WIC Nutrition Risk Criteria: A Scientific Assessment (1996)

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DIETARY RISK CRITERIA 251 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 

DIETARY RISK CRITERIA 252 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 11 — — sodium 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). 

DIETARY RISK CRITERIA 253 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 

DIETARY RISK CRITERIA 254 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, 

DIETARY RISK CRITERIA 255 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. 

DIETARY RISK CRITERIA 256 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. 

DIETARY RISK CRITERIA 257 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). 

DIETARY RISK CRITERIA 258 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. 

DIETARY RISK CRITERIA 259 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. 

DIETARY RISK CRITERIA 260 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). 

DIETARY RISK CRITERIA 261 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). 

DIETARY RISK CRITERIA 262 Infants should not be fed whole cow milk, skim milk, 1 or 2 percent fat milk, or evaporated milk formulas during the first 12 months of life (CN-AAP, 1992a, 1993). Solid foods should be introduced when an infant is able to sit with support and the infant has good control of the head and neck, usually at 4 to 6 months of age (CN-AAP, 1993). Solid foods of appropriate consistency should be started one at a time at weekly intervals to identify any food intolerance. Infants need dependable sources of iron after 4 to 6 months of age. Prevalence of Inappropriate Infant Feeding Over time, infant feeding practices have gradually become more consistent with the recommendations and guidelines of CN-AAP. Breastfeeding of newborns was twice as common in 1990 as it was in 1970 (CN-AAP, 1993), the feeding of cow milk to infants under 4 months of age is much less common (Fomon, 1987), and the feeding of solid foods to infants under 2 months of age is infrequent today (CN-AAP, 1993). Nevertheless, data from national population-based surveys show that there is room for improvement of infant feeding practices. Data from the 1988 National Maternal and Infant Health Survey (NMIHS) show that only 24 percent of low- income infants and 32 percent of higher-income infants had feeding practices consistent with CN-AAP guidelines throughout their first 6 months. These percentages are so low largely because cow milk and solid foods are introduced before the age of 4 months. However, in the first month of life, guidelines were met by 85 percent of low-income infants participating in the WIC program, 89 percent of low-income infants not participating in WIC program, and 94 percent of higher-income infants (Gordon and Nelson, 1995). Despite strong recommendations for breastfeeding by CN-AAP, infant formula tends to be the milk source chosen for most U.S. infants over much of their first year. In 1990, approximately half of all infants started breastfeeding while they were in the hospital (CN-AAP, 1993). However, the percentage of breastfeeding infants declined to 18 percent at age 6 months and to 6 percent by age 12 months. Despite strong recommendations to the contrary, cow milk is fed to many infants, especially in the second 6 months of life. The percentage of infants fed either whole cow milk or evaporated milk formulas rose: from 5 percent at 6 months to 79 percent at 12 months of age (CN-AAP, 1993). The use of reduced- fat cow milk is also common. Market research data collected by Ross Laboratories during the early 1980s showed that of the infants ages 8 to 13 months consuming cow milk, 42 percent were fed reduced-fat milk (Fomon, 1987). Data were not available on the prevalence of other inappropriate infant feeding practices. 

DIETARY RISK CRITERIA 263 Inappropriate Infant Feeding as an Indicator of Nutrition and Health Risk Most empirical evidence on the effects of inappropriate infant feeding focuses on the use of cow milk and shows that its use during the first 12 months is associated with at least two adverse outcomes. First, infants fed cow milk have poorer iron status, a higher prevalence of iron deficiency anemia, lower plasma iron concentrations, lower transferrin saturation concentrations, and lower plasma ferritin concentrations than those fed infant formula (Penrod et al., 1990). In part, this may be due to increased intestinal blood loss compared with infants fed formula (Wilson, 1984; Woodruff, 1983; Ziegler et al., 1990). Evidence also suggests that cow milk inhibits the availability of iron from such other dietary sources as infant cereals, most likely because of the high concentrations of calcium and phosphorus and the low concentration of ascorbic acid in cow milk (CN-AAP, 1993). Second, infants fed cow milk have higher than recommended intakes of sodium, potassium, chloride, and protein and lower than recommended intakes of linoleic acid and vitamin E (CN-AAP, 1993; Martinez et al., 1985). The median potential renal solute load of diets of infants fed cow milk is substantially higher than that of diets of infants fed formula (Ernst et al., 1990; Martinez et al., 1985). In early infancy, diets high in potential renal solute load lead to dehydration more rapidly during episodes of fever and diarrhea. The use of reduced-fat cow milk exacerbates the risks associated with cow milk, primarily because larger volumes are necessary to meet the energy needs of infants. Infants fed low-fat or skim milk tend to have inadequate food energy and linoleic acid intakes and very high protein intakes and potential renal solute loads (Ernst et al., 1990; Fomon, 1993). Breastfed infants and infants who are fed formula that is not fortified with iron are subject to iron deficiency if they do not obtain adequate iron from solid foods or supplemental iron. There are no known nutritional advantages to introducing solid foods before 4 to 6 months of age (CN-AAP, 1958, 1993). Although little evidence exists to document poor outcomes resulting from the early introduction of solid foods into infant diets, studies in developing countries clearly document the risk in environments in which sanitation is poor. The recommendation to delay the introduction of solid foods to U.S. infants generally reflects knowledge of the development of gastrointestinal function and nutrition needs (Weaver and Lucas, 1991). Adding such foods as infant cereals to bottles rather than spoon feeding is not recommended as this deprives children of the opportunity to learn to feed themselves (CN-AAP, 1993). This also increases risks from poor sanitation in young infants. Other examples of inappropriate infant feeding practices include improper dilution of formula, feeding of sugar-based beverages (e.g., fruit flavored 

DIETARY RISK CRITERIA 264 drinks) or other foods low in nutrient density in place of formula, and lack of sanitation in the preparation of nursing bottles. Such practices can lead to severely impaired growth, dehydration (from concentrated formula), and/or gastrointestinal infections. Infrequent breastfeeding as the sole source of nutrients can lead to serious undernutrition and dehydration. Inappropriate Infant Feeding as an Indicator of Nutrition and Health Benefit Although the evidence is indirect, by and large it suggests that educational efforts and food supplementation can improve infant feeding practices. Probably the strongest evidence comes from reviewing the trends in infant feeding discussed above, which show increased breastfeeding, decreased feeding of cow milk, and later introduction of solid foods for all U.S. infants (Fomon, 1993). In addition, data from the Pediatric Nutrition Surveillance System indicate that the prevalence of anemia among white low-income infants has decreased significantly over time, a finding largely attributed to improvements in status resulting from infants' participation in public health programs, especially the WIC program (Yip et al., 1992). Other studies also found that infant participation in the WIC program was associated with increased serum iron content and a lower incidence of iron deficiency anemia (Edozien et al., 1979; Miller et al., 1985). Limited information is available on the effects of the WIC program and other nutrition education programs on the diets of low-income infants. A study among Hmong women at several WIC sites showed that a short-term nutrition education intervention increased the number of women who initiated breastfeeding and the duration of their breastfeeding (Tuttle and Dewey, 1995). An early study (Edozien et al., 1979), subsequently corroborated by the National WIC Evaluation (Rush, 1988), found that WIC program participation was associated with higher iron and vitamin C intakes—nutrients supplied by the iron-fortified cereal and formula and the vitamin C-rich juices in the infant food package. Gordon and Nelson (1995) found that mothers of infant WIC participants and of income-eligible nonparticipants followed the CN-AAP guidelines to a similar extent during the first 4 months of feeding. Mothers of WIC infants were significantly more likely than mothers of income-eligible nonparticipants, however, to follow the CN-AAP guidelines in the fifth and sixth months, primarily because they were less likely to feed their infants cow milk in these months. 

DIETARY RISK CRITERIA 265 Tools and Cutoff Points to Assess Inappropriate Infant Feeding in the WIC Setting Almost all states use inappropriate infant feeding as a nutrition risk criterion for infants. In general, inappropriate intake is assessed by either a 24-hour recall or specially targeted questions about infant feeding practices. In a field test of the impact of the WIC program on the growth and development of children, Puma and colleagues (1991) documented the inadequacies of using 24-hour recalls for assessing the dietary intakes of infants. These investigators examined infant feeding by asking a set of questions on breastfeeding, the type of milk or formula being used, the type of solid foods being consumed, and when these foods were introduced into infant diets. Similarly, the 1988 NMIHS included a series of questions on infant feeding practices that could be used in the WIC program setting to assess infant feeding practices (Gordon and Nelson, 1995). Recommendation for Inappropriate Infant Feeding Risks from most inappropriate infant feeding practices described above are well documented. Acceptable methods are available for identifying these practices. The potential for benefit from participation in the WIC program is expected to be good based on theoretical and indirect empirical evidence. Therefore, the committee recommends use of selected inappropriate infant feeding practices as risk criteria for use by all states, as listed in Table 6-3. Inappropriate Use of Nursing Bottle Rampant dental caries affecting the primary teeth of infants and young children can result from the practice of allowing the child to fall asleep with a bottle filled with a fermentable liquid (fruit juice, milk, or other beverage with added sugar). This form of caries is known by several names, including nursing bottle caries, baby bottle tooth decay, and nursing bottle syndrome. Prevalence of Inappropriate Use of Nursing Bottle Data on the prevalence of baby bottle tooth decay are inadequate because young children do not usually receive routine dental care or examinations. Reports have indicated that 2.5 to 14 percent of U.S. preschool age children show evidence of extensive tooth decay (Derkson and Ponti, 1982; Johnsen, 

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DIETARY RISK CRITERIA 268 1984; Johnsen et al., 1984). Some subgroups are at higher risk, including low-income children and American-Indian children (Broderick et al., 1989; Nowjack and Gift, 1990). Inappropriate Use of Nursing Bottle as an Indicator of Nutrition and Health Risk The maxillary anterior teeth are affected first and most severely because of their prolonged and repeated exposure (Dilley et al., 1980; Fass, 1962; Fomon, 1993; Johnsen, 1984; Johnsen et al., 1984; Marks, 1951; Ripa, 1978). The fermentation of carbohydrates on the surface of the tooth produces organic acids that demineralize and destroy enamel, with subsequent tooth decay. Generally, many teeth are involved, the decay develops rapidly, and the decay occurs on surfaces normally thought to be at low risk for decay (Ripa, 1988). If inappropriate use of the nursing bottle persists, the child is at substantial risk of painful toothaches, costly dental treatment, loos of primary teeth, and, sometimes, developmental lags in eating and chewing ability. Moreover, if the child continues to be bottle-fed well beyond the usual weaning period, there is a risk of decay of permanent teeth. Inappropriate Use of Nursing Bottle as an Indicator of Nutrition and Health Benefit Inappropriate use of nursing bottles is relatively easily identified in the WIC program setting and is most appropriately corrected with educational intervention. The potential for health, nutrition, and economic benefits from effective intervention is substantial. Recommendation for Inappropriate Use of Nursing Bottle The risk from inappropriate use of nursing bottles is well documented. The potential to benefit from participation in the WIC program is expected to be high based on theoretical evidence. Therefore, the committee recommends use of the nutrition risk criterion inappropriate use of nursing bottle by state WIC programs. Inappropriate Diets in Children Some state WIC programs use additional criteria for inappropriate diets for children including high intake of sugar or of high-calorie, low-nutrient snacks, 

DIETARY RISK CRITERIA 269 use of skim or low-fat milk before age 2 years, and self-feeding difficulties. These are not discussed further since they are covered in other sections of the report. See the section ''Dietary Patterns that Fail to Meet Dietary Guidelines for Americans" in this chapter and "Central Nervous System Disorders" in Chapter 5. Excessive Caffeine Intake Caffeine is a plant alkaloid found in coffee, tea, cocoa, cola beverages and some other soft drinks, chocolate, and over-the-counter medications including cold tablets, allergy and analgesic preparations, appetite suppressants, and stimulants (Dalvi, 1986; Watkinson and Fried, 1985). Chocolate and other confectioneries contain only minor amounts of caffeine. Prevalence of Excessive Caffeine Intake Women. Estimated average caffeine intakes during pregnancy for U.S. and Canadian women range from 99 to 270 mg/day (Beaulac-Baillargeon and Desrosiers, 1986; Graham, 1978; Srisuphan and Bracken, 1986; Tebbutt et al., 1984), and the prevalence of caffeine use during pregnancy has been estimated to range from 69 to 79 percent (Graham, 1978; Srisuphan and Bracken, 1986) to 90 to 98 percent (Beaulac-Baillargeon and Desrosiers, 1986; Hill, 1973; Watkinson and Fried, 1985). Heavier caffeine consumption among pregnant women has been found to be related to less formal education, older maternal age, greater gravity and parity, alcohol use, and cigarette smoking (Beaulac-Baillargeon and Desrosiers, 1986; Istvan and Martarazzo, 1984; Linn et al., 1982; Srisuphan and Bracken, 1986; Watkinson and Fried, 1985). Children. The prevalence of high caffeine intakes in children served by the WIC program is unknown, but it is clear from the available data (Ellison et al., 1995) that almost all school age children consume some caffeine-containing beverages (e.g., soft drinks, iced tea, cocoa) and foods. Excessive Caffeine as an Indicator of Nutrition and Health Risk Women. Although substantial evidence indicates that caffeine in large doses is teratogenic in animals, there is no convincing evidence that it is associated with birth defects in humans (IOM, 1990). The available evidence is equivocal about whether consuming relatively large amounts of either caffeine or coffee reduces birth weight, increases the risk of spontaneous abortion (IOM, 

DIETARY RISK CRITERIA 270 1990; Armstrong et al., 1992; McDonald et al., 1992a, b), contributes to nutrient inadequacy (Morck et al., 1983; Pecoud et al., 1975; Watkinson and Fried, 1985), or has other adverse effects (Massey and Hollingbery, 1988a, b; Munoz et al., 1988). Caffeine consumed by lactating women passes into their milk. If the dose is sufficiently high, it may cause irritability in the infant (IOM, 1990). Although the preponderance of current evidence is that women who ingest caffeine during pregnancy or lactation do not put their fetuses or infants at serious risk, there are recommendations to moderate such intake during these periods (FDA, 1980; IOM, 1990, 1991). Children. Health or nutrition risks resulting from high levels of caffeine consumption by children are not clear. A variety of behavioral and metabolic abnormalities have been attributed to caffeine intake, but the results of the few studies are inconsistent (Ellison et al., 1995). Excessive Caffeine Intake as an Indicator of Nutrition and Health Benefit Without evidence of risk, there can be no evidence of benefit related to high caffeine consumption by women or children. Tools and Cutoff Points to Assess Caffeine Intake Caffeine intake can be assessed with questions regarding the usual number of servings of the few concentrated sources of these compounds. Recommendation for Excessive Caffeine Because of lack of evidence of nutrition risk, the committee recommends discontinuation of use of excessive caffeine intake as nutrition risk criterion by state WIC agencies. Pica Pica is a perceived craving for and ingestion of nonfood items, including, but not limited to, clay, starch (laundry and cornstarch), ice or freezer frost, dirt, and paint chips. Although pica is a long-standing dietary practice, little research on pica has been conducted over the last decade (Edwards et al., 1994; Horner, et al., 1991; Lacey, 1990). Reid (1992) identified pica as a culturally prescribed behavior in some groups. 

DIETARY RISK CRITERIA 271 Prevalence of Pica Women. In the United States, pica has been observed primarily among low- income southern black pregnant women (Horner, et al., 1991). The true prevalence is unknown. In a cohort of 553 pregnant women in an urban environment, Edwards and colleagues (1994) found that 3 percent self-reported that they ate freezer frost, about 4 percent said that they ate ice, and over 1 percent reported that they ate starch. In this same group of women, 28 percent stated that they had seen others in their social network (mothers, other relatives, and pregnant women) eat nonfood items. Older studies reported higher prevalences (approximately 30 percent) of pica among pregnant women (Keith et al., 1968). A link between hunger and pica has been discussed because starch, in particular, offers a source of bulk and calories (Edwards et al., 1994). Children. Since ingestion of lead-contaminated paint is the most common form of pica among young children, the prevalence of pica among young children can be indirectly inferred from the prevalence of elevated concentrations of lead in blood. See the section "Lead Poisoning" in Chapter 5. Pica as an Indicator of Nutrition and Health Risk Geophagy (eating clay or dirt) during pregnancy and as a traditional practice in the United States, South America, and Africa has been interpreted as offering beneficial anti-diarrheal properties or protection to prevent gastric distress (Vermeer, 1979, 1985) through the chemical binding properties of the clay matrix. The potential chelating action of the clay particles also is thought to bind minerals and hence to be a contributing cause of nutrient deficiencies (Arcasoy et al., 1978). Many of the data on the health risks of pica are quite old, and the quality of the data is variable. The ingestion of significant amounts of clay or starch has been associated with a variety of poor pregnancy outcomes, including toxemia (Edwards et al., 1964; O'Rourke et al., 1967), maternal death (Key et al., 1981), prematurity (Sage, 1962), and low birth weight and poor functional status of infants (Edwards et al., 1964). Cases of toxemia, hypertension, and intestinal obstruction have been reported for women practicing pica during pregnancy (NRC, 1983). The strongest and most persistent association of nutrition risk with pica is anemia in women. There has been a long debate over the direction of the association: whether anemia predisposes a woman to pica (Crosby, 1982; Keith et al., 1968, 1970), or whether anemia is the consequence of pica (Reid, 1992). The ingestion of large amounts of laundry starch or clay may not by itself inhibit the absorption of iron, but it may displace foods that contain iron (NRC, 

DIETARY RISK CRITERIA 272 1983; Talkington et al., 1969). Low intake of iron, folate, pyridoxine, magnesium, and zinc has been reported for women who were actively practicing pica (Edwards et al., 1994). Pica as an Indicator of Nutrition and Health Benefit Two studies report that craving for nonfood substances could be reduced or corrected with iron therapy (Lanzkowsky, 1959; Reynolds et al., 1977). Once pica is identified, the WIC program's food package, nutrition education, and referral for health care all offer the potential for nutrition and health benefit. The supplemental foods provided through the WIC program supply critical nutrients, but they cannot be expected to prevent adverse effects of the ingestion of lead or clay. Tools and Cutoff Points to Assess Pica Pica can be identified through specific questioning about consumption of specific nonfood substances. However, since the practice is widely known to be viewed negatively by health professionals, it may be underreported. For children, questions should be directed toward hand-to-mouth activity and environmental lead exposure. Recommendation for Pica The risk of pica is very high in children because of its link with lead poisoning (see Chapter 5). The potential for benefit from nutrition education and referral for children is expected to be good on theoretical grounds. The risk of pica for women is less well documented. The committee recommends use of pica as a nutrition risk criterion for children by all state WIC programs and for pregnant women in areas where the prevalence is high enough to justify it. INADEQUATE DIET Dietary inadequacy can be defined as food or nutrient intake insufficient to meet a specified percentage of Recommended Dietary Allowances (RDAs)—the nutrient intake recommendations of the Food and Nutrition Board, National Academy of Sciences (NRC, 1989). 

DIETARY RISK CRITERIA 273 Prevalence of Inadequate Diets Existing data do not permit definitive statements about the prevalence of inadequate dietary intake among low-income women, infants, or children. Limitations arise from inconsistent definitions for an inadequate diet, unknown variations in the degree of undersampling of the poorest households, and more serious methodologic issues stemming from the inherent limitations of practical survey methods for measuring usual dietary intakes (Willett, 1990). There is indisputable evidence that the prevalence of diets that are low in nutrients when compared with the RDAs is very high among the population of women and children eligible for the WIC program. However, there is no other evidence of widespread nutrient deficiencies. Moreover, having a mean nutrient intake below the RDAs does not necessarily indicate the presence or likelihood of nutrition and health problems. When survey data are examined to estimate the prevalence of individual diets that fall below a specified percent of the RDA, the estimates of true low intake are known to be inflated (NRC, 1986). However, a higher prevalence of low nutrient intake for low-income groups than for higher-income groups is cause for concern, especially if there is other evidence of nutrient deficiencies among the low-income groups. Cook and Martin (1995), using 1986 data from the Continuing Survey of Food Intake by Individuals (CSFII), examined the prevalence of nutrient intake below 70 percent of the RDA (averaged over 4 days of data collected over a 1- year period) for children ages 1 to 5 years defined as poor (household income < 130 percent of federal poverty guidelines) and nonpoor (household income ≥ 130 percent of federal poverty guidelines). Prevalence of low intakes ranged from 1.5-fold to several-fold higher for poor than for nonpoor children. Prevalence estimates exceeded 15 percent for low intakes of energy, vitamin C, and vitamin B6 by poor children and 30 percent for vitamin E, iron, and zinc. However, data on weight-for-height of young children suggest that an energy deficit is an uncommon problem (see Chapter 4). Similarly, among 3- to 5-year-old children in NHANES II, there were significant differences between poor and nonpoor children in the estimated prevalences of very low intakes (< 50 percent of the RDA) for vitamins A and C, calcium, and food energy. The relative risk of low intake among poor children ranged from approximately 1.3 to almost twice that among nonpoor children (Cook and martin, 1995). Inadequate Diet as an Indicator of Nutrition or Health Risk There is no doubt that substantial nutrition and health risks result from diets that are truly inadequate in nutrients among pregnant and lactating women, 

DIETARY RISK CRITERIA 274 infants, and young children. The adverse health consequences of specific nutrient deficiencies in pregnant and lactating women and in infants and young children are well documented (CN-AAP, 1993; IOM, 1990, 1991; NRC, 1989). Iron deficiency, the most common micronutrient deficiency among U.S. women and children, may increase the risk of low birth weight and pregnancy complications in pregnant women (IOM, 1990), result in reduced cognitive and intellectual functioning and development in infants and young children, and impair general well-being, work performance, and physical activity at all ages (Pollitt, 1994, 1995). Inadequate intake of folate around the time of conception has now been convincingly shown to increase the risk of neural tube defects (NTD), one of the most common congenital abnormalities—especially in women with a previously affected pregnancy (CDC, 1991; MRC Vitamin Study Research Group, 1991). If intake of one or more vitamins or minerals is chronically very low, serious overt deficiency diseases can develop (e.g., rickets resulting from vitamin D deficiency). Suboptimal nutrient intakes may increase long-term impacts on morbidity and on risks of heart disease and cancer (Block, 1991; Knekt et al., 1991; Olson, 1993; Steinberg et al., 1992). Among lactating women, low maternal intakes may have relatively little effect on the concentrations of iron, copper, zinc, calcium, and folate in breast milk but may lead to depleted maternal stores of these nutrients (IOM, 1991). Such depletion of stores compromises the mother's nutritional status, the health of subsequent infants, or both. Long-term deficiency of vitamin B12 intake by a lactating woman can lead to vitamin B12 deficiency in the infant (see the section "Vegetarian Diets"). Inadequate Diet as an Indicator of Nutrition and Health Benefit A major goal of the WIC program is to improve the quality and sufficiency of diets consumed by low-income pregnant, postpartum, and breastfeeding women, infants, and children who are at nutrition risk. The nutritious foods provided by the WIC program can help correct subclinical deficiency states and replenish stores of many nutrients. The supplemental food package provided through the WIC program consists of foods chosen because they are concentrated sources of a number of nutrients believed to be in short supply in the diets of low-income women and children. Evaluations of the WIC program indicate that the program has had positive and measurable effects in reducing the prevalence of iron deficiency anemia (Yip et al., 1987, 1992) and the incidence of low and very low birth weight (Devaney et al., 1992; Edozien et al., 1979; Kennedy et al., 1982; Metcoff et al., 1985). These reductions are likely mediated wholly or in part through dietary 

DIETARY RISK CRITERIA 275 improvement. In addition, the program has been shown to be effective in improving dietary quality among children (Rush, 1988). Nutrition assessment and education in the program focus on diet in the prevention or amelioration of nutrition problems. Several studies of WIC program participants and other groups have shown nutrition education to be effective in changing both knowledge and attitudes about nutrition (Johnson and Johnson, 1985; Navaie et al., 1994), and such nutrition-related behaviors as meal planning, shopping, and food preparation (Koblinsky et al., 1992). Use of Inadequate Diet as a Risk Indicator in the WIC Setting Table 6-1 provides information about the use of inadequate diets as a nutrition risk criterion by WIC state agencies. The most often cited risk criteria are deficiencies in vitamins A, C, and D; iron; protein; and/or calcium (not shown). Many WIC programs report using "inadequate or excessive calorie intake" as a risk criterion. The RDA cutoff points reported to be used by WIC agencies in 1992 ranged from 66 to 100 percent of the RDA. Tools and Cutoff Points to Assess Inadequate Diets Dietary assessment is used to obtain presumptive evidence of dietary deficiencies or excesses in individuals. Self-report of recent or usual intake is the only practical approach in the WIC program setting. For women and children, the most commonly used instrument for assessment of dietary inadequacy in the WIC program is some type of food frequency questionnaire (FFQ), a 24-hour recall of food intake, or both. The actual instruments used vary widely (Gardner et al., 1991), as do the guidelines for interpretation of the information obtained, including definitions of inadequacy. Twenty-four-hour recall data on food intake are generally interpreted either in terms of food groups (see previous section "Inappropriate Dietary Patterns") or in terms of the Recommended Dietary Allowances (RDA) (NRC, 1989). Most FFQs used by the WIC program examine patterns of food intake and do not produce estimates of nutrient intake. Recently, FFQs have been developed that can provide computer-generated estimates of nutrient intakes and then compare them to the RDAs (Jacobson et al., 1990; USDA,_1994). Either a 24- hour recall of food intake or a food frequency questionnaire (FFQ) may be useful for nutrition education purposes, but each has different limitations when used as the basis for estimating adequacy of nutrient intake. Since 24-hour recalls or FFQs are methods currently in use in WIC programs, the performance 

DIETARY RISK CRITERIA 276 of these measures in identifying inadequate diets among individuals is briefly reviewed. Twenty-four-hour recalls. The major factor constraining the ability to infer usual intake from a recall of recent food intake (last 24 hours or the previous day's intake) is within-person variation in food intake over time, including day- to-day variation and periodic variation (e.g., day-of-the-week effects, effects related to the timing of household income, and seasonal effects) (Beaton et al., 1979; LSRO/FASEB, 1986; NRC, 1986). The ratio of within-person to between- person variance in nutrient intake from food intake data collected by a 24-hour recall is large enough that a single 24-hour period cannot be used with any reliability to assess the usual intakes of individuals. Single 24-hour recall data can be used to describe the mean intakes of populations or groups of people if the sample is large enough; the limitation is in the extrapolation of the data to the probability of the risk of deficiency or excess for an individual. For most nutrients, within-person variation can be reduced if the individual's mean of many days is used, but the number of days is so large as to be impractical in the WIC setting. Food frequency assessments. Food frequency questionnaires or interviews theoretically provide relatively stable estimates of usual intakes because they cover an extended period: in the WIC program this is typically the previous week or month. With a food frequency instrument, a prespecified list of foods is used and the respondent is asked to estimate the frequency of consumption of each item. Compared with diet recalls, FFQs are less subject to omissions because of incomplete recall. Some FFQs ask the respondent to estimate usual portion sizes. Most of the methodologic development and validation of food frequency instruments has been within the context of chronic disease epidemiology, rather than with attention to considerations of targeting. The Block FFQ (Block et al., 1986) was developed on the basis of 24-hour dietary recall collected from adults in NHANES II, including the major food sources of energy and 17 nutrients and incorporating the usual portion sizes of those foods. Validation studies of the original (100-item) version of the Block FFQ have been reported for a variety of adult groups (Block et al., 1990, 1992; Coates et al., 1991; Mares-Perlman et al., 1993; Sobell et al., 1989). Two new versions, one for children and one for women, have been developed and tested for use in WIC (USDA, 1994). A second widely used food frequency questionnaire, available in several versions, was developed at Harvard University by Willett and others (Willett, 1990) and has been modified for several specific populations. The food lists were drawn from food records collected from participants in several different pilot studies. Validation studies have been reported for female nurses (Salvini et 

DIETARY RISK CRITERIA 277 al., 1989; Willett et al., 1985, 1987), male health professionals (Feskanich et al., 1993; Rimm et al., 1992), low-income pregnant women (Suitor et al., 1989), and children (Stein et al., 1992). The Harvard FFQ has been adapted for use in the WIC program and tested for practicality in Massachusetts (M. Rodan, Georgetown University, personal communication, 1995). It provides an index of nutritional quality and information about food patterns, but it was intentionally designed not to automatically generate estimates of absolute nutrient intakes. (These estimates can be accessed for data analysis, however.) Recently, Block and colleagues (USDA, 1994) completed a systematic validation study of both the Harvard and the Block FFQs with more than 600 individuals (pregnant, breastfeeding, and postpartum nonbreastfeeding women and children ages 1 to 5 years) within the WIC program setting. The sample included approximately equal numbers of black, Hispanic, and white subjects. These subjects were recruited from sites in four geographic areas of the country (Northeast, Pacific, South, and Midwest). Study participants completed either the Harvard FFQ or the Block FFQ, three nonconsecutive 24-hour dietary recalls (by telephone), and a second food frequency questionnaire. The multiple 24-hour dietary recall data were used as the standard of comparison for the nutrients targeted by the WIC program: protein, vitamin A, vitamin C, iron, and calcium. In addition, total energy intake was estimated. The Block FFQ performed better than the Harvard FFQ for black and white women. For the Block FFQ, correlations with nutrient estimates from the three diet recalls were equal to or greater than 0.4, and the Block FFQ also showed more statistically significant ranking agreements by quartile than did the Harvard FFQ (six versus two). Neither FFQ performed well for Hispanic women or for children of any ethnic background. On the basis of that work, the authors recommended further research to develop appropriate food frequency questionnaires or methods of administration for Hispanic women. For children, they recommended further development and validation of a brief set of questions for assessing appropriate dietary intakes (USDA, 1994). For black and white women, the Block FFQ performed as well as validated FFQs that are widely used in epidemiologic studies. Correlations of approximately 0.6, while considered acceptable for epidemiologic studies, result in much misclassification (and thus low yield of risk). Moreover, a substantial fraction (up to 15 to 20 percent) of WIC participants appear to have difficulty completing FFQs appropriately, with gross overestimation of intake the most common problem (P. Pehresson, Nutrient Data Laboratory, USDA Agricultural Research Service, personal communication, 1995; Suitor et al., 1989; USDA, 1994). 

DIETARY RISK CRITERIA 278 Interpretation of Nutrient Intake Data When data from a 24-hour recall or a quantitative food frequency assessment are to be converted to estimates of nutrient intakes, they must be processed through a computerized program that matches data on foods and serving sizes to data on the nutrient composition of food items. Increasingly, nutrient analysis software is becoming available in clinic-adapted forms. However, to date, only the North Dakota WIC program has computerized its system for collecting dietary data. Thus, comparison of calculated nutrient intake values with a standard such as the RDAs is impractical as an eligibility criterion in most settings. Block's recent study, which analyzed data from multiple nonconsecutive days of intake recall, indicates that if intake of a single nutrient below 100 percent of the RDA were used as a cutoff point, essentially all of the women eligible for WIC program participation on the basis of income would be considered at risk (USDA, 1994). However, except for energy, RDAs are set high enough to provide for adequate estimated intakes for essentially all of the healthy population; thus, the majority of the population will have adequate intakes at levels below the RDAs. The use of self-reported food intake, whether by 24-hour recalls or food frequency methods, is not a valid method of estimating calorie intake. Whether the dietary information is obtained by 24-hour recalls or FFQs, heavy adults and adolescents fairly consistently underreport their total energy intakes, and mothers may overreport the energy intakes of their young children. More appropriate ways to identify inadequate energy intake are assessment of weight-for-height and change in weight, and asking questions designed to elicit information about access to food. Recommendations for Inadequate Diet There is no doubt that if true inadequate nutrient intake could be identified with sensitivity and specificity, inadequate diet would constitute a high priority nutrition risk criterion. If the usual intake of any of the nutrients targeted by the WIC program is truly low, there is also no doubt that the WIC program's food package and nutrition education would result in a nutrition and health benefit. However, the assessment tools currently in use for identifying usual nutrient intakes have very low yield. That is, of the individuals identified to have a nutrition risk, a high proportion may not actually be at risk for inadequate diet. Moreover, a high proportion of false negatives is also likely. Therefore, the committee recommends discontinuation of use of inadequate diet as a nutrition risk criterion. For similar reasons, the committee recommends 

DIETARY RISK CRITERIA 279 discontinuation of excessive caloric intake as a nutrition risk criterion. Nonetheless, the value of collecting information about food intake as a basis for well-targeted nutrition education in the WIC program provides strong support for continued use of diet assessment. Research is urgently needed to develop practical and valid assessment tools for the identification of inadequate diets. FOOD INSECURITY Definition of Food Insecurity The term food security was first used in the international development literature in the 1960s. By the mid-1980s, national and regional definitions reflected concern about the food security of households, recognizing that limited access to food supplies at the level of the household (consumption unit) is a primary determinant of malnutrition (Maxwell and Frankenberger, 1992; Bickel et al., 1995). Attention was directed to the generally understood but ill-defined concept of ''hunger," and the multiple social and health effects of poverty (Mayer, 1990). During the 1980s, several groups conducted substantial theoretical and empirical work from which to develop measurement tools for hunger and risk of hunger (Campbell, 1991; FCS, 1994; Margen and Neuhauser, 1987; Mayer, 1990, and accompanying papers; Radimer et al., 1990, 1992; Wehler et al., 1992). The important theoretical contribution of these efforts was the concept and empirical demonstration of hunger as an active "managed process" of adaptation and coping (Radimer et al., 1990, 1992). This concept was congruent with the work in international contexts that described a sequence of progressively less reversible management decisions by which households cope with food scarcity and shortage (Maxwell and Frankenberger, 1992). The incorporation of the concern with household-level "hunger" into the notion of household-level food insecurity in the United States was articulated clearly for the first time by a Life Sciences Research Organization expert panel in 1990. This panel clearly defined food security, food insecurity, and hunger in the U.S. context, as follows (LSRO/FASEB, 1990): Food Security is access … at all times to enough food for an active, healthy life and includes at a minimum: a) the ready availability of nutritionally adequate and safe foods, and b) the assured ability to acquire acceptable foods in socially acceptable ways. Food Insecurity exists whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain. 

DIETARY RISK CRITERIA 280 Hunger, in its meaning of the uneasy or painful sensation caused by a lack of food, is in this definition a potential, although not necessary, consequence of food insecurity. Malnutrition is also a potential, although not necessary, consequence of food insecurity. Since the federal definition of poverty is based on the ability to purchase the USDA Thrifty Food Plan with no more than one-third of the household's income, households with incomes below the poverty level might be considered by definition to be suffering from food insecurity. In some areas, high relative costs of such other necessities as housing and utilities place individuals at risk of food insecurity even if their incomes are considerably above the official poverty level. In a recent analysis of the 1986 CSFII, Cook and Martin (1995) demonstrated a higher prevalence of low energy intakes (< 50 percent of the RDA) among children ages 3 to 5 years in households with incomes less than 130 percent of the federal poverty level versus those in households with incomes higher than that cutoff. Prevalence of Food Insecurity The prevalence of food insecurity is assumed to be high based on the income eligibility criteria for WIC participation. The concept of food insecurity as a measurable and scalable continuum rather than as a dichotomous variable underlies current efforts to develop adequate tools to measure prevalence. A basic question on food security was included in the 1977–1978 NFCS, when for the first time respondents were asked to describe the food eaten in their household as "enough and the kind we wanted to eat"; "enough, but not always the kind we wanted to eat"; ''sometimes not enough to eat"; and "often not enough to eat." This question has also been incorporated in the CSFII surveys. NHANES III incorporated a modification of the question plus some indicators adapted from the work by Wehler and colleagues (Briefel and Woteki, 1992). In 1992, the National Nutrition Monitoring and Related Research Program recommended that the USDA and the National Center for Health Statistics develop a standardized mechanism, instrument, and associated methodologies for defining and obtaining data on the prevalence of "food insecurity" or "food insufficiency" in the United States (Federal Register 58(32):752–806). In response to this and earlier mandates, an instrument was developed that includes a series of questions designed to measure food shopping behavior (all households). For those households with income and expenditure patterns that indicate risk of food insecurity, the instrument includes sections on food sufficiency, coping mechanisms and food scarcity, and concern about food sufficiency. The aim was to develop a scaled, ordinal measure of the degree of household food insecurity that would lead to empirically based categories of (1) 

DIETARY RISK CRITERIA 281 food secure households; (2) mild (Level 1) food insecurity; (3) more serious (Level 2) food insecurity; and, (4) severe (Level 3) food insecurity. The data for validation of this tool were collected as part of the supplement to the Current Population Survey by the Bureau of the Census in April 1995. Analyses of those data are not available at this writing but should provide a basis for prevalence estimates in the population and in various subgroups. No data on the proportion of WIC program participants who meet any particular criterion for food insecurity, beyond the income levels that certify them for participation in the program, were available to the committee. Food Insecurity as a Predictor of Nutrition and Health Risk Few published data directly link measures of household food insecurity to dietary quality or indices of malnutrition. However, food insecurity is a logical mediating variable between poverty and poor dietary quality and indices of malnutrition (particularly iron deficiency) that are strongly related to poverty. Available data indicate that homeless individuals, among whom food insecurity is almost certain, have diets low in dairy products, fruits and vegetables, and whole grains (Cohen et al., 1992). The 1989–1991 CSFII showed somewhat lower total energy intakes and a higher proportion of dietary energy from fat in children from less food-secure households (Kennedy and Goldberg, 1995). Aside from the direct linkages of food insecurity with poor diet and poor nutrition status, food insecurity likely leads to preventable non-nutrition-related health risks. When income is sufficiently low that food cannot be reliably purchased in sufficient quantities, other unessential expenditures are bound to be curtailed by households. Thus, needed medical care, especially for preventive services for women and children may not be sought even if there is no direct charge, because of transportation costs, lost wages, or other factors. Food insecurity itself may be regarded as a poor nutrition outcome, apart from the dietary, nutrition, and health risks that it may create (Campbell, 1991). The right to access to adequate food, particularly for children, has been codified in numerous international documents and declarations (Eide et al., 1992; Kent, 1993), including the United Nations Children's Fund's "Declaration on the Rights of the Child," to which the United States became a signatory in early 1995. Food Insecurity as a Predictor of Nutrition and Health Benefit The WIC program is designed specifically to provide enhanced nutrition and health care during vulnerable periods of growth and development. It is logical to assume that the benefit from food, nutrition education, and referrals 

DIETARY RISK CRITERIA 282 will be greatest for individuals residing in households where the food supply is least assured and least adequate. Limited data from the United States and other countries indicate that infants and young children tend to be relatively protected by families during periods when food is in short supply because adults and older children in the household tend to make food available by decreasing their food intakes (Harrison and Muramoto, 1994; Neumann et al., 1989; Radimer et al., 1992). The provision of adequate and nutritious food to infants through the WIC program, and the provision of food supplements for their mothers and young siblings, spares the household's resources and thus may benefit all household members, even those who do not partake directly of the WIC program's food package. Assessing Food Insecurity in the WIC Setting In 1992, only one state WIC agency (Montana) reported using hunger or food insecurity as a criterion for WIC program eligibility (Montana WIC Program Policy Statement, 1992). Tools and Cutoff Points to Assess Food Insecurity In the WIC setting, the focus should be on identification of individuals truly experiencing hunger or at risk for hunger through intermittent or continuing household food insecurity of a moderate or severe degree. Available brief assessment tools and the rapidly evolving work on measurement tools related to food insecurity provide resources for the WIC program to consider when developing such tools for the WIC population. Development and validation of appropriate assessment tools for the WIC setting should have high priority. Recommendations for Food Insecurity Food insecurity presents risks of malnutrition and unhealthful dietary patterns in both the present and the future. Furthermore, food insecurity can be considered a concern in its own right. Because of the fundamental relationship of food availability to nutrition and health, the committee assumes that identification of true food insufficiency in the WIC program setting would ordinarily result in certification for eligibility of those who are at nutrition and health risk. The potential to benefit from WIC participation is expected to be high on theoretical grounds. Therefore, the committee recommends use of food insecurity as a risk criterion and further research to specify better the overall yield of benefit and the components of that yield. 

DIETARY RISK CRITERIA 283 SUMMARY Assessment of dietary intake and eating practices is integral to the WIC program. Such assessment focuses attention on food and diet as central to health, provides a basis to tailor the educational and referral components of WIC program interventions, and may be used as a basis for determining program eligibility. See Table 6-3 above for the committee's recommendations for dietary risk criteria. Review of data on use of the food frequency questionnaire or 24-hour recall of food intake to identify nutrient inadequacy indicates the yields of these techniques are likely to be quite low. Thus, the committee recommends that they not be used for this purpose in the WIC program, but modifications of these tools may be useful for identifying inappropriate diet. Since the whole-diet approach to assessment focuses attention on diet in relation to health and provides a basis for nutrition education, use of diet recalls or food frequency questionnaires is recommended for this purpose. Given the limitations of the methods used for the assessment of dietary risks, research efforts should be undertaken to develop, refine, and validate practical assessment tools that can be used to detect inappropriate diet, inadequate diet, and food insecurity in the context of the WIC program. REFERENCES Ammerman, A.S., P.S. Haines, P.F. DeVellis, D.S. Strogatz, T.C. Keyserling, R.J. Simpson, Jr., and D.S. Siscovik. 1991. A brief dietary assessment to guide cholesterol reduction in low- income individuals: Design and validation. J. Am. Diet. Assoc. 91:1385–1390. Arcasoy, A., A.O. Cavdar, and E. Babacan. 1978. Decreased iron and zinc absorption in Turkish children with iron deficiency and geophagia. Acta Haemat. 60:76–84. Armstrong, B.G., A.D. McDonald, and M. Sloan. 1992. Cigarette, alcohol, and coffee consumption and spontaneous abortion. Am. J. Public Health 82:85–87. Beaton, G.H., J. Milner, P. Corey, V. McGuire, M. Cousins, B. Stewart, M. de Ramos, D. Hewitt, B. Grambasch, N. Kassim, and J.A. Little. 1979. Sources of variance in 24-hour dietary recall data: Implications for nutrition study design and interpretation. Am. J. Clin. Nutr. 32:2546– 2559. Beaulac-Baillargeon, L., and C. Desrosiers. 1986. Profile of the consumption of caffeine, cigarettes and alcohol by women in Quebec during pregnancy. Union Med. Can. 115:813–817, 821. Bickel, G., M. Andrews, and B. Klein. 1995. Measuring the food security of the American people: The Food Security Supplement to the Current Population Survey. Forthcoming, Food and Consumer Services, U.S. Department of Agriculture. Block, G. 1991. Vitamin C and cancer prevention: The epidemiologic evidence. Am. J. Clin. Nutr. 53:270S–282S. 

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