregnant relates to the high rate of unplanned pregnancies in the United States and the risk of birth defects from alcohol consumption even in the first few weeks of pregnancy (Dietary Guidelines Advisory Committee, 2000). Breastfeeding women (especially those not breastfeeding exclusively) are among the women who may become pregnant. Issues Related to Setting a Dietary Risk Criterion. The approved medical risk criterion for alcohol intake by pregnant women (see Appendix A) is compatible with the Dietary Guidelines—that is, a cut-off point of any alcohol use. The approved medical risk criterion concerning alcohol intake by breastfeeding women is much more lenient than a criterion that would be derived from the Dietary Guidelines (i.e., a cut-off point of any alcohol use), but medical risk places the approved criterion in Priority I—a much higher priority than is given to dietary risk. Consequently, the committee gave no further consideration to the use of alcohol as a dietary risk criterion. Summary The most promising approach to using the Dietary Guidelines for establishing dietary risk criteria for the WIC program is to focus on the single guideline Let the Pyramid guide your food choices. The major advantages and disadvantages are summarized in Box 3-1.
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Dietary Risk Assessment in the WIC Program BOX 3-1 Major Advantages and Disadvantages of Focusing on Let the Pyramid Guide Your Food Choices to Evaluate Dietary Risk Based on Failure to meet Dietary Guidelines Advantages Following the guideline, Let the Pyramid guide your food choices, helps ensure nutrient adequacy according to the 1989 Recommended Dietary Allowances (NRC, 1989). The Pyramid guideline covers at least two other guidelines: Eat a variety of grains daily … and Choose a variety of fruits and vegetables daily. Meeting recommendations for grains, fruits, and vegetables also may reflect moderation in intake of fats and sugars. The guideline provides a basis for definite cut-off points for each of the five basic food groups based on energy needs. Disadvantages The Food Guide Pyramid has not been updated to reflect new nutrient recommendations reflected in the Dietary Reference Intakes (IOM, 1997, 1998, 2000b, 2001). The Pyramid does not address physical activity or any aspect of food safety or salt intake. Energy needs are difficult to estimate accurately, and these affect the recommended servings of food groups. The Pyramid guideline provides no practical way to set cut-off points that relate to dietary aspects of aiming for a healthy weight or limiting intakes of saturated fat and sugars. The physical activity guideline merits further examination.
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Representative terms from entire chapter: