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--> 6 Dietary Risk Criteria The third category of nutrition risk criteria used in the WIC program (the Special Supplemental Nutrition Program for Women, Infants, and Children) is dietary deficiencies that impair or endanger health, such as inadequate dietary patterns assessed by a 24-hour dietary recall, dietary history, or food frequency checklist (7 CFR Subpart C, Section 246.7(e)(2)(iii)). In general, dietary risk criteria are used to certify pregnant and breastfeeding women and infants at nutrition risk as demonstrated by inadequate dietary pattern under priority IV, children under priority V, and nonbreastfeeding postpartum women under priority VI. For the WIC program to work most effectively to prevent the occurrence of overt problems of dietary origin, methods are needed to identify behaviors or conditions related to diet that can lead to overt nutrition problems. Dietary risk criteria are intended to do this. This chapter addresses the evidence that dietary risk criteria are valid indicators of nutrition and health risk and of an individual's potential to benefit from participation in the WIC program. In addition, the chapter addresses methods by which dietary risk is assessed in the WIC program setting and the validity of those assessments. Chapters 4 and 5 cover many of the adverse effects of dietary inadequacy. Dietary assessments are routinely carried out by all WIC programs as a basis for nutrition education—whether or not the assessments are used to certify an individual. These assessments provide a tool for individualizing nutrition education (and sometimes the food package itself and health care referrals). Thus, dietary assessment is an important part of the benefit package of the WIC program. The multiple roles of dietary assessment need to be considered
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--> because time and resources are expended in a dietary assessment. If its only role were in determining program eligibility, yield of benefit would be central. However, the dietary assessment has extra value since it forms an essential part of the intervention package. State and local WIC programs use a variety of criteria for dietary risk in the certification of participants. Most agencies report assessing dietary quality for women using categories of moderately inadequate, severely inadequate, deficient, or excessive for energy intake, nutrient intake, or food group consumption. Recently, some states have proposed the use of hunger of food insecurity as a dietary risk criterion. This chapter places dietary risks into three categories: (1) inappropriate dietary patterns, (2) inadequate diet, and (3) food insecurity. The first two categories are consistent with nutrition risk criteria specified by the WIC program. Food insecurity is a proposed new category. A list of the risk criteria used by state WIC agencies appears in Table 6-1. A summary of broad cate TABLE 6-1 Summary of Broad Dietary Risk Criteria in the WIC Program and Use by States States Usinga Risk Criterion Pregnant Women Infants Children Inappropriate dietary patterns — 44 48 Excessive consumption of sugar, fat, or sodium 11 — — Insufficient or excessive calories 14 — — Inappropriate use of nursing bottle — 27 28 Inappropriate introduction to solids/foods — 23 9 Excessive/insufficient vitamins/minerals 11 13 11 Excessive caffeine intake — — — Pica 33 20 22 Inadequate diet — 44 48 Moderately inadequate 42 — — Seriously inadequate 40 — — Food insecurity 1 1 1 NOTE: Dashes indicate that the criterion was not reported for that population. a Data for postpartum women were not readily available. SOURCE: Adapted from USDA (1994).
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--> gories of risk criteria as predictive of risk or benefit appears in Table 6-2. The names of some of the risk criteria used by this committee differ from some of those reported by state WIC agencies to increase specificity. Inappropriate Dietary Patterns As used by WIC state agencies, the term inappropriate dietary pattern encompasses many dietary risk criteria (see Table 6-1). These include overall descriptors of dietary patterns, developmentally or age-inappropriate patterns of feeding, and identification of the ingestion of specific inappropriate substances. This section addresses the major nutrition risk criteria for an inappropriate dietary pattern. Dietary Patterns That Fail to Meet Dietary Guidelines for Americans Dietary Guidelines for Americans (USDA/DHSS, 1995) is designed to help Americans over 2 years of age to consume diets that will meet nutrient requirements, promote health, support active lives, and reduce chronic disease risks. These guidelines suggest the following goals for daily fat intake: no more than 30 percent of total calories from fat, less than 10 percent of calories from saturated fat, less than 300 mg of cholesterol, and less fat from animal sources. The guidelines recommend using sugar in moderation and choosing a diet moderate in salt and sodium. The Food Guide Pyramid, which is incorporated in TABLE 6-2 Summary of Broad Dietary Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children Women Infants Children Risk Criteriona Risk Benefit Risk Benefit Risk Benefit Inappropriate diet ✓ ✓ ✓ ✓ Inappropriate infant feedinga ✓ ✓ Caffeine intake 0 ? ? ? Pica ✓ ? ✓ ✓ Inadequate diet ✓b ✓b ✓ ✓ ✓b ✓b Food insecurity ✓ ✓ ✓ ✓ ✓ ✓ NOTE: ✓ = predictive of risk or benefit; ? = no evidence; 0 = evidence, but no effect; blank = not applicable to that group. a Guidelines also apply to children 1 to 2 years of age. b Current assessment methods are inadequate for targeting.
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--> the Dietary Guidelines, recommends numbers of servings from each of five food groups. These recommendations include eating 6 to 11 servings of grain products; 3 to 5 servings of vegetables; 2 to 4 servings of fruits; 2 to 3 servings of meat, fish, poultry, or legumes; and 2 to 3 servings of milk products daily (USDA, 1995). Prevalence of Dietary Patterns That Fail to Meet Dietary Guidelines for Americans Information about dietary patterns of low-income women and children has been obtained using data from the second National Health and Nutrition Examination Survey (NHANES II), a nationally representative sample of individuals surveyed from 1976 to 1980 (USDA, 1987). In that study, a "food group deficiency" for the individual was defined as an average daily intake (in number of servings per day) of any one of the food groups that fell below the following cutoffs: Food Group Children Pregnant Women Bread and Cereals less than 4 less than 3 Fruits and Vegetables less than 4 less than 3 Milk and Dairy less than 3 less than 2 Meat and Protein less than 2 less than 1 By applying these cutoffs to data from a 24-hour recall and a weekly-food-frequency recall, almost 60 percent of low-income women ages 12 to 49 years and 43 percent of children ages 12 months to 5 years were identified as having a dietary risk (called an inappropriate dietary pattern). No strong age relationships were found, but women younger than 18 years had a slightly lower dietary risk than older women (56 versus 60 percent). In children, the prevalence of inappropriate dietary patterns increased steadily with age, from 40 percent of those ages 1 to 2 years to 46 percent of those ages 4 to 5 years. Using data from the 1989–1991 Continuing Surveys of Food Intakes by Individuals, Krebs-Smith and co-workers (1995) report a mean daily fruit and vegetable intake of 3.6 servings daily for individuals from households earning less than $10,000 per year, and increasing mean fruit and vegetable intake with increased household income. Over a 3-day period, 63 percent of individuals from households earning less than $10,000 per year consumed less than one serving of fruit per day, and 14 percent consumed less than one serving of vegetables per day. Other studies have focused on the degree to which individuals of all income levels follow the Dietary Guidelines for fat and cholesterol intake. For children,
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--> identification of fat and cholesterol intakes exceeding the Dietary Guidelines is relevant only for those ages 2 years and older (USDA, 1995). Data from Phase I of the third National Health and Nutrition Examination Survey (NHANES III) (McDowell et al., 1994; CDC, 1994) and from the 1987–1988 National Food Consumption Survey (Johnson et al., 1994) indicate that the mean fat intake (expressed as a percentage of total dietary energy intake) remains above the recommended 30 percent for women ages 12 to 49 years and for children ages 3 to 5 (approximately 34 and 33 percent, respectively) (Johnson et al., 1994; Kennedy and Goldberg, 1995), regardless of income. The data show slightly higher fat intakes (average 36 percent of energy) by non-Hispanic black women. Mean dietary cholesterol intakes for women and children were below the recommended daily consumption of 300 mg/day (McDowell et al., 1994); only 13 percent of children under 5 years had 3-day cholesterol intakes exceeding 300 mg. About one-quarter of children had daily sodium intakes in excess of the recommended 2,400 mg. Dietary Patterns That Fail to Meet Dietary Guidelines for Americans as an Indicator of Nutrition and Health Risk Women. Dietary patterns that fail to meet Dietary Guidelines may provide lower than recommended amounts of essential nutrients. The fewer the number of servings from a food group, the greater the chance that nutrient intake will not cover nutrient needs. Such dietary patterns are associated with long-term risk of chronic diseases that are ordinarily diagnosed in middle age. These risks, however, are real and profound (Pennington, 1991). Cardiovascular disease, primarily atherosclerotic heart disease, is the most prevalent cause of death among postmenopausal women. Hypertension, a clear risk factor for both heart disease and stroke, is aggravated by high sodium intakes in sodium-sensitive individuals. A large body of literature supports the conclusions that chronically high intakes of total fat, saturated fat, and cholesterol contribute to risk of cardiovascular disease, heart attack, and premature mortality and that the relatively lower risk of cardiovascular disease enjoyed by women compared to men essentially disappears after menopause. High fat intake may also increase risk of certain kinds of cancer, such as breast cancer and colon cancer (Clifford and Kramer, 1993). Low intake of fruits and vegetables is associated with increased risk of many types of cancer (Graham et al., 1991; Landa et al., 1994; Shibata et al., 1992; Steinmetz et al., 1994; Tavani and LaVecchia, 1995). Low intake of milk products may contribute to later risk of osteoporosis (NIH, 1994). These are active research areas.
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--> Children. As for women, dietary patterns that are low in basic food groups may provide lower than recommended nutrient intakes. Considerable controversy exists over the relevance to children of guidelines to reduce fat, saturated fat, and cholesterol consumption (Olson, 1995). Early concerns focused on case reports of the ill effects of overzealous restriction of dietary fat in children's diets by some health-conscious parents (Lifschitz and Moses, 1989; Pugliese et al., 1983). In those studies, the adverse effects on growth and nutrition status were likely due to failure to meet energy needs. Two recent studies addressed the adequacy of diets with fat intakes at a level of 30 percent of total calories for young children. One obtained multiple days of dietary data from 215 3- to 4-year-olds (Shea et al., 1993), and one studied 106 4-year-old Canadian children (Gibson et al., 1993). Both indicate that adequate energy intake, nutrient intake, and growth are quite possible with fat intakes at or slightly below 30 percent of total calories provided that low-fat dairy products are included in the diet. Children with high serum cholesterol concentrations tend to continue to have high concentrations as adults (Lauer and Clarke, 1990). Data from two studies (Newman et al., 1991; PDAY Research Group, 1990) indicate that the earliest development of atherosclerotic lesions of the aorta in children appears to be related to concentrations of low-density lipoprotein and very-low-density lipoprotein cholesterol. Data from the Bogalusa Heart Study indicate that children with higher serum cholesterol concentrations have significantly higher fat intakes than children with lower serum cholesterol concentrations (Nicklas et al., 1989). The American Heart Association, the National Cholesterol Education Program, and the American Academy of Pediatrics all agree that dietary fat intake for children over the age of 2 years should average 30 percent of total calories and should be coupled with adequate dietary energy for growth and activity (CN-AAP, 1992b; DHHS, 1991). Failure to Meet the Dietary Guidelines for Americans as an Indicator of Nutrition and Health Benefit Increasing intake of fruits (including juices) and vegetables is associated with increased intake of vitamins A, C, and folate as well as many other micronutrients important to growth, reproduction, and health. The standard WIC package provides the equivalent of about one serving of vitamin C-rich fruit juice daily. High intake of calcium-rich milk products may reduce risk of developing preeclampsia (Repke, 1994). Milk products make a major contribution to supplying the calcium and other nutrients needed for growth, pregnancy, and breastfeeding. The standard WIC package provides the equivalent of three or more servings of milk daily.
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--> Pregnancy and the early postpartum period may represent periods in women's lives when they are especially receptive to education and when they may be motivated to improve their own health and that of their families. However, the committee is aware of no studies that have addressed the effects of dietary change during pregnancy and the postpartum period on long-term dietary patterns in adult women. The opportunity to reach women with effective nutrition education can be used to provide and reinforce messages about the potential long-term health benefits of following the Dietary Guidelines and using the Food Pyramid (USDA, 1992). The benefits from assessment and education to improve the composition of the diet to more closely approximate the Dietary Guidelines (USDA, 1995) for children older than 2 years of age are less clear, but following the guidelines clearly promotes a healthful diet, and the WIC food package can help achieve that goal. Failure to Meet Dietary Guidelines for Americans as a Risk Indicator in the WIC Setting Table 6-1 lists some parts of Dietary Guidelines for Americans (e.g., excessive consumption of sugar, fat, or sodium) that are used as nutrition risk criteria by WIC state agencies. Many states use a food group approach and categorize shortfalls in food group intake as dietary inadequacies rather than as inappropriate diet. Tools and Cutoff Points to Assess Dietary Patterns That Fail to Meet the Dietary Guidelines for Americans In the WIC program, data on dietary patterns are usually derived from brief 24-hour recalls or questions about the frequency of intake of food groups (Gardner et al., 1991). It is relatively easy to hand-tally numbers of servings from food groups, to compare the results with the recommended number of servings, and to use the results in nutrition education tailored to WIC program participants. Results from two food group scoring methods suggest that screening diets for food group consumption provides meaningful information about their quality (Guthrie and Scheer, 1981; Kant et al., 1991; Krebs-Smith and Clark, 1989), but the committee could find no evidence on which to single out the most effective method of comparing intake with the Dietary Guidelines. The North Dakota WIC program adopted, as its standard dietary assessment method, a computerized food frequency questionnaire that provides information about food group consumption and an index of nutritional quality (J. R. Rice, North Dakota Department of Health, personal communication, 1995).
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--> Some evidence indicates that it is possible to identify dietary patterns with relatively high fat content through short assessment questionnaires. A number of investigators have developed and conducted validity studies on brief assessment instruments to identify individuals with high fat intakes (e.g., Ammerman et al., 1991; Block et al., 1989; Coates et al., 1995; Heller et al., 1981; Hopkins et al., 1989; Kinlay et al., 1991; Knapp et al., 1988; Kristal et al., 1989, 1990; Van Assema et al., 1992). Some of these are simplified, targeted food frequency-type instruments. Others focus on behaviors associated with fat intake. Scores obtained using these short questionnaires have compared favorably with estimates from multiple food records or more extensive questionnaires. The committee is not aware of similar short instruments for identifying high sodium intakes. However, a brief screen for fruit, vegetable, and fiber intake is available (Serdula et al., 1993). Cholesterol intake can be assessed with questions regarding the usual number of servings of the few concentrated sources of these compounds. In general, brief dietary assessment instruments offer significant time and cost advantages relative to traditional nutrient-based dietary approaches. Carefully designed instruments have often been shown to be as good as more complex methods in ranking individuals and identifying high or low levels of intake of a limited number of food groups or nutrients. They are, however, likely to be quite population specific, especially those that rely on eating and food preparation behaviors to identify extremes of intake (Thompson and Byers, 1994). Moreover, such instruments may have limited usefulness as nutrition education tools. Recommendations for Dietary Patterns That Fail to Meet Dietary Guidelines for Americans The risk of dietary patterns that fail to meet Dietary Guidelines is well documented for adults. The potential for benefit from participation in the WIC program is good on theoretical grounds. Therefore, the committee recommends use of failure to meet Dietary Guidelines as a nutrition risk criterion. The committee believes that any cutoff points would be arbitrary. The more generous the cutoff points, the higher the false positive rate and the lower the yield of benefit. In addition, the committee recommends research to develop practical dietary assessment instruments to identify those who fail to meet Dietary Guidelines and to test their validity in WIC program subgroups.
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--> Vegetarian Diets Vegetarian diets usually include at least a few kinds of foods of animal origin, most commonly eggs and dairy products. Vegan diets are complete vegetarian diets. That is, they exclude the use of animal foods of any type. Prevalence of Vegetarian Diets Liberal vegetarian diets are becoming much more common, with one survey finding 13.5 percent of U.S. households claiming at least one vegetarian member. This represents an eight-fold increase in vegetarianism between 1979 and 1992 (Johnston, 1994). The prevalence of vegans in the United States has been estimated from less than 1 percent (Vegetarian Resource Group, 1994) to as much as 5 to 6 percent (Johnston, 1994) of the population. The prevalence of adherence to various kinds of vegetarian diets among families with young children is not known. When the definition is restricted vegan diets, the prevalence is probably quite low. Vegetarian Diets as an Indicator of Nutrition and Health Risk Liberal vegetarian diets that include dairy products and eggs are generally high in essential nutrients and unlikely to pose health risks. In fact, vegetarian eating practices have been associated with good health (USDA, 1995). However, there is clear evidence that strict adherence to vegan diets places women and their infants at nutrition and health risk. Unless specially fortified foods are consumed, the diet lacks vitamins B12 and D, as reviewed in Nutrition During Lactation (IOM, 1991). Vitamin B12 deficiency has been found in breastfed infants of vegan mothers, and infants may develop clinical signs of deficiency before their mothers do. The more limited the diet, the greater the risk of serious nutrient deficiencies (Haddad, 1994). Inadequate energy intake may also occur if the diet is very high in bulk and low in fat. Children reared in strict vegan families that permit no animal products at all are at risk of poor growth and, in northern parts of the United States, where insufficient exposure to sunlight may occur, vitamin D-deficiency rickets (Dwyer, 1991). Other nutrient deficiencies include vitamin B12 and sometimes calcium.
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--> Vegetarian Diets as an Indicator of Nutrition and Health Benefit Education is the principal intervention for most women and children at risk because of a vegan eating pattern. The eggs, milk, and cheese in the food package would not be consumed. Tools and Cutoff Points to Assess Vegetarian Diets Vegetarian and/or vegan diets in women and children can be assessed by asking a few well-targeted questions. Recommendation for Vegetarian Diets The risk from unfortified vegan diets is well documented. The potential to benefit from participation in the WIC program is expected to be good on theoretical grounds. Therefore, the committee recommends use of vegan dietary practices as a nutrition risk criterion for women, infants, and children. Highly Restrictive Diets Highly restrictive diets are diets that are very low in calories, that severely limit intake of important food sources of nutrients (e.g., fruit and nut diets), or otherwise involve high-risk eating patterns. A vegan diet is a type of restrictive diet that is covered in the previous section. Prevalence of Highly Restrictive Diets The prevalence of highly restrictive diets was unavailable to the committee but is believed to be quite low. Highly Restrictive Diets as an Indicator of Nutrition and Health Risk Highly restrictive diets severely limit nutrient intake, may interfere with growth if taken regularly, and, if very low in calories, may lead to a number of adverse physiological effects. Highly restrictive diets pose particular risks during pregnancy and lactation (IOM, 1990, 1991). For example, regular intake of fewer than 1,500 kcal may impair the milk production of lactating women (Strode et al., 1986).
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--> Highly Restrictive Diets as an Indicator of Nutrition and Health Benefit Given the clear health and nutrition risks associated with highly restrictive diets and the motivation of most women to optimize their own and their infant's health during the critical periods targeted by the WIC program, one might predict a good potential for benefit from WIC program participation. Essentially no evidence in the published literature supports this conclusion, however, perhaps because the prevalence of the patterns mentioned is low enough to make systematic study difficult. Tools and Cutoff Points to Assess Highly Restrictive Diets Several conditions indicating highly restrictive diets in women are assessed by asking a few well-targeted questions (e.g., see IOM, 1992). Dieting is so prevalent among U.S. women that it likely requires some specific probing to identify high-risk behaviors such as prolonged fasting, purging, or very low calorie diets. Recommendation for Highly Restrictive Diets There is theoretical evidence that highly restrictive diets pose health and nutrition risks. Potential for benefit from participation in the WIC program is expected to be good on theoretical grounds. Therefore, the committee recommends use of highly restrictive diets as a risk criterion in the WIC program. Inappropriate Infant Feeding Infant feeding practices include breastfeeding habits, the type of formula or milk fed, and the timing and contents of the supplemental foods and fluids introduced. The Committee on Nutrition of the American Academy of Pediatrics (CN-AAP) has set forth recommendations for feeding healthy infants (CN-AAP, 1980, 1992a, 1993), which are summarized briefly below. During infancy, breast milk or an appropriate formula is the major source of nutrients. Breastfeeding is the preferred method of feeding infants (CN-AAP, 1993; IOM, 1991). Pediatricians and family physicians generally recommend the use of iron-fortified formulas if infants are fed formula (Fomon, 1993). American Academy of Pediatrics guidelines help breastfeeding mothers know that they are providing sufficient milk for their baby's health and growth (CN-AAP, 1993).
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