Appendix A

Workshop Agenda and Presentations

Workshop on Dietary Risk Assessment in the WIC Program

Thursday, June 1, 2000

National Academy of Sciences

Lecture Room

2101 Constitution Avenue, N.W., Washington D.C.

8:00 a.m.

Welcome and Introduction

Virginia Stallings, Committee Chair

8:15

Overview of WIC Operational Issues and Practices which may Impacton the Selection of Dietary Risk Assessment Methodology

Jean Anliker, University of Maryland A-3

8:45

Overview of Assessing Adequacy of Intake: Reliability and Sourcesof Error

Valerie Tarasuk, University of Toronto A-5

9:30

Development of the Dietary Guidelines and their Application to theWIC Population

Cutberto Garza, Cornell University A-7

10:00

Development of the Food Guide Pyramid and its Application to theWIC Population

Kristin Marcoe, U.S. Department of Agriculture A-12

10:30

Break

10:45

Assessing Individuals Total Food Intake and Cognitive Aspects ofQuestionnaires

Amy Subar, National Cancer Institute A-17

11:30

Use of the Block Questionnaire in the WIC Program

Gladys Block, University of California, Berkeley A-19

12:15 p.m.

Lunch

1:00

Use of the Harvard Food Frequency Questionnaire in the WIC Population

Graham Colditz, Harvard School of Public Health A-22

1:45

Assessing Dietary Intake and Risk During Pregnancy and Special Considerationsin Evaluating Intake in the Hispanic Population

Anna Maria Siega-Riz, University of North Carolina A-25

2:30

Break



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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Appendix A Workshop Agenda and Presentations Workshop on Dietary Risk Assessment in the WIC Program Thursday, June 1, 2000 National Academy of Sciences Lecture Room 2101 Constitution Avenue, N.W., Washington D.C. 8:00 a.m. Welcome and Introduction Virginia Stallings, Committee Chair 8:15 Overview of WIC Operational Issues and Practices which may Impacton the Selection of Dietary Risk Assessment Methodology Jean Anliker, University of Maryland A-3 8:45 Overview of Assessing Adequacy of Intake: Reliability and Sourcesof Error Valerie Tarasuk, University of Toronto A-5 9:30 Development of the Dietary Guidelines and their Application to theWIC Population Cutberto Garza, Cornell University A-7 10:00 Development of the Food Guide Pyramid and its Application to theWIC Population Kristin Marcoe, U.S. Department of Agriculture A-12 10:30 Break 10:45 Assessing Individuals Total Food Intake and Cognitive Aspects ofQuestionnaires Amy Subar, National Cancer Institute A-17 11:30 Use of the Block Questionnaire in the WIC Program Gladys Block, University of California, Berkeley A-19 12:15 p.m. Lunch 1:00 Use of the Harvard Food Frequency Questionnaire in the WIC Population Graham Colditz, Harvard School of Public Health A-22 1:45 Assessing Dietary Intake and Risk During Pregnancy and Special Considerationsin Evaluating Intake in the Hispanic Population Anna Maria Siega-Riz, University of North Carolina A-25 2:30 Break

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport 2:45 Practical Issues in the Use of Various Tools in WIC Settings A-31 Jill Leppert, North Dakota State Department of Health; Amanda Watkins,Arizona Department of Health Services; Ann Barone, Rhode Island Departmentof Health; Carol Rankin, Mississippi Department of Health 3:45 The Role of WIC in Assistance to the Poor and Food Insecurity asa Predictor of Dietary Risk A-38 Bob Greenstein, Center on Budget and Policy Priorities; Lynn Parker,Food Research and Action Center 4:30 Open Discussion and Comments 5:30 Adjourn

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Overview of WIC Operational Issues and Practices which may Impacton the Selection of Dietary Risk Assessment Methodology Presented by Jean Anliker, Ph.D., R.D. Adjunct Associate Professor University of Maryland, Baltimore Dietary assessment is an effective tool for identifying risk, tailoringinterventions, and testing the effects of nutrition education targetedto WIC participants. The Maryland WIC 5-A-Day Promotion Program andthe Maryland Food for Life Program, both funded by the National CancerInstitute, are two programs in which dietary assessment instrumentswere developed and utilized to evaluate program interventions. Bothused trained peer educators to recruit program participants and brieflyexplain questionnaire instructions. However, in order to avoid anyadministrator bias, neither were permitted to help the participantsin any capacity besides reading difficulties. While the instrumentswere not validated in terms of comparing survey results to actualfood consumed, the experiences of both programs provide valuableinsight into the feasibility and challenges of conducting detaileddietary assessment in the WIC program. The Maryland WIC Five-A-Day promotion program was a randomized cross-overdesign with a 6-month intervention administered in 16 sites throughoutMaryland. Eight sights were selected to be intervention sites thefirst year; the other eight served as control sites. Their statuswas reversed in the second year so that each site served as theirown control. Subjects included 3,102 English-speaking women at least18 years of age who were either pregnant, breast feeding, or weremothers of children enrolled in WIC. Sites were chosen with differentdemographic characteristics including rural and urban populations,as well as different racial and ethnic profiles. The program had5 objectives: The intervention group would show significantly greaterincreases than the control group in (1) their knowledge about fruitand vegetable consumption; (2) their attitudes about fruits and vegetablesconsumption; (3) their self efficacy for fruit and vegetable consumption;(4) the stage of change for fruit and vegetable consumption; and(5) their actual fruit and vegetable consumption. Survey development incorporated focus groups, pilot testing, andcognitive testing prior to initiation of its use in the study. Thecognitive testing involved participants reading out loud and verbalizingtheir thought processes as they answered questions. It was helpfulin ensuring that participants understood what was really being asked,and therefore, fine-tuning questions. The standard National CancerInstitute seven-item fruit and vegetable frequency consumption assessmentwas used along with a 35-item, 24-hour checklist for fruits and vegetables.The survey also considered psychosocial variables, including self-efficacy,perceived barriers, attitudes, social support, responsibility forfood preparation and purchasing, and knowledge relating to fruitsand vegetables. The final survey was self-administered and took participants15 to 30 minutes to complete. A $10 incentive was given to participantsafter the post-survey (8 months later) was completed. Results of the study showed a significant difference, with a directlinear relationship between fruit and vegetable consumption and programattendance. An increase in 0.13 servings per day among the controlgroup and increase of 0.56 servings per day in the intervention group(p<0.002) were observed. Those who attended all sessions increasedconsumption by 1.25 servings per day. Other significant differenceswere seen in participant's knowledge regarding

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport the number of servings recommended for fruits and vegetables, attitudesabout fruits and vegetables, self-efficacy for fruit and vegetableconsumption, and perceived social support. The Maryland Food for Life Program was similar in design to the Five-A-Dayprogram, however only 10 sites were selected and the program interventionwas 6 months rather than 8. While final data analysis has not yetoccurred, the food assessment methodology can be described. The food survey development for the Food for Life program includedsimilar formative research (cognitive and pilot testing) to thatof the Five-A-Day program. In addition, Gladys Block, Ph.D. servedas a consultant in developing a food frequency instrument that wouldbe culturally appropriate for the program. Objectives for this programfocused on lowering the percentage of calories from fat, increasingdietary fiber, and increasing the number of servings of fruits andvegetables. Hence, the survey instrument needed to evaluate dietarypatterns rather than just servings of fruits and vegetables. An 83-itemfood frequency instrument, capable of generating a complete nutrientprofile, was developed for this program. In addition, a questionnairewas used to assess the fat levels of commonly eaten foods, stagesof change for fruit and vegetable consumption, as well as fat andfiber consumption. The 83-item food frequency questionnaire included estimations ofportion size. Serving sizes were shown on the questionnaire and participantswere asked to estimate their usual servings as small, medium, orlarge. This self-administered questionnaire utilized computer-scannedbubble sheets and took participants an average of 30 to 45 minutesto complete. A $20 incentive was given to participants after thefinal survey was completed. Data generated by the food frequency assessment instrument was vast.Profiles of nutrient data included calories, protein, fat, carbohydrate,cholesterol, fiber, vitamins, and minerals. Servings of food groupsfrom the food guide pyramid were also generated. The data generatedcould be used not only for evaluation, but was enormously valuablefor identifying target behaviors for interventions, both at the individualand population level. Experience with both of these programs lead to the following conclusionsregarding dietary assessment in WIC programs: (1) WIC participantswill complete food surveys, even surveys that take 15 to 45 minutesto complete; (2) literacy was not a common problem; 80 percent ofthe participants had high school education and in only a few instanceswere peer educators asked to help with reading; (3) food survey questionswere well understood; (4) dietary data can be a useful tool in tailoringnutrition education; (5) trained peer educators can collect dietarydata; and (6) self-administered forms which can be computer scannedwork very well. The forms were scanned by the computer at the university,but having scanners on site in the WIC clinics would likely be feasible.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Assessing Adequacy of Intake: Reliability and Sources of Error Presented by Valerie Tarasuk, Ph.D. Associate Professor, Department of Nutritional Sciences Faculty of Medicine, University of Toronto Applying dietary assessment techniques to appraise the adequacy ofan individual's intake requires: (1) an estimate of the individual's usual or habitual dietary intake over the time period of interestand (2) an estimate of the individual's dietary requirements. Neitherestimate is straightforward. The estimation of usual intake is complicated by the fact that individuals' intakes vary markedly from one day to the next. This variation isa function of environmental and biological pressures on intake andmeasurement errors. Further, the level of day-to-day variation differsacross nutrients, depending on their concentrations in the foodsthat comprise the individual's diet. Classically, the highest variationis seen for vitamin A and the lowest is seen for energy. An equation developed by Basiotis et al. (1987) can be used to determinethe confidence interval around an estimate of usual intake basedon the assessment of actual intake on one or more days. Using thisequation, it can be demonstrated that the error term around an estimateof usual intake for an individual decreases as the number of daysof intake data increases. However, the error term for estimates basedon 1, 3, or even 7 days is very large, indicating that using a limitednumber of days to assess dietary risk for an individual is hugelyproblematic. The difficulty in estimating individuals' usual intakes is compounded by the fact that the precise magnitudeand nature of day-to-day variation differs substantially betweenpeople. Further, data from low-income women seeking food assistancein Toronto suggest that issues of day-to-day variation are probablyeven more pronounced in the target group for WIC. Intakes becomeeven more erratic when economic constraints are added to everydayenvironmental and biologic influences. Because day-to-day variationcomes from multiple sources that vary among individuals, it is likelyimpossible to strategize data collection in such a way as to eliminatethis source of error in the estimation of individuals' usual intakes.Although there are statistical techniques to estimate within-personvariation and adjust for its effects on intake estimates in largepopulation studies, these methods are not appropriate for use atthe level of individuals. Other potential sources of error in the estimation of individuals' usual intakes include systematic under- or overreporting, proxyreporting, social desirability, and errors in the assumptions maderegarding food composition and nutrient bioavailability. Underreportingappears to be pervasive in dietary intake surveys, affecting an estimated10 to 45 percent of samples. It has been associated with a numberof factors, but appears to be a particular problem among women withhigh body weight. There is also some evidence that children or youngadults are less prone to underreporting, and that individuals withlower socioeconomic status, education, and literacy levels are morelikely to underreport. It is unclear exactly what is being underreportedalthough there is some data to suggest that the reporting of fat,sugar, and alcohol may be particularly problematic. In contrast tothis, some studies have suggested that individuals may be likelyto overreport on the consumption of foods perceived to be healthful,particularly if they had been engaged in interventions designed toimprove healthful intake. Usual intake can be estimated from the measurement of actual intakeover a limited number of days (using dietary recalls or records).Alternatively, a food frequency questionnaire

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport can be used. However, neither method yields an estimate of usualintake without error. This is well illustrated by a study of Crawfordet al. (1994) in which a small sample (n = 58) of 9-10 year-old girlshad their lunch time intake observed and were asked to report theirintake by one of three methods: 24-hour recall, 3-day food record,or 5-day food frequency. Median percent error between observed andreported intake by the different assessment methods (see Table 1) indicates that while the particular nature of the errors differed,all three methods measured intake with error. TABLE 1 Median Percent Error Between Observed and Reported Intake from Lunch,by Method *   24-hour recall (n = 19) 3-day food record (n = 20) 5-day food frequency (n = 19) Energy 19 12 28 Protein 19 14 26 Carbohydrate 26 16 33 Fat 39 20 23 * Percent Error = 100 × (| observed - reported |) / observed. SOURCE: Crawford et al., 1994. Lastly, the problem of measurement is compounded by the difficultyin interpreting comparisons of intake estimates with dietary standardsor nutrient requirement estimates. Individuals differ from one anotherin their dietary requirements. Thus, if an individual's usual intakeof some nutrient falls below a particular reference value, for example,it cannot be assumed that the intake is inadequate to meet her requirementfor that nutrient. Nonetheless, the lower an individual's usual intakeis, the greater the probability that the intake is inadequate tomeet her needs. Both the between-person variation in nutritionalrequirements and the error inherent in our estimation of individuals' usual intakes need to be considered when applying dietary assessmentmethods to determine nutritional risk. References: Basiotis PP, Welsh SO, Cronin FJ, Kelsay JL, Mertz W. 1987. Number of days of food intake records required to estimate individualand group nutrient intakes with defined confidence. J Nutr 117: 1638–1641. Crawford PB, Obarzanek E, Morrison J, Sabry ZI. 1994. Comparative advantage of 3-day food records over 24-hour recall and5-day food frequency validated by observation of 9- and 10-year oldgirls. J Am Diet Assoc 94: 626–630.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Development of the Dietary Guidelines for Americans and their Applicationto the WIC Population Presented by Cutberto Garza, M.D., Ph.D. Professor, Division of Nutritional Sciences Cornell University By law, the dietary guidelines represent the basis for federal policyand are used to guide nutrition information, education, and interventions.While the food guide pyramid is one of the major tools used for consumereducation, the dietary guidelines, which incorporate the food guidepyramid, are developed to be used as a policy instrument. The guidelinesare quite relevant to this committee's task, in that the guidelinesform the basis of federal food and nutrition education programs. The development of the new Dietary Guidelines for Americans was avery complex exercise which relied heavily on available consensusdocuments. Contributing to the complexity was incorporating all agegroups from age 2 and older, all socioeconomic groups, both genders,and multiple physiological states. In addition, the information neededto be reduced in such a way as to be understandable to the averageconsumer, and yet be scientifically accurate. In developing the dietary guidelines, it was necessary to come upwith generic information when, in fact, the basis for it was questionablein terms of the available science. Most difficult has been the nearlycomplete lack of usable data on the nutrient needs of infants, children,adolescents, pregnant and lactating women—the groups that the WICprogram deals with. While the DRIs are currently being revised, theinformation gaps in the estimation of average requirements by lifestage and gender have been very difficult to come by. For this reason,it is important to understand that there is an enormous amount ofscientific judgment that goes into the development of these guidelines.But yet, the best scientific information for developing the dietaryguidelines was available to this last guideline committee—more sothan to other committees who worked on previous versions of the guidelines. The first “dietary goals” were issued by the McGovern report and were released in 1977. Thework of the Senate select committee was very controversial. Nutritionscientists were, quite literally, almost killing each other overwhether the science was adequate enough for these dietary goals tobe set. History would suggest that, in fact, the Senate committeewas quite wise in their recommendations on the whole. Most of themare quite relevant today and have since been borne out by the additionalscience. In 1979, the American Society for Clinical Nutrition brought togethera panel that was to review the relationship between dietary practicesand health outcomes. Their findings were incorporated in the SurgeonGeneral's report on health promotion and disease prevention. Thesewere then the basis of the 1980 guidelines issued jointly by theDepartment of Health and Human Services (DHHS) and the United StatesDepartment of Agriculture (USDA). While it was primarily a federaleffort, some external individuals were involved as well. In 1983,nongovernment scientists were selected to review and make the recommendationsto USDA and DHHS about the first edition. Today, it is an externalgroup which reviews the wide breadth of information for all agesand income groups and then advises the government. Ultimately, theguidelines are issued jointly by USDA and DHHS based on the recommendationsof the external group.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport The dietary guidelines are to be based on current knowledge abouthow dietary intake may reduce the risk of major chronic diseasesand how a healthful diet may improve nutrition. The basis is notjust deficiency diseases, but in fact, the emphasis is on how dietarypatterns can be used to both avoid deficiency and also achieve otherhealth outcomes that are believed to be related to diet and dietarypatterns. There is now a public law that requires publication andrevision of the guidelines at least every 5 years. The guidelines serve five very broad objectives. The first is toassist consumers in making dietary choices—choices which are mostlikely to promote well-being and avoid or postpone the onset of diet-relatedchronic diseases. This presents some challenges given the paucityof data in terms of nutrient requirements of children and pregnantor lactating women. When one adds to this the relationship betweendiet, nutrient-specific recommendations, and chronic disease, onehas to rely almost exclusively on epidemiological data. This typeof data is great for hypotheses and associations, but in terms ofcausality, it presents some challenges. The remaining objectives of the guidelines are: to assist federal,state, and local agencies in the development, implementation, andformulation of regulatory policies and programs; to assist healthcare providers in primary disease prevention efforts; and lastly,to guide other domestic and international for-profit and not-for-profitorganizations in the implementation of nutrition and health goals. In developing the new dietary guidelines, the number of guidelinesincreased from seven to ten and are now grouped under the categoriesof Aim for Fitness, Build a Healthy Base, and Choose Sensibly (see Table 1). TABLE 1 Dietary Guidelines for Americans AIM FOR FITNESS... Aim for a healthy weight. Be physically active each day. BUILD A HEALTHY BASE... Let the Pyramid guide your food choices. Choose a variety of grains daily, especially whole grains. Choose a variety of fruits and vegetables daily. Keep foods safe to eat. CHOOSE SENSIBLY... Choose a diet that is low in saturated fat and cholesterol and moderatein total fat. Choose beverages and foods to moderate your intake of sugars. Choose and prepare foods with less salt. If you drink alcoholic beverages, do so in moderation. Aim for Fitness. Under this heading are the guidelines Aim for a healthy weight and Be physically active each day. These guidelines are just as relevant to pregnant or lactating womenand young children over the age of 2 as they are for any other agegroup. While there are no specific recommendations as to what a healthyweight should be for a pregnant woman, weight is discussed for ageneral adult population. The advice regarding physical activityis relevant to pregnant and lactating women.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Build a Healthy Base-Let the Pyramid guide your food choices is the second group of guidelines and represents somewhat of a tautology.The pyramid is supposed to reflect the guidelines and the guidelinesare saying to follow the pyramid. Under this guideline is a sectionof particular relevance to pregnant women—Use of dietary supplements. The guideline committee felt that it was very difficult for pregnantwomen to meet the iron requirements for pregnancy and for this reasona statement was added to this effect. The other point that this guidelinemakes is for folate. Women who are pregnant or who are at risk forbecoming pregnant should choose foods that are fortified in folateor take a folate supplement. It was felt that, given present levelsof supplementation, if women were judicious in their food choices,a supplement would not be necessary. Choose a variety of grains daily, especially whole grains. This guideline is of relevance to the WIC population because of theconcern regarding folate intake for pregnant women. When the U.S.fortification policy and consumption patterns were looked at, theguideline committee came to the conclusion that it was necessaryto put the emphasis on whole grains because many grains are not fortifiedand without the emphasis, women could be put at risk of folate deficiencyand birth defects. Another reason whole grains were emphasized was recent epidemiologicaldata suggesting that whole grains can be, for reasons we do not yetunderstand, associated with significant reductions in cardiovasculardisease risk. The reason for using the word especially was that the grains group was the food group for which Americanshave the largest gap between consumption patterns and recommendations.By using the word especially, the development committee hoped to emphasize grains and increasepublic attention to this area. Whole grains were separated from Choose a variety of fruits and vegetables because dietary patterns based on grains, fruits, and vegetablesappear to be associated with the highest reductions in disease risk.Consumers have treated these groups as interchangeable when, in fact,benefits from these nutrients are significantly distinct. By separatingthe groups, it was intended to point out that they are not interchangeable. Keep foods safe to eat is the other new guideline and is the second guideline where pregnancyis specifically mentioned. The committee felt very strongly thatif a recommendation is made for a healthy diet, it had to be safeas well. One could not divorce microbiological safety or other contaminantsin the food supply from a healthful diet. So these were not nutrientguidelines but food-based dietary guidelines. Obviously, women maybe at risk if they are not following food safety guidelines, andthey may benefit from WIC, to the extent that WIC incorporates thisinto their educational materials. Pregnant women, along with theelderly, young children, and immune-compromised groups are at thehighest risk for certain food-borne pathogens. The third group, Choose Sensibly, is the most complicated of all the guidelines. The difficulty stemsfrom the guideline Choose a diet that is low in saturated fat and cholesterol and moderatein total fat. Becausethe emphasis has been placed on low-fat dietswhen most of the concern was being driven by saturated fat, the messageregarding dietary fats and cholesterol was not being adequately translatedby either industry or consumers. This guideline is complicated becauseconsumers are now being asked to differentiate between total fat,saturated fat, polyunsaturated fats, monounsaturated fats, and trans-fats.While there is science to back this up, trying to educate the publicon these various types of fats will be an enormous challenge. However,it is one that the committee felt was significant enough because most of the risk is

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport related to saturated fats and trans-fats. The guideline committee5 years ago did not have the science that is available today on theissue of trans-fatty acids. The most controversial guideline, certainly in terms of public comment,was the guideline Choose beverages and foods to moderate your intake of sugars. There was quite a bit of debate among the development group abouthow the guideline should be worded. The controversy was whether theword moderate or limit should be used. In addition, dietary intake trends indicated thatthe highest level of increasing sugar consumption came from addedsugars in beverages. There was significant concern that many consumersdidn't recognize beverages as a source of sugars—they were not foods in their minds. For this reason, the committeeneeded to also include the word beverages in the guideline. The development committee needed to be very careful whenever theterm moderation was being used in terms of quantitating the advice. One of the majorchanges they tried to make with the new guidelines was to make themmore actionable. For example, the word moderate in the total fat guideline—the wording states to aim for a total fat intake of no more than30 percent of calories, but one does not need to go much beyond that.The committee felt that telling consumers to moderate their intakewas very difficult to put into action. On the other hand, there weremany others who felt that by using the term limit, the committee was going beyond what the science provided. The committee's rationale was that given the increasing rates of obesity in thiscountry, it is obvious that there is an energy balance problem. Ifconsumers are asked to eat more of certain products, they neededto be asked to eat less of other products. Consumers were asked tolimit their consumption of alcohol, fat, and sugar. The next guideline in this grouping, Choose and prepare foods with less salt has been reworded but the message is essentially the same. The onlydifference is that there is now a quantitative recommendation forsalt intake. The third guideline in which pregnancy is specifically mentionedis If you drink alcoholic beverages, do so in moderation. Throughout committee deliberations, it was clear that there was noway to distinguish at what level of drinking would birth defectsbecome a problem or have other adverse effects in women. For thisreason, pregnant women or those at risk of becoming pregnant wereasked not to drink alcohol at all. The other reason for the way the guideline is stated is because thereare health benefits associated with alcohol. It does not matter whatform the alcohol is in (wine, beer, distilled), it is the ethanolthat appears to be the active agent. There is a significant reductionin risk to cardiovascular disease that appears to operate via a reductionin platelet aggregation. Because it is an acute effect, one doesnot obtain any benefits from a lifetime of drinking. Rather, if oneis interested in drinking for health benefits, there is no reasonthat drinking should begin at age 21 because the benefit does notbecome available until one is at risk for cardiovascular disease—45 years of age for men and 55 years of age for women. It is alsoclear that, at least for women, more than one drink a day increasesrisk for breast cancer. However, women should not be asked to refrainfrom drinking alcohol because there are benefits as well as risks.For this reason, postponing drinking until after the age of 55 ifconsuming it for health reasons seems the most rational and prudentthing to do. Overall, the major changes in the guidelines are mainly the groupingof the recommendations and the addition of guidelines on physicalactivity and food safety. Because pregnancy is such a teachable moment,it is hoped that WIC provides an opportunity to impress the pointthat physical activity is important for everyone. It is not justfor women in other age groups, men, or for those who need to loseweight. There are significant health benefits that

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport physical activity provides. Physical activity permits individualsto increase food intake and therefore increases the likelihood ofgetting all the nutrients needed from food. Other changes in the2000 guidelines include a separation of guidelines on grains fromfruits and vegetables, a shift from an emphasis on total fat to thereduction of specific types of fats, a recognition of the trendsin sugar intake, and greater specificity in the alcohol guidelines. The guidelines are quite applicable to the WIC population, but onlyafter the age of 2. The likely reason that everybody has shied awayfrom the under 2 population is that trying to look at nutrient-specificrequirements is very difficult based on the data available for thefirst year of life. However, focusing on women's health in the WICsetting can be very beneficial and advantage should be taken of thisopportunity. In fact, it is scientifically appropriate to do so.Pregnancy represents an ideal time to get women to focus on theirhealth and enhance their knowledge, behavior, and practices. In manyhouseholds, women are the gatekeepers for health. In addition, formany women, problems with overweight and obesity appear to beginduring pregnancy and the postpartum period. While the guidelines are very applicable to the WIC population interms of defining an inadequate diet, it is not likely possible tocome up with a simple paradigm or algorithm for compliance by lookingat only a few of the guidelines. The grouping of guidelines werenot intended to be prioritized in any way; they all are relevantto good health. It is important to remember that the risk is to long-termoutcomes. For the individual, we have gone to some lengths to askpeople to look at their own family histories and their own risks.For example, if one knows that there is no hypertension in theirfamily history and no one has ever died of stroke, then for thatindividual, perhaps the salt guideline under those conditions wouldnot be as important. Perhaps in this particular family history, everyoneseems to be dying at the age of 50 from atherosclerosis. For thisindividual, paying attention to fat and physical activity or havingone drink a day once over the age of 40 may be more important tolowering this individual's risk. The guidelines could perhaps beprioritized in some way for each individual. However, from a publichealth perspective, it is not likely possible.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Practical Issues in the Use of Various Tools in WIC Settings Presented by Carol Rankin, M.S., R.D., L.D. Nutritionist, Mississippi WIC Program Mississippi State Department of Health In Mississippi, the tools used to assess dietary risk are basic,but provide the information needed to determine whether an applicantis at nutritional risk. Three separate forms are used for dietaryassessment of women, infants, and children. A food frequency toolis on all forms and a 24-hour recall is on all except for the formfor the infant. There is a section for inappropriate feeding practicesas well, which are used as talking points for the counselor and canbe checked off to indicate risk. The dietary assessment is used forboth determination of eligibility and nutrition education. For infants, food frequencies are checked against the recommendations.If any group is missing or there are two inappropriate food groups,then the infant is certified based on inappropriate diet. Inappropriatefeeding practices are broken down for the different ages: 0 to 3months, 4 to 5 months, 6 to 9 months, and lastly, 10 to 12 months.The dietary assessment forms for women and children include boththe food frequency and the 24-hour diet recall. Children are dividedinto age groups of 1 to 3 years of age and 3 to 5 years of age. The tools used for nutrition assessment were chosen in order to fulfillU.S. Department of Agriculture (USDA) and Mississippi WIC requirementsfor the specific populations served. Accepted dietary guidelines,food guide pyramid recommendations, and other established feedingpractices such as American Academy of Pediatrics recommendationswere considered. In addition, two other factors contributed to theselection of the nutrition assessment tools: ease of obtaining usableinformation in a format for busy clinics and ease of use by nonnutritionprofessionals. Additional nutrition assessments are used for pregnant women andinfants who are enrolled in the perinatal high-risk and infant servicesprogram. This is a program where a team of health professionals casemanage high-risk, Medicaid-eligible patients. The team consists ofa nutritionist, nurse, and social worker. The pregnant woman is followedthrough 60 days postpartum and the infant until 1 year of age. Allof these patients also qualify for the WIC program. The nutritionassessment for these special populations is more in-depth, requiringadditional calculations of calorie levels, growth parameters, andquestions about food security and preparation. The WIC nutritionstaff use the information in determining WIC eligibility and in orderto provide nutrition education targeted to the needs of the patient. The forms may appear complicated, but once training is received theforms are simple to use. They are used by paraprofessionals, nurses,and lactation specialists. It takes about 10 minutes to completeone of the dietary assessment forms. There is then an additional5 to 10 minutes for nutrition education. Mississippi WIC sites donot currently have computers but are expected to within the next1 to 2 years. High risk applicants and those who are certified based on inappropriatedietary intake receive a diet history during every clinic visit.All other clients should get a nutrition assessment at least onceper year. If an individual is certified based on another type ofrisk, they may not receive a dietary assessment. However, if an individualmeets no other risk and does have a

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport dietary assessment, it is rare that they would not be certified.According to USDA figures, 22 percent of WIC clients in Mississippiqualify for the program based on dietary risk.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport The Role of WIC in the Framework of Overall Assistance to the Poor Presented by Robert Greenstein Executive Director, Center on Budget and Policy Priorities Washington D.C. It has been suggested by many over the years that additional nutritioncriteria on which eligibility is based be done away with. However,for several reasons, the WIC program has continued to operate, thrive,and produce significant positive health outcomes with program eligibilitybased on both income and nutrition criteria. Overall, research on the impact of the WIC program on diet and healthover the last quarter century has shown striking results in termsof its impact on birth outcomes and lowering the incidence of lowbirth weight. In 1992, the General Accounting Office (GAO) did anevaluation synthesis in which it concluded that the WIC program reducedthe incidence of low birth weight by 25 percent and very low birthweight by 44 percent (USGAO, 1992). While these figures are not precisedue to questions on selection bias and other matters, when lookingat the body of research as a whole, it is pretty clear that the findingsare robust and the that the direction is strong in terms of the significanceof effects on reducing the incidence of low birth weight. Overall,the research has led to findings that low-income women who receiveWIC during pregnancy have better birth outcomes than low-income womenwho do not. The WIC program also appears to reduce the incidence of anemia inchildren. Researchers at the Centers for Disease Control (CDC) comparedthe anemia levels of infants and children at the time of initialenrollment in WIC to their anemia level at the time of WIC follow-upvisits. Significant reductions in anemia rates were found for mostage groups of infants and young children in most years for whichdata were examined. Researchers reported that the prevalence of anemiawas consistently higher for children seen at initial visits thanfor those seen at WIC follow-up visits (Yip et al., 1987). BarbaraDevaney and others who have looked at the data from CDC have concludedthat the evidence is pretty strong in terms of the WIC program'sanemia-reducing effects (Devaney, 1998). An area that until recently was the most controversial was whetheror not WIC improved the diets of children. Findings from the nationalWIC evaluation of the mid-1980s found very strong effects in reducingthe frequency of low intakes of certain nutrients among infants andchildren (Rush et al., 1988). While no one was quite sure what tomake of the findings because the study had been marred by significantselection bias problems, Devaney and others noted that the selectionbias problems were more likely to understate, rather than overstate,WIC's effects because the control group was better off than the treatmentgroup (Devaney, 1998). Nevertheless, the problems were significantenough to cast doubt on the findings that WIC improved the dietsof children. In the last 3 years, however, this has changed in partbecause of a better controlled study by Rose, Habicht, and Devaney(Rose et al., 1998). These researchers found that WIC had significanteffects in increasing preschoolers intakes of ten nutrients, includingiron, zinc, and vitamin E. These three nutrients are among the fourmost frequently deficient in the diets of low-income preschoolers.The increases in WIC participants in iron and zinc were particularlylarge. Within the past month, a new study was released by Oliveira and Gundersonof the Economic Research Service (Oliveira and Gunderson, 2000).This study, which uses data from the 1994 to 1996 Continuing Surveyof Food Intake by Individuals (CSFII), found that

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport participation in WIC significantly increases children's intake of iron, folate and vitamin B6. With the addition of this study, there is now a body of evidencethat, when looked at together, suggests that WIC both reduces anemiaand improves diets among children. In particular, WIC apparentlyreduces the incidence of low intakes of particularly important nutrientssuch as iron among low income children. In addition, a review ofthe literature conducted and published by Leighton Ku of the UrbanInstitute, prior to the study by Oliveira and Gunderson, found similarresults (Ku, 1999). While noting that there are holes in the research,Ku concluded that taken as a whole, it is hard to think of any publicprogram with so consistent a body of positive research findings. At the Center for Budget and Policy Research, the gamut is coveredwhen it comes to means tested benefit programs at both federal andlocal levels (e.g., health, income, supports, housing programs).Research is constantly being reviewed and evaluated. Some programsare found to be less effective, others are found to be more effective,and some are found to need various changes. However, there is notanother means-tested program for which the literature of efficacyapproaches that of the WIC program. WIC is an important remedialand preventive program. Inadequate dietary pattern as a nutrition risk criteria to determine eligibility for WIC hasbeen described as being applied in an imprecise and sometimes loosemanner. However, to some degree, policy makers have known that inadequatedietary pattern was imprecise and loosely applied and, to some degree,that is the kind of criteria they have wanted. At two points, inthe late 1970s and again in the mid-1980s, policy makers gave seriousconsideration to eliminating nutrition risk as an eligibility criterionfor pregnant women or for pregnant women and infants. Ultimately,this was not done for a few reasons, which could largely be put underthe heading of optics. There was very much a sense on the part of both policy makers andstate WIC directors that if income was the only eligibility criterion,it would lead to the perception of WIC as merely another welfare program as opposed to a health program. It was felt that this would be damaging to WIC's political viability, its image in the community, its effectivenessin reaching working families who do not want to be on welfare, andlastly, that it might result in some agencies paying less attentionto providing the dietary, nutrition, and other health informationand counseling needed. The decision not to drop the nutrition risk criteria was aided bythe fact that in exploring the elimination of the nutrition riskcriteria, policy makers found that hardly any pregnant women whomet the income criteria and applied for the program were turned awaybecause of not meeting the nutritional risk criteria. This is whatmany policy makers wanted. A nutrition assessment could be performedand the image of a health program rather than a welfare program wouldbe maintained, and yet low income individuals for whom there wouldbe a preventive value would not be denied entry into the program.This raises an important question for this committee: How can thenecessary information be collected in an effective manner while avoidinga significant narrowing of the criteria that could possibly makea few million individuals who are currently eligible for WIC, ineligible? Shrinking the eligible pool of individuals for WIC by narrowing theeligibility criteria would seem reasonable if this meant openingslots for needier individuals. However, while this may have beenthe case some years ago, it is not the case now. WIC actually hasas much money right now as it needs to serve virtually everybodywho walks in the door and applies. The program has substantial amountsof carry-over funding. It has been funded for the last 3 or 4 yearsby the Congress to serve between 7.4 and 7.5 million women, infants,and children and each year it has served 7.3 million individuals.Last year, there was close to $200 million of

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport available WIC funds that were unspent and carried forward to thefollowing year. While there sometimes are occasional problems ofa few months when there is too much money in a given state and notenough money in another, it can not be said that substantial numbersof people are trying to get into WIC and are turned away. Another argument for narrowing the eligibility criteria would beif one thought that the eligibility criteria was too loose and thatmoney could be better spent on other important functions. There area few problems with this argument. The first is that narrowing theeligibility criteria could weaken WIC's effectiveness as a preventiveprogram. People who meet the income test but do not immediately meetone of the more rigorous nutritional risk screens could be deniedWIC, only to meet the nutritional screen subsequently if their nutritionalstatus deteriorates. In addition, the current budgetary situationis not one of deficits that threaten the economy. Rather, the pictureis one of growing surpluses. In the next 4 weeks, both OMB and theCongressional Budget Office (CBO) will release new budget forecaststhat place the new surplus estimate, outside Social Security, atmore than $1.5 trillion over the next 10 years. In other words, OMBand CBO are about to double the size of the surpluses they projectedonly 4 months ago. Congress already is preparing to start expendingmore money on both the tax and the spending side. A plethora of taxbills that cost significant sums is starting to move through theHouse and Senate, the latest of which would ultimately reduce revenue$50 billion a year by eliminating the estate tax, even though thattax applies to the estates only of the wealthiest 2 percent of peoplewho die in the United States. The point is that if one were to narrowsignificantly the eligibility criteria for WIC, the result wouldsimply be fewer people served and a reduction in WIC funding levels.Where would the money saved go? These days, a bigger tax cut wouldbe the likely outcome. The idea of WIC becoming an entitlement program is politically anonstarter. As previously mentioned, there are currently WIC fundsavailable that are not being spent, and participation in the programhas dropped by 3 percent since its peak in 1996. In 1996–1997, WICparticipation reached its peak of approximately 7.4 million participants.Now participation is 7.2 million. (In comparison, food stamp participationhas dropped 40 percent since 1994.) The drop in WIC participationis likely due primarily to the economy; there are fewer numbers oflow-income individuals now. In addition, in all assistance programs,the working poor have a lower participation rate than the welfarepoor. Making WIC an entitlement was considered by policy makers in thelate 1970s and mid-1980s. It was not something that proved to bea viable option politically then. It is even less likely to be considereda viable option now, given the more conservative Congress today.The chance that it would be seriously considered is near zero. It is important to look at what improvements can made in the nutritionalrisk criteria, particularly if such improvements can improve informationfor WIC clinics and provide participants with more effective counselingand other services. However, one would hope that the Committee onDietary Risk Assessment in the WIC Program keeps the Hippocraticoath in mind if it considers options that could significantly narrowthe pool of low-income women, infants, and children who are eligiblefor WIC. The principal effect of such an approach would be fewerlow-income individuals being provided with WIC benefits and servicesand more money made available for tax cuts likely to accrue primarilyto relatively high-income individuals.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport References: Devaney B. 1998. Commentary. In Rossi PL, ed, Feeding the Poor. Washington, D.C.: AEI Press. Ku L. 1999. Debating WIC. The Public Interest Spring: 108–112. Oliveira V, Gunderson, C. 2000. WIC and the Nutrient Intake of Children. Food and Rural Economics Division Research Report No. 5. Washington, D.C.: Economic Research Service, U.S. Department of Agriculture. Rose D, Habicht JP, Devaney B. 1998. Household participation in the Food Stamp and WIC programs increases the nutritional intakes of preschool children. J Nutr 128: 548–555. Rush D, Sloan NL, Leighton J, Alvir JM, Horvitz DG, Seaver WB, Garbowski GC, Johnson SS, Kulka RA, Holt M. 1988. The National WIC Evaluation: Evaluation of the Special SupplementalFood Program for Women, Infants, and Children. V. Longitudinal study of pregnant women. Am J Clin Nutr 48: 439S–483S. USGAO (United States General Accounting Office). 1992. Early Intervention: Federal Investments Can Produce Savings. Washington, D.C.: U.S. Government Printing Office. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. 1987. Declining prevalence of anemia among low-income children in the UnitedStates. J Am Med Assoc 258: 1619–1623.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Food Insecurity as a Predictor of Dietary Risk Presented by Lynn Parker, M.S. Director of Child Nutrition Programs and Nutrition Policy Food Research and Action Center, Washington D.C. In considering how food insecurity applies to WIC, it is importantto understand the history of where this concept came from. The ideaof measuring food insecurity started in the United States in the1980s during the period of recession when there were major cut backsin federal nutrition programs. Many more people were coming in foremergency food assistance and service providers began to documentenormous jumps in need. Concerns, however, were discounted by policymakers and there was a strong desire around the country to convincethem that a hunger problem not only existed, but was increasing,and had negative consequences for the country. The Food Research and Action Center, working in partnership withthe Connecticut Association for Human Services, developed a systematicapproach to studying the problem of hunger among families with children,which was called the Community Childhood Hunger Identification Project(CCHIP). It was the first time a group attempted to develop an objectivemeasurement of hunger that could be used in a national survey (Wehleret al., 1995). Hunger was defined as food insufficiency due to constrainedresources, not voluntary hunger, but involuntary hunger because ofnot enough money to buy food. A survey was developed for familieswith children under the age of 12. It consisted of a series of eightquestions and based on the results, families were categorized ashungry, not hungry, or at risk of hunger. This type of survey was needed as it would not have been feasibleto measure blood levels of nutrients or to administer 24-hour recalls.These measures would have been incredibly time consuming, extremelyexpensive, and would have required a level of training on the partof interviewers that would not have been feasible with the type ofcommunity groups involved. Results from the surveys showed that a highly significant numberof children were hungry and that families were food insecure. Inaddition, a relationship was found between hunger and reported infections,fatigue, irritability, headaches, and ear infections and colds amongkids. We also found that parents are the first to be hungry and childrenare the last. This has come through again and again in national surveys.When children are found to be food insecure, it is a very severeproblem in the family. We also learned that who the interviewer is and who the respondentis can affect the response. There appeared to be a difference inresponse because our interviewers were paraprofessionals who weretrained to carry out the survey. Parents may not be as truthful ifthey are afraid their child will be taken away if they admit to agovernment interviewer that they cannot feed them. In addition, individualsliving in rural areas were less likely to admit that they were hungrythan those who lived in urban areas. At the same time that the CCHIP survey was being used, work was alsobeing done by researchers at Cornell University, and the Life SciencesResearch Office (LSRO) came out with definitions on how to definehunger, food security, and food insecurity (see Box 1). Also during this time, the Nutrition Monitoring Act was signedinto law. The Act had a provision in it that required the federalgovernment to develop some kind of measure of food insufficiency. In 1994,

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport the Department of Health and Human Services, United States Departmentof Agriculture, and the Census Bureau got together and developedwhat is now the food security module, which is an annual part ofthe Current Population Survey. The population survey is given outto approximately 58,000 households monthly (Hamilton et al., 1997).The food security module has been included in the population surveyfor one month of the year, every year since 1995. (In 1998, resultsshowed that 19 million adults and 12 million children were in householdsclassified as food insecure.) There are several categories of food insecurity based on severity. Even individuals who are classifiedas “food secure” may still have indicated on the survey that they worry aboutfood running out or that the food they bought did not last. The questionson the survey are listed in the typical order in which they may beanswered affirmatively (Table 1). The conservative nature of this measure is evident here. BOX 1 LSRO Definitions on How to Define Hunger, Food Security and FoodInsecurity Food security—Access by all people at all times to enough food for an active, healthylife. Food security includes at a minimum: (1) the ready availabilityof nutritionally adequate and safe foods, and (2) an assured abilityto acquire acceptable foods in socially acceptable ways (e.g., withoutresorting to emergency food supplies, scavenging, stealing, or othercoping strategies.) Food insecurity—Limited or uncertain availability of nutritionally adequate and safefoods or limited or uncertain ability to acquire acceptable foodsin socially acceptable ways. Hunger—The uneasy or painful sensation caused by a lack of food. The recurrentand involuntary lack of access to food. Hunger may produce malnutritionover time. Hunger, as the recurrent and involuntary lack of accessto food which may produce malnutrition over time, is discussed asfood insecurity in this report. Hunger, in its meaning of the uneasy or painful sensation causedby lack of food, is in this definition a potential, although notnecessary, consequence of food insecurity. Malnutrition is also apotential, although not necessary, consequence of food insecurity(Wehler et al., 1995). Results indicated that approximately 10 percent of the householdssurveyed were considered food insecure—two-thirds of them withouthunger and one-third with hunger. Households that were more likelyto be found food insecure were those with children, households headedby single females, and black or Hispanic households. Inner city andrural families were also more likely to be food insecure than suburbanhouseholds and food insecurity ran higher in the southern and westernparts of the United States than it was in any other regions of thecountry. Questions from the food insecurity module or various combinationsof them are now being included or are in the process of being includedin several national surveys such as the National Health and NutritionExamination Survey, the Continuing Survey of Food Intake by Individuals(CSFII), and the National Behavior and Knowledge Survey. Shortly,there will likely be good research data to answer questions regardingfood insecurity and how it relates to dietary behavior and nutritionalstatus.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport In 1996, the report from the IOM Committee on the Scientific Evaluationof WIC Nutrition Risk Criteria found limited evidence to evaluatethe causal links between food insecurity and nutrition and healthrisk. They also found insufficient scientific evidence to selecta cut-off point for WIC eligibility based on food insecurity. However,they did recommend use of the food insecurity measure at some point. TABLE 1 Response Profile By Category (Percentage of Households in Each FoodSecurity Category Answering Each Question Affirmatively)   Food Security Status Questions (in order of increasing severity) Food Securea Food Insecure, without Hungerb Food Insecure, with Moderate Hungerc Food Insecure, with Severe Hungerd Q53 Worried food will run out 5.0 89.5 97.2 99.1 Q54 Food bought didn't last 2.3 80.9 98.1 99.4 Q55 Adult not eat balanced meals 1.9 75.4 94.9 98.5 Q58 Child fed few low-cost foods 2.3 63.4 91.0 100.0 Q24 Adult cut size or skipped meals 0.4 36.8 93.1 99.1 Q56 Couldn't feed child balanced meals 0.3 41.2 77.4 95.5 Q32 Adult eat less than felt they should 0.3 34.4 90.3 98.8 Q25 Adult cut size or skipped meals, 3+ months 0.1 20.0 77.2 94.6 Q57 Child not eating enough 0.1 15.5 53.5 96.2 Q35 Adult hungry but didn't eat 0.1 8.3 57.5 94.3 Q38 Adult lost weight 0.0 2.8 30.5 71.7 Q40 Cut size of child's meals 0.0 2.1 24.2 70.7 Q28 Adult not eat whole day 0.0 2.4 20.7 87.6 Q47 Child hungry 0.0 1.7 20.0 72.9 Q29 Adult not eat whole day, 3+ months 0.0 0.8 11.6 80.6 Q43 Child skipped meal 0.0 0.6 8.1 56.4 Q44 Child skipped meal, 3+ months 0.0 0.2 4.7 43.6 Q50 Child not eat for whole day 0.0 0.1 1.4 18.1 Number of households in sample (unweighted)e 39,736 3,254 1,326 331 a No or minimal indicators of food insecurity evident. b Multiple indicators of food insecurity, but no or minimal indicatorsof resource-constrained hunger evident for household members. c Multiple indicators of resource-constrained hunger evident for adulthousehold members. d Multiple indicators of resource-constrained hunger evident for childrenin household and/or indicators of severe adult hunger. e For questions applicable only to households with children, the unweightedsample in the four groups is: 14,192, 1,934, 655, and 133.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport There have been a number of studies showing an association betweenfood insecurity and dietary risk in terms of nutritional inadequacyin a number of nutrients. Recent research by Dixon et al. (in press)showed low fasting levels of vitamin E and C in relationship to foodinsecurity. This was the first time a biochemical measure has beenrelated to food insecurity. It has also been interesting to notethat the research has shown a deeper and broader impact of food insecurityon nutrient levels in women than was originally thought. Cristofarand Basiotis (1992) looked at data from the CSFII for women aged19 to 50 and children 1 to 5. They were able to demonstrate a relationshipbetween food security status and nutrient intakes for women. Whilethey did not see a strong relationship with children, it was notsurprising given the demonstrated protective factor placed on children(i.e., adults apprear to sacrifice eating first before allowing theirchildren to eat less or go hungry.) Kendall, Olson, and Frongillo(1996) used the RadimerCornell Hunger and Food Insecurity measureand found a relationship between food insecurity and a lower consumptionof fruits and vegetables and lower levels of vitamin C, potassium,and fiber in the diet. They also saw much more disordered eatingpatterns in food insecure households. Rose and Olivera (1997) alsodemonstrated that in all nutrients looked at, adult women who werefood insufficient did worse in terms of nutritional adequacy. Tarasukand Beaton (1999) have also shown similar results using a slightlyaltered survey in Canada. Dr. Christine Olson (2000) recently reported on a relationship betweenfood insecurity and body mass index (BMI). She found that women whowere food secure and women who were food insecure with hunger had,on average, very similar BMIs that were not indicative of obesity.The women who were food insecure without hunger were much more likelyto be obese. She theorizes that food deprivation may lead to over-eatingat times when food insecure people do have enough food or have enoughmoney to buy food. If an individual is very poor, chronically food-deprived,and lacking the opportunity to overeat, the individual will havea lower BMI. However, if the individual is going through the constantups and downs of having enough and not having enough to eat, it maylead them to adopt unhealthy eating habits that can lead to obesity.Dr. Olson's conclusion was that ending health disparities relatedto chronic disease will require ending food insecurity. There have also been a number of studies looking at the impact offood insecurity on psychosocial indicators in school-aged children.Associations have been found with increased depression, anxiety,and inattentiveness in class. There is also research showing an impacton children's ability to learn, explore, and interact with theirenvironment. Overall, the research is important to consider in terms of the WICprogram. WIC has been very successful at being a preventive program.Many of the people who come to the WIC clinic may be food insecureone day and not the next. They tend to go in and out of poverty.It may be as little as one child needing a new coat that could leadthe family to go for a few weeks with less food than needed. It isimportant to remember what food insecurity looks like in these families.There has been work done on adapting the food insecurity survey tomake it shorter. It may be possible to build only one or two questionsinto the dietary assessments in WIC settings. A few food insecurityquestions would be helpful. Just as dietary assessment questionshelp to guide nutrition counseling, food insecurity questions couldlead a nutritionist to recognize when a family may need other assistanceprograms such as food stamps, Temporary Assistance to Needy Families,Medicaid, or emergency food. Using these questions, the nutritionistcould assist in increasing the food security in a family as wellas helping them improve their diet.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport References: Cristofar SP, Basiotis PP. 1992. Dietary intakes and selected characteristics of women age 19–50 and their children ages 1–5 years by reported perception of food sufficiency. Nutr Ed 24: 53–58. Dixon LB, Radimer K, Winkeeby M, Krebs-Smith S. In press. Differences in foods, dietary nutrients, and serum nutrients betweenfood insufficient and food sufficient low income adults, NHANES III,1988–1994. Hamilton WL, Cook JT, Thompson WW, Burron LF, Frongillo EA, Olson CM, Wehler CA. 1997. Household Food Insecurity in the United States in 1995: Summary Reportof the Food Security Measurement Project. Washington, D.C.: Food and Consumer Service, U.S. Department of Agriculture. Kendall A, Olson CM, Frongillo EA. 1996. Relationship of hunger and food insecurity to food availability andconsumption. J Am Diet Assoc 96: 1019–1024. Rose D, Oliveira V. 1997. Nutrient intakes of individuals from food insufficient householdsin the United States. Am J Public Health 87: 1956–1961. Tarasuk V, Beaton GH. 1999. Women's dietary intakes in the context of household food insecurity. J Nutr 129: 672–679. Olson CM. 2000. Presentation at the National Nutrition Summit, Food Insecurity andthe Health of Working Americans, May 30, 2000, Washington, D.C. Wehler CA, Scott IS, Anderson JJ, Summer L, Parker L. 1995. Community Childhood Hunger Identification Project: A Survey of Childhood Hunger in the U.S.Washington, D.C.: Food Research and Action Center.