Framework for Dietary Risk Assessment in the WIC Program Interim Report (2000) / Chapter Skim
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Appendix A Workshop Agenda and Presentations
Appendix A Workshop Agenda and Presentations
Pages 21-66
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Department of Agriculture A-12 Break Assessing Individuals Total Food Intake and Cognitive Aspects of Questionnaires Amy Subar,NationalCancerinstitute A-17 Use of the Block Questionnaire in the WIC Program Gladys Block University of California, Berkeley A-19 12:15 p.m. Lunch T:00 ~ :45 2:30 Use of the Harvard Food Frequency Questionnaire in the WIC Population Graham Colditz, Harvard School of Public Health A-22 Assessing Dietary Intake and Risk During Pregnancy and Special Considerations in Evaluating Intake in the Hispanic Population Anna Maria Siega-Riz, University of North Carolina A-25 Break A-l
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Workshop Agenda, continued 2:45 3:45 Practical Issues in the Use of Various Tools in WIC Settings A-31 Jill Leppert, North Dakota State Department of Health; Amancla Watkins, Arizona Department of Health Services; Ann Barone, Rhode Islanc! Department of Health; Carol Rankin, Mississippi Department of Health The Role of WIC in Assistance to the Poor and Food Insecurity as a 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 A-2
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The Maryland WIC 5-ADay Promotion Program and the Maryland Food for Life Program, both funded by the National Cancer Institute, are two programs in which dietary assessment instruments were developed and utilized to evaluate program interventions. Both used trained peer educators to recruit program participants and briefly explain questionnaire instructions.
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In addition, a questionnaire was used to assess the fat levels of commonly eaten foods, stages of change for fruit and vegetable consumption, as well as fat and fiber consumption. The 83-item food frequency questionnaire included estimations of portion size.
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. Alternatively, a food frequency questionnaire A-5
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Nonetheless, the lower an individual's usual intake is, the greater the probability that the intake is inadequate to meet her needs. Both the between-person variation in nutritional requirements and the error inherent in our estimation of individuals' usual intakes need to be considered when applying dietary assessment methods to determine nutritional risk.
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While the food guide pyramid is one of the major tools used for consumer education, the dietary guidelines, which incorporate the food guide pyramid, are developed to be used as a policy instrument. The guidelines are quite relevant to this committee's task, in that the guidelines form the basis of federal food and nutrition education programs.
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. TABLE 1 Dietary Guidelines for Americans AIM FOR FITNESS...
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This guideline is of relevance to the WIC population because of the concern regarding folate intake for pregnant women.
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For this reason, pregnant women or those at risk of becoming pregnant were asked not to drink alcohol at all. The other reason for the way the guideline is stated is because there are health benefits associated with alcohol.
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Other changes in the 2000 guidelines include a separation of guidelines on grains from fruits and vegetables, a shift from an emphasis on total fat to the reduction of specific types of fats, a recognition of the trends in sugar intake, and greater specificity in the alcohol guidelines. The guidelines are quite applicable to the WIC population, but only after the age of 2.
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A food guide translates recommendations on nutrient intake into recommendations on food intake. The Food Guide Pyramid and, subsequently, the Food Guide Pyramid for Young Children were developed using a sound research process and were based on a set of established philosophical goals.
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Nutrient profiles for each composite were calculated using forms of food items lowest in fat and added sugars. This reflected the philosophical goals that the food guide should be realistic and allow maximum flexibility for users to select specific sources of fats and sugars within their diets.
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This information appears in the newly-released Dietary Guidelines 2000. As indicated previously, sample Food Guide Pyramid diet patterns were developed and composites and their nutrient profiles used in these at three calorie levels that would meet established goals for protein, vitamins, and minerals.
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In order to meet the objective of adapting the original Food Guide Pyramid to a younger audience, a literature search was first conducted to help decide on the target audience of 2-6year-olds. The philosophical and nutritional goals, developed for the original Pyramid, were reexamined and adapted for young children.
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By using updated composites in the Food Guide Pyramid diet patterns, and comparing expected nutrient levels to nutritional objectives, it can be determined whether or not the patterns meet objectives. if not, there are several options.
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Asking about shorter time frames such as the past month or week may be easier but may not best represent Tong-term usual intakes. Many of the stumbling blocks for respondents are simple things that can be easily changed helping respondents to easily get through the process of completing the instrument.
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A significantly Tower proportion of respondents skipped or missed portion size and supplement questions on the DHQ versus the standard FFQ. These findings suggest that intensive cognitive interviewing is beneficial in the development of dietary assessment instruments and would be beneficial in developing a dietary assessment tool to be used in the WIC setting.
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and the Harvard Food Frequency Questionnaire (Harvard FFQ)
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TABLE 2 Validity Coefficients of the Harvard and Block Food Frequency Questionnaires Mean Nutrient Intake by Recall Data Harvard Block Hispanic Women Energy (kcal) 0.19 0.14 Protein (g)
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Since the Block FFQ was not designed to contain Hispanic food choices, it is not currently a good choice for this copulation. The instrument would need to be ~ ~ .
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Dr.P.H. Professor of Medicine Harvard School of Public Health The Harvard Food Frequency Questionnaire (HFFQ)
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A luminary of the correlation coefficients found in these studies can be found in Table 1. TABLE ~ Summary of Validation Studies Performed on the Harvard Food Frequency Questionnaire Number of Nutrients Average for which Average Pearson Tools and Sample Correlation was Correlation References Children Pregnant Women Derived Coefficient Children's HFFQ Blum et al., 1999 X 19 0.55a 1-2 years 0.57 3-5 years 0 55 Native American 0.56 Caucasian 0.52 Women's HFFQ Suitoretal., 1989 X 8 o.5alb Weietal., 1999 X 26 0.47h a Adjusted for within person variation.
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1999. Validity of a food frequency questionnaire in assessing nutrient intakes of Tow-income pregnant women.
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The majority of native-born Hispanics have less than ~ years of formal education. Many of the available food frequency questionnaires (FFQs)
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in summary, in order to conduct dietary assessments in the Hispanic population, it is recommended that the WTC program promote and support the attitudes, behaviors, knowledge, and skills necessary for staff to work respectfully and effectively with clients. Bibliography: The National Coalition of Hispanic Health and Human Services Organizations.
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Dietary intake was assessed during the second trimester using a Food Frequency Questionnaire. The DQ1-P includes eight components: percent of recommended servings of grains, vegetables, and fruits based on the Food Guide Pyramid, percent of dietary reference intakes (DRI)
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The DQ] -P may be a useful public health tool for evaluating the overall diet quality of pregnant women.
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In order to identify meal patterns of pregnant women and investigate the relationship between these meal patterns and preterm delivery, an analysis was performed using data from pregnant women (n=2,065) in the Pregnancy, Infection, and Nutrition Study (Siega-Riz et al., in press)
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Measuring meal and snack intake, as well as the timing of meals and snacks, may be a very simple public health too} that can be used to evaluate the prenatal diet and could easily be incorporated into assessments of dietary risk for WIC eligibility. References: Binienda Z
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Prior to the adoption of this tool, the state used both the 24-hour diet recall and a food frequency method. Concerns over time constraints, repetition, and lack of consistent results prompted a search for a better tool.
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While Congress did not set up the WIC program this way, it would best if the risk assessment were divorced from the eligibility criteria. While assessment is important for nutrition education, it would be best if eligibility were based on income alone.
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The state is currently in the process of automating the WIC program and in an effort to incorporate diet assessment into the automation process, Arizona reviewed numerous tools and decided to have a new food frequency questionnaire created. The Arizona Department of Health Services has contracted with Dr.
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Department of Agriculture Food Guide Pyramid, be used for dietary counseling, measure changes in dietary patterns, be easily incorporated into Arizona's automated system and, preferably, be a food frequency questionnaire. Ideally, the too]
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While a 24-hour recall and food frequency toot continue to be used, the food frequency toot is now based on the food guide pyramid rather than being nutrient based. In addition, some of the required servings have been adjusted (e.g., calcium serving size and protein requirements for children)
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The dietary assessment forms for women and children include both the food frequency and the 24-hour diet recall. Children are divided into age groups of ~ to 3 years of age and 3 to 5 years of age.
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dietary assessment, it is rare that they would not be certified. According to USDA figures, 22 percent of WIC clients in Mississippi qualify for the program based on dietary risk.
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However, for several reasons, the WIC program has continued to operate, thrive, and produce significant positive health outcomes with program eligibility based on both income and nutrition criteria. Overall, research on the impact of the WIC program on diet and health over the last quarter century has shown striking results in terms of its impact on birth outcomes and Towering the incidence of low birth weight.
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A nutrition assessment could be performed and the image of a health program rather than a welfare program would be maintained, and yet low income individuals for whom there would be a preventive value would not be denied entry into the program. This raises an important question for this committee: How can the necessary information be collected in an effective manner while avoiding a significant narrowing of the criteria that could possibly make a few million individuals who are currently eligible for WIC, ineligible?
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However, one would hope that the Committee on Dietary Risk Assessment in the WIC Program keeps the Hippocratic oath in mind if it considers options that could significantly narrow the pool of Tow-income women, infants, and children who are eligible for WIC. The principal effect of such an approach would be fewer Tow-income individuals being provided with WIC benefits and services and more money made available for tax cuts likely to accrue primarily to relatively high-income individuals.
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1998. Household participation in the Food Stamp and WIC programs increases the nutritional intakes of preschool children.
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At the same time that the CCHIP survey was being used, work was also being done by researchers at Cornell University, and the Life Sciences Research Office (LSRO) came out with definitions on how to define hunger, food security, and food insecurity (see Box I)
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Inner city and rural families were also more likely to be food insecure than suburban households and food insecurity ran higher in the southern and western parts of the United States than it was in any other regions of the country. Questions from the food insecurity module or various combinations of them are now being included or are in the process of being included in several national surveys such as the National Health and Nutrition Examination Survey, the Continuing Survey of Food Intake by Individuals (CSFIT)
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b Multinle indicators of food insecurity, but no or minimal indicators of resource-constrained hunger 1,326 331 evident for household members. c Multiple indicators of resource-constrained hunger evident for adult household members.
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Just as dietary assessment questions help to guide nutrition counseling, food insecurity questions could lead a nutritionist to recognize when a family may need other assistance programs such as food stamps, Temporary Assistance to Needy Families, Medicaid, or emergency food. Using these questions, the nutritionist could assist in increasing the food security in a family as well as helping them improve their diet.
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1997. Household Food Insecurity in the United States in 1995: Summary Report of the Food Security Measurement Project.
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