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--> 7 Predisposing Nutrition Risk Criteria A final category of nutrition risk criteria used in the WIC program (Special Supplemental Nutrition Program for Women, Infants, and Children) is conditions that predispose persons to inadequate nutrition patterns or nutritionally related medical conditions (7 CFR Subpart 2, Section (d)(2)(iv)). In general, predisposing risk criteria are used to certify women, infants, and children for participation in the WIC program under Priority VII. In the face of funding constraints, however, individuals eligible for participation in the WIC program under Priority VII often are not served by the program. Yet, of all of the nutrition risk criteria discussed in this report, predisposing nutrition risk criteria may support most clearly the preventive nature of the WIC program. Legislatively, the use of predisposing risk criteria has an interesting history. The Child Nutrition Amendments in 1978 (Public Law 95-627) expanded the definition of nutrition risk to include predisposing conditions including, but not limited to, alcoholism and drug addiction . … Subsequent changes in regulations added homelessness and migrancy as specific predisposing nutrition risk criteria. Since health professionals have recently come to consider alcoholism and drug addiction as medical risks, these criteria too are now generally used as medical risk criteria to place individuals in one of the top three priorities. The Food and Consumer Service (FCS, administrative home to the WIC program at the U.S. Department of Agriculture [USDA]) has not considered homelessness, migrancy, or most other predisposing nutrition risk criteria as conditions that warrant placement of individuals in one of the top three priorities without a documented nutrition or medical risk (Federal Register, 59(66): 16, 146-16, 149).
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--> The category of predisposing conditions poses a challenge to the committee's analysis of the scientific basis of the nutrition risk criteria. A large number of behavioral, cultural, nutrition, and medical conditions can place individuals at risk of poor nutrition status, and states have used considerable latitude in defining predisposing nutrition risk criteria. In addition to homelessness and migrancy, other predisposing risks used to certify the eligibility of individuals for participation in the WIC program include passive smoking, low maternal education, young caregiver, battering, child of a mentally retarded parent, and child abuse and neglect. This chapter summarizes the scientific evidence for these predisposing nutrition risk criteria. Table 7-1 presents the number of states using each of these predisposing risk criteria for women, infants, and children. Table 7-2 provides a summary of these criteria as predictors of nutrition risk and of benefit from WIC program participation. This chapter does not cover caretaker physically disabled or inadequate facilities for food preparation or storage. Physical disability is a broad term covering widely varying conditions, most of which are compatible with appropriate child care. Apart from homelessness, the committee did not find a scientific basis on which to review the relationship between food preparation facilities and nutrition risk or benefit. TABLE 7-1 Summary of Predisposing Risk Criteria in the WIC Program and Use by States States Using Risk Criterion Pregnant Womena Infants Children Homelessness 1 — — Migrancy — 21 20 Passive smoking 3 — — Low level of maternal education and illiteracy 2 — — Young caregiver — 6 0 Maternal depression — — — Battering 7 — — Child abuse or neglect — 9 7 Child of a mentally retarded parent — 35 26 NOTE: Dashes denote that the criterion was not reported for that population. a Data for postpartum women were not readily available. SOURCE: Adapted from USDA (1992).
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--> TABLE 7-2 Summary of Predisposing Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children Women Infants Children Risk Criterion Risk Benefit Risk Benefit Risk Benefit Homelessness ✓ ? ✓ ? ✓ ? Migrancy ✓ ? ✓ ? ✓ ? Passive smoking ✓a ? ✓a 0 ✓a ? Low level of maternal education and illiteracy ✓ ? ✓ ? ✓ ? Maternal depression ✓ ? ✓ ? ✓ ? Battering ✓ ? Child abuse or neglect ✓ ? ✓ ? Child of a young caregiver ✓ ? ✓ ? Child of a mentally retarded parent ✓ ✓ ✓ ✓ NOTE: ✓ = predictive of risk or benefit; ? = no evidence; 0 = evidence, but no effect; blank = not applicable to the group. a Health risk only, no evidence of nutrition risk. The committee's recommendations for predisposing nutrition risk criteria are summarized in Table 7-3. Homelessness Until recently, homelessness by itself was not accepted as a valid nutrition risk criterion for eligibility for participation in the WIC program. Homeless women, infants, and children were eligible for the WIC program only if they had some other documented nutrition risk. However, based on the recommendations of the National Advisory Council on Maternal, Infant, and Fetal Nutrition (USDA, 1992), recent final regulations for participation in the WIC program (Federal Register , April 19, 1995) added homelessness and migrancy to the predisposing nutrition risk criteria for the WIC program. The regulations place individuals who are eligible solely on the basis of homelessness or migrancy under Priority VII. However, state WIC agencies, at their discretion, may place these individuals in priority groups as follows: pregnant or breastfeeding women and infants in Priority IV; children in Priority V; and postpartum women in Priority VI.
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--> TABLE 7-3 Summary of Dietary Risk Criteria and Committee Recommendations for the Specific WIC Population Postpartum Women Risk Criterion Committee Recommendation Pregnant Women Lactating Nonlactating Infants Children Homelessness Use ✓ ✓ ✓ ✓ ✓ Migrancy Use ✓ ✓ ✓ ✓ ✓ Passive smoking Do not use Low level of maternal education or illiteracy Use ✓ ✓ ✓ ✓ ✓ Maternal depression Add ✓ ✓ ✓ ✓ ✓ Battering Use ✓ ✓ ✓ Child abuse or neglect Use ✓ ✓ Child of a young caregiver Use ✓ ✓ Child of a mentally retarded parent Use ✓ ✓ NOTE: ✓ = subgroup to which the recommendation applies.
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--> Prevalence of and Factors Associated with Homelessness The definition of a homeless individual used by the WIC program is broad: a woman, infant or child who lacks a fixed and regular nighttime residence; or whose nighttime residence is: a supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; a temporary accommodation in the residence of another individual; or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (Federal Register, 59(66):16, 146-16, 149). Estimates of the number of homeless people vary widely because of ambiguities in the definition of homelessness and lack of a reliable counting method. During the 1980s, point-prevalence estimates of homelessness in the United States ranged from 350,000 to more than 3 million (USDA, 1991). Owing to inevitable design problems, surveys that actually try to count the number of homeless individuals generally provide smaller estimates than do other methods of estimating prevalence (Link et al., 1994). This recent study reports lifetime (any time) and 5-year prevalence estimates of homelessness that are significantly higher than previous point-prevalence estimates: (1) a lifetime combined prevalence of all types of homelessness of 14.0 percent (26 million individuals); (2) a 5-year (1985 to 1990) prevalence of all types of homelessness of 4.6 percent (8.5 million individuals); and (3) a lifetime prevalence of literal homelessness (sleeping in shelters, abandoned buildings, bus and train stations, etc.) of 7.4 percent (13.5 million individuals). Comparison of these 5-year and lifetime prevalence estimates with the earlier point-prevalence estimates of homelessness suggests a fluid process with people flowing in and out of homelessness. Despite controversy over the absolute numbers, there is consensus that the number of homeless individuals increased steadily during the 1980s (Rossi et al., 1987). During this period several surveys of local areas found that between 30 and 50 percent of the homeless were families with children, usually headed by single women with at least one child under 18 years (Bassuk et al., 1986; Miller and Lin, 1988; New York Coalition for the Homeless, 1986; U.S. Conference of Mayors, 1984, 1986, 1987). A variety of risk factors are associated with homelessness. Weitzman (1989) suggests that pregnancy and recent birth are precipitating factors for homelessness. Homeless women, especially homeless pregnant women, are more likely than housed low-income women to have alcohol problems, to use drugs, and to smoke (Becker et al., 1992; Fischer, 1991; Jaffee et al., 1992). Homeless women are also likely to be victims of domestic violence; 33 to 89
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--> percent of all homeless women are estimated to have experienced abuse at some point during their life (Bassuk and Weinreb, 1993). Homelessness as an Indicator of Nutrition and Health Risk Although somewhat sparse, the empirical evidence, as identified below, documents poorer pregnancy outcomes, increased risk of malnutrition and health problems, low utilization of preventive health services, and a higher incidence of developmental delays and learning problems among homeless families with women and their children. Women. In general, homeless women experience a variety of health disorders and problems. Higher than expected levels of iron deficiency anemia, overweight and obesity, and high serum cholesterol concentrations were found among single homeless women living in temporary housing shelters in Kansas City, Missouri (Drake, 1992), and among homeless men and women in New York City (Luder et al., 1990). Homeless women are also found to have higher prevalence of such chronic health problems as hypertension, diabetes mellitus, coronary heart disease, mental illness, alcoholism, and tuberculosis (Drake, 1992; Luder et al., 1990). Pregnancy outcomes are worse for low-income homeless women than for other low-income women. A study of homeless pregnant women in New York City found significantly higher infant mortality rates and rates of low birth weight (LBW) among the homeless women than among women living in low-income public housing (Chavkin et al., 1987). Another study of birth outcomes in New York City found that pregnant WIC participants were three times more likely to have LBW newborns if they were homeless (Jaffee et al., 1992). The explanation of the poorer pregnancy and health outcomes for homeless pregnant women is most likely a combination of inadequate prenatal care, poor nutrition, and other behavioral and health problems. In the 1982–1984 New York City study of homeless pregnant women and housed low-income pregnant women, 40 percent of the homeless women received no prenatal care, compared with less than 15 percent of the women living in public housing (Chavkin et al., 1987). In Jaffee's study of homeless pregnant women in New York City, pregnant homeless WIC program participants were four times more likely to lack prenatal care than similar WIC program participants with housing (Jaffee et al., 1992). Studies of the diets and eating patterns of all homeless individuals suggest the following: increased risk of protein-energy malnutrition and chronic malnutrition; high intakes of sodium, saturated fat, and cholesterol; shortages of essential nutrients; low dietary adequacy scores; and primary sources of food that include fast-food restaurants, shelters, delicatessens, and garbage bins
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--> (Luder et al., 1989, 1990; Wiecha et al., 1991; Wolgemuth et al., 1992). The few studies of dietary intakes by single homeless women living in shelters found (1) low mean intakes of iron, calcium, magnesium, zinc, and folate (< 50 percent of Recommended Dietary Allowances [RDAs]) (Drake, 1992); and (2) higher than recommended fat intake (Drake, 1992); and (3) low average intake of servings in each of four food groups and a high intake of foods of low nutrient density (28 percent of total food intake) (Bunston and Breton, 1990). Children. The socioeconomic, health, and nutrition problems faced by homeless women are exacerbated for their homeless infants and children. Homeless children are at increased risks of infectious diseases, growth and developmental delays, behavioral and emotional problems, and a host of other biologic and developmental insults. The frequency of health problems among homeless children exceeds that of housed comparison groups or standard reference populations with places to live. In particular, homeless children have very high rates of delayed immunizations (Acker et al., 1987; Alperstein et al., 1988; Miller and Lin, 1988). Other health problems experienced by homeless children include a high reported rate of child abuse and neglect; a higher incidence of asthma; and increased risks of infectious disease, especially conjunctivitis, ringworm, gastrointestinal disorders, upper respiratory infections, and scabies and lice infestations (Khan, 1991). High proportions of homeless children and their families have no regular source of medical care, and they over-rely on hospital emergency rooms for primary health care (Hu et al., 1989; Roth and Fox, 1990; Wood and Valdez, 1991). Homeless children also suffer disproportionately from significant behavioral and developmental problems that affect their cognitive growth and development (Bassuk and Rubin, 1987; Bassuk et al., 1986; Eddins, 1993; Parker et al., 1991). Studies examining measures of physical growth of homeless children provide mixed evidence on the prevalence of acute and chronic malnutrition. Those studies differ considerably on the basis of the geographic areas studied and the age groups examined, but together, they present a broad-based overview of the physical growth status of homeless children. Some studies of homeless children reported weight-for-height and height-for-age measurements similar to those for other low-income children, suggesting that malnutrition is not disproportionately prevalent among homeless children (Lewis and Meyers 1989; Alperstein et al., 1988; Wood et al., 1990). In contrast, one study of homeless children in New York City reported a higher than expected prevalence of stunting (low height-for-age) but not wasting (low weight-for-height), suggesting moderate, chronic malnutrition (Fierman et al., 1991). Another study of homeless preschoolers in Baltimore found a higher than expected prevalence of wasting, suggesting that some homeless children may have experienced acute undernutrition (Taylor and Koblinsky, 1993).
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--> The most typical growth problem found among homeless children is an increased risk of obesity. Estimates of the percentage of homeless children who are overweight range from 12 to 35 percent (Miller and Lin, 1988; Taylor and Koblinsky, 1993; Wood et al., 1990). Estimates of the prevalence of anemia among homeless children vary widely across studies, ranging from 2 percent to nearly 50 percent (Acker et al., 1987; Arnstein and Alperstein, 1987; Wright and Weber-Burdin, 1987). Although limited in number, most studies find that the prevalence of anemia is significantly higher among homeless children than among other low-income children (Acker et al., 1987). Higher than expected rates of obesity, anemia, and stunting among homeless children are consistent with poor dietary quality. One comprehensive study found a wide range of poor eating habits and inadequate diets among homeless children in two temporary housing shelters in Kansas City, Missouri, during 1989 (Drake, 1992). Although a sufficient quantity of food was available for these children, the foods offered were typically convenience and prepackaged foods that were high in fat and saturated fat and low in nutrient density. The most common method of food preparation was frying. Average intakes of iron, magnesium, zinc, and folate were about 50 percent of the RDA. Most mothers of infants did not use iron-fortified formulas, as recommended, but instead fed their infants homogenized whole milk from a bottle. Taylor and Koblinsky (1993) confirm the inadequate iron intakes of homeless children, and several studies find that diets of homeless children are lacking in fresh fruits and vegetables (Drake, 1992; Taylor and Koblinsky, 1993; Wood et al., 1990). There are apparently no research studies that have investigated the dietary or health effects of WIC program participation on homeless women and their children. Homelessness as an Indicator of Nutrition and Health Benefit Despite the lack of empirical evidence, the nutrition and health problems experienced by homeless women and their children underscore their need for the nutrition education, nutritious foods, and referrals to health care provided through the WIC program. Low iron intakes and higher than expected prevalence of anemia could be addressed through the provision of supplemental food through the WIC program and education on food sources of iron, ways to increase iron absorption, and the appropriate use of iron supplements, especially iron-fortified formula for bottle-fed infants and iron-fortified infant cereal for all infants older than 3 to 4 months. Obesity and other growth problems could be diminished through the provision of supplemental nutritious foods through the WIC program and through education on food sources of nutrients and food preparation techniques. Finally, referrals to appropriate health care, and other
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--> services, such as the Food Stamp Program or prenatal care, would also hold potential for reducing nutrition risk. Limited evidence suggests that WIC program participation by homeless families with women, infants, and children is less than that by similar low-income families with housing. In New York City in 1988, only 44 percent of homeless women who were pregnant or who had new infants were participating in the WIC program, compared with 60 percent of eligible housed women (Weitzman, 1989). In Boston, a study of homeless families with children reported a participation rate in the WIC program of 54 percent (Lewis and Meyers, 1989). The authors suggest that the lack of storage for perishable foods and the high mobility of homeless families contribute to low rates of WIC participation in the WIC program. Siegler and colleagues (1993) report on a WIC food package that was adapted for the living conditions of homeless families and nutrition education that focused on food safety, foods requiring little or no cooking, and healthful snacks for children. Other factors that may contribute to low participation rates include the lack of adequate kitchen facilities in homeless shelters, lack of transportation, mistrust of health care providers, the lack of a safe and stable living environment, mental illness, domestic violence, alcoholism, and drug abuse. Use of Homelessness as a Nutrition Risk Criterion in the WIC Setting As discussed earlier, homelessness has only recently been allowed for use as a predisposing nutrition risk criterion by state WIC programs. Given the severe health and nutrition problems experienced by homeless women, infants, and children, it is highly likely that they are placed in a priority higher than VII by virtue of an anthropometric, medical, or dietary nutrition risk criterion or by virtue of the state's option to place homeless program applicants in Priorities IV through VI. This may be less likely for those who are newly homeless. In the face of the funding constraints encountered by the WIC program, concerns have been raised that homeless women, infants, and especially children may not be served because of the lower priority assigned to homelessness as a nutrition risk (Lenihan, 1994). Recommendation for Homelessness In summary, the scientific evidence unquestionably documents significant health and nutrition risks associated with homelessness and identification of homelessness is relatively straightforward. There is theoretical evidence of benefit from WIC program participation among homeless women, infants, and children. The committee recommends that homelessness be used as a nutrition risk criterion for women, infants, and children in the WIC program, at a priority
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--> level higher than VII, and emphasizes the value of specially tailored food packages for the homeless. Migrancy Testimony before the National Advisory Council on Migrant Health indicates that lack of permanent housing for the migrant population predisposes migrants to the same set of problems identified above for homeless individuals. As a result, the final WIC program regulations published in the April 19, 1995, Federal Register also included migrancy as a predisposing nutrition risk criterion certifying eligibility for participation in the WIC program. Migrant individuals who are eligible for participation in the WIC program on the basis of categorical criteria and income but who lack any other documented medical or nutrition risk criterion are placed in Priority VII, with the state having the option of placing individuals in Priorities IV through VI. Prevalence of and Factors Associated with Migrancy Lack of reliable data on the number of migrants makes it difficult to calculate rates of mortality and morbidity and the prevalence of health problems and disability. As with homelessness, estimates of the prevalence of migrancy reflect both variations in its definition and counting methods. There is no standard definition of migrant among government agencies. WIC program regulations refer to the term migrant and migrant farmworker interchangeably and define a migrant farmworker as ''an individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode" (Federal Register, 59(66):16, 146–16, 149). Estimates from the USDA and the U.S. Department of Labor generally count only employed farmworkers over age 14 years, ignoring the dependents of migrant workers. Thus, those estimates are lower than estimates from the Department of Health and Human Services (DHHS). The DHHS Office of Migrant Health estimated that there were about 3 million migrant and seasonal farmworkers and their dependents in the mid-1980s (Rust, 1990), whereas more recent estimates range between 4 million and 5 million (DHHS, 1990; Mobed et al., 1992). In general, migrant farmworkers have low-incomes, live in crowded and unsanitary conditions, and perform strenuous physical labor for long hours. The migrant population comprises people of various racial and ethnic backgrounds, but the majority are Hispanic in origin. Although most migrant farmworkers are U.S. citizens, English is often not their primary language and many have low
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--> levels of education. Studies of migrant farmworkers in Wisconsin in 1978 reported that 35 percent of migrant women of childbearing age were functionally illiterate (4 or fewer years of schooling) (Slesinger et al., 1986). Literacy levels improved during the 1980s, but they are still below national levels (Slesinger and Ofstead, 1993). A very high proportion (63 percent) are children under the age of 16 years, a group that is particularly at risk of infectious diseases and other health problems from adverse and crowded living conditions (National Advisory Council on Migrant Health, 1992). The high rate of mobility of migrant farmworkers makes it difficult for these individuals to maintain continuous and comprehensive health care. Migrancy as an Indicator of Nutrition and Health Risk The array of health and nutrition problems experienced by migrant farmworkers and their dependents is different from that experienced by the general population. Common problems documented in the literature include increased risk of respiratory infections, gastroenteritis, intestinal parasites, skin infections, otitis media, scabies and head lice, pesticide exposure, tuberculosis, poor nutrition, anemia, short stature, obesity, hypertension, diabetes mellitus, congenital anomalies, delayed development, injuries, adolescent pregnancy, inadequate dental care, and delayed immunizations (AAP, CCHS, 1989; Dever, 1991). However, large gaps exist in the literature on the health status of migrant individuals, and on factors that contribute to their poor health and nutrition status (Rust, 1990). Women. Most studies of the health and nutrition status of migrant farmworkers combine men and women in the analyses. Yet the data show convincingly that migrant farmworkers and their dependents experience poor health and both acute and chronic illnesses. Access to health care is limited, and most migrant and seasonal workers seek medical treatment for acute illnesses rather than for preventive services and the management of chronic conditions. Recent data on pregnancy outcomes for migrant women are not available. The few older studies (Chase et al., 1971; Slesinger et al., 1986; de la Torre and Rush, 1989) demonstrated elevated infant mortality rates relative to the rate for the general U.S. population. Chase and co-workers (1971) reported an infant mortality rate that was nearly three times the U.S. infant mortality rate at that time. De la Torre and Rush (1989) found that 24 percent of the migrant women in their study had experienced one or more miscarriages or fetal death and that 8 percent had experienced at least one infant death. Old data suggest that inadequate levels of prenatal care, lack of access to appropriate labor and delivery facilities, and poor nutrition contribute to these higher than average rates of infant mortality (Chase, 1971). Reasons cited for
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--> The infants of mentally retarded mothers can be at risk of poor health from circumstances existing prior to their birth. Mentally retarded mothers may not receive optimal prenatal care if they are unaware of the need for prenatal care or they lack access to it. Their infants are at higher than normal risk of malnutrition, alcohol or lead exposure, infection, and other prenatal complications (Rolfe, 1990). Assessment of growth and development in the infant or child may reveal much about the adequacy of the child's environment. Nonorganic failure to thrive in the infant or child of a mentally retarded parent is a reliable indicator of neglect (Rolfe, 1990). Mentally Retarded Parent as an Indicator of Nutrition and Health Benefit The children of mentally retarded parents can benefit from educational interventions for their parents. Educational programs for mentally retarded adults with preschool-age children have been shown to improve their parenting skills (Whitman et al., 1990). A parent training program conducted in St. Louis combined basic teaching at their center with one or two observational home visits weekly. Child care and parent-child relationships were the major areas covered, with food preparation being an important component. All families made progress in selected parenting skills. In earlier research, teaching mentally retarded adults grocery shopping and menu planning skills assisted them in serving more nutritious meals (Feldman, 1994; Sarber et al., 1983). Feldman and colleagues (1992a, b) studied mothers with developmental disabilities who lacked child care skills. Instruction in proper feeding techniques, correct formula preparation, bottle cleaning techniques, and meal planning and preparation improved the mothers' skills and was associated with such benefits as increased weight gain and fewer illnesses in their children. Research indicates that the most effective training for parents with intellectual disabilities should be performance based and should use modeling, practice, feedback, and praise (Feldman, 1994). The WIC program's supplemental food package and nutrition education could help mentally retarded parents provide nutritionally balanced diets to infants and children. Although some WIC programs teach participants grocery shopping skills and menu planning, the specialized training required by an intellectually disabled parent to acquire child care skills is most likely beyond the scope of the WIC program. Nonetheless, WIC program referrals can direct the mentally retarded parent to other social and health services that can improve parenting skills.
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--> Use of Mentally Retarded Parent as a Risk Criterion in the WIC Program Documentation or a diagnosis of mental retardation in a parent is generally done outside of the WIC program setting by a medical or mental health professional. If an initial certification for participation in the WIC program identifies gross indicators of abuse or neglect this could lead to a finding of mental retardation in a parent. Recommendation for Child of a Mentally Retarded Parent The risk for a child of a mentally retarded parent is well documented. Many families with a mentally retarded parent experience poverty and have difficulty maintaining their family because of a lack of support systems. On a theoretical basis, WIC program services and referrals may help to prevent or treat problems resulting from the parenting inadequacies of a mentally retarded parent. Therefore, the committee recommends use of child of a mentally retarded parent as a nutrition risk criterion for infants and children by the WIC program at a higher priority. Summary The assessment of conditions that may predispose low-income individuals to health or nutrition risks has become an important part of the WIC program. Some predisposing risk criteria have been used by state WIC agencies for many years, and some have been adopted recently. A summary of the risk and potential to benefit with predisposing risks covered in this chapter appears above in Table 7-2. Based on available evidence concerning nutrition and health risks and potential to benefit, the committee recommends use of nutrition risk criteria as shown previously in Table 7-3. References AAP, CCHS (American Academy of Pediatrics, Committee on Community Health Services). 1989. Health care for children of migrant families. Pediatrics 84:739–740. Accardo, P.J., and B.Y. Whitman. 1990. Children of parents with mental retardation: Problems and diagnoses. Pp. 123–131 in When a Parent is Mentally Retarded, B.Y. Whitman and P.J. Accardo, eds. Baltimore, Md.: Paul H. Brookes Pub. Co. Acker, P.J., A.H. Fierman, and B.P. Dreyer. 1987. An assessment of parameters of health care and nutrition in homeless children. Am. J. Dis. Child. 141:388.
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--> Alperstein, G., C. Rappaport, and J.M. Flanigan. 1988. Health problems of homeless children in New York City. Am. J. Public Health 78:1232–1233. AMA (American Medical Association). 1992. Diagnostic treatment guidelines on child physical abuse and neglect. Arch. Fam. Med. 1:187–197. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: APA. Arnstein, E., and G. Alperstein. 1987. Health care for the homeless. Public Health Currents 27:29–34. Bassuk, E., and L. Rubin. 1987. Homeless children: A neglected population. Am. J. orthopsychiatry 57:279–286. Bassuk, E.L., and L. Weinreb. 1993. Homeless pregnant women: Two generations at risk. Am. J. orthopsychiatry 63:348–355. Bassuk, E.L., L. Rubin, and A.S. Lauriat. 1986. Characteristics of sheltered homeless families. Am. J. Public Health 76:1097–1101. Becker, J., A. Robinson, S. Gortmaker, L. Weinreb, and E. Bassuk. 1992. Reproductive health Status of Homeless Pregnant Women. Paper presented at the National Conference of American Public Health Association, Washington, D.C.: American Public Health Association. Belsky, J. 1984. The determinants of parenting: A process model. Child Dev. 55:83–96. Berenson, A.B., C.M. Wiemann, G.S. Wilkinson, W.A. Jones, and W.G. anderson. 1994. Perinatal morbidity associated with violence experienced by pregnant women. Am. J. Obstet. Gynecol. 170:1760–1769. Bunston, T., and M. Breton. 1990. The eating patterns and problems of homeless women. Women Health 16:43–62. Burns, D., and J.P. Pierce. 1992. Tobacco use in California, 1990–1991. Sacramento, Calif.: California Department of Health Services. Cardenas, J., C.E. Gibbs, and E.A. Young. 1976. Nutritional beliefs and practices in primagravid Mexican-American women. J. Am. Diet. Assoc. 69:262–265. Casper, R.C., D.E. Redmond, Jr., M.M. Katz, C.B. Schaffer, J.M. Davis, and S.H. Koslow. 1985. Somatic symptoms in primary affective disorder. Presence and relationship to the classification of depression. Arch. Gen. Psychiatry 42:1098–1104. CDC (Centers for Disease Control and Prevention). 1994. Physical violence during the 12 months preceding childbirth—Alaska, Maine, Oklahoma and West Virginia, 1990–1991. Morbid. Mortal. Weekly Rep. 43(8):132–137. Chase, H.P., V. Kumar, J.M. Dodds, H.E. Sauberlich, R.M. Hunter, R.S. Burton, and V. Spalding. 1971. Nutritional status of preschool Mexican-American migrant farm children. Am. J. Dis. Child. 122:316–324. Chavkin, W., A. Kristal, C. Seabron, and P.E. Guigli. 1987. The reproductive experience of women living in hotels for the homeless in New York City. N.Y. State J. Med. 87:10–13. Chen, L.H., and D.B. Petitti. 1995. Case-control study of passive smoking and the risk of small-for-gestational-age at term. Am. J. Epidemiol. 142:158–165. Chen, Y., L.L. Pederson, and N.M. Lefcoe. 1989. Passive smoking and low birth weight. Lancet 2:54–55. Chi, P.S. 1985. Medical utilization patterns of migrant farm workers in Wayne County, New York. Public Health Rep. 100:480–490.
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