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4 Food Intake of WIC-Eligible Populations INTRODUCTION An assessment method that relates food intake to the Dietary Guidelines for Americans (USDA/DHHS, 2000) could be very useful in determining needed changes in the WIC food package. The Dietary Guidelines provide science-based advice to promote health and to reduce risk for major chronic diseases through diet and physical activity. According to Public Law No. 101-445 (U.S. Congress, 1990) the Dietary Guidelines form the basis of federal food, nutrition education, and information programs, including the WIC program. However, since Dietary Guidelines are targeted to healthy people two years and older, other guidance needs to be considered for addressing the younger age groups. This chapter covers selected aspects of Dietary Guidelines for children ages 2 through 4 years and for women, related food intake data, and widely accepted guidance from professional groups pertaining to infants and children younger than two years. Food safety considerations, which are a part both of Dietary Guidelines and guidance from professional groups, are addressed separately in Chapter 2. DIETARY INTAKES OF CHILDREN AGES 2 THROUGH 4 YEARS AND OF WOMEN Methods of Assessing Intake Comparison of Intakes with Food Guide Pyramid Servings The most widely used methods to compare food intake with the Dietary Guidelines for Americans (Box 4-1) (USDA/DHHS, 2000) have relied on the USDA food patterns that accompany the Food Guide Pyramid (Figure 4-1) developed in 1992 (USDA/DHHS, 1992; Welsh et al., 1993)--before the release of the Dietary Reference Intakes, which were discussed in Chapter 3 (IOM, 1997, 1998, 2000b, 2001, 2002a, 2004). This Pyramid is part of a food guidance system that is based upon earlier editions of the Dietary Guidelines and upon recommended nutrient intakes (Recommended Dietary Allowances [RDAs]) from the National Research Council (1989b) and the Institute of Medicine (IOM, 1997). The Food Guide Pyramid was designed to feature foods commonly eaten by Americans and to address the diet as a whole, 4-1

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4-2 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES BOX 4-1 Summary of the Dietary Guidelines for Americans 2000 For good health... Aim for Fitness Aim for a healthy weight. Be physically active each day. Build a Healthy Base Let the Pyramid guide your food choices. Choose a variety of grains daily, especially whole grains. Choose a variety of fruits and vegetables daily. Keep food safe to eat. Choose Sensibly Choose a diet that is low in saturated fat and cholesterol and moderate in total fat. Choose beverages and foods to moderate your intake of sugars. Choose and prepare foods with less salt. If you drink alcoholic beverages, do so in moderation. SOURCE: USDA/DHHS, 2000 providing for proportionality and moderation as well as for nutrient adequacy (Dixon et al., 2001). The Pyramid, shown in Figure 4-1, features the five major food groups and suggests "healthy food choices" within each food group. Accompanying tables specify the number of servings needed from each group for different life stages and food energy intakes. Accompanying text promotes the selection of a variety of foods from the five major food groups. A person who consumes foods from each of the major food groups in the amounts recommended based on his or her food energy intake is expected to achieve recommended nutrient intake levels without requiring highly fortified food. That person also would meet the 2000 Dietary Guidelines related to the intake of grains and fruits and vegetables. Attention to the "healthy food choices" and the tip of the Pyramid addresses the two guidelines related to fats and sugars, but only added sugars (as described in Chapter 3) are covered in this chapter. The Dietary Guidelines recommend a diet that is low in saturated fat and cholesterol and moderate in total fat for all individuals over the age of two years (IOM, 2002a). The WIC Program, in general, and WIC food packages, specifically, should encourage participants to follow these general recommendations. Data on fat intake are excluded because the analyses in Chapter 3 provide more accurate estimates of the intakes of interest than do the data sources used in this chapter. With the upcoming release of Dietary Guidelines 2005, the standards for whole grains and vegetables are likely to become higher than those of the 1992 Pyramid system (Dietary Guidelines Advisory Committee, 2004; public information). Thus, the related findings in this chapter may be conservative estimates.

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FOOD INTAKE OF WIC ELIGIBLE POPULATIONS 4-3 FIGURE 4-1 Food Guide Pyramid. SOURCE: USDA/DHHS, 1992. In 1997, Cleveland and co-workers (1997) developed a method to determine the number of Pyramid servings accurately for comparison with Pyramid recommendations. This method disaggregates food mixtures into their component parts so that each ingredient can be credited to a food group in the correct amount. For example, the ingredients in pizza are credited to the grains, milk, vegetable, and (if meat is present) to the meat and meat alternatives groups. If the meat is not lean, part of the weight is credited to the meat group and part to the discretionary fat group. The grain in a sweetened ready-to-eat cereal would be credited to the grains group and the sugar to added sugars in the Pyramid tip. The weight in grams of each food or ingredient is divided by a predetermined weight per serving to obtain the number of servings consumed. To compare the dietary intake of a population group with Pyramid recommendations, investigators have applied the method described above (Cleveland et al., 1997) to food intake data obtained from diet recalls or diet records. The resulting analyses produce data on the percentages of persons consuming a specified number of servings from one or more food groups. To compare dietary intake of a population group with the Dietary Guidelines as a whole, one also must examine the intakes of fat, cholesterol, salt (i.e., sodium), and sugars. Total fat, sodium, and added sugars are discussed in Chapter 3; added sugars are addressed in different ways in the Chapters 3 and 4. The Dietary Guidelines contain some overall guidance about

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4-4 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES specific components of food. For example, trans fatty acids tend to raise blood cholesterol, and intakes of foods high in hydrogenated fats should be limited (USDA/DHHS, 2000). It should be noted that in the various ways of comparing dietary intake with the Dietary Guidelines, the published estimates are made with the unadjusted daily intake data. Unlike the nutrient analyses in the previous chapter, the food group assessments have not been adjusted to remove the effect of day-to-day variations in intakes. Use of Indexes that Address Overall Diet Quality The Center for Nutrition Policy and Promotion of USDA developed the Healthy Eating Index (HEI) (CNPP, 1995; Kennedy et al., 1995, 1999; Bowman et al., 1998; Ballew et al., 2000; Basiotis et al., 2002) to make an overall comparison of food intake with the Dietary Guidelines. This index represents the sum of equally weighted scores for each of 10 components derived from the Dietary Guidelines. The Diet Quality Index Revised (DQI-R) is a similar scoring method for population groups (Haines et al., 1999), but it differs from the HEI in some of its 10 components. Because the HEI and the DQI-R are summary measures, they do not provide information useful to developing recommendations for the contents of the WIC food packages. However, the Committee examined articles that reported these summary measures to look for scores for the individual components for the relevant population groups. The Committee found no data more recent than that used below. FINDINGS FOR YOUNG CHILDREN AND WOMEN The scientific literature includes analyses of Pyramid servings data, by selected age groups and gender (Krebs-Smith et al., 1990, 1996, 1997a, 1997b; Welsh et al., 1994; Munoz et al., 1997, 1998; Crane et al., 1999; Cleveland et al., 2000; Smiciklas-Wright, 2002). None of these sources addressed intakes for all the five basic food groups for all the relevant age groups served by the WIC program. However, using the Food Guide Pyramid servings methods described above (and in more detail by Cleveland and colleagues, 1997), the Food Surveys Research Group, ARS, USDA, has published Pyramid Servings Data (FSRG, 1999a, 1999b) using data from the 19941996 Continuing Survey of Food Intakes by Individuals (see Chapter 3 for a description of this survey). To examine the food intake of young children and women, the Committee relied on the information in Pyramid Serving Data (FSRG, 1999b), which reports results by gender, age group, and three income levels but not by WIC participation. This chapter presents data on the subjects having incomes under 131 percent of the federal poverty level, the group closest to that served by the WIC program. Separate data are not available for pregnant and lactating women. The data presented in this chapter cover the age groups most relevant to the WIC program--boys and girls ages 2 to 5 years and for females ages 12 to 19 years and 20 to 39 years. The data represent 2-day averages, but they have not been adjusted for within-person variation. Thus, as discussed in Chapter 3, the food intake data are subject to greater error than are the nutrient data presented in that chapter. In addition, the food intake data on children are subject to over-reporting bias, and the data on women are subject to under-reporting bias, as identified in Chapter 3. Table 4-1 shows mean servings of foods from the five basic food groups and for selected food subgroups. It also gives the mean number of teaspoons of added sugars consumed. Table 4-2 shows the percentages of individuals consuming the minimum number of Pyramid servings recommended. The Committee chose this as a conservative estimate of the

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FOOD INTAKE OF WIC ELIGIBLE POPULATIONS 4-5 TABLE 4-1 Mean Numbers of Servings from the Five Basic Food Groups with Selected Subgroups, and Mean Teaspoons of Added Sugars, Consumed by Selected Age Groups, Income Under 131 Percent of Federal Poverty Level Sex: Recommended Male Female Minimum Age: Number 25 y 25 y 1219 y 20-39 y of Servings a Mean Number of Servings Consumed a Grains, total 6 6.3 6.0 6.3 5.4 Whole grain 0.8 0.8 0.9 0.8 Vegetables, total 3 2.3 2.3 2.8 2.8 Dark green leafy 0.1 0.1 0.1 Deep yellow 0.1 0.1 0.1 0.1 Cooked dry beans and peas 0.2 0.2 0.2 0.2 White potatoes 1.0 1.0 1.2 0.7 Other starchy 0.2 0.2 0.1 0.2 Tomatoes 0.4 0.3 0.5 0.4 Other vegetables 0.4 0.4 0.7 1.0 Fruit, total 2 1.9 1.8 1.1 1.2 Citrus, melons, berries 0.7 0.8 0.6 0.6 Dairy, totalb 2 1.8 1.8 -- 1.1 Ages 9-18 y 3 -- -- 1.4 -- Milk 1.5 1.5 0.9 0.7 Yogurt Cheese 0.3 0.3 0.4 0.4 Meat and meat alternatives c (oz) Total 5 3.2 3.0 4.3 4.3 Ages 2-3 y 3 Meat 1.1 1.1 1.9 1.7 Poultry 0.8 0.7 0.9 1.1 Fish 0.1 0.2 0.2 0.4 Organ Meat * * * * Frankfurter and lunch meat 0.7 0.6 0.8 0.6 Eggs 0.4 0.3 0.4 0.4 Soybean products * * * * Nuts and seeds 0.1 0.1 0.1 0.1 Mean Number of Teaspoons Consumed Added Sugars N/A 14.9 14.9 19.4 17.4 Note: = value less than 0.05 but greater than 0, = recommended minimum number of servings is different for specific age groups,* = statistical reliability is reduced due to small cell size, N/A = not applicable. a Servings from each food group: fruits and vegetables, cup or equivalent; grains, 1 oz dry or cup cooked; dairy, 1 cup milk or equivalent; meat and meat alternatives, equivalent to 1 oz of lean meat. b Intakes include small amounts of miscellaneous dairy products, such as whey and nonfat sour cream, that are not included in the subgroups milk, yogurt, and cheese. c Intakes exclude cooked dry beans and peas that were tabulated as vegetables. Data Source: Intake date are from 1996-1996 CSFII and are 2-day average intakes based on daily intakes (FSRG, 1999b). The recommended number of servings are from the Food Guide Pyramid (USDA/DHHS, 1992).

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4-6 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES TABLE 4-2 Percentages of Individuals Consuming the Minimum Number of Recommended Servings per Day as Specified by USDA's Food Guide Pyramid, Selected Age Groups, Income Under 131 Percent of Poverty Sex: Recommended Male Female Minimum Age: Number of 2-5 y 2-5 y 12-19 y 20-39 y Servings Grains 6 52 45 46 32 Vegetables 3 29 28 40 35 Fruit 2 38 40 20 20 Dairy 2-3 35 38 21 14 Meat 5 oz N/A N/A 35 30 Note: N/A = not applicable from available data. Data Source: Intake date are from 1996-1996 CSFII and are 2-day average intakes based on daily intakes (FSRG, 1999b). The recommended number of servings are from the Food Guide Pyramid (USDA/DHHS, 1992). percentages of individuals with food patterns consistent with the food group recommendations because no adjustment for daily variation in food group intakes was made. Like the DRIs, the Pyramid system does not include a target minimum for added sugars intake. It does, however, specify a suggested maximum amount of added sugars for each of the calorie levels. The maximum reflects an amount of added sugars that can be consumed that is consistent with meeting nutrient goals for a specified number of calories. For children ages 2 to 6 years of age, this amount is about 6 teaspoons (USDA, 1999; Davis et al, 1999). For women, the suggested maximum ranges from about 8 to 12 teaspoons, depending on food energy intakes (USDA/DHHS, 1992) and food energy requirements (NRC, 1989b). Children Ages 2 through 4 Years Mean Servings Compared with Minimum Pyramid Servings Recommendations For young children, Table 4-1 shows that the mean number of servings reported is smaller than the recommended minimum number of servings for the vegetable, fruit, dairy, and meat and meat alternatives groups. Using these mean numbers, the deficit in the intakes of children compared to the recommended minimum number of servings is largest for the vegetable group, 0.7 servings. In contrast, the mean number of servings of grains is slightly higher than the recommended minimum. From this analysis of the data available for intake of the major food groups (Table 4-1), the vegetable group appears to be the major inadequacy in the diets of children ages 2 to 5 years. The mean servings for the food group subcategories provide useful information because of differences in the average nutrient content of the foods in the subgroups (e.g., citrus, berries, and melon provide more vitamin C and certain other micronutrients than do other fruits) and because of differences in the average cost of foods in some of the subgroups (e.g., potatoes are less costly than most other vegetables). As shown, mean intake of potatoes is much greater than of any of the other vegetables, and mean intake of frankfurters and lunch meat is relatively high. On the

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FOOD INTAKE OF WIC ELIGIBLE POPULATIONS 4-7 other hand, mean intakes of dark green leafy vegetables, deep yellow vegetables, and legumes are very low. These subgroups are rich in a number of the nutrients of concern identified in Chapter 3. Similarly, whole grains are a better source of fiber and certain other nutrients than are refined grains, but mean intake of the whole grains is less than one serving in a day. From this analysis of the data available for intake of foods in subgroups (Table 4-1), the vegetable group again appears to be the major inadequacy in the diets of children ages 2 to 5 years. Data on the mean intake of added sugars, expressed as teaspoons of sugar, can be used for assessment purposes only indirectly. The 15-teaspoon mean intake by children is equivalent to just under 1/3 cup of added sugars, whereas their suggested maximum is 5 to 6 teaspoons--one third as much. These sugars may improve the perceived palatability of the food; and, in some cases, added sugars may lead to increased intake of foods (e.g., milk, breakfast cereal) that are excellent nutrient sources (Frary et al., 2004). However, 1/3 cup of added sugars provides no essential nutrients while providing about 240 kcal. Percentages Meeting Minimum Pyramid Servings Recommendations As shown in Table 4-2, approximately 30 percent meet the minimum for the vegetable group, approximately 40 percent meet the minimum for the dairy and fruit groups, and approximately half of the children meet the minimum for grains. Available data on meat are misleading for the children since the data source used 5 oz as the minimum recommendation whereas 3.5 oz is the actual minimum recommendation for children 2 through 3 years old and 5 oz, for children four years old (CNPP, 1999). For this reason, the Committee could not determine the percentage of boys and girls who meet at least the minimum number of recommended servings for the meat and meat alternatives group and omitted the original data in Table 4-2. From this analysis of the of the percentage of children consuming the minimum pyramid servings recommended (Table 4-1), the vegetable group again appears to be the major inadequacy in the diets of children ages 2 to 5 years. The results in Table 4-2 are similar to those reported by Krebs-Smith et al. (1996) and Munoz et al. (1997, 1998) for earlier periods. However, a comparison of recent findings with results from the earlier surveys (data not shown) indicates that in the 1994-1996 CSFII higher percentages of children consumed at least one serving of fruit and at least one serving of vegetables than in the 1989-1991 Continuing Survey of Food Intakes by Individuals (Krebs-Smith et al., 1996) , substantially lower percentages of children consumed the number of dairy group servings recommended based on calorie intake in 1996 than in the 1989-1991 Continuing Survey of Food Intakes by Individuals (Munoz et al., 1997, 1998). Data are not available to determine the extent of change occurring between the 1994-1996 survey and the present. Women in the Childbearing Years Mean Servings Compared with Minimum Pyramid Servings Recommendations For women, Table 4-1 shows that the mean number of servings reported is smaller than the recommended minimum number of servings for all five food groups. For the 12- through 19- year-old females, reported mean intake of grains is slightly higher than the recommended minimum. The mean servings of fruit reported by the women are only slightly more than half of the minimum recommendation, but about half of the fruit is in the nutrient-rich citrus, melons,

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4-8 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES and berries subgroup. Reported intakes from the dairy group also are quite low. The mean of 1.4 servings reported by the teens is especially notable since their recommended minimum is 3 servings. Of their total meat and meat alternatives intake, the women reported higher intake of red meat than of the other choices. From this analysis of the data available for mean intakes of the food groups (Table 4-1), the fruit group (with a deficit of 0.8 servings) and dairy groups (with a deficit of 0.9 to 1.6 servings) appear to be the major inadequacies in the diets of low- income women ages 12 to 39 years. Mean intake of added sugars by the teens (20 tsp) is somewhat greater than that of the women (17 tsp), but both means exceed the suggested maximum, which ranges from 8 to 12 teaspoons. Percentages Meeting Minimum Pyramid Servings Recommendations Once again, the data need to be examined with respect to the percentages of women meeting Food Guide Pyramid recommendations. Using the least stringent definition of recommended servings--the minimum number recommended, the data show that fewer than 50 percent of the women meet the recommendation for grains, 40 percent or fewer meet the minimum recommendations for vegetable and meats, and fewer than 25 percent meet the minimums for fruit and dairy products. Less than 10 percent of the teens meet the higher 3-cup recommendation for dairy products. In summary, the percentages of individuals consuming the minimum recommended number of servings are low for each of the five food groups. The percentages meeting the minimum recommended Pyramid servings differ for the three different age groups in Table 4-2. The major concerns are definitely the fruit and dairy groups women and the vegetable group for children. Overall, however, the percentages of individuals consuming the minimum recommended number of servings is low for each of the five food groups. The extent of the identified shortfalls may be overestimated for the women because of underreporting of intakes and the limitations of data that have not been corrected for day-to-day variation in intake. For the children, the direction of the bias is less certain. DIETARY INTAKES OF INFANTS AND CHILDREN YOUNGER THAN TWO YEARS Widely Accepted Guidance from Professional Groups One possible way to identify food-related priorities for infants and children younger than two years of age is to obtain descriptive information about their intakes and examine it in relation to widely accepted recommendations from professional organizations, summarized in Table 4-3. Breastfeeding Rates In 2002, reported breastfeeding rates for WIC participants were about 59 percent in the hospital and 22 percent at six months (Abbott Laboratories, 2003). While these rates represent significant short- and long-term increases (Abbott Laboratories, 2002, 2003), these rates are about 10 percentage points lower than the rates for all postpartum women and 20 percent lower

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FOOD INTAKE OF WIC ELIGIBLE POPULATIONS 4-9 TABLE 4-3 Dietary Guidance for Infants and Children Under the Age of Two Years Dietary Guidance Source Breastfeeding is the preferred method of infant feeding becauseof AAP, 2004 the nutritional value and health benefits of human milk Increase breastfeeding rates; targets in U.S. general population are DHHS, 2000b 75% breastfeeding in early postpartum, 50% at 6 months, 25% at 12 months Encourage breastfeeding with exclusion of other foods for first 4 to AAP, 2004 6 months Continue breastfeeding for first year of life AAP, 2004 Continue breastfeeding into second year of life if mutually desired AAP, 1997; Kleinman, 2000; by the motherand child AAP, 2001b; AAP, 2004 For infants who are not currently breastfeeding, use infant formula Kleinman, 2000; AAP, 2004 throughout the first year of life Infant formula used during the first year of life should be iron- AAP, 1997; AAP, 2001b; fortified AAP, 2004 Infants with specific medical conditions may require medical AAP, 2001b formula and this should be readily available through programs such as the WIC program Introduce solid foods at 4 to 6 months of age AAP, 2004 Fruit juice may be introduced at 6 months of age; avoid introducing Kleinman, 2000; AAP, juice before 6 months of age 2001a; AAP, 2004 Limit intake of fruit juice to 8 oz per day for children ages 6 to AAP, 1997; Kleinman, 2000; 12 months AAP, 2001a Introduce single-ingredient complementary foods, one at a time for AAP, 2004 a several day trial Introduce iron-rich solid foods at 6 to 12 months of age AAP, 2004 Delay introduction of cow's milk until the second year of life AAP, 1992; AAP, 2004 Cow's milk fed during the second year of like should be whole AAP, 1992 milk Avoid feeding of hard, small particulate foods during first 2 to 3 Kleinman, 2000; AAP, 2004 years of life due to choking hazard Limit intake of fruit juice to 4 to 6 oz per day for children ages 1 to AAP, 2001a; AAP, 2004 6 years Encourage children to eat whole fruits to meet their recommended AAP, 2001a; AAP, 2004 daily fruit intake WIC food prescriptions should be nutritionally and culturally AAP, 2001b; AAP, 2004 appropriate Provide children with repeated exposure to new foods to optimize ADA, 1999; AAP, 2004 acceptance and encourage development of eating habits that promote selection of a varied diet Promotion of healthy eating should begin early in life ADA, 1999; AAP, 2004

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4-10 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES than the rates for low-income non-WIC participants. The rates of breastfeeding among WIC participants also are substantially lower than the public health goals for the U.S. (see Table 4-3) (DHHS, 2000b). These low breastfeeding rates are of concern because of the many short- and long-term health benefits of breastfeeding.1 Breastfeeding promotion efforts in the WIC setting have been able to increase initiation rates, but sustained effects on the duration of breastfeeding--particularly exclusive breastfeeding in the first six months--have been much more difficult to achieve (Ahluwalia et al., 2000). Findings Related to Adherence to Dietary Guidance Introduction of Complementary Foods Based on data from the Feeding Infants and Toddler Study, Briefel and colleagues (2004) reported that infants were introduced to complementary foods at very young ages. Almost 30 percent of infants were fed complementary foods prior to four months of age, and 17 percent of infants consumed juice prior to six months of age. An earlier study of WIC participants had similar findings (Bayder et al., 1997). Furthermore, some infants are fed cow's milk too early. Almost one-quarter of infants 9 through 11 months were fed cow's milk on a daily basis, although cow's milk is not recommended for infants under one year of age (Briefel et al., 2004). An earlier study of WIC participants had similar findings (Bayder et al., 1997). Beverage and Fruit/Vegetable Consumption The Feeding Infants and Toddlers Study also found that milk may be displaced in toddler diets by other beverages. The calcium density of toddler diets decreased with increasing consumption of 100 percent juice, fruit drinks, and carbonated beverages (Skinner et al., 2004). For children who consumed 100% fruit juice (more than half of the sample), mean reported intake by those ages 15 through 18 months was 8.8 oz per day; and by those ages 19 through 24 months, it was 9.5 oz per day (Skinner et al., 2004). Both mean values exceed the recommended maximum of 4 to 6 oz per day for children ages 1 to 6 years (AAP, 2004). Almost all toddlers consumed milk, however, and calcium intakes of infants and toddlers were adequate (Devaney et al., 2004). In addition, non-juice fruit and vegetable consumption was low. About 20 percent of toddlers did not consume any vegetable on a given day and about one-third of older toddlers did not consume any fruit (excluding juice). The most common vegetable consumed by toddlers 15 months and older was fried potatoes (Fox et al., 2004). 1 Benefits to infants from breastfeeding include reduced illness from gastrointestinal (Beaudry et al., 1995; WHO, 2000), respiratory (Wilson et al., 1998; WHO, 2000), and ear (Scariati et al., 1997) infections; reduced risk of atopic illness (adverse conditions resulting from allergic/immune responses) such as food allergy (Saarinen and Kajosaari, 1995), atopic eczema (Saarinen and Kajosaari, 1995), and asthma (Saarinen and Kajosaari, 1995; Oddy et al., 1999); reduced risk of sudden infant death syndrome (Ford et al., 1993); higher scores on cognitive development tests for breastfed infants (Anderson et al., 1999); protective effects on later blood pressure (Wilson et al., 1998); and a somewhat reduced risk of childhood obesity (Dewey, 2003). Additional benefits of breastfeeding include reduced maternal risk of subsequent breast cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2002), less maternal postpartum weight retention (Dewey et al., 1993), and less maternal absenteeism from work due to the infants' better health compared to formula-fed infants (Cohen et al., 1995).

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FOOD INTAKE OF WIC ELIGIBLE POPULATIONS 4-11 Development of Long-Term Eating Patterns The early eating environment is very important in the development of long-term eating patterns. Young children need frequent exposure to new foods, including tasting, to learn to like a variety of foods (Birch et al., 1984, 1987). However, the Feeding Infants and Toddlers Study found that most caregivers offered a new food no more than 3 to 5 times before deciding that their infant or toddler disliked it (Carruth et al., 2004). In older children, studies indicate that acceptance of a new food is enhanced by offering it 8 to 15 times (Sullivan and Birch, 1990; Birch et al., 1995). Thus, mechanisms that promote acceptance of a variety of foods in children appear to be lacking. Food preferences, as well as household food availability, are correlated with food intake in children (Harvey-Berino et al., 1997; Cullen et al., 2003). SUMMARY The Committee's findings show that low-income women and young children have mean intakes of servings from each of the five food groups that are less than the minimum Pyramid recommendations--with the exception of the grain group for the children and teens. In general, fewer than half of the individuals had intakes that met any one of the minimum Pyramid recommendations. In comparison with recommendations, dairy and fruit intakes were lowest for the women and vegetable intake was lowest for the children. Intakes of added sugars were higher than those suggested by the Pyramid. The Committee may need to consider both the added sugars content and the fat content of the food packages (based on the findings from Chapter 3) to assist participants in maintaining energy balance. Data show that the dietary practices of most concern for the infants and toddlers less than two years of age include the short duration of breastfeeding, excessive consumption of fruit juice, early introduction of solid food and cow's milk, low consumption of fruits (other than juice) and vegetables, and infrequent exposure to new foods.

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