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WIC Nutrition Risk Criteria: A Scientific Assessment (1996)

Chapter: 7 Predisposing Nutrition Risk Criteria

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Suggested Citation:"7 Predisposing Nutrition Risk Criteria." Institute of Medicine. 1996. WIC Nutrition Risk Criteria: A Scientific Assessment. Washington, DC: The National Academies Press. doi: 10.17226/5071.
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Suggested Citation:"7 Predisposing Nutrition Risk Criteria." Institute of Medicine. 1996. WIC Nutrition Risk Criteria: A Scientific Assessment. Washington, DC: The National Academies Press. doi: 10.17226/5071.
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PREDISPOSING NUTRITION RISK CRITERIA 295 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).

PREDISPOSING NUTRITION RISK CRITERIA 296 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 2 — — illiteracy 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).

PREDISPOSING NUTRITION RISK CRITERIA 297 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.

PREDISPOSING NUTRITION RISK CRITERIA 298

PREDISPOSING NUTRITION RISK CRITERIA 299 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

PREDISPOSING NUTRITION RISK CRITERIA 300 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

PREDISPOSING NUTRITION RISK CRITERIA 301 (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).

PREDISPOSING NUTRITION RISK CRITERIA 302 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

PREDISPOSING NUTRITION RISK CRITERIA 303 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

PREDISPOSING NUTRITION RISK CRITERIA 304 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

PREDISPOSING NUTRITION RISK CRITERIA 305 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

PREDISPOSING NUTRITION RISK CRITERIA 306 not receiving prenatal care included lack of money, lack of transportation, lack of child care, and lack of a perceived need for prenatal care (National Advisory Council on Migrant Health, 1992). One-fourth of farmworkers in Wayne County, New York, expressed a fear and distrust of the medical profession (Chi, 1985). Data on the adequacies of the diets of migrant farmworkers are very limited (Cardenas et al., 1976). A study conducted by Public Voice in 1989 reported that one-half of migrant farmworkers had diets that did not meet the RDA for vitamin A, iron, or calcium; almost one-third reported running out of food sometime during the past year; and over one-fifth suffered from intestinal parasites. Finally, less than one-quarter of eligible migrant farmworkers participated in the Food Stamp Program—many migrants were not aware of their eligibility (Shotland et al., 1989). Many aspects of the living conditions of migrant farmworkers and their families contribute to poor dietary patterns. Inadequate cooking and food storage facilities, lack of money for food purchases, limited access to supermarkets, long working hours, a lack of time to prepare nutritious meals, and overconsumption of prepackaged and convenience foods may all contribute to poor nutrition. Children. Information on the health and nutrition status of migrant children is even more limited than that for migrant women and is similarly based on old survey data (Chase et al., 1971). In 1969, 55 percent of the preschool-age migrant children studied in Colorado had below-normal serum vitamin A concentrations. Other nutrition problems included anemia, stunting, low head circumference, and low alkaline phosphates concentrations, all suggestive of undernutrition among preschool-age migrant children. Like Chase and colleagues, Slesinger provided further evidence of the high proportions of migrant children under 16 years of age who had not received basic health services. Chronic health conditions were more common among migrant children than among all U.S. children surveyed in the 1969 to 1970 National Health Interview Survey (11 percent of migrant children versus 3 percent of all U.S. children). Migrancy as an Indicator of Nutrition and Health Benefit There is no empirical evidence on migrancy as a predictor of nutrition and health benefit. However, the wide range of health and nutrition problems of migrant women and their children suggests that interventions like those provided through the WIC program have potentially large expected benefits. Poor dietary quality and the resulting high rates of vitamin deficiencies, stunting, obesity, and poor perinatal outcomes are evidence of the need for both

PREDISPOSING NUTRITION RISK CRITERIA 307 nutrition education and WIC program foods that are high in key nutrients. Health care and social service referrals and education on the importance of health care could address perceptions among migrants that preventive health care and prenatal care are not needed, ways to get appropriate health care, and the importance of timely immunizations. Many local agencies have developed programs to overcome language barriers and cultural differences, transportation problems, lack of child care, and long working hours of their clientele. Sometimes working in combination with the Expanded Food and Nutrition Education Program, they adapt their educational programs to the needs of migrants. Through referral systems, they strive to achieve a comprehensive approach to meeting their clients' health needs. Very little information is available on the WIC program participation rate by migrant women and their children, and no published studies have investigated the effects of the WIC program on the health of migrant participants. However, a joint project in North Carolina that includes a WIC program (Watkins et al., 1990) provides some useful data: (1) more than 90 percent of migrant farmworker women and children were enrolled in the center's WIC program; (2) by the third year, there were increases in the average number of prenatal visits (7 to 10), and in the proportion of women entering prenatal care in the first trimester (from 41 percent to 51 percent); (3) there was a decrease in the percentage of women with low-birth-weight newborns in the 1986 and 1987 cohorts; (4) the proportion of children receiving development screens increased (34 percent to more than 75 percent), and the proportion of children with complete immunization rose (40 percent to more than 60 percent); and (5) although anemia remained a common problem throughout the study period, a higher proportion of returning children than children coming to the center for only one season had a normal hematocrit level. In that health center, some nutrition problems have persisted. Although the women's diets did not include excessive amounts of high-calorie, nutrient-poor foods, and pica was not a common problem, both women and children reported low intakes of foods in the dairy and the fruit and vegetable groups. Moreover, 18 percent of infants and children were classified as obese, defined as weight-for- height at or above the 90th percentile, and the prevalence of stunting was more than twice the expected rate (Watkins et al., 1990). This project and its evaluation demonstrate the kind of data collection and analysis that are needed both to assess the nutrition and health risks of migrant women and children and to determine the effectiveness of the WIC program in addressing these risks.

PREDISPOSING NUTRITION RISK CRITERIA 308 Use of Migrancy as a Nutrition Risk Criterion in the WIC Setting FCS has long recognized the special needs of migrant populations and has incorporated special regulations addressing the unique circumstances of migrant farmworkers. The Child Nutrition Act of 1966, as amended, stipulates that not less than 0.9 percent of the sums appropriated for the WIC program must be made available to eligible members of migrant populations. In addition, state WIC program plans are required to include information on how program benefits will be provided to migrant farmworkers and their families, nutrition education plans must address the special needs of migrant families, and states must provide expedited processing services for migrant applicants. Migrant participants in the WIC program are not required to be recertified if they move to a different state during the middle of an eligibility period. The recent addition of migrancy as an explicit predisposing nutrition risk criterion allows migrant women, infants, and children eligible for participation in the WIC program on the basis of categorical criteria and income to be certified under Priority VII. However, in the face of funding constraints, migrants eligible only under Priority VII may not be served. However, states have the option of placing migrants in Priorities IV through VI. Data from the 1992 Study of WIC Participant and Program Characteristics (PC92) provide limited information on the extent to which using Priority VII for migrancy actually results in unserved migrant individuals. PC92 data were derived directly from certification records of individuals certified for participation in the WIC program in April 1992, before migrancy was allowed as a predisposing nutrition risk criterion. Data on the nutrition risks show that biochemical risks (hematocrit or hemoglobin level) were reported more frequently for migrant WIC program participants than for the overall caseload in the WIC program (USDA, 1994), suggesting that migrant workers are likely to have some other documented medical or nutrition risks that would place them in a higher priority. On the other hand, the proportion of migrant WIC participants without a reported categorization of risk priority is higher than for the WIC program overall, suggesting that migrancy itself might serve as the predisposing nutrition risk criterion. Recommendations for Migrancy The nutrition and health risks associated with migrancy are well documented in women, infants, and children and it is easy to identify migrancy. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of migrancy as a nutrition risk criterion for women, infants, and children by the WIC program.

PREDISPOSING NUTRITION RISK CRITERIA 309 However, because evidence on the nutrition risk of migrancy was obtained 15 to 20 years ago and is based on either small clinic-based samples or a few regional or statewide surveys of the health status of migrant individuals, research is needed—including a focus on other nutritional status measures such as obesity, iron deficiency anemia, and poor eating habits. PASSIVE SMOKING Exposure to tobacco smoke includes exposure during pregnancy and after birth to tobacco-smoke-contaminated air either at home or in other environmental contexts (Samet et al., 1994). Generally, the sources of air contamination are side-stream smoke from the cigarette's burning end and the smoke exhaled by the smokers. Passive smoking and involuntary smoking are terms frequently used to refer to exposure to tobacco-contaminated air, which is the topic in this section. Maternal smoking, which causes even higher fetal exposure to substances in smoke, is addressed in Chapter 5. Prevalence of and Factors Associated with Passive Smoking Since 1964, the prevalence of tobacco use has decreased dramatically as a result of educational efforts to discourage tobacco use among adults (DHHS, 1994a). However, smoking continues to be a major public health threat in the United States among families who meet the criteria for eligibility for participation in the WIC program. Of interest to the WIC program is that young females with low levels of education have shown the least reduction in their smoking habits (U.S. Bureau of the Census, 1993) (see Chapter 5). Young pregnant women may discontinue smoking during pregnancy, but smokers are likely to resume smoking after giving birth and thus expose their young children to tobacco-contaminated air. Concern over the exposure to tobacco smoke among young children is rising, as observed in the results of a 1988 nationwide survey (Overpeck and Moss, 1991). Almost one-half of all U.S. children (42 percent) under age 5 years were exposed to tobacco smoke. As income and maternal education levels decreased, the probability of children's exposure to tobacco smoke increased. In addition, a recent survey in California found that 25 percent of female nonsmokers 18 to 44 years of age were exposed to passive smoking at work and 34 percent were exposed at work and at home (Burns and Pierce, 1992). Exposure rates were higher in Hispanics, Asians, and women with less than 12 years of education.

PREDISPOSING NUTRITION RISK CRITERIA 310 Passive Smoking as an Indicator of Nutrition and Health Risk The level of contamination of indoor air secondary to tobacco use depends on the number of smokers, the intensity of smoking, the size of the indoor space, the rate of exchange of indoor and outdoor air, and the use of air cleaning devices (Samet et al., 1994). Empirical evidence shows increased levels of nicotine and cotinine (a metabolic by-product of nicotine and a very good indicator of nicotine exposure) in the serum, urine, and umbilical cord blood of women exposed to passive smoking (Jordanov, 1990; and Ueda et al., 1989). Studies of the association between passive smoking during pregnancy and birth outcomes provide mixed findings. Some studies reported a reduction in mean birth weight of infants whose mothers were exposed to passive smoking during pregnancy (Martin and Bracken, 1986; Rubin et al., 1986), whereas other studies found either no relationship between mean birth weight and passive smoking (Chen et al., 1989) or an increase in mean birth weight of infants born to mothers exposed to passive smokers (MacArthur and Knox, 1987). Studies that examined the relative risk of low birth weight of infants born at term generally find that maternal exposure to passive smoking during pregnancy is not associated with an increased risk of term infants being born small-for- gestational-age (Chen and Petitti, 1995). A study of day care centers showed that the nicotine exposure for children from homes where at least one person smoked was ten times higher than that for children from homes where no one smoked (cited in Samet et al., 1994). More recently, a study on exposure to tobacco smoke among 6- to 8-week-old infants living in homes where one member of the family (other than the mother) smoked showed that their level of urine cotinine was five to six times higher than the level in infants not exposed to smoking. The infants of mothers and fathers who both smoked had cotinine concentrations 12 times greater than the concentrations in infants whose parents that did not smoke (Chilmonczyk et al., 1990). Recent reviews have extensively documented the effects of involuntary smoking on children (DHHS, 1989; Poswillo and Alberman, 1992; Samet et al., 1994). The data consistently show that children of smokers experience an increased risk of lower respiratory infections, respiratory symptoms, reduced lung growth, exacerbation of asthma, and irritation of eyes, nose, throat, and lower respiratory tract (Samet et al., 1994). Recent evidence from the National Longitudinal Survey of Youth (1992), based on a nationally representative sample, indicates that involuntary smoking may lead to behavioral problems in children (Weitzman et al., 1992). Independently of duration, 4- to 11-year-olds exposed to maternal cigarette smoking showed increased occurrences of behavioral problems (as indicated by a behavior problem index). In this sample, which included 2,252 children, 54 percent of the mothers reported smoking during and/or after pregnancy.

PREDISPOSING NUTRITION RISK CRITERIA 311 There was a dose-response relationship for children whose mothers smoked either after pregnancy or both before and after pregnancy. In the group whose mothers smoked only after pregnancy, children had an average of 0.7 additional behavior problems (p = .10) if their mothers smoked less than a pack per day and 2.1 additional behavior problems (p = .0004) if their mothers smoked a pack or more per day, compared to those who did not smoke. Despite the apparent health risks, however, there is little evidence of specific risk to the nutrition status of women infants and children exposed to tobacco- smoke-contaminated air. Passive Smoking as an Indicator of Nutrition and Health Benefit While the health benefits of smoking cessation by parents to the overall health of women, infants, and children in the household are clear, there is no indication that supplemental food, nutrition education, or participation in the WIC program can abate the risk posed by passive smoking. Passive Smoking as a Nutrition Risk Criterion in the WIC Setting Three state WIC agencies used passive smoking as a nutrition risk criterion for women in 1992 (see Table 7-1). Recommendation for Passive Smoking Biologic markers indicate that infants and children exposed to particles from secondhand smoke are at risk for impaired health, growth, and development. Similarly, exposure to tobacco smoke is associated with upper and lower respiratory problems, asthma, and irritation of sensory channels. The health risk from passive smoking is documented, but nutrition risk and evidence of benefit from WIC participation are not. Therefore, the committee recommends discontinuation of use of passive smoking as a risk criterion for women, infants, and children in the WIC program. LOW LEVEL OF MATERNAL EDUCATION AND ILLITERACY In public health programmatic and research activities, education is generally defined by the number of years of formal schooling. Years of education are often classified into such broad categories as less than 12 years, 12 years, and greater than 12 years (Kramer et al., 1995). A low level of parental education is also defined as less than a 9th-grade education. In some instances, illiteracy is the indicator of choice.

PREDISPOSING NUTRITION RISK CRITERIA 312 Immigrants and Puerto Ricans represent a substantial portion of the U.S. population and some of them may be unable to speak, read, or write in English. WIC offices may require appropriate bilingual personnel and offer materials written in their native language. Prevalence of and Factors Associated with Low Level of Maternal Education and Illiteracy Participants in the WIC program have, on average, comparatively low levels of education. In the National WIC Evaluation, 55 percent of the pregnant women enrolled had less than 12 years of education (Rush et al., 1988). In the general population of women (18 years of age and over) in the 1990 census, 21 percent had less than 12 years of education (U.S. Bureau of the Census, 1993). Low Level of Maternal Education and Illiteracy as Indicators of Nutrition and Health Risk Maternal education is negatively associated with infant and childhood mortality, low birth weight, and mild mental retardation. It is positively associated with the health (including cognitive development) and nutrition of the offspring. Children of illiterate women are especially at risk for poor health and nutrition. In some international studies, maternal literacy was the most powerful of numerous social and economic predictors for positive child health outcomes (Hobcraft et al., 1984). Because maternal education is associated with family income, wealth, parental occupation, and quality of housing, there is concern whether maternal education and literacy are the explanatory variables. Preliminary data suggest that these two variables are causally related to the health and nutrition of the offspring. Following tight control of potential confounders, numerous studies have shown that maternal education accounts for significant percentages of differences in health and nutrition outcomes (Cleland and Van Ginneken 1988; Victora et al., 1992). Cleland and Van Ginneken (1988) attribute about 50 percent of the variability of childhood mortality to low levels of maternal education, but this research was conducted in developing countries and may have limited applicability to the WIC program setting. Data from the 1980 National Natality Survey show that mothers with less than 12 years of education were at a higher risk of having an LBW baby than those with 12 or more years of education. After controlling for maternal smoking, height, and weight, women with less than 12 years of education had an LBW odds ratio of 1.6. However if women with less than 12 years of education stopped smoking during pregnancy, the incidence of LBW would decline by

PREDISPOSING NUTRITION RISK CRITERIA 313 35 percent (Kleinman and Madans, 1985), bringing the odds ratio much closer to 1.0. In a study of newborns served by Medicaid in five states, low maternal education was associated with significant decreases in newborn birth weight and an increase in the incidence of LBW (Devaney et al., 1990). Dietary information gathered in the Hispanic Health and Nutrition Examination Survey and the second National Health and Nutrition Examination Survey (NHANES II) shows that the educational level of Hispanic women and of white, non-Hispanic women predicts the quality of their diet (Guendelman and Abrams, 1995). In particular, the lower their education level, the higher the risk of poor dietary intake as defined by an average consumption of less than 50 percent of the RDA for eight nutrients (protein, calcium, iron, zinc, folate, and vitamins A, C, and E). As the level of maternal education (and literacy) increases, the mother's use of health services increases, and women assume a greater role in making child care decisions (Weiss et al., 1991). Low Level of Maternal Education and Illiteracy as Indicators of Nutrition and Health Benefit Increasingly, WIC programs are designing their educational programs to be useful to a clientele with low literacy. For example, Navaje and co-workers (1994) found that WIC clients processed and retained nutrition education messages better if they were simple and few in number. Videos and food demonstrations in the WIC program provide a very useful method for increasing the nutrition knowledge and skills of women with low literacy even for those who do not speak English. This suggests good potential for women with low literacy to benefit from the WIC program. A few WIC programs have joined forces with adult education and offer GED courses that center on food and nutrition. Women with low literacy would have few other opportunities to gain this information. Although formal schooling and literacy are not prerequisites for the good health of the offspring, it is likely that the identification of illiterate women or women with low levels of education within the WIC program will also identify children at some degree of risk for poor health and nutrition status. Use of Low Level of Maternal Education and Illiteracy as a Nutrition Risk Criterion in the WIC Setting The two states that used low maternal education as a nutrition risk criterion (see Table 7-1) used cutoff values of 8th grade or 9th grade. The use of less than 9 years of formal schooling as a cutoff point for low level of maternal education is supported by evidence that a 10th grade reading level is required to

PREDISPOSING NUTRITION RISK CRITERIA 314 comprehend reading materials from the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the March of Dimes (Davis et al., 1994). However, up to 11 to 14 years of education is required to comprehend hospital forms and many patient education materials (Davis et al., 1990). Self-reported education is often not a reliable marker for determining the reading ability required to understand and use written health and nutrition materials. Many individuals with reading problems are unwilling to acknowledge them to care providers. To the extent possible, validated instruments such as the Rapid Estimate of Adult Literacy in Medicine (Davis et al., 1993) are recommended for evaluating reading comprehension. Recommendation for Low Level of Maternal Education and Illiteracy A low level of maternal education and a low literacy level appear to be linked to measures of poor health outcomes and inadequate dietary patterns. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of low level of maternal education and illiteracy as a nutrition risk criterion for women, infants, and children in the WIC program. At this time, scientific evidence is inadequate to recommend a definitive cutoff value for low level of maternal education and literacy. MATERNAL DEPRESSION Maternal depression was reviewed by the committee in lieu of mental illness since the relevant information in the scientific literature addresses only maternal depression. Depression is a term used to characterize either depressive symptoms or a clinical diagnosis of depression. Depressive symptoms include a variety of emotions and feelings—sadness, helplessness, gloom, loss of interest, emotional emptiness, and feeling of flatness. A clinical diagnosis of depression includes both depressive and somatic symptoms that last for an extended period (Zuckerman and Beardslee, 1987). Depression can vary in severity, from mild swings in moods to extreme psychosis. Prevalence of and Factors Associated with Depression Estimates of the prevalence of depression vary widely by the population group studied, the assessment tools used, and the definitions of depression used. In general, however, the prevalence of depressive symptoms is higher than that of diagnosed depression (Zuckerman and Beardslee, 1987). Based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, roughly 2 to 3 percent of men and between 5 and 9 percent of women can be diagnosed

PREDISPOSING NUTRITION RISK CRITERIA 315 as depressed (APA, 1994). In contrast, depression measures from population- based, self-reported data from the first National Health and Nutrition Examination Survey (NHANES I) show that roughly 10 percent of men and 20 percent of women report depressive symptoms (Eaton and Kessler, 1981). Several factors are associated with depressive symptoms. Prevalence of depression is significantly higher among low-income individuals. In particular, low-income blacks have extremely high rates of depression, with nearly 50 percent reporting depressive symptoms (Eaton and Kessler, 1981; Orr and James, 1984). Mothers of young children, especially those without a strongly supportive social network, report high rates of depression. Estimates of these rates range from 12 percent, by using strict diagnostic criteria, to 52 percent, by using self-reports of depressive symptoms (Parker et al., 1988). Other factors that have been associated with maternal depression include immigrant status, housing dissatisfaction, low education, poor marital relationship, and stressful life events (Williams and Carmichael, 1985; Zuckerman and Beardslee, 1987). Depression during the postpartum period is common among women. Postpartum depression ranges from ''postpartum blues," which is a transient change in mood affecting 50 to 60 percent of all women, through postpartum depression, which lasts 5 to 6 weeks and affects roughly 20 percent of all women, to postpartum psychosis, which is very rare (Zuckerman and Beardslee, 1987). Maternal Depression as an Indicator of Nutrition and Health Risk Appetite changes are a distinguishing feature of depression; 77 to 90 percent of all depressed individuals show appetite changes (Casper et al., 1985; Leckman et al., 1984; Maes et al., 1991). The most common change is a reduction in appetite, although sometimes the opposite occurs. In one study of appetite and weight change in 193 patients with depressive symptoms who were ages 20 to 65 years, 54 percent of patients had a decreased appetite, 27 percent had an increased appetite, and the remainder had no change in appetite (Harris et al., 1984). Other studies confirm this pattern (Casper et al., 1985; Paykel, 1977). In addition, greater appetite change in both directions is related to increased severity of depression (Harris et al., 1984; Paykel, 1977). Severe depression is often associated with anorexia, bulimia, and weight loss (Hudson and Pope, 1990; Maes et al., 1991). The relationship between maternal psychological status and pregnancy outcomes has long been of interest, although little systematic research has been conducted (Wolkind, 1981). A recent review of prior studies presented evidence that maternal depressive symptoms are associated with preterm birth among low-income urban African-American women (Orr and Miller, 1995). Other studies have found that depressed pregnant women are more likely to smoke

PREDISPOSING NUTRITION RISK CRITERIA 316 during pregnancy, attend prenatal care less frequently, have a higher incidence of LBW infants, and experience higher perinatal mortality rates than non-depressed pregnant controls (Wolkind, 1981; Zax et al., 1977). A study of depressed parents and their children found: (1) increased use of mid or high forceps at delivery, (2) a weak or abnormal cry at birth, and (3) a higher incidence of not breathing for one or more minutes after birth (Weissman et al., 1986). Maternal depression was also associated with recurrent stomachaches and headaches in a community study of preschool-age children (Zuckerman et al., 1987). Maternal depression is strongly associated with children's emotional well- being and development. Specifically, maternal depression is linked with delayed achievement of developmental milestones (Weissman et al., 1986), long-term child behavior problems (Ghodsian et al., 1984), and a host of negative behavioral and developmental outcomes, including sleep problems, feeding problems, attention deficit disorders, child depression, socially isolating behavior, and withdrawn and defiant behaviors (Parker et al., 1988). Maternal Depression as an Indicator of Nutrition and Health Benefit There is little evidence that maternal depression can serve as an indicator of potential benefit from WIC participation, either for women or for their children. However, given the empirical evidence showing appetite changes among depressed patients, it is likely that depressed women and their families would benefit from participation in the WIC program. The nutrition education and supplemental foods provided through the WIC program could help mitigate the relationship between depression and eating habits, and the social service and medical referrals and support could potentially address the social and emotional isolation typically experienced by low-income depressed mothers. Use of Depression as a Nutrition Risk Criterion in the WIC Setting Depression is not currently used as a nutrition risk criterion in the WIC program. Diagnosis of depression could be reported to WIC personnel by a health care professional or self-reported measures of depression could be collected during nutrition assessments at WIC program clinics. Several measures of depression are available that could be used in the WIC setting. One widely used depression measure is the Center for Epidemiologic Studies Depression Scale (CES-D), which is designed to measure the symptoms of clinical depression (Radloff, 1977; Weissman et al., 1977). This scale includes 20 items that ask for the frequency with which a given symptom was experienced during the previous week. The standard cutoff of 16 or more depressive symptoms is used to identify depression; this cutoff includes a high

PREDISPOSING NUTRITION RISK CRITERIA 317 proportion of individuals with a major depressive disorder and dysthymia (less severe clinical depression), as well as some individuals who suffer from depressive symptoms but who do not satisfy the diagnostic criteria (Eaton and Kessler, 1981). The CES-D has been extensively validated and correlates well with other self-reported depression measures and with clinical ratings of depression. It has been used in many previous studies of low-income populations and evaluations of demonstration programs including the JOBS evaluation, the evaluation of the Teenage Parent Demonstration (in progress), and the evaluation of the Comprehensive Child Development Program (DHHS, 1994b). Recommendation for Maternal Depression Depression presents health and nutrition risks to the mother and her children, and a suitable method for identifying the risk is available. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of maternal depression as a nutrition risk criterion for women in all state WIC programs. This is a recommendation for a new nutrition risk criterion. BATTERING Battering refers to violent assaults on women by their husbands, exhusbands, boyfriends, or lovers (Rudolf, 1990). Prevalence of and Factors Associated with Battering The prevalence of physical assault of pregnant women has been estimated to be around 8 percent among a random sample drawn from public and private clinics and between 7 and 11 percent among nonrandom samples drawn from university obstetrics clinics (Newberger et al., 1992). In a prospective study of 1,203 pregnant women, 24 percent reported experiencing physical or sexual abuse during the previous year (Parker et al., 1994). In another prospective study of 275 women, 19 percent reported experiencing moderate or severe violence during pregnancy; this increased to 25 percent during the postpartum period (Gielen et al., 1994). Data from the 1990 and 1991 Pregnancy Risk Assessment Monitoring System (PRAMS) suggested that the prevalences of battering (self- reports of being physically hurt by a husband or partner during the 12 months prior to delivery) were 6.1, 3.8, 6.9, and 5.1 percent for Alaska, Maine, Oklahoma, and West Virginia, respectively (CDC, 1994). Two studies identified young maternal age, late prenatal care, substance abuse, poverty, a low level of education, a history of emotional problems, and

PREDISPOSING NUTRITION RISK CRITERIA 318 previous history of abuse as more prevalent among battered pregnant women than among nonabused pregnant women (Parker et al., 1994; Stewart and Cecutti, 1993). In the PRAMS study, nonwhite race, unplanned pregnancies, and WIC program participation were associated with higher rates of physical abuse. The proportion of women reporting physical abuse was two to three times higher among WIC program participants than among nonparticipants (CDC, 1994). Battering as an Indicator of Nutrition and Health Risk Several mechanisms have been proposed to explain a link between battering and pregnancy outcome (Newberger et al., 1992). Maternal trauma resulting from battering could cause preterm labor, bleeding, infection, or other conditions that threaten maternal or fetal health and survival. Even when maternal trauma is not serious enough to directly cause poor health consequences, battering may produce intermediate risks for poor pregnancy outcome. For example, the social isolation often experienced by battered women could limit their access to health care; the stress of battering might encourage substance abuse; or inadequate income or denial of food as part of the pattern of victimization could lead to poor nutrition (Newberger et al., 1992). Relatively few studies have examined pregnancy outcomes in battered women. Some evidence indicates that battering during pregnancy is associated with increased risks of low birth weight (Parker et al., 1994), preterm delivery, and chorioamnionitis (Berenson et al., 1994). Other studies have found no increased risk of poor pregnancy outcome (O'Campo et al., 1994). The lack of consistency in the results may reflect methodologic constraints in carrying out this research. Battering is associated with poor nutrition and health behaviors. Compared with women not exposed to domestic violence, battered women are more likely to have a low maternal weight gain (<7 kg), to be anemic, to consume an unhealthy diet, and to abuse drugs, alcohol, and cigarettes (Parker et al., 1994; Stewart and Cecutti, 1993). Battering as an Indicator of Nutrition and Health Benefit The committee identified no reports of trials of the effects of provision of WIC nutrition services to abused or battered pregnant women that measured improvement of pregnancy outcome and no studies providing indirect evidence of benefit. There is good potential for battered women to benefit from the supplemental food provided by the WIC program. Moreover, battered women require immediate access to protection, crisis intervention, and support services (Newberger et al., 1992), which WIC referrals could facilitate.

PREDISPOSING NUTRITION RISK CRITERIA 319 Use of Battering as a Nutrition Risk Criterion in the WIC Setting In 1992, seven state WIC agencies used battering during pregnancy as a nutrition risk criterion (see Table 7-1). Recommendation for Battering The nutrition risk of battering is documented for women. There is a theoretical basis but no documentation of benefit via improved outcome of pregnancy as a result of WIC participation. The committee recommends use of battering as a nutrition risk criterion for women by the WIC program, unless contradictory information becomes available, and that it remain in the predisposing risks category. CHILD ABUSE OR NEGLECT Child neglect is defined as an omission of care by a child's primary caregiver that produces harm, such as inadequate nutrition, clothing, or medical attention (Children's Bureau, DHEW, 1978; Gaudin, 1993). Child maltreatment includes physical abuse, sexual abuse, neglect and emotional maltreatment (NRC, 1993). Prevalence of and Factors Associated with Child Abuse or Neglect Reports of child abuse or neglect have increased dramatically, perhaps because of increased reporting, but the actual prevalence of this condition is not known (Johnson, 1995; Wilcox and Marks, 1995). Surveillance of child abuse is limited by a lack of consistent definitions, differences in legal requirements, and the lack of standardization of recordkeeping (Wilcox and Marks, 1995). It has been estimated that each year approximately 2 million children in the United States are seriously abused by their caregivers, and this leads to death in about 1,000 of these cases (AMA, 1992). Child abuse or neglect can occur in any family. Abuse or neglect is more likely to occur when parents or other caregivers who live under difficult social conditions have little knowledge of child development and unrealistic expectations of child behavior (Johnson, 1995). Child abuse or neglect is reported more frequently among poor families, perhaps in part because of increased attention to the health and social issues among the poor. Psychosocial stress, unplanned pregnancy, teenage parents, low levels of education, and substance abuse are all associated with child abuse and neglect. Child abuse and spousal abuse are related, and parents who were themselves abused as children

PREDISPOSING NUTRITION RISK CRITERIA 320 are more likely to be abusive. The risk of physical abuse is higher for infants and children with chronic medical conditions or physical or mental disabilities. Child Abuse or Neglect as an Indicator of Nutrition and Health Risk Serious neglect and physical, emotional, or sexual abuse have shortand long-term physical, emotional, and functional consequences. Nutrition neglect, which is a form of child abuse, is the most common cause of poor growth in infancy and may account for as much as half of all cases of nonorganic failure to thrive (Johnson, 1995) (see also Chapter 5). It has been reported that preschool- age children who were abused were more than 16 times more likely to be malnourished than nonabused children from the same neighborhood (Karp et al., 1989). Other data suggest that among abused children with poor growth, those who were placed in long-term foster care demonstrated catch-up growth that was not observed in children who remained in their original families (King and Taitz, 1985). It may be possible to identify infants at risk of child abuse early in the postpartum period (Leventhal et al., 1989). The ability to target high-risk families may allow the application of educational and social interventions to prevent child abuse and neglect. Child Abuse or Neglect as an Indicator of Nutrition and Health Benefit Through intensive and comprehensive treatment, 80 to 90 percent of families involved in child neglect or abuse can become able to provide adequate care to the children, but this is more difficult when substance abuse is involved (Johnson, 1995). In examining mechanisms to prevent child abuse and neglect, the National Research Council Panel on Child Abuse and Neglect recognized the potential benefit of participation in the WIC program (NRC, 1993). The provision of nutritionally dense foods and education about appropriate feeding practices is especially important for those children with nonorganic failure to thrive, but these interventions, as well as linkages to the medical and social systems, are also likely to benefit children who have been traumatized by physical, emotional, or sexual abuse. Use of Child Abuse or Neglect as a Risk Criterion in the WIC Program In 1992, seven state WIC agencies considered abuse or neglect to be a nutrition risk criterion for children, and nine considered physical abuse to be a nutrition risk criterion for infants (see Table 7-1).

PREDISPOSING NUTRITION RISK CRITERIA 321 Recommendation for Child Abuse or Neglect There is empirical and theoretical evidence that child abuse or neglect pose nutrition risks. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of reported or diagnosed child abuse or neglect as a nutrition risk criterion for infants and children in the WIC program. CHILD OF A YOUNG CAREGIVER There is little disagreement that adolescent women generally are less prepared economically, emotionally, socially, and physically for motherhood than their somewhat older counterparts (Hofferth, 1987; Phipps-Yonas, 1980; Trussel, 1988). By and large, the scientific community has focused on the physical risk that early pregnancy imposes on young women and on its potential for poor pregnancy outcomes and health problems (see Chapter 5). Adolescent pregnancies and motherhood, however, impose risks that go well beyond the medical consequences of teenage pregnancies. Prevalence of and Factors Associated with Child of a Young Caregiver Currently, about 1 million adolescent women (12 percent of women 15 to 19 years of age) become pregnant, and about half give birth (Guttmacher Institute, 1994). More than 80 percent of young women who give birth are poor. Although older teenagers (ages 18 to 19 years) account for most teenage pregnancies and births, 9,000 women under age 15 gave birth and 161,000 women ages 15 to 17 years gave birth in 1988. Virtually all of these births were outside of marriage (Trussel, 1988). According to USDA (1994), just under 1.3 million women participated in the WIC program in 1992. Of the women whose age was reported in that study, 11 percent (over 136,000) were age 17 years and under. At the time of the study, 68 percent of these young mothers were pregnant, 6 percent were breastfeeding mothers, and 26 percent were postpartum, nonnursing mothers. Child of a Young Caregiver as an Indicator of Nutrition and Health Risk Despite the wide array of literature on teenage motherhood and its health consequences for children, young age is seldom isolated from other contributing factors, such as economic and social status, family support, motivation, educational performance, and achievement (Phipps-Yonas, 1980; Trussel, 1988). Thus, there is little research directly linking nutrition status among

PREDISPOSING NUTRITION RISK CRITERIA 322 infants and children to young age of their mother. Since parental diet and eating habits influence the diet and eating habits of children, this could be a fruitful line of research. Children born to teenage mothers are at higher risk of abuse, neglect, maltreatment, poor growth, and problems in mother-child interaction than other children (Earp and Ory, 1980; Egeland and Brunnquell, 1979; Herrenkohl and Herrenkohl, 1979; Steir et al., 1993). The study by Steir and colleagues (1993), a longitudinal, cohort study of 219 children born to women 18 years of age or younger and of 219 children born to women 19 years of age or older, is notable for its careful design. These investigators reviewed birth records to match children by date of birth, ethnicity, gender, birth order, and method of payment for the hospitalization (Medicaid, private insurance, or self-payment) as a marker for socioeconomic status. Analysis of the records revealed that maltreatment (abuse, neglect, or sexual abuse) occurred twice as frequently among the children of the younger mothers, and that poor growth occurred in 6.9 percent of the children of the young mothers compared with 4.1 percent of the children of the older mothers. Child of a Young Caregiver as an Indicator of Nutrition and Health Benefit The committee found no direct or indirect empirical evidence evaluating the benefit of participation in the WIC program on the children of young caregivers. Although adult age of the caregiver is not a prerequisite for infants' and children's good health, it is likely that identifying young caregivers will identify infants and children who can benefit from WIC participation. There is potential for the children to benefit from the provision of nutritious food and nutrition education of their caregivers, as well as from referrals. Use of Child of a Young Caregiver as a Risk Criterion in the WIC Program Of the five states that included young age of the mother as a nutrition risk criterion for infants (see Table 7-1), two broadened the definition to include a nonmaternal caregiver. The specific age of a young mother or caregiver ranged from less than 18 to less than 19 years of age. Recommendations for Child of a Young Caregiver Child of a young mother or caregiver thus far has been found to be a weak indicator of nutrition risk among infants and children. Even though there is a theoretical basis for benefit from participation in the WIC program, the benefit is expected to be minor. However, the lack of empirical evidence for young

PREDISPOSING NUTRITION RISK CRITERIA 323 caregiver is a result of lack of studies of this risk criterion, rather than studies showing no risk or benefit. Therefore, the committee recommends using child of a young caregiver as a risk criterion for infants and children in the WIC program pending further scientific evidence. The committee recommends research on young age of caregivers and the health and nutrition status of the children in their care. CHILD OF A MENTALLY RETARDED PARENT Prevalence of and Factors Associated with a Child of a Mentally Retarded Parent The committee found no data on the prevalence of children with a mentally retarded parent in the U.S. population or in the WIC program population. However, on the basis of a study of parents considered to have intellectual impairment in the state of Oregon, the Association for Retarded Citizens estimates that approximately 32,500 U.S. parents are mentally retarded (Ingram, 1993). Mentally Retarded Parent as an Indicator of Nutrition and Health Risk Although it is likely that many mentally retarded parents are adequate care providers, parents with intellectual disabilities frequently have problems in ensuring that a child's physical, nutrition, health, and safety needs are met (Feldman, 1994). If abuse and neglect occur, children of parents with mental retardation are at risk of poor outcomes (medical, cognitive, and emotional problems) (Accardo and Whitman, 1990; Whitman et al., 1990). The occurrence of neglect appears to be secondary to a lack of parental education in combination with the unavailability of supportive services (Schilling et al., 1982; Seagull and Scheurer, 1986). In fact, the best predictor of neglect appears to be the lack of familial or societal supports that can help prevent the circumstances leading to neglect (Tymchuk, 1992). Without information about such supports, an intelligence (IQ) quotient score below a certain level, usually taken to be 60, may be useful as a predictor of neglect. Many parents with a low IQ have other risk factors that are associated with child maltreatment such as poverty, personality disorders, low self-esteem, history of abuse, unemployment, and transient living arrangements (Belsky, 1984; Tymchuk and Feldman, 1991). In 13 of the 14 studies reviewed by Schilling and colleagues (1982), mentally retarded parents were overrepresented in samples of parents who abused or neglected their children. They concluded that research suggests there is an increased risk of maltreatment of children raised by mentally retarded parents.

PREDISPOSING NUTRITION RISK CRITERIA 324 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.

PREDISPOSING NUTRITION RISK CRITERIA 325 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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WIC Nutrition Risk Criteria: A Scientific Assessment Get This Book
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This book reviews the scientific basis for nutrition risk criteria used to establish eligibility for participation in the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The volume also examines the specific segments of the WIC population at risk for each criterion, identifies gaps in the scientific knowledge base, formulates recommendations regarding appropriate criteria, and where applicable, recommends values for determining who is at risk for each criterion. Recommendations for program action and research are made to strengthen the validity of nutrition risk criteria used in the WIC program.

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