1
Overview

The Special Supplemental Nutrition Program for Women, Infants, and Children (the WIC program; originally the Special Supplemental Food Program for Women, Infants, and Children) provides supplemental foods, nutrition education, and social service and health care referrals to five categories of low-income individuals (categorical criteria): pregnant, breastfeeding, and postpartum women, infants (0 through 12 months of age), and children (13 months up to 5 years of age) if they are identified at nutrition risk. The WIC program is based on the premise that many low-income people are at risk of poor nutrition and health outcomes because of insufficient nutrition during the critical growth and developmental periods of pregnancy, infancy, and early childhood. The WIC program is a supplemental food and nutrition program to help meet the special needs of low-income women, infants, and children during these periods.

In addition to categorical criteria and income standards, eligibility for participation in the WIC program requires evidence of nutrition risk. To become a participant, each applicant must be determined to be at nutrition risk on the basis of a medical or nutrition assessment conducted by a competent professional authority such as a physician, physician assistant, nutritionist, dietitian, nurse, or state or locally medically trained health official (7 CFR Subpart A, Section 246.2). Public Law 94-105 broadly defines nutrition risk as "(a) detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measures, (b) other documented nutritionally related medical conditions, (c) dietary deficiencies that impair or endanger health, or (d) conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical



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--> 1 Overview The Special Supplemental Nutrition Program for Women, Infants, and Children (the WIC program; originally the Special Supplemental Food Program for Women, Infants, and Children) provides supplemental foods, nutrition education, and social service and health care referrals to five categories of low-income individuals (categorical criteria): pregnant, breastfeeding, and postpartum women, infants (0 through 12 months of age), and children (13 months up to 5 years of age) if they are identified at nutrition risk. The WIC program is based on the premise that many low-income people are at risk of poor nutrition and health outcomes because of insufficient nutrition during the critical growth and developmental periods of pregnancy, infancy, and early childhood. The WIC program is a supplemental food and nutrition program to help meet the special needs of low-income women, infants, and children during these periods. In addition to categorical criteria and income standards, eligibility for participation in the WIC program requires evidence of nutrition risk. To become a participant, each applicant must be determined to be at nutrition risk on the basis of a medical or nutrition assessment conducted by a competent professional authority such as a physician, physician assistant, nutritionist, dietitian, nurse, or state or locally medically trained health official (7 CFR Subpart A, Section 246.2). Public Law 94-105 broadly defines nutrition risk as "(a) detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measures, (b) other documented nutritionally related medical conditions, (c) dietary deficiencies that impair or endanger health, or (d) conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical

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--> conditions." Each state, territorial, or tribal WIC agency uses specific criteria for nutrition risk assessment within these guidelines.1 The criteria (nutrition risk indicators and their cutoff points) used for nutrition risk assessments vary widely across states. Over the years, concerns have been expressed about this variation and the resulting potential for unequal access to the program on the basis of geographic residence (GAO, 1979, 1980; USDA, 1986). As a result, the U.S. Congress in 1989 mandated that the U.S. Department of Agriculture (USDA), in consultation with state WIC agency directors and other nutrition experts, conduct a review of the nutrition risk criteria used by the WIC program (Public Law 101-147). USDA then reviewed a selected group of 14 existing nutrition risk criteria and published a compilation of these reviews in 1991 to fulfill this legislative mandate (USDA, 1991). In its 1992 report, the National Advisory Council on Maternal, Infant, and Fetal Nutrition commented on the 1991 reviews and made recommendations regarding existing nutrition risk criteria. In particular, it recommended that homelessness, migrancy, and alcohol and drug abuse be included as independent nutrition risk criteria (USDA, 1992). Charge To The Committee With continued concern over the variation among nutrition risk criteria across state WIC programs, the Food and Nutrition Service (FNS; now the food and Consumer Service [FCS], USDA) requested that the Institute of Medicine (IOM) review the scientific basis for the nutrition risk criteria used in the WIC program. In October 1993, the Food and Nutrition Board of the IOM established the Committee on the Scientific Evaluation of WIC Nutrition Risk Criteria. The committee was charged with conducting a study to include the following: Performing a critical review of the literature surrounding the various nutrition risk criteria used by the WIC program. Developing scientific consensus (where possible) regarding the nutrition risk criteria used by the WIC program, taking into account the preventive nature of the program. Identifying specific segments of the WIC population at risk for each criterion. Identifying gaps in the scientific knowledge base for current nutrition risk criteria used by the WIC program. 1   Throughout this report, the generic terms state WIC agency and state agency are used to denote programs or program requirements that apply uniformly to state, territorial, or tribal WIC programs.

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--> Formulating recommendations regarding appropriate criteria and, if applicable, recommendations of numerical values for determining who is at risk for each criterion. Identifying critical areas for future research. Identifying the practicality of consensus recommendations for nutrition risk criteria for the variety of WIC program delivery settings. This report responds to these tasks. The Wic Program Program Benefits The WIC program is a broad-based and comprehensive food and nutrition program providing three main benefits to participants: (1) supplemental foods, (2) nutrition education, and (3) referrals to health care and social service providers. The WIC program serves as an adjunct to available health care to prevent the occurrence of nutrition-related health problems and to improve the health status of participants. Thus, in standard public health terms, the WIC program serves as both a secondary prevention and tertiary prevention program by providing risk appraisal and risk reduction (secondary prevention) and by providing treatment or rehabilitation to individuals with a diagnosed health condition (tertiary prevention) (Kaufman, 1990). The structure of the program's components is shown in Figure 1-1 and includes the following anticipated benefits: For pregnant women, the WIC food supplements are expected to improve their nutrition status during pregnancy, which, in turn, is expected to improve pregnancy outcomes and enhance the nutrition status of both mother and infant. For breastfeeding women, the WIC food supplements (basic or enhanced breastfeeding food packages) are expected to provide nutrients to meet the special dietary needs of mothers who are breastfeeding, improve lactation performance, and enhance the nutrition status of both mother and infant. For nonbreastfeeding, postpartum women, the WIC food supplements are expected to improve their nutrition status, thus reducing the incidence of health problems associated with the physical demands of the postpartum period and improving health and nutrition status during the interconceptional period. For infants and children, the WIC food supplements are expected to reduce the prevalence of iron deficiency anemia, improve diets, and improve physical and mental growth and development.

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--> FIGURE 1-1 WIC program components, services, benefits, and projected outcomes.

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--> The nutrition education component of the WIC program is expected to stress the relationship between nutrition and good health, with special emphasis on the needs of pregnant, postpartum, and breastfeeding women, infants, and children under 5 years of age; to assist individuals at nutrition risk in achieving positive changes in food habits; and to take into account ethnic, cultural, and geographic food preferences. Referrals to health care providers are expected to promote good health care among participants. For pregnant women, the health care referral system is expected to increase their use of prenatal and postpartum care; for breastfeeding and postpartum women, infants, and children, the WIC program is expected to facilitate their access to routine preventive as well as other health care services, such as immunization, family planning, smoking cessation, and drug treatment and counseling programs. Social service referrals to substance abuse treatment and counseling, housing assistance, Medicaid, Aid to Families with Dependent Children (AFDC), and food stamps are expected to aid in addressing the full range of the health and nutrition needs of low-income women and their children. Supplemental food is provided in the form of food or, more commonly, a food instrument (either a voucher or a check) that can be used to purchase food in a store. The food instrument identifies the quantities of specific foods, including brand names, that can be redeemed with that instrument. WIC food packages include various combinations of iron-fortified infant formula or milk and cheese, eggs, iron-fortified adult or infant cereals, fruit or vegetable juices rich in vitamin C, and dried peas or beans and peanut butter. The food packages contain food sources of specific nutrients that are assumed to be lacking in the diets of the population potentially eligible to participate in the WIC program: protein, vitamin A, vitamin C, calcium, and iron. WIC program regulations require tailored food packages that provide specified types and amounts of food appropriate for seven categories of participants: (1) infants from birth to 3 months of age, (2) infants from 4 to 12 months of age, (3) women, infants, and children with special dietary needs, (4) children from 1 year of age to the 5th birthday, (5) pregnant women, (6) postpartum nonbreastfeeding mothers, and (7) breastfeeding mothers (basic or enhanced food package). The amounts and types of food in each package vary by type of recipient (e.g., breastfeeding versus nonbreastfeeding mothers) and their individual nutrition need. USDA regulations specify the maximum amounts for each food package. Competent professional authorities at the local level tailor WIC food packages to meet specific individual needs, based on guidance from state WIC agencies. Special formulas or medical foods may be provided if medically indicated for infants, children, and women with special dietary needs. Monthly food packages for infants who are not being breastfed may contain up to 403 fluid ounces of concentrated, liquid, iron-fortified infant formula (or

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--> powdered or ready-to-feed formula in equivalent amounts), 24 ounces of dry iron-fortified infant cereal, and 63 fluid ounces of vitamin C-rich infant juice (or equivalent amounts of adult-strength fluid or concentrated juice). Monthly food packages for pregnant and breastfeeding women may contain up to 28 quarts of fluid milk (with substitutions allowed for cheese and evaporated, skim, or dry milk), 2.5 dozen eggs (or egg powder), 36 ounces of dry, iron-fortified cereal, 276 ounces of fluid vitamin C-rich juice, and either 1 pound of dried beans or peas or 18 ounces of peanut butter. Children 1 to 5 years of age receive the same foods (and allowable substitutions as stated above) in the same quantities except for fluid milk (up to 24 quarts). The enhanced food package for breastfeeding women adds cheese (1 pound) in addition to fluid milk, provides more juice (a total of 322-336 fluid ounces), includes both dried beans or peas and peanut butter, adds 26 ounces of canned tuna fish, and adds fresh, frozen, or canned carrots (2 pounds fresh or frozen or two 16- to 20-ounce cans). The WIC program also provides nutrition education to improve the nutrition status of participants. Local agencies must spend at least one-sixth of WIC program administrative funds on nutrition education and counseling. WIC agencies must offer at least two nutrition education sessions to a participating woman in each 6-month certification period. However, participants cannot be denied food supplements if they do not attend the specified nutrition education sessions. Programs to promote breastfeeding and to foster successful lactation performance are an important part of the WIC program's nutrition education efforts, and program resources are specifically earmarked for this purpose. Federal funds designated for WIC nutrition services and program administration may be used to purchase breastfeeding aids such as breast pumps for use by breastfeeding women. To qualify as a provider of WIC program services, the local agency must arrange for health care services to be available and accessible to low-income women, infants, and children. The WIC program advises clients about the types of health care available, the locations of health care facilities, how they can receive health care, and why it is beneficial. Many WIC program service sites are located at or adjacent to public health clinics. In summary, the overarching goal of the WIC program is to improve the nutrition and health status of women, infants, and children, which in turn should improve pregnancy outcomes and promote optimal child growth and development. Although supplemental food assistance is the cornerstone of the WIC program, nutrition education and health care and social service referrals are also integral components of benefit to WIC participants.

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--> WIC Program Eligibility Criteria Eligibility for participation in the WIC program is based on categorical criteria, income criteria, and evidence of nutrition risk. To be eligible on the basis of the categorical criteria, an individual must be either (1) a pregnant woman, (2) a breastfeeding woman less than 1 year postpartum, (3) a nonbreastfeeding, postpartum woman up to 6 months after delivery, (4) an infant up to 1 year of age, or (5) a child 1 year of age to the 5th birthday. States have the option of setting eligibility on the basis of income at the income level required to obtain free or reduced-price health services, provided that the income levels used range from between 100 and 185 percent of the federal poverty level. Nearly all states currently use income at 185 percent of the poverty level as the eligibility threshold on the basis of income. Some states have given their local agencies authority to set their own income eligibility thresholds, within the 100 to 185 percent range (if they use lower income eligibility thresholds for free or reduced-price health care in their local areas), and to use weekly, monthly, or annual income as the basis for eligibility. In addition, categorically eligible individuals can become income eligible for participation in the WIC program through participation in the Medicaid, Food Stamps, or Aid to Families with Dependent Children programs (known as adjunct or automatic eligibility). The participant must be determined to be at nutrition risk on the basis of a medical or nutrition assessment by a competent professional, such as a physician, a nutritionist, a nurse, or some other health professional. Each state WIC agency establishes and uses specific assessment criteria for nutrition risk within federal guidelines. The minimum information that must be collected on each WIC program participant includes: height (length for infants), weight, and results from a blood test for iron deficiency anemia (infants younger than 6 months are exempt from the blood test). Eligibility can be determined on the basis of data collected at the local agency or with referral data from a competent professional not on staff at the local agency. The cutoff values used to determine nutrition risk vary widely across states. Legislative and Programmatic History of the WIC Program By the late 1960s, the federal focus on feeding low-income Americans had expanded dramatically to reflect the decade's War on Poverty programs, and policymakers were becoming more interested in the relationship between nutrition and health. School food programs, commonly referred to as school ''feeding" programs, began to be called child "nutrition" programs following enactment of the Child Nutrition Act of 1966.

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--> More emphasis on diet, nutrition, and health followed the publication of the final report of the White House Conference on Food, Nutrition, and Health (WHC, 1970). In 1969, largely in response to growing concerns about malnutrition and related health problems among low-income pregnant women and children, and because of the political pressures generated by the 1968 Poor People's Campaign, USDA began what was later to be called the Commodity Supplemental Food Program. This program provided free, government-purchased commodities to low-income, nutritionally at-risk pregnant women, new mothers, and children under 6 years of age. At approximately the same time, physicians began to notice an increase in the number of young, pregnant women or mothers and infants arriving at public health clinics who, after clinical examination, were determined to have a variety of symptoms but no overt evidence of disease (Leonard, 1994). These patients' primary complaint was a lack of food for their families. In 1968, a group including community-based public health physicians; staff of the Bureau of Women and Children of the then U.S. Department of Health, Education, and Welfare; and staff of the then Consumer and Marketing Service, USDA, met to discuss the problem. The suggestion was made to build food commissaries attached to neighborhood health clinics and to stock them with commodity foods and infant formula. Food prescribed via vouchers by clinic physicians or staff would provide low-income women, infants, and children with a supplemental food package at the same time that they received health care services. USDA opened a demonstration commissary-clinic in Atlanta, Georgia, in the fall of 1968. Later, another health clinic-food distribution program began in Baltimore, Maryland, through the Johns Hopkins University School of Medicine. Expansion of these demonstration projects was given statutory authority by the U.S. Congress in 1972 (Public Law 92-433). Thus, the WIC program officially began as a 2-year pilot program linking health care to food assistance for low-income pregnant women, nursing mothers, infants, and preschool-age children considered to be at health risk because of poor nutrition. It was authorized under Section 17 of the Child Nutrition Act and was to supplement the Food Stamp Program and two other smaller programs that served similar target groups. The WIC program made cash grants to state health departments or comparable health agencies for distribution to the local agencies operating the programs. During the initial years, eligible recipients were low-income pregnant and postpartum women, infants (to age 1 year), and children (ages 1 to 4 years) who were determined by competent professionals to be at nutrition risk because of inadequate nutrition and inadequate income. Participants received specified food items either directly by picking them up at WIC centers or through home delivery, or by using coupons or vouchers to redeem specific food items at local grocery stores. Recipients had to live in areas that were served by clinics or other health facilities that had been determined to have significant numbers of

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--> infants and pregnant and postpartum women at nutrition risk. The 1972 law also required that the benefits of the program be evaluated and reported to Congress. A special task force was established to design the program, and on July 11, 1973, this task force published initial regulations. These regulations required local clinics to apply for WIC program grants through their state departments of health. The USDA's Food and Nutrition Service designed the eligibility criteria used by state agencies for participants and the contents of the monthly supplemental food package (i.e., the kinds and amounts of food). Between August and December 1973, a total of 216 WIC programs were approved. National Expansion The WIC program's legislative history shows an increasing focus on the preventive nature of the WIC program. The 1975 Amendments to the National School Lunch Act of 1946 and the Child Nutrition Act of 1966 restated the WIC program's purpose: "to provide supplemental nutritious food as an adjunct to good health care during such critical times of growth and development in order to prevent the occurrence of health problems" (Public Law 94-105). These amendments also liberalized eligibility, extending the period for breastfeeding mothers to 1 year postpartum and that for nonbreastfeeding mothers to 6 months postpartum, and raising the age limit for children from the fourth birthday to the fifth birthday. In addition, the law provided for a National Advisory Council on Maternal, Infant, and Fetal Nutrition, with members to be appointed by the Secretary of Agriculture. The 1978 amendments further reinforced the preventive focus of the WIC program by amending the purpose to add "to prevent the occurrence of health problems and improve the health status of these persons" (Public Law 95-627). The 1978 law reiterated the earlier provision requiring nutrition risk determination by specifying that individuals would not be eligible solely on the basis of low-income but also had to exhibit evidence of nutrition risk, as determined by a competent professional authority. State agencies were given the responsibility to include in their state plans a description of the methods used to determine nutrition risk. Maximum income levels for eligibility in the WIC program were set by the 1978 amendments. Previously, the law was silent on this issue, but by regulation USDA had set the income limit for eligibility at the same level as that locally determined for eligibility to receive free or reduced-price health care. (In most cases, states set this level at between 100 and 200 percent of the poverty level.) The 1978 law set the income ceiling for eligibility for participation in the WIC program at the ceiling used for eligibility for reduced-price school meals under the National School Lunch Act (Public Law 79-396); the ceiling was then

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--> 195 percent of the Secretary of Agriculture's income poverty guidelines, adjusted annually to reflect changes in the Consumer Price Index. Subsequent to the 1978 law, USDA changed its regulations, permitting states to set income criteria for eligibility in local WIC agencies at the same levels as those set for free or reduced-price health care, provided these were no higher than the income level set for reduced-price school lunches and no lower than 100 percent of the poverty guidelines published by the U.S. Department of Health and Human Services (Federal Register, February 10, 1994, 59(28): 6277–6278). Other Programmatic and Administrative Changes During the 1970s In an effort to increase the nutrition education component of the WIC program, the 1978 amendments required the Secretary of Agriculture to ensure that nutrition education be provided to all adult participants in the WIC program. It required the state agency to provide training to the individuals who provided such nutrition education and to use not less than one-sixth of federal administrative funds for nutrition education activities. State agencies were also required to evaluate annually their nutrition education programs and to provide nutrition education materials in relevant non-English languages in areas with substantial non-English-speaking, low-income populations. A competent professional (e.g., physician, nutritionist, dietitian, or registered nurse) was made responsible for both certifying nutrition need and prescribing the appropriate foods to be provided to participants. The Secretary of Agriculture was required to issue regulations on the types of supplemental food that could be made available through the WIC program. To the degree possible, the Secretary was directed to ensure that the fat, sugar, and salt contents of foods be appropriate. Programmatic and Administrative Changes During the 1980s The Omnibus Budget Reconciliation Act (OBRA) of 1980 included a provision extending funding authority for the WIC program through fiscal year (FY) 1984 and changing the authorization from a specified ceiling to the amount approved through the annual appropriations process (Public Law 96-499). The OBRA of 1981 (Public Law 97-35) reduced the maximum income levels that states could use to define eligibility for WIC program participation by lowering the income level for eligibility for reduced-price school lunches from 195 to 185 percent of the poverty guidelines. This law also reduced the number of required items that states had to include in their annual program plan in order to receive WIC program funds.

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--> The Hunger Prevention Act of 1988 added new provisions for the WIC program dealing with service to homeless people. These provisions require coordination among local agencies to provide outreach to eligible homeless mothers, infants, and children as part of each state's WIC program plan. They also permit states to adopt methods for the delivery of benefits to homeless people and to adapt WIC food packages to meet the special needs of homeless participants. This law also added a demonstration project that provided for 3-year grant awards to 10 states to assist them to implement and operate a program that gave coupons, with a value of up to $20 annually, to WIC program participants to redeem for fresh fruits and vegetables at local farmers' markets. Programmatic and Administrative Changes During the 1990s The Healthy Meals for Healthy Americans Act of 1994 (Public Law 103-488) reauthorized the WIC program through FY 1998 and established several provisions to improve program management and accessibility. The legislation officially changed the name of the WIC program to the Special Supplemental Nutrition Program for Women, Infants, and Children. It also provided state WIC agencies the option of allowing pregnant women who meet the income standards for eligibility to be temporarily eligible to participate in the program and to receive immediate certification for participation in the program. Full determination of nutrition risk for such women would follow within 60 days and benefits would be discontinued if it was shown that the pregnant woman did not meet the eligibility criteria for nutrition risk. In April 1995, USDA published final rules incorporating homelessness and migrancy as nutrition risk conditions. The regulation also codified the name change included in the Healthy Meals for Healthy Americans Act and modified the definition of nutrition risk to include more medical and health conditions previously categorized as predisposing nutrition risks as direct nutrition risks (Federal Register, April 19, 1995, 60(75):19,487–19,491). Program Size The WIC program operates in each of the 50 states, the District of Columbia, Puerto Rico, Guam, the American Virgin Islands, and 33 American Indian tribal organizations. In total, the WIC program is operated through more than 2,000 local agencies and more than 10,000 service sites nationwide. During 1995, the program was expected to serve an average of 6.8 million women, infants, and children. USDA estimated that 7.5 million people were eligible for participation in the WIC program in 1984 (USDA, 1987). Actually participating in the WIC program in 1984 were 3.05 million women, infants, and children, or 40 percent

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--> of those estimated to be eligible. Although the WIC program served only about 40 percent of eligible participants in 1984, it served considerably larger proportions of the high-risk and very-low-income populations eligible to participate in the program. Among those being served, the WIC program was found to target its services best among the groups designated for higher priority service. The Congressional Budget Office estimated that it would have cost a total of $3.75 billion in FY 1992 to serve all of those eligible and likely to apply for the program. This would have required $1.15 billion (44 percent) more than the $2.6 billion actually appropriated for the program in FY 1992. The WIC program has been one of the fastest growing of the federal nutrition programs. Federal WIC program funding nearly quadrupled between 1980 and 1993, rising from about $725 million in FY 1980 to more than $2.8 billion in FY 1993. During that same period, total participation rose from 1.9 million to 5.9 million individuals (see Table 1-1). The average monthly food benefit doubled between 1974 and 1984. In 1989, following legislative mandates that required states to implement competitive bids for infant formula, average food package costs declined somewhat from a high of $33 per month and stabilized at approximately $30 per month. Overview of The Report and The Committee Process The first three chapters of this report cover an overview of the committee's task, the relationship of low-income to nutrition risk, and principles for defining nutrition risk, respectively. Chapters 4 through 7 examine the scientific basis for WIC nutrition risk criteria: a description of each risk criterion, the prevalence of the condition in the U.S. population and WIC participants (if available), factors associated with the condition, the criterion as an indicator of nutrition and health risk, the criterion as an indicator of nutrition and health benefit, the use of the risk criterion in the WIC program setting, and the committee's recommendation for each risk criterion. Chapter 8 provides the committee's conclusions and recommendations. The committee met five times, held many conference calls, conducted two public meetings (see Appendixes A and B for detailed information), made site visits to local WIC program clinics, and exchanged much written information. The USDA's FCS provided a wealth of programmatic information to the committee through formal presentations and written materials. The committee began by reviewing the WIC program. It obtained a list of nutrition risk criteria used by WIC state agencies in 1992. This list is considerably more detailed than both the risks specified by federal regulation and the prioritized list of risk criteria provided by FCS (see Appendix C). The committee examined more than 74 nutrition risk criteria, categorized into anthropometric,

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--> TABLE 1-1 WIC Program Participation by Subgroup and Federal Costs, 1974-1993 Number of Participants (thousands) Federal Cost (millions) Fiscal Year Women Infants Children Totala Average Monthly Food Benefit/Person Current Dollarsb Constant 1992 Dollarsc 1974 17 26 44 88 15.68 9.90 — 1975 55 103 186 344 18.58 82.80 — 1976 81 148 291 520 19.60 142.50 — 1977 165 213 471 848 20.80 255.90 597.10 1978 240 308 633 1,181 21.99 379.60 827.50 1979 312 389 782 1,483 24.09 525.40 1,039.60 1980 411 507 995 1,913 25.43 724.70 1,261.90 1981 446 585 1,088 2,119 27.84 874.40 1,370.10 1982 478 623 1,088 2,189 28.83 948.20 1,384.50 1983 542 730 1,265 2,537 29.62 1,123.10 1,583.50 1984 657 825 1,563 3,045 30.58 1,386.30 1,876.70 1985 655 874 1,600 3,138 31.69 1,488.90 1,945.60 1986 712 945 1,665 3,312 31.82 1,580.50 2,014.30 1987 751 1,019 1,660 3,429 32.68 1,663.60 2,016.70 1988 815 1,095 1,683 3,593 33.28 1,802.40 2,145.90 1989 952 1,260 1,907 4,118 30.14 1,929.40 2,192.20 1990 1,035 1,413 2,069 4,517 30.20 2,125.90 2,301.00 1991 1,120 1,559 2,214 4,893 29.84 2,301.10 2,370.90 1992 1,221 1,684 2,505 5,411 30.20 2,566.50 2,566.50 1993 1,365 1,742 2,813 5,920 29.77 2,819.50 2,737.00 aTotal participation may not equal sum of categories because of rounding. bIncludes funding for WIC studies, surveys, and pilot projects. cConstant dollars were calculated using the FY 1992 CPI-U (Consumer Price Index-Universal). SOURCE: USDA (1994).

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--> pometric, biochemical and medical, dietary, and predisposing risks. The committee conducted bibliographic searches of the scientific literature and critically reviewed research findings surrounding risk criteria. In reviewing each nutrition risk criterion, the committee examined two issues: the risk criterion as an indicator of nutrition and health risk and the risk criterion as an indicator of health and nutrition benefit from participation in the WIC program, as explained in detail in Chapter 3. The potential to benefit from the services provided by the WIC program is a key feature of the committee's approach. This approach differs from the approach that has guided the development of risk criteria used by WIC programs: assessing poor outcomes only. The application of the concept of potential to benefit moves the program focus from curative (tertiary prevention) to risk reduction (secondary prevention). Utilizing such an approach can provide for more efficient targeting of the scarce resources available to the WIC program and also improve outcomes. The committee did not specifically examine two nutrition risk criteria used to certify infants for the WIC program: (1) breastfeeding mother and infant dyad and (2) infant of a mother eligible for the WIC program or of a mother at nutrition risk during pregnancy. Together, these two risk criteria account for 78 percent of all infants certified for the WIC program (Randall and Boast, 1994). Because of their nature, however, these two nutrition risk criteria do not fit with either the charge to the committee or the framework used to assess the WIC nutrition risk criteria. Specifically, these two risk criteria do not have a scientific literature that examines the nutrition and health risks associated with these conditions. in practice, these two criteria implicitly serve to certify nearly all income-eligible infants. Thus, Chapter 2 of this report, which examines the relationship between poverty and nutrition risk, may be viewed, in part, as presenting the nutrition and health risks for infants certified on the basis of either a breastfeeding mother or a mother eligible or participating in the WIC program during pregnancy. Moreover, the evidence presented in Chapter 2 on the effectiveness of the WIC program for infants can be used to infer the degree to which these two risk criteria for infants serve as indicators of health and nutrition benefit from the WIC program. Throughout its work, the committee faced a number of limitations regarding the use of currently available data on nutrition risks in the WIC program setting. The scientific literature addressing the anthropometric, biomedical and medical, dietary, and predisposing risks for poor nutrition and health status among women, infants, and children is imperfect and incomplete. Interpretation of studies is a challenge because of the difficulty of obtaining accurate and reliable estimates of nutrition status. Furthermore, during reproduction, growth, and development, the effect of a nutritional insult may be based on its timing or severity, but the critical time frame may not be understood. Health outcomes related to pregnancy, lactation, and growth are difficult to measure accurately and reliably. Even if measurements of excellent quality could be obtained, the complex

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--> interrelationships between genetic, social, cultural, economic, and nutrition factors make it difficult to isolate the independent effect of nutrition on human health and development. Non-nutrition-related variables need to be controlled or otherwise considered when studies are conducted or analyzed, but often they are not. These limitations made it especially important for the committee to develop a clear framework for its decision-making process. This framework is presented at the end of Chapter 3. Many of the studies assessing an indicator of nutrition and health risk were observational and could identify associations but not causal relationships. However, carefully designed observational studies that control for confounding variables and that have adequate sample sizes can serve as excellent sources of understanding about how medical, anthropometric, dietary, and predisposing factors are associated with nutrition and health status. Well-controlled, randomized experiments that intervene to improve nutrition status in pregnant or lactating mothers, infants, or children provide the best opportunity to test causal relationships and assess indicators of nutrition and health benefit. However, that type of study is usually extremely expensive, complex to design, and difficult to carry out in the field. A variety of problems can influence their results and the interpretation of those results. For example, the food supplement may replace part of the diet rather than supplement it, the length of treatment may be too short, the timing of supplementation may be inappropriate, or the composition or quantity of the supplementation may not be correctly related to the degree of poor nutrition. In addition, problems with compliance, loss to follow-up, unanticipated interventions in the control group, and other sources of inconsistency and bias can limit the ability to interpret study results. Finally, it may not be feasible to conduct controlled studies in the populations with the highest likelihood of responding. Nevertheless, the available studies attempting to control for nondiet factors form the backbone of researchers' understanding of nutrition intervention and, when available, were emphasized in the reviews. Names, definitions, and cutoff points used with nutrition risk criteria vary substantially across research studies, and these made comparison of results a difficult task. Additionally, the committee identified few studies that attempted to quantify the efficacy of a particular indicator of nutrition risk or benefit, for example, by examining its yield or sensitivity as an assessment variable (see Chapter 3). Estimates of the prevalence of many of the conditions that pose nutrition or health risks among the WIC program population or the population eligible for participation in the WIC program were not easy to obtain. Little of the available literature specifically addressed the WIC program population. For many nutrition risk indicators, the only data available were from populations outside of the United States with substantially higher prevalences of undernutrition, and the relevance of these studies to the WIC program population had to be considered.

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--> When WIC program evaluations or other studies of WIC program populations were available, they focused almost entirely on perinatal outcomes; on the whole, data on lactating or postpartum women, infants, or children were lacking. Studies of the WIC program addressing perinatal outcomes almost exclusively addressed birth outcomes, such as birth weight. Thus, those studies did not contribute information about the impact of the WIC program on indicators such as hematocrit concentration or maternal weight gain, nor were data available to address how subgroups of women with such problems as homelessness or substance abuse respond to WIC program interventions. The public meetings were designed to solicit information from WIC program administrators, staff, and participants as well as from researchers in the fields related to the nutrition risk criteria under study (see Appendixes A and B). Through the public meetings and visits to WIC program clinics, the committee obtained valuable information about the use of nutrition risk criteria in WIC clinics, the methods of conducting nutrition assessments and determining appropriate nutrition and health interventions, and practical considerations. The presentations made at the public meetings also provided the committee with information about the nutrition risk criteria being developed by some states or criteria that had been disallowed by the FCS. References GAO (U.S. General Accounting Office). 1979. Special Supplemental Food Program for Women, Infants, and Children (WIC). Pub. No. CED-79-55. Washington, D.C.: U.S. Government Printing Office. GAO (U.S. General Accounting Office). 1980. Better Management and More Resources Needed to Improve Federal Efforts to Improve Pregnancy Outcome. Pub. No. HRD-80-24. Washington, D.C.: U.S. Government Printing Office. Kaufman, M., ed. 1990. Nutrition in Public Health: A Handbook for Developing Programs and Services. Rockville, Md.: Aspen Publishers, Inc. Leonard, R. 1994. Recalling WIC program's 1960s humble beginnings. CNI Weekly Report 24(15):4–7. Randall, B., and L. Boast. 1994. Study of WIC Participant and Program Characteristics, 1992. Office of Analysis and Evaluation, food and Nutrition Service, U.S. Department of Agriculture. Washington, D.C.: U.S. Department of Agriculture. USDA (U.S. Department of Agriculture). 1986. 1986 Biennial Report on the Special Supplemental Food Program for Women, Infants and Children and on the Commodity Supplemental Food Program . National Advisory Council on Maternal, Infant, and Fetal Nutrition. Food and Nutrition Service. Washington, D.C.: USDA. USDA (U.S. Department of Agriculture). 1987. Estimation of Eligibility for the WIC Program: Report of the WIC Eligibility Study. Summary of Data, Methods, and Findings. Office of Analysis and Evaluation, Food and Nutrition Service. Contract No. 53-3198-3-138. Washington, D.C.: USDA.

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--> USDA (U.S. Department of Agriculture). 1991. Technical Papers: Review of WIC Nutritional Risk Criteria. Prepared for the Food and Nutrition Service by the Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson. Washington, D.C.: USDA. USDA (U.S. Department of Agriculture). 1992. 1992 Biennial Report on the Special Supplemental Food Program for Women, Infants and Children and on the Commodity Supplemental Food Program. National Advisory Council on Maternal, Infant, and Fetal Nutrition. Food and Nutrition Service. Washington, D.C.: USDA. USDA (U.S. Department of Agriculture). 1994. Annual Historical Review. Washington, D.C: USDA. WHC (White House Conference on Food, Nutrition, and Health). 1970. Final Report: White House Conference on Food, Nutrition, and Health. Washington, D.C.: U.S. Government Printing Office.

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