Assessing Dietary Risk Among WIC Program Applicants

BACKGROUND

Dietary risk is one of several categories of nutrition risk criteria used, togetherwith low income, to establish eligibility for program benefits fromthe Special Supplemental Nutrition Program for Women, Infants, andChildren (WIC). Dietary risk refers to dietary deficiencies that impair or endanger health, such as inadequatedietary patterns assessed by a 24-hour dietary recall, dietary history, or food frequency checklist (7CFR Subpart C,Section 246.7(e)(2)(iii)).WIC eligibility based on the category of dietary risk is intended to prevent the occurrence of malnutrition or other overtproblems of dietary origin due to suboptimal dietary patterns, andresult in improved outcomes in terms of the health of the pregnantwoman, mother, fetus, infant, and young child.

In the event that a WIC agency has reached its maximum caseload givenfunding constraints, nutrition risk criteria provide the basis fora priority system in which program applicants can be placed on aneligibility waiting list. As openings become available, applicantsfrom the waiting list may enter the program according to prioritylevel. In general, priority is first accorded to individuals withnutrition risk conditions detectable by biochemical or anthropometricmeasurements, followed by other documented medical conditions, dietaryrisk, and lastly, homelessness or migrancy (IOM, 1996). Pregnantwomen, lactating women, and infants (birth to 12 months) are givenpriority over children (>12 months through 5 years), and childrenare given priority over nonlactating postpartum women. The currentseven-level priority system can be found in Table 1. Many states have set subpriority levels within these seven prioritycategories.

The federal definition for dietary risk focuses on underconsumptionof essential nutrients. However, the health risks associated withunbalanced dietary patterns, overconsumption, and excess body weightcall for an expanded definition of dietary risk—one that considersbalance and moderation in food intake. Data suggest that high weightfor height is a significant and



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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Assessing Dietary Risk Among WIC Program Applicants BACKGROUND Dietary risk is one of several categories of nutrition risk criteria used, togetherwith low income, to establish eligibility for program benefits fromthe Special Supplemental Nutrition Program for Women, Infants, andChildren (WIC). Dietary risk refers to dietary deficiencies that impair or endanger health, such as inadequatedietary patterns assessed by a 24-hour dietary recall, dietary history, or food frequency checklist (7CFR Subpart C,Section 246.7(e)(2)(iii)).WIC eligibility based on the category of dietary risk is intended to prevent the occurrence of malnutrition or other overtproblems of dietary origin due to suboptimal dietary patterns, andresult in improved outcomes in terms of the health of the pregnantwoman, mother, fetus, infant, and young child. In the event that a WIC agency has reached its maximum caseload givenfunding constraints, nutrition risk criteria provide the basis fora priority system in which program applicants can be placed on aneligibility waiting list. As openings become available, applicantsfrom the waiting list may enter the program according to prioritylevel. In general, priority is first accorded to individuals withnutrition risk conditions detectable by biochemical or anthropometricmeasurements, followed by other documented medical conditions, dietaryrisk, and lastly, homelessness or migrancy (IOM, 1996). Pregnantwomen, lactating women, and infants (birth to 12 months) are givenpriority over children (>12 months through 5 years), and childrenare given priority over nonlactating postpartum women. The currentseven-level priority system can be found in Table 1. Many states have set subpriority levels within these seven prioritycategories. The federal definition for dietary risk focuses on underconsumptionof essential nutrients. However, the health risks associated withunbalanced dietary patterns, overconsumption, and excess body weightcall for an expanded definition of dietary risk—one that considersbalance and moderation in food intake. Data suggest that high weightfor height is a significant and

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport TABLE 1 WIC Priority System Priority I Pregnant and breastfeeding women and infants at nutrition risk asdemonstrated by anthropometric or hematologic measurements or byother documented nutrition-related medical condition. II Infants up to 6 months of age of mothers who participated in WICduring pregnancy or who would have been eligible to participate underPriority I documented medical condition. This priority may also beassigned to a breastfeeding mother of an infant who is classifiedas Priority II. III Children at nutrition risk, as demonstrated by anthropometric orhematological assessment or other documented medical condition. AtState option, this priority can also include high-risk postpartumwomen. IV Pregnant and breastfeeding women and infants at nutrition risk asdemonstrated by inadequate dietary pattern. At State option, thispriority can also include homeless and migrant pregnant and breastfeedingwomen and infants and high-risk postpartum women. V Children at nutrition risk because of inadequate dietary pattern.At State option, this priority can also include homeless and migrantchildren and high-risk postpartum women. VI Postpartum women, not breastfeeding, at nutrition risk either medicalor dietary criteria unless they are assigned to higher prioritiesat State discretion. At State option, this priority may also includehomeless and migrant postpartum women. VII Previously certified participants likely to regress in nutritionalstatus without continuation of supplemental foods. At State option,this priority can also include homeless and migrant participants. growing concern among women and children enrolled in WIC (Mei etal., 1998; USDA, 2000). This is consistent with recent CDC reportsthat obesity rates among children and adolescents have doubled overthe past 20 years (Troiano and Flegal, 1998) Dietary risk includes two major types of risk through which individuals may becomeeligible for participation in the WIC program. Inadequate diet as a risk criterion includes reported food intakes that are identifiedto be potentially low in nutrients. Inappropriate dietary pattern includes descriptors of dietary intake or habits, developmentallyor age-inappropriate patterns of feeding, and the ingestion of specificinappropriate substances. Dietary inadequacy has been defined (IOM,1996) as food or nutrient intake insufficient to meet a specifiedpercentage of the Recommended Dietary Allowances (RDAs) (NRC, 1989)for one or more nutrients. Determination of inadequate diets usuallyinvolves estimating nutrient intakes using some method of dietaryrecall or food frequency, and then comparing the intake with a specifiedpercentage of the RDAs for the individual (often between 70 and 100percent of the RDA) (IOM, 1996). Examples of inappropriate dietarypatterns include inappropriate infant or child feeding practices,pica, high caffeine intakes, and reported food intakes that do notmeet one or more of the Dietary Guidelines for Americans (USDA/DHHS,2000). The latter may include consumption of less than the recommendednumber of servings from food groups of the Food Guide Pyramid, unsupplementedvegan diets, or other highly restrictive diets. In 1998, approximately 49 percent of all WIC enrollees (47 percentof women, 13 percent of infants, and 68 percent of children overthe age of 1 year) were certified for participation on the basisof dietary risk, either alone or in conjunction with other nutritional risks

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport (USDA/DHHS, 2000). While many applicants to the WIC program areeligible for program benefits based on identification of other nutritionrisks, for some dietary risk is the only nutrition criterion uponwhich they can be certified as eligible for program benefits. EVOLUTION OF NUTRITION RISK CRITERIA From the inception of the WIC program, state agencies were permittedto develop nutrition risk criteria using broad federal guidelinesto determine a participant's eligibility for the program. However,prompted by concern over the variation among state agencies in determiningeligibility, in 1989 Congress mandated a review of nutrition riskcriteria and the priority system. In 1993, the Food and Nutrition Service (FNS) of the U.S. Departmentof Agriculture (USDA) contracted with the Food and Nutrition Board(FNB) of the Institute of Medicine (IOM) to conduct a comprehensivescientific assessment of the nutrition risk criteria for use as eligibilitycriteria in the WIC program. In 1996, an FNB committee released itsrecommendations in the report WIC Nutrition Risk Criteria: A Scientific Assessment (IOM, 1996). With regard to the dietary risk classifications, thecommittee reviewed three major categories: inappropriate dietarypatterns, inadequate diets, and food insecurity. The committee foundclear health and nutrition risks associated with selected inappropriatedietary patterns. They concluded that individuals with these inappropriate dietarypatterns had high potential to benefit from participation in theWIC program. The committee also found evidence to support the useof dietary patterns that fail to meet the Dietary Guidelines as an indicator of both health risk and health benefit in the WICprogram. Consequently, it recommended the use of the 1995 U.S. DietaryGuidelines for Americans (USDA/DHHS, 1995)1 as a risk criterion for identifying inappropriate diets for womenand children over 2 years of age (Table 2). The committee did not, however, find evidence for an effectivemethod to assess an individual's usual intake in comparison withthe Dietary Guidelines, nor did it specify cut-off points. The 1996 FNB committee recommended discontinuing the use of the criterioninadequate diets. Although it concluded that individuals in this category would benefitgreatly from the supplemental food provided through participationin the WIC program, it also concluded that currently available assessmenttools have inherent limitations that make them unacceptable for determiningwhich income-eligible individuals consume inadequate diets. Lastly, with regard to food insecurity, the committee concluded thatthose at risk would likely benefit from participation in the WICprogram. However, while the committee recommended that food insecuritybe included as a risk criterion, they found insufficient scientificevidence on which to select a cut-off point to identify those mostlikely to benefit. Following the release of the FNB committee's report, the National Association of WIC Directors (NAWD) and FNSestablished a collaborative partnership—the Risk Identification andSelection Collaborative (RISC)—to address recommendations of theIOM report and to develop standardized and scientifically sound nutritionrisk criteria. Their intent was to achieve 1   Earlier this year a revised report, Dietary Guidelines for Americans, 2000 (USDA/DHHS, 2000), was released (see Table 2). While structured differently, the new guidelines are similar incontent to the 1995 guidelines, with the exception of an additionalguideline regarding food safety.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport TABLE 2 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. SOURCE: USDA/DHHS, 2000. greater consistency among state and local WIC agencies. Throughmultiple subcommittees, the joint NAWD/FNS Workgroup developed threelists of nutrition risk criteria: criteria that are allowed, criteriathat are not allowed, and criteria that are in need of future review.RISC was created to address criteria still in need of review andto provide ongoing review. FNS released a final policy memorandumthat described over 100 allowable nutrition risk criteria along withcutoffs/thresholds. These criteria were implemented as of April 1,1999 (FNS, 1998). While state agencies are allowed to establish morerestrictive cut-offs/thresholds, the final policy memorandum of allowablenutrition risk criteria provides for a reasonable degree of consistencyfrom state to state and some flexibility to meet local priorities(FNS, 1998). The list of official allowable nutrition risk criteria contains 18dietary risk criteria (Table 3). Inadequate diet and inappropriate diet (failure to meet DietaryGuidelines) are included among the 18, however these are the onlytwo criteria for which definitions, cut-off values, and prioritylevels have not been officially set. While priority levels for typesof participants have been assigned for these two categories (seeTable 4), definitions and cut-off values have not been. States are stillgiven discretion within broad federal guidelines to define dietaryrisk, choose tools to assess it, and set their own cut-off pointswhen using those tools. CHARGE TO THE COMMITTEE For the aforementioned reasons, FNS/USDA contracted with the FNB/IOMto appoint a committee of experts to review the scientific basisfor methods currently employed in the assessment of individuals foreligibility to the WIC program based on dietary risk. The committee's task is to evaluate the use of various dietary assessment toolsand to make recommendations for the assessment of inadequate or inappropriatedietary patterns. These assessments should accurately identify dietaryrisk of individuals and thus eligibility for

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport TABLE 3 Dietary Risk Assessment Criteria Allowed for WIC Program Certification 400 Inadequate/Inappropriate Nutrient Intake 401 Failure to Meet Dietary Guidelines 402 Vegan Diets 403 Highly Restrictive Diets 410 Other Dietary Risk 411 Inappropriate Infant Feeding 412 Early Introduction of Solid Foods 413 Feeding Cow's Milk During First 12 Months 414 No Dependable Source of Iron for Full-Term Infants at 6 Monthsof Age or Later 415 Improper Dilution of Formula 416 Feeding Other Foods Low in Essential Nutrients 417 Lack of Sanitation in Preparation/Handling of Nursing Bottles 418 Infrequent Breastfeeding as Sole Source of Nutrients 419 Inappropriate Use of Nursing Bottles 420 Excessive Caffeine Intake (Breastfeeding Woman) 421 Pica 422 Inadequate Diet 423 Inappropriate or Excessive Intake of Dietary Supplements IncludingVitamins, Minerals, and Herbal Remedies 424 Inadequate Vitamin/Mineral Supplementation 425 Inappropriate Feeding Practices for Children participation in WIC. More specifically, during its deliberations,the committee is charged with the following tasks: Propose a framework for assessing dietary risk among WIC programapplicants, focusing on “Failure to Meet Dietary Guidelines” as a risk criterion. Identify and prioritize areas of greatest concern2 when the U.S. Dietary Guidelines are incorporated into WIC programs. Examine the use of food-based and behavior-based approaches in assessing“Failure to Meet Dietary Guidelines” requirements. Evaluate possible approaches for use specifically in the WIC setting. Provide specific cut-offs for establishing WIC eligibility usingthe identified approaches. Identify needed research and tools necessary to implement the approachesidentified as having the greatest potential for identifying thoseat nutrition risk. Although asked to focus on “Failure to Meet Dietary Guidelines” as the type of dietary risk, the final report may consider otherpossible criteria where evidence substantiates an increased riskdue to food choices and practices, including criteria related tofood insecurity. 2   Given that the U.S. Dietary Guidelines include a number of specificrecommendations, the intent of this component of the task is to determinewhich of the Dietary Guidelines recommendations are most importantand relevant to include in assessing dietary risk specific to theWIC population.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport TABLE 4 Dietary Risk Criteria Without Standard Definitions and Cut-off Values INADEQUATE DIET * Definition/cut-off value Based on definition currently in use by State agency Participant Category Priority Category and priority level Pregnant Women Breastfeeding Women Nonbreastfeeding Women Infants Children IV IV VI IV V Justification To be provided by State agency   References To be provided by State agency   INAPPROPRIATE DIET: FAILURE TO MEET DIETARY GUIDELINES * Definition/cut-off value Based on definition currently in use by State agency Participant Category Priority Category and priority level Pregnant Women Lactating Women Nonlactating Women Children IV IV VI V Justification To be provided by State agency   References To be provided by State agency   *While recommended for use as an allowed risk criterion for the WICprogram by the IOM, this criterion is referred to the Risk Identificationand Selection Collaborative (RISC) for long-term research. NAWD andFNS concur in the following recommendations: (1) to merge this criterionwith 422, “Inadequate Diet”, and (2) to eliminate the use of identified specificnutrient deficiencies until a valid assessment tool for both criteriais defined. NAWD and FNS agree with IOM's recommendation for researchto develop practical and valid assessment tools for identificationof inadequate diets or inappropriate dietary patterns. Dietary adequacywill be considered a high priority for further research. It may takeyears to develop the necessary practical and valid assessment toolsand related definitions/cut-off values. Therefore, unlike other criteriathat are being referred to RISC, “Inadequate Diet” and “Failure to Meet Dietary Guidelines” will not be subject to the April 1, 1999 expiration date. SOURCE: FNS, 1998. SOURCES OF INFORMATION To assist the committee in its deliberations, a workshop on DietaryRisk Assessment in the WIC Program was held on June 1, 2000, in Washington,D.C. Eight experts on various

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport aspects of dietary assessment, four state WIC representatives whosestates use different assessment methods and serve demographicallydiverse population groups, and two public policy experts gave formalpresentations. Additionally, four attendees provided comments inresponse to an open invitation for such input to the committee. Theworkshop agenda and summaries of presentations can be found in Appendix A. The committee also conducted a search of the literature. A listingof references that the committee found to be of potential use canbe found in Appendix B. METHODS/TOOLS TO IDENTIFY DIETARY RISK Dietary assessments are used not only to establish eligibility inthe WIC program, but also as a basis for the individualization ofnutrition education and food packages. For this reason, dietary intakesare generally assessed for most WIC applicants regardless of whetheror not they have already met eligibility requirements based on nutritionrisk criterion other than dietary risk. In 1998, 86 percent of stateagencies had policies that required obtaining dietary intake informationfrom all participants (USDA, 2000). The characteristics of the toolsused in the assessment of dietary intake necessary for certificationmay differ, however, from those necessary for dietary counseling. Currently, a few states use dietary assessment methods with a publishedresearch base. Many use methods developed or adapted by state andlocal WIC agencies that appear to have been less well studied. Moststates define dietary risk as failure to consume a minimum numberof servings from one or more food groups represented in the FoodGuide Pyramid, which they interpret as indicating inadequate diet.Approximately 82 percent of states use 24-hour recalls and/or foodfrequency/food item checklists in their assessments of dietary intake(USDA, 2000). The following summaries provide overviews of some of the more commonmethods of assessing usual dietary intake that have been used inresearch settings in which significant time is usually availablefor interviews and follow-up questioning. In some cases, these methodshave been adapted for use in WIC programs, but the committee foundfew reported studies of their validity in this setting. Food Frequency Questionnaires Food frequency questionnaires (FFQs) are designed to obtain informationon the frequency of consumption of selected foods over a definedperiod. In WIC, the period of time usually ranges from 1 week to1 month. The number and choice of foods depends on the objectiveof the FFQ. For example, the FFQ might focus on important sourcesof only one or two nutrients, or it might be comprehensive and attemptto obtain an accurate picture of overall nutrient intake. Thus, thenumber of foods listed may vary greatly. Ideally, FFQs list foodsindividually rather than in groups because it can be very difficultfor the respondent to estimate a combined frequency of intake offoods (e.g., the combined frequency of intake of apples, applesauce,and pears). The time interval over which the respondent is askedto report usual consumption can vary from “not stated” to “the last year,” “last month,” or “last week.” Each time interval hasimplications for accuracy of memory and for the reliability of the assessment of

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport usual diet. Averaging usual intake over time may be difficult forsome participants (Cullen et al., 1999). Some FFQs attempt to obtain portion size information, whereas otherssimply assume a specified portion size. The portion size might bea standard measurement (e.g., 1/2 cup), or it might be chosen toreflect a median portion size found in a nationwide survey. OftenFFQs are designed to be self-administered. If the client can readand follow the directions, and if the results are computerized, datacollection and processing can be achieved quickly and at relativelylow cost. If interviewer administration is required, the processmay be time consuming, but the interviewer does not have to be highlytrained. FFQs lack the detail that is characteristic of diet recallsor records, and they provide no information about meal and snackpatterns. However, they may provide more information about the varietyof foods usually consumed (e.g., vegetables and fruits) than do 24-hourdiet recalls. The validity of FFQs is usually determined by correlating estimatesof nutrient intake with nutrient-intake estimates obtained from aset of diet recalls or prospectively collected diet records. Thecorrelation coefficients for intake of specific nutrients betweenFFQ and diet records or recalls (after adjustment for within-personvariability) are usually 0.5 to 0.7 for FFQs used in epidemiologicstudies (e.g., Block et al., 1990; Friis et al., 1997; Willett etal., 1987). Another method of assessing the performance of FFQs isto compare the FFQ's classification of nutrient intake by quintilewith that obtained by a set of diet recalls or records. Typically,there is considerable disagreement in the results obtained by thetwo methods (e.g., Friis et al., 1997). Little evidence is availableconcerning the ability of FFQs to estimate intake correctly whenservings of foods or food groups (rather than nutrients) are theunits of comparison (Thompson, et al., 2000). 24-hour Recall For a 24-hour recall, the client is asked to remember all food, beverages,and supplements consumed within the past 24 hours. Typically, therecall is obtained by an interviewer who is a registered dietitianor, at a minimum, a person who has been trained intensively to usethis method. Often the recall is obtained face-to-face but sometimesis obtained by telephone. To improve accuracy, the interviewer probesthe informant to help remember every eating occasion, including snacksand extra beverages, and to obtain descriptions of the method offood preparation and brand name of the products. For example, ifan informant reports drinking a cup of coffee (decaffeinated or withcaffeine), a standard probe would be made for the use of lightener(cream, nondairy creamer, milk [whole, 2 percent, 1 percent, skim])and sweetener (sugar, honey, saccharine, aspartame). Food models,household measures (bowls, cups, teaspoons, tablespoons), fast foodor other commercial containers, and two-dimensional food picturesare often used to help the informant estimate portion size. The interviewercan collect data on unusual foods and special recipes and, with fewexceptions, can accommodate the diets of most informants. A single research quality dietary recall usually requires 20 minutesfor the interview (Thompson and Byers, 1994). Although time demandsimposed upon the informant are relatively small, memory demands canbe difficult for many, especially without probing. Because the recallis interviewer administered, literacy is not a major issue.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport A major disadvantage of the single diet recall is that it does notassess usual intake. This is because individual diets vary by day of the week,season of the year, and from day to day. Consequently, multiple averaged24-hour recalls are needed to estimate the usual food or nutrientintake of individuals. Moreover, detailed quality control for achievingaccuracy involves a protocol for administering the recall and forthe training and periodic retraining of the interviewers and datacoders. Data coding, data entry, and data analysis are usually moreexpensive than those entailed with the food frequency method. Estimates of nutrient intake from a single 24-hour recall are poorlycorrelated with nutrient intake estimates obtained from a set ofdiet records, from weighed intakes, or from intakes recorded by independentobservers (Bingham, 1991). Small, but statistically significant,correlations (r~0.2) have been found between dietary (averaged 24-hourrecalls) and circulating micronutrients (e.g., dietary folate andserum folate [Huber et al., 1988; Scholl et al, 1996]). Overweightadults and adolescents tend to have greater under-reporting thannormal weight individuals (Briefel et al., 1997). Studies of adultshave shown that energy intake estimated from 24-hour recalls is under-reportedwhen compared with expenditure estimated by doubly labeled water(Johnson et al., 1998; Kroke et al., 1999; Sawaya et al., 1996; Tranet al., 2000), but this may not be true for all population groups(Harrison et al., 2000). Diet Records Diet records are intended to provide quantitative and descriptiveinformation about all foods and beverages consumed over a specifiedtime, usually several days. Good record keeping requires substantialtraining of the client or caregiver—a time-consuming process. Foodrecords have many of the characteristics of diet recalls (e.g., asingle day's record does not provide a sound basis for estimatingusual intake, and coding of records may be time consuming, but unusualfoods can be included). If recorded faithfully at the time the foodis eaten, food records minimize the problem of memory, but they maychange eating behavior. Invariably, the staff member needs to spendtime interviewing the client to clarify entries or check on potentiallymissing items. Diet History The term diet history generally refers to any comprehensive measure of usual intake. Itis typically composed of a detailed interview to establish usualconsumption patterns. The interview usually begins with a 24-hourrecall that is expanded by probing to gather information regardingday-to-day and seasonal variation. The second phase of the interviewinvolves completion of an FFQ that includes questions on portionsize. Finally, clients are asked to keep a record of everything consumedfor a 72-hour period. Diet histories allow the practitioner to gather information on awide variety of nutrients, foods consumed over time, and eating patterns.The combined use of several methods allows the detection and clarificationof discrepancies in reporting. The disadvantages of diet historiesare those inherent in the separate methodologies of 24-hour recallsand food frequencies. Specifically, recall bias may result from faultymemory or poor conceptualization by the client and interviewer biasmay result from inadequate or inappropriate probing. Proper training of

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport interviewers minimizes these effects. However, the use of multipleassessment methods is time consuming. Behavioral Approaches in Assessing Dietary Intake The above dietary assessment methods focus on determining what and/or how much of a food or nutrient a WIC client consumes. In comparison, a behavioralapproach to diet assessment can be viewed as examining the contextof eating—where, when, and how. For example, behavioral questions might determine such things asthe frequency of eating at restaurants (where), eating quickly versusslowly (how), or eating between meals or skipping breakfast (when).Such questionnaires can also seek to determine the whys behind food consumption (e.g., eating when bored or feeding a toddlerto calm fussiness). Eating is a complex motivated behavior with multiple social, emotional,and environmental determinants. What or how much an adult or childeats (or an adult offers to a young child to eat) is the result ofa complex sequence of decisions. These decisions are not usuallyconsciously deliberated and can be affected by contextual factors,such as eating during social gatherings; the cost, convenience, orfamiliarity of certain foods; or cues to eating from emotional statessuch as loneliness. Contextual factors that motivate the what andhow much aspects of diet may be easier to recall, less susceptibleto various types of reporting bias, and might be the most appropriatetargets for dietary counseling (Kristal et al., 1990). All of thesewould be practical advantages of a behavioral approach to assessingdietary risk. There are several examples of behavioral approaches. A behavioralscreening questionnaire focused on dietary fat (Kristal et al., 1990)assessed practices associated with dietary fat intake, such as “How often do you take the skin off chicken?” and “How often do you drink skim or low-fat instead of regular milk?” People who frequently ate at fast food restaurants tended to consumemore dietary saturated fat (Clemens et al., 1999). Another example relates to the feeding of preschool children. Birchand coworkers reported that when parents used food as a reward infeeding preschool children (Birch et al., 1980) or restricted accessto food (Fisher and Birch, 1999a), children may have overeaten andbecome overweight (Birch and Fisher, 2000; Fisher and Birch, 1999a,1999b). FRAMEWORK FOR ASSESSING DIETARY RISK Through deliberations, the Committee on Dietary Risk Assessment inthe WIC Program developed a framework for evaluating possible methodsto assess dietary risk among WIC program applicants. Building onthe approach used in the 1996 WIC report, the committee set as anoverall goal: an assessment tool that can identify dietary patternsfor which there is (1) scientific evidence of nutrition or healthrisk in either the short or long-term, and (2) evidence of the abilityto benefit from WIC participation for individuals with a given risk.The evaluation framework consists of characteristics that a foodor behavior-based tool should have to be considered useful and effectivein the WIC setting. At this point, the committee has not ruled outthe possible inclusion of some type of assessment of nutrient intakesor of aspects of food security as part of this framework. The eightcharacteristics are as follows:

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport 1. The tools use specific criteria that are related to health, growth,or disease. Ideally, any risk criterion adopted for inappropriate dietary patternsshould be predictive of the individual's risk of short-term or long-termhealth problems or growth problems, or of developing a dietary deficiency.It also should predict the likelihood that the individual would benefitfrom the WIC food package and/or nutrition education. For childrenages 2 to 5 years and for pregnant, lactating, and nonlactating postpartumwomen, the 1996 IOM report suggested using the indicator “failureto meet Dietary Guidelines” (IOM, 1996). To be current, this wouldinvolve using the consensus document Dietary Guidelines for Americans (USDA/DHHS, 2000) as a reference. Although the Dietary Guidelines were not developed to serve as criteriathat are directly predictive of optimal health or growth, they werebased on extensive review of the literature and deliberations byan expert committee—the Dietary Guidelines Advisory Committee. Thatcommittee's intent was to promote good health of Americans throughuse of the entire set of guidelines—priority was not given to justone or a few of them. Neither the 1996 IOM report nor the reportof the Dietary Guidelines Advisory Committee makes recommendationsfor cut-off points for determining when the guidelines have not beenmet. Useful screening tools based on Dietary Guidelines need to determinehow an individual's intake compares with an appropriate cut-off pointbased on those guidelines. For such vulnerable populations as pregnantand lactating women and children ages 2 to 5 years, should the criterionbe a dietary intake that fails to meet any one of the guidelines,or should it be more stringent? Should the criterion used differfor the three categories of women served by WIC? Should there bean emphasis on “too much” along with “not enough”? Assessment tools need to identify shortfalls or excess intake dependingon the criterion or criteria selected as most predictive of riskand benefit for the target population. The criteria (indicators andtheir cut-off points) need to be specified clearly for the tools,along with the rationales. Because the criteria must be related to health, growth, or disease,they must be tailored to subgroups served by WIC. For example, anindicator to determine “failure to meet Dietary Guidelines” may not be appropriate for children youngerthan 2 years of age since Dietary Guidelines were developed onlyfor people 2 years and older. Criteria to identify what constitutesan inappropriate diet for this younger age group still need to berelated to risk of health, growth, or development problems. 2. The tools allow prioritization within the category of dietaryrisk. Currently, funding for the food grant portion of WIC is sufficientto meet current participation levels, and all who apply and meeteligibility criteria receive the food assistance component of WIC.When resources for WIC are insufficient to serve all those eligible,a tool needs to allow the prioritization of risk within the dietaryrisk category. The goal should be to ensure that those at greatestdietary risk and those most likely to benefit are served first. Tomeet this goal, a set of criteria should be established that havedifferent degrees of stringency reflecting different degrees of risk.Where the prioritized criteria are established, the committee willgive the rationale for the prioritization developed.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport 3. The tools have acceptable performance characteristics. All instruments should be held to two performance criteria: validityand reliability (Windsor et al., 1994). Validity addresses whetherone is really measuring what was intended. For example, 24-hour dietaryrecalls are intended to measure dietary intake for the previous 24hourperiod, but several recent studies have revealed that as much as30 percent of foods reported by children were not eaten the previousday (Baxter et al., 1997). Foods reported but not eaten are calledintrusions or phantom foods (Domel et al., 1994). An instrument thatsystematically mismeasures something (e.g., overestimates consumptionby including a large number of phantom foods) is biased and considereda validity issue. Reliability concerns whether applying the sameinstrument twice (or more times) provides the same results. Reliabilitythereby indicates the degree of random error in dietary assessment.Random error could be caused by the respondent or interviewer beingupset at the time of assessment, excessive noise during assessment,the vagaries of memory, a person's inability to properly averageintake to provide a desired response on an FFQ, etc. One source of random error that has received substantial attentionin dietary assessment is intraindividual variability—that is, variationin an individual's intake from day to day (Nelson et al., 1989).In most dietary assessment research, the investigator intends tomeasure a person's usual intake. However, research has demonstratedthat a person's food intake varies substantially from day to day(Nelson et al., 1989). The major problems with measures that containsubstantial amounts of error (low reliability) are that estimatesof true values may be substantially off the mark, and correlationswith other variables will be attenuated (i.e., they will be lowerthan correlations obtained if measures without error were available)(Traub, 1994). One method for minimizing intraindividual variability in dietarydata is to collect many days of dietary intake and average the data.The number of days needed to attain a usually desired level of reliabilityof 0.8 or higher varies by the nutrient or food group to be measured(IOM, 2000; Nelson et al., 1989). Although the errors of individualsin a group tend to cancel each other out and leave an unbiased estimateof the true value for the group, the error terms for any single memberof that group remain if only a single day's intake has been obtained.Assessing diets with sufficient accuracy to characterize an individual's intake generally requires either multiple days of assessment (IOM,2000) or a lengthy questionnaire. When using these dietary assessmentprocedures for group assessment, researchers have generally beenwilling to tolerate a substantial amount of error, for which theycould partially compensate by increasing the number of participantsin their research or using statistical correction procedures, calledcorrections for attenuation (Traub, 1994). Error in the assessment of an individual for certification in theWIC program (that is, misclassification error), however, has moreserious consequences: truly eligible individuals may not be classifiedas eligible for the services (less than perfect sensitivity), or individuals not truly eligible for the services may receivethem (less than perfect specificity). Policy makers and the public must decide how much and what typeof misclassification error they are willing to tolerate when certifyingpeople to receive or not receive federally funded WIC services. Theextent to which specific cut-offs recommended in the final reportmisclassify individuals (see Chapter 3 of the 1996 IOM report for further discussion) will be consideredby the committee in its deliberations; recommendations derived willbe provided in the final report along with the rationale used by the committee.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport Given concerns about reliability and validity, all tools used todetermine WIC dietary risk should undergo testing for these performancecriteria. If a WIC agency uses several tools for the same clientcategory, their relative ability to ascertain dietary risk accuratelyshould also be addressed. 4. The tools are suitable for the culture and language of the populationserved. The WIC program serves a multiethnic, multicultural, heterogeneouspopulation. Forty percent of WIC participants are Caucasian, 31 percentare Latino, 24 percent are African American, 3 percent are Asianor Pacific Islander, and 2 percent are American Indian or AlaskanNative. The percentages of non-Caucasians and the diversity of culturesare expected to increase. Diversity in heritage, geography, foodsconsumed, and culture translates into diversity in dietary patternsand practices. To assess dietary intake and patterns effectively,dietary assessment tools need to be developed with each specificculture in mind. Thus, many WIC agencies are likely to require severalor even many different dietary assessment tools to serve their populationmix. Language translation alone will not provide an acceptable toolfor a different culture because the types of foods consumed, theportion sizes, food combinations, and the way foods and eating areconceptualized are likely to differ. Thus, the rigorous process ofdevelopment and validity and reliability testing is recommended forall dietary assessment tools designed for small target client subpopulationsregardless of how small the unique target client subpopulation maybe. Effective administration and use of tools with different culturalgroups is likely to require special training, but this topic is notwithin the charge to this committee. The committee is aware thatlittle information exists regarding successful adaptations of dietaryassessment instruments for use in different cultures whose memberswish to avail themselves of WIC services. Thus, the final reportwill develop recommendations to assist in ascertaining dietary riskin such subgroups when the scientific basis is sparse. 5. The tools are suitable for the skill levels of the populationserved. Due to time constraints of WIC staff, asking the client to fill outa questionnaire is a reasonable option. However, dietary assessmenttools are complex by nature. Self-administration of the forms maynot be a legitimate option for providing quality services in someWIC agencies for several reasons: the questionnaire may be too complex,the task itself is complex, and some clients have limited literacyand/or limited familiarity with completing forms (including scanableforms). It is also possible that oral administration of a questionnairemay be superior to written administration for obtaining the desiredinformation in some settings or client groups. Thus, the method ofadministration is a fundamental consideration for the developmentand selection of appropriate dietary assessment tools for the WICprogram. Pilot testing with WIC clients can help develop user-friendlytools that are appropriate for the WIC client. 6. The tools are appropriate for age and physiological condition. Several subgroups are served in the WIC program: pregnant, breastfeeding,and nonbreastfeeding women and teenagers, along with their infantsand children. When assessing dietary risk, consideration needs tobe given to the different nutritional goals and appropriate feedingpatterns for these groups. For example, appropriate feeding patterns change continually

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport throughout the first 2 years of life. In infants 0 to 6 months ofage who are not exclusively breastfed, many state agencies focuson caregiver behaviors such as the proper and sanitary preparationof infant formula, and on discouraging additions, such as cereal,to the infant's bottle. Beginning at 4 to 6 months of age, issuesrelated to the transition from breast or formula feeding to a mixeddiet of appropriate texture and consistency become important. Fortoddlers, the appraisal may relate to the transition from pureedfoods to family foods and to self-feeding. Also, questions at thisstage about hand-to-mouth activity often lead to the subsequent identificationof children with pica who are at risk of exposure to environmentallead from the ingestion of nonfood substances. Therefore, the needfor specialized tools for each client subgroup must be consideredin the development of appropriate tools for assessing dietary riskin the WIC program. 7. The tools are responsive to operational constraints. Time constraints for both staff and participants necessitate theuse of an assessment tool that can be administered, scored, and interpretedrapidly. It is imperative that the tools under consideration takeinto account the variety of skills and knowledge levels of the competentprofessional authorities (CPAs) who assess dietary intake in theWIC setting. CPAs are often paraprofessional staff who have receivedbasic nutrition training. Whether CPAs are paraprofessional or professional,the assessment tools they use need to be linguistically and culturallyappropriate for different population groups served by WIC clinics. A tool should provide consistent results regardless of the staffmember who administers it. Subjective measures in scoring shouldbe avoided to eliminate administrator bias. Furthermore, the toolshould be constructed in a manner so as not to influence the client.Features that may influence responses inappropriately include scoringmechanisms placed directly on a self-administered form and phrasingthat invites desirable or favorable responses rather than accurateones. Additional points that need to be considered include the impact ofthe tool(s) on the systems used by the WIC agency, and of expectedfuture changes to the system, such as automation or computerization. 8. The tools are standardized across states/agencies. To some degree, tools used to determine eligibility for WIC participationbased on dietary risk need to be standardized across state agenciesfor each of the physiological groups served by WIC. While differencesin culture and language preclude the use of a single tool in allsettings or even in a single setting, some form of standardizationneeds to occur to ensure equal access to program benefits regardlessof the individual's place of residence or cultural background. Moreover,if federal funding for the program is limited, standardization needsto ensure that individuals at greatest risk and with potential tobenefit are served first. Framework Summary The eight criteria for tools to be used to identify dietary riskhave many dimensions and must take into account numerous constraints.It may be that the environment in which the WIC

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport program operates precludes the use of tools that have both greaterpredictive reliability and greater sensitivity. The final reportwill address methods of dietary risk assessment in the context ofthese constraints and of the scientific base available. REFERENCES Baxter SD, Thompson WO, Davis HC, Johnson MH. 1997. Impact of gender, ethnicity, meal component, and time interval betweeneating and reporting on accuracy of fourth-graders' self-reportsof school lunch. J Am Diet Assoc 97: 1293–1298. Bingham SA. 1991. Limitations of the various methods for collecting dietary intakedata. Ann Nutr Metab 35: 117–127. Birch LL, Fisher JO. 2000. Mothers' child-feeding practices influence daughters' eating and weight. Am J Clin Nutr 71: 1054–1061. Birch LL, Zimmerman SI, Hind H. 1980. The influence of social-affective context on the formation of children's food preferences. Child Dev 51: 856–861. Block G, Woods M, Potosky A, Clifford C. 1990. Validation of a self-administered diet history questionnaire usingmultiple diet records. J Clin Epidemiol 43: 1327–1335. Briefel RR, Sempos CT, McDowell MA, Chien S, Alaimo K. 1997. Dietary methods research in the Third National Health and NutritionExamination Survey: Underreporting of energy intake. Am J Clin Nutr 65: 1203S–1209S. Clemens LH, Slawson DL, Klesges RC. 1999. The effect of eating out on quality of diet in premenopausal women. J Am Diet Assoc 99: 442–444. Cullen KW, Baranowski T, Baranowski J, Bebert D, de Moor C. 1999. Pilot study of the validity and reliability of brief fruit, juice,and vegetable screeners among inner city African American boys and17-20 year old adults. J Am Coll Nutr 18: 442–450. Domel S, Baranowski T, Davis H, Leonard SB, Riley P, Baranowski J. 1994. Fruit and vegetable food frequencies by fourth and fifth grade students:Validity and reliability. J Am Coll Nutr 13: 1–7. Fisher JO, Birch LL. 1999a. Restricting access to foods and children's eating. Appetite 32: 405–419. Fisher JO, Birch LL. 1999b. Restricting access to palatable foods affects children's behavioral response, food selection, and intake. Am J Clin Nutr 69: 1264–1272. FNS (Food and Nutrition Service). 1998. WIC Policy Memorandum 98-9: Nutrition Risk Criteria (June 29, 1998). Supplemental Foods Program Division, Food and Nutrition Service,U.S. Department of Agriculture, Alexandria, VA. Photocopy. Friis S, Kruger Kjaer S, Stripp C, Overvad K. 1997. Reproducibility and relative validity of a self-administered semiquantitativefood frequency questionnaire applied to younger women. J Clin Epidemiol 50: 303–311. Harrison GG, Galal OM, Ibrahim N, Khorshid A, Stormer A, Leslie J, Saleh NT. 2000. Underreporting of food intake by dietary recall is not universal:A comparison of data from Egyptian and American women. J Nutr 130: 2049–2054. Huber AM, Wallins LL, de Russo P. 1988. Folate nutriture in pregnancy. J Am Diet Assoc 88: 791–795. IOM (Institute of Medicine). 1996. WIC Nutrition Risk Criteria: A Scientific Assessment. Washington, D.C.: National Academy Press.

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Framework for Dietary Risk Assessment in the WIC Program: InterimReport USDA (United States Department of Agriculture)/DHHS (United StatesDepartment of Health and Human Services). 2000. Nutrition and Your Health: Dietary Guidelines for Americans, 2000, 5th Edition. USDA Home and Garden Bulletin No. 232. Willett WC, Reynolds RD, Cottrell-Hoehner S, Sampson L, Browne ML. 1987. Validation of a semi-quantitative food frequency questionnaire: Comparisonwith a 1-year diet record. J Am Diet Assoc 87: 43–47. Windsor R, Baranowski T, Clark N, Cutter G. 1994. Evaluation of Health Promotion, Health Education, and Disease Prevention Programs, 2nd Edition. Mountain View, CA: Mayfield Publishing Co.

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