WIC Nutrition Risk Criteria: A Scientific Assessment

Committee on Scientific Evaluation of WIC Nutrition Risk Criteria

Food and Nutrition Board

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1996



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--> WIC Nutrition Risk Criteria: A Scientific Assessment Committee on Scientific Evaluation of WIC Nutrition Risk Criteria Food and Nutrition Board INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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--> 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. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported under contract no. 59-3198-3-044 from the Food and Nutrition Service, U.S. Department of Agriculture. Library of Congress Catalog Card No. 95-72317 International Standard Book Number 0-309-05385-4 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Washington, D.C. metropolitan area) or visit the online bookstore at http://www.nas.edu/nap/online/. Copyright 1996 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 image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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--> Committee on Scientific Evaluation of WIC Nutrition Risk Criteria RICHARD E. BEHRMAN (Chair),* Center for the Future of Children, David and Lucile Packard Foundation, Los Altos, California BARBARA ABRAMS, School of Public Health, University of California, Berkeley A. SUE BROWN (through February 1995), Commission on Health Care Finance, Government of the District of Columbia, Washington, D.C. MARY ELLEN COLLINS, Brigham and Women's Hospital, Boston, Massachusetts CATHERINE COWELL, School of Public Health, Columbia University, New York, New York BARBARA DEVANEY, Mathematica Policy Research, Inc., Plainsboro, New Jersey LEON GORDIS,* School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland JEAN-PIERRE HABICHT, Division of Nutritional Sciences, Cornell University, Ithaca, New York K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver GAIL G. HARRISON, School of Public Health, University of California, Los Angeles JEAN YAVIS JONES, Congressional Research Service, Library of Congress, Washington, D.C. ROY M. PITKIN,* School of Medicine, University of California, Los Angeles ERNESTO POLLITT, Department of Pediatrics, University of California, Davis KATHLEEN M. RASMUSSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York EARNESTINE WILLIS, MACC Fund Research Center and Department of Pediatrics, Medical College of Wisconsin, Milwaukee Staff ROBERT EARL, Study Director (through November 1995) CAROL WEST SUITOR, Study Director (beginning November 1995) SANDRA A. SCHLICKER, Senior Program Officer (beginning November 1995) SHEILA A. MOATS, Research Associate KIMBERLY M. BREWER, Research Assistant (beginning September 1995) GERALDINE KENNEDO, Project Assistant *   Member, Institute of Medicine

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--> Food and Nutrition Board CUTBERTO GARZA (Chair), Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois, Urbana PERRY L. ADKISSON, † Department of Entomology, Texas A&M University, College Station LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis DENNIS M. BIER, USDA Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas FERGUS M. CLYDESDALE, Department of Food Science and Nutrition, University of Massachusetts, Amherst MICHAEL P. DOYLE, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver JANET C. KING, * USDA Western Human Nutrition Research Center, Presidio of San Francisco, California SANFORD A. MILLER, Graduate Studies and Biological Sciences, University of Texas Health Science Center, San Antonio ALFRED SOMMER, * School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland STEVE L. TAYLOR (Ex officio), Food Processing Center, University of Nebraska, Lincoln VERNON R. YOUNG, † Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge *   Member, Institute of Medicine †   Member, National Academy of Sciences

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--> Staff ALLISON A. YATES, Director (beginning July 1994) CATHERINE E. WOTEKI, Director (through December 1993) BERNADETTE M. MARRIOTT, Associate Director and Interim Director (through June 30, 1994) GAIL SPEARS, Administrative Assistant (beginning September 1994) MARCIA S. LEWIS, Administrative Assistant (through August 1994) JAMAINE L. TINKER, Financial Associate

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--> Acknowledgments This report represents the collaborative efforts of many individuals, particularly the study committee and staff whose names appear at the beginning of this document. Completion of this study was a complex task and it required substantial dedication and effort by all those who participated in its completion. The committee wishes to acknowledge the assistance of the National Association of WIC Directors (NAWD) for furnishing volumes of information about nutrition risk criteria in use in state WIC programs. NAWD's president during the majority of the study, Alice Lenihan, was particularly helpful and supportive. The committee wants to express their appreciation of the input received from the entire WIC community, too numerous to mention by name, through public meetings, site visits, additional information about nutrition risk criteria, and informal communications. Drs. Robert Kuczmarski and Anne Looker of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, made presentations to the committee on upcoming data from the third National Health and Nutrition Examination Survey and revision of NCHS infant and child growth charts. Dr. Tiefu Shen of the Division of Nutritional Sciences, Cornell University, and Cyn O'Malley and Suzan Carmichael of the School of Public Health, University of California, Berkeley, provided substantial assistance with the development of the chapter on anthropometric risk criteria. This report was sponsored by the Food and Consumer Service, U.S. Department of Agriculture (USDA). Without their vision for the need to undertake this scientific assessment, this report would not have become a reality. The committee acknowledges their commitment to the WIC program

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--> and their support of this project, particularly the support of project officers Jay Hirschman and Dr. Janet Tognetti Schiller. In addition, the committee recognizes other major informational contributions of several USDA staff: Donna Hines, Julie Kresge, Michele Lawler, Elaine Lynn, and Debra Whitford. The committee also wishes to express its appreciation to the staff of the Food and Nutrition Board of the Institute of Medicine, whose tireless efforts on our behalf were so critical to the committee's deliberations and the production of this report. Our appreciation goes to Robert Earl, who provided administrative support to the committee. The committee is especially grateful for the substantial efforts of Dr. Carol Suitor, who, with the assistance of Dr. Sandra Schlicker and Kim Brewer, worked closely with committee members to complete the analysis and finalize the report. The efforts of Sheila Moats, Geraldine Kennedo, Susan Knasiak, and Dr. Allison Yates on behalf of the committee are also deserving of our heartfelt thanks. RICHARD E. BEHRMAN, Chair Committee on Scientific Evaluation of WIC Nutrition Risk Criteria

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--> Contents     SUMMARY   1     Committee Process and Structure of the Report   3     Principles of Nutrition Risk Assessment   5     General Conclusions   7     Recommendations for Specific Nutrition Risk Criteria   9     Recommendations for Future Research and Action   20 1   OVERVIEW   23     Charge to the Committee   24     The WIC Program   25     Overview of the Report and the Committee Process   34     References   38 2   POVERTY AND NUTRITION RISK   41     Definition of Poverty   41     Prevalence of Poverty   43     Poverty and Nutrition Risk for Women   43     Poverty and Nutrition Risk for Infants and Children   45     Effects of WIC Program Participation   47     References   49 3   PRINCIPLES UNDERLYING THE NUTRITION RISK CRITERIA FOR WIC ELIGIBILITY   53     Principles of Nutrition Risk Assessment   53

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-->     WIC Nutrition Risk Criteria   60     Priority System of the WIC Program   60     Summary and Implications   63     References   65 4   ANTHROPOMETRIC RISK CRITERIA   67     Use of Anthropometric Measures in the WIC Program   67     Maternal Anthropometric Risk Criteria   70     Prepregnancy Underweight   70     Low Maternal Weight Gain   73     Maternal Weight Loss During Pregnancy   79     Prepregnancy Overweight   80     High Gestational Weight Gain   84     Maternal Short Stature   87     Postpartum Underweight   89     Postpartum Overweight   92     Abnormal Postpartum Weight Change   96     Anthropometric Risk Criteria for Infants and Children   97     Low Birth Weight   97     Small for Gestational Age   100     Short Stature   104     Underweight   110     Low Head Circumference   114     Large for Gestational Age   117     Overweight   118     Slow Growth   123     Summary and Conclusions   125     References   128 5   BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA   149     Criteria Related to Nutrient Deficiencies   154     Anemia   154     Failure to Thrive and Other Nutrient Deficiency Disease   159     Medical Conditions Applicable to the Entire WIC Population   166     Gastrointestinal Disorders   166     Diabetes Mellitus   169     Thyroid Disorders   170     Chronic Hypertension   172     Renal Disease   174     Cancer   175     Central Nervous System Disorders   177     Genetic and Congenital Disorders   179

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-->     Inborn Errors of Metabolism   181     Chronic or Recurrent Infections   183     HIV Infection and AIDS   185     Recent Major Surgery, Trauma, Burns, or Severe Acute Infections   188     Other Medical Conditions   190     Conditions Related to the Intake of Specific Foods   192     Food Allergies   192     Food Intolerances   194     Conditions Specific to Pregnancy   195     Pregnancy at a Young Age   195     Pregnancy Age Older Than 35 Years   197     Closely Spaced Pregnancies   197     High Parity   200     History of Preterm Delivery   204     History of Postterm Delivery   206     History of Low Birth Weight   206     History of Neonatal Loss   207     History of Previous Birth of an Infant with a Congenital or Birth Defect   207     Lack of Prenatal Care   208     Multifetal Gestation   210     Fetal Growth Restriction   211     Preeclampsia and Eclampsia   213     Placental Abnormalities   214     Conditions Specific to Infants and/or Children   215     Prematurity   215     Hypoglycemia   217     Potentially Toxic Substances   218     Long-Term Drug-Nutrient Interactions or Misuse of Medications   218     Maternal Smoking   220     Alcohol and Illegal Drug Use   226     Lead Poisoning   229     Summary   232     References   233 6   DIETARY RISK CRITERIA   251     Inappropriate Dietary Patterns   253     Dietary Patterns That Fail to Meet Dietary Guidelines for Americans   253     Vegetarian Diets   259     Highly Restrictive Diets   260

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-->     Inappropriate Infant Feeding   261     Inappropriate Use of Nursing Bottle   265     Inappropriate Diets in Children   268     Excessive Caffeine Intake   269     Pica   270     Inadequate Diet   272     Food Insecurity   279     Definition of Food Insecurity   279     Summary   283     References   283 7   PREDISPOSING NUTRITION RISK CRITERIA   295     Homelessness   297     Migrancy   304     Passive Smoking   309     Low Level of Maternal Education and Illiteracy   311     Maternal Depression   314     Battering   317     Child Abuse or Neglect   319     Child of a Young Caregiver   321     Child of a Mentally Retarded Parent   323     Summary   325     References   325 8   CONCLUSIONS AND RECOMMENDATIONS   335     General Conclusions   336     Recommendations for Specific Nutrition Risk Criteria   337     Recommendations for Future Research and Action   350     APPENDIXES     A   Participants at the First Public Meeting, May 19, 1994   353 B   Participants at the Second Public Meeting, September 19–20, 1994   355 C   WIC Program: Common Nutritional Risk Criteria   357 D   Definitions of Yield and Sensitivity of Cutoff Points for Nutrition Risk   359 E   Biographical Sketches   361     ACRONYMS   371     INDEX OF RISK CRITERIA   373

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--> List of Tables and Figures TABLES S-1   Nutrition Risk Criteria and Committee Recommendations for the Specific WIC Population, by Category of Nutrition Risk,   10 1-1   WIC Program Participation by Subgroup and Federal Costs, 1974–1993,   35 3-1   Nutrition Risk Criteria Defined by WIC Program Regulations,   61 3-2   The WIC Priority System,   62 4-1   Summary of Anthropometric Risk Criteria in the WIC Program and Use by States,   68 4-2   Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Pregnant and Postpartum Women,   70 4-3   Summary of Anthropometric Risk Criteria as Predictive of Risk or Benefit Among Infants and Children,   98 4-4   Summary of Anthropometric Risk Criteria and Committee Recommendations for the Specific WIC Population,   126 5-1   Summary of Biochemical and Other Medical Risk Criteria in the WIC Program and Use by States,   150 5-2   Summary of Broad Categories of Biochemical and Other Medical Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,   153 5-3   Cutoff Points for Anemia Used in the WIC Program and Recommended Cutoff Points from the Centers for Disease Control and Prevention and the Institute of Medicine for Women, Infants, and Children,   158 5-4   Summary of Medical Risk Criteria and Committee Recommendations for the Specific WIC Population,   160

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--> 6-1   Summary of Broad Dietary Risk Criteria in the WIC Program and Use by States,   252 6-2   Summary of Broad Dietary Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,   253 6-3   Summary of Broad Dietary Risk Criteria and Committee Recommendations for the Specific WIC Population,   266 7-1   Summary of Predisposing Risk Criteria in the WIC Program and Use by States,   296 7-2   Summary of Predisposing Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children,   297 7-3   Summary of Dietary Risk Criteria and Committee Recommendations for the Specific WIC Population,   298 8-1   Nutrition of Risk Criteria and Committee Recommendations for the Specific WIC Population, by Category of Nutrition Risk,   338 8-2   Committee Recommendations for Changes in Risk Criteria,   347 FIGURES S-1   WIC program components, services, benefits, and projected outcomes,   2 1-1   WIC program components, services, benefits, and projected outcomes,   26