5

Food Intake of WIC-Eligible Populations

In phase I, the committee was tasked with assessing food intake of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible populations. This chapter summarizes the committee’s findings. The approaches applied included an evaluation of findings from published surveys on dietary intake (for individuals younger than 2 years of age), National Health and Nutrition Examination Survey (NHANES) analyses similar to the nutrient intake analyses described in Chapter 4, and a literature search for supplemental information. The information summarized in this chapter, in combination with the nutrient intake information presented in Chapter 4, support identification of nutrient and food group priorities for the WIC food packages.

LITERATURE AND REPORT FINDINGS: FOOD INTAKE OF WIC PARTICIPANTS

The committee reviewed the literature for information on food intakes of WIC participants, with a particular focus on complementary feeding practices. A summary of the committee’s findings is presented here.

Food Intake of WIC Participants Compared to Nonparticipants

The committee identified five cross-sectional studies that compared food intakes of WIC participants to nonparticipants. Three conducted crude analysis on food intake data: (1) a small regional study in South Carolina (McElligott et al., 2012), (2) an analysis of data from the Feeding

Infants and Toddlers Study (FITS) (Deming et al., 2014), and (3) a study of NHANES 2005–2010 (Watowicz and Taylor, 2014). Ages ranged from 6 months to 4 years. All three studies found higher intakes of juice among WIC participants compared to nonparticipants. Other notable findings were lower intakes of whole fruit among 1- to 4-year-old WIC participants (Deming et al., 2014) and higher milk intakes among 2- to 4-year-old WIC participants compared to nonparticipants, although the latter finding was not statistically significant (Watowicz and Taylor, 2014). Additional detail on findings from the FITS study is presented later in this chapter.

The U.S. Department of Agriculture’s Food and Nutrition Service (USDA-FNS) Diet Quality of American Young Children study (see Chapter 4 for a description of the methodology) examined food intakes of WIC-participating and non-WIC children using NHANES 2005–2008. Their analysis indicated that compared to income-eligible nonparticipants, WIC participating children were more likely to consume WIC juice, cow’s milk, whole milk, regular soda, beans, and WIC cereals, and less likely to consume fruit (excluding juice) and fats and oils added to foods (USDA/FNS, 2015).

Food Intake and the Revised Food Packages

Except for studies on breastfeeding, data characterizing the effect of the 2009 WIC food package changes on children’s food intake or health are sparse. The data that do exist are regional. Two prospective cohort studies were conducted using the same population sample, a group of Hispanic and African American mother–child pairs from 12 Chicago WIC clinics (Kong et al. 2014; Odoms-Young et al., 2014). Baseline data were collected in summer 2009 before the WIC food package revisions were implemented. Odoms-Young et al. (2014) reported that, 6 months postrevision, fruit consumption increased among Hispanic mothers; low-fat dairy consumption increased among Hispanic mothers, Hispanic children and African American children; and whole milk consumption decreased among all groups. Additionally, home food availability of low-fat dairy and whole grains increased. No significant changes in diet quality were observed for any other group. Kong et al. (2014) reported that, 18 months postrevision, low-fat milk intake increased for African American and Hispanic children and that whole milk intake decreased for all groups.

Four pre-post studies compared food intake before and after the 2009 WIC food package revisions. Again, as with the two Chicago studies, all four were regional. One was conducted in New York State (Chiasson et al., 2013), one among Indian Tribal Organizations across multiple states (Ishdorj and Capps, 2013), the third in California (Whaley et al., 2012), and the fourth in Georgia (Meiquari, 2015). Despite numerous differences among the populations sampled, including varying cultural food prefer-

ences, the studies consistently suggest that the 2009 WIC food package changes were associated with increased consumption of fruits, vegetables, whole grains, and low-fat/fat-free milk and decreased consumption of whole milk. Specifically, Chiasson et al. (2013) reported that food intake and healthy behaviors of more than 3.5 million children ages 0 to 4 years participating in the New York State WIC program showed an improvement between 2008 and 2011. In particular, these improvements included delayed introduction of solids and increased consumption of fruits, vegetables, and whole grains and reduced-fat milk. In a study of 1,642 Native American children ages 2 to 4 years who participated in WIC, Ishdorj and Capps (2013) found increases in lower-fat milk, fruit, vegetable, and whole grain intake following revisions of the food packages. Whaley et al. (2012) conducted a random telephone survey of California WIC families before and after the 2009 changes to the WIC packages. Based on their assessment of 3,004 (in 2009) and 2,996 (in 2010) households, they found significant increases in consumption of fruits, vegetables, and whole grains and decreases in consumption of whole milk. Their findings were for families, but the increased consumption of reduced fat milk was specifically identified in children. In their recent systematic review, Schultz et al. (2015) reported that there was an overall improvement in dietary intake after the 2009 food package changes, although the body of evidence was limited. The committee came to the same conclusion after its own independent review.

Finally, Meiquari et al. (2015) conducted a pre-post study that surveyed African American WIC participant mothers and their eldest child at two WIC clinics in Atlanta, Georgia, specifically to examine the impact of the 2009 food package changes on milk intake. The authors reported that children significantly increased their intake of low-fat milk after the food package changes, although “low-fat” was defined as all forms other than whole, including 2% milk. There was no change in intake of “low-fat” milk (as defined in this study) by women. Importantly, this study was conducted prior to issuance of the final rule eliminating 2% milk from most food packages and allowing only skim or 1% (USDA/FNS, 2014).

Racial and Ethnic Differences in Intake of WIC and Other Foods

Many findings suggest that food purchasing and consumption patterns may be strongly connected to culture, race, or ethnicity (Dubowitz et al., 2007, 2008; Bermúdez-Millán et al., 2009; Kong et al., 2013; Pooler and Gleason, 2014; Chaparro et al., 2015). This is evident in the WIC population, for example, Kong et al. (2013) compared the diets of African American and Hispanic mothers and their 2- to 3-year-old children who were enrolled in WIC prior to the 2009 food package revisions. Although the dietary intake of all groups fell short of national recommendations, the

diets of Hispanic mothers and children were lower in percentage of calories from fat, added sugars, sodium, and sweetened beverages and higher in vitamin A, calcium, whole grains, fruits, and dairy foods, compared to their African American counterparts. Reported differences in intake among and between racial and ethnic groups, however, are not always consistent (Faith et al., 2006; Odoms-Young et al., 2014; Chaparro et al., 2015; Cho et al., 2015). Chapter 2 contains additional information on racial and ethnic differences and the impact of the 2009 revisions on intake and acceptability of WIC package food items.

Geographical Differences in Food Intakes

The committee identified one cross-sectional study on geographic differences in food intake. In a comparison of fruit and vegetable consumption between urban and rural African American Texas WIC participants, Ettienne-Gittens et al. (2013) found urban African American women consumed a wider variety of fruits than their rural counterparts. Compared to rural children, urban children were provided with a wider variety of vegetables and consumed them more frequently. Additional information on the effect of rural versus urban settings on food accessibility is presented in Chapter 2.

Complementary Food Intake of Individuals Younger Than 2 Years of Age

Complementary feeding is broadly defined as the addition of any foods other than human milk or formula to an infant’s diet. This transition to table foods typically starts when the nutritional needs of the infant surpass what can be provided through human milk, usually occurring at around 6 months of age and lasting until a child is around 24 months of age (AAP, 2014). Although several large-scale surveys have asked parents and guardians to report when complementary foods were first introduced in their children’s diets, infant dietary intake has not been a primary focus for most of these studies (NIS-Child Hard Copy Questionnaire, 2015; ECLS-B 9-Month Questionnaire; SLAITS-National Survey of Early Childhood Health, 2000). The WIC Infant and Toddler Feeding Practices Study, a longitudinal, nationally representative study of infants in low-income families, is currently underway, and the committee anticipates results for review in phase II (Harrison et al., 2014).

For this report, the committee relied on food intake data from three large contemporary datasets: (1) Infant Feeding Practices Study II (IFPS II), (2) 2008 Feeding Infants and Toddlers Study (FITS 2008), and (3) NHANES. Findings from IFPS II and FITS 2008 are summarized and supplemented with relevant findings from a recently released analysis of the 2005–2012

NHANES on foods that contribute to energy and nutrient intake in infants 0–24 months old (Grimes et al., 2015). Findings from the committee’s own analyses of NHANES data are summarized later in this chapter. A comparison of the designs of IFPS II and FITS 2008 is outlined in Table 5-1. It should be noted that the data from these two studies were collected before the October 1, 2009, deadline for states to implement revisions to the WIC food packages. The IFPS II analysis detailed below combined WIC with non-WIC infants, and the results reflect all consumption in the 7 days before the survey. The FITS 2008 analysis described in this section, in contrast, compared WIC and non-WIC participants, and the data collected were for food intake only during the 24 hours before the interview.

Food group intake findings from IFPS II (Grummer-Strawn et al., 2008) and FITS 2008 (Deming et al., 2014) are summarized in Table 5-2. Findings from a recent NHANES analysis evaluating food group contributions to energy and nutrient intake (Grimes et al., 2015) are summarized in Table 5-3. Highlights of the three selected reports are discussed below.

TABLE 5-1 Study Designs and Characteristics of Selected Reports, IFPS II, FITS 2008, and NHANES 2005–2012

NOTES: FITS = 2008 Feeding Infants and Toddlers Study; IFPS II = Infant Feeding Practices Study II.

^a Overall study design, Fein et al., 2008a; CDC, 2014.

^b Overall study design, Briefel et al., 2010.

^cGrimes et al., 2015.

^d A year 6 follow-up study of children initially assessed in the IFPS II has been conducted, evaluating links between early feeding practices and various health outcomes (Fein, 2014).

^e Number represents sample included in the analysis, not entire NHANES sample.

^f Information about dietary supplement use was collected in each of the overall study designs, but the three reports on food group intakes did not evaluate supplement use.

^g Report-specific analysis, Deming et al., 2014.

^h Two days of dietary intake per sampled child was used to calculate usual nutrient intake distributions, Briefel et al., 2010.

ⁱ While two 24-hour recalls are part of the NHANES procedures, Grimes et al. (2015) only evaluated intake reported on the first day of recall.

SOURCE: As indicated by the referenced publications.

TABLE 5-2 Complementary Food Intake of Infants, Ages 0 to 2 Years of Age, from IFPS II and FITS 2008

NOTE: NR = not reported.

^aGrummer-Strawn et al., 2008.

^bDeming et al., 2014 (Data reprinted with permission).

^c Point estimate imprecise due to small sample size and it being an uncommon or very common response.

^d Significantly different from WIC group at 0.01 level by t-test.

^e Significantly different from WIC group at 0.05 level by t-test.

^f FITS 2008 classified this category as “Meat and other protein sources” and included cheese and yogurt in this category while IFPS II has a separate “Other Dairy” category.

SOURCES: Grummer-Strawn et al., 2008; Deming et al., 2014.

Fruit, Excluding Juice

Fruits were introduced to IFPS II infants at a median age of 5–6 months, and the proportion of infants consuming fruit in the week prior to the survey increased with age (Grummer-Strawn et al., 2008). The FITS 2008 data showed that fruit consumption on a given day was less common in WIC participants 12–23.9 months old than in their nonparticipant counterparts (Deming et al., 2014). For NHANES infants, fruit composed a greater proportion of energy intake of children aged 12–23.9 month scompared to infants 6–11.9 months old (4.8 percent versus 2.3 percent, respectively; Grimes et al., 2015).

TABLE 5-3 Percentage of Daily Energy Intake of Complementary Food Groups by Infants 6 to 23.9 Months of Age, NHANES 2005–2012^a,^b

NOTE: NA = data not available.

^aGrimes et al., 2015.

^b Intake of human milk and infant formulas not represented in this table.

^c All NA notations indicate that data were not presented in Grimes et al. (2015), as intake contributed to less than 1 percent of total energy intake.

^d Sum of “White Potatoes” group and “Vegetables, excluding potatoes” group.

100% Juice

The proportion of IFPS II infants who consumed 100% juice in the week prior to the survey increased as they aged (Grummer-Strawn et al., 2008). In the FITS 2008 study, a greater proportion of WIC infants 6–11.9 months old consumed 100% juice compared to their non-WIC counterparts, but a significant difference was not seen in the 12–23.9 month groups (Deming et al., 2014). The 2005–2012 NHANES analysis showed 100% juice contributed to 1.5 percent and 5.9 percent of total energy intake of infants 6–11.9 months and 12–23.9 months of age, respectively (Grimes et al., 2015).

Vegetables

Vegetables were introduced to the IFPS II infants at a median age of 5–6 months (Grummer-Strawn et al., 2008). FITS 2008 data suggest that a lower percentage of WIC infants 6–11.9 months old consumed any vegetable on a given day compared to non-participants, a difference not seen 12–23.9 month groups (Deming et al., 2014). Due to small sample sizes and the infrequency of the responses, point estimates for intake of specific types of vegetables (e.g., dark green, deep yellow) were largely imprecise for infants less than 1 year of age. On a given day, a portion of WIC participants 12–23.9 months old in the FITS 2008 study reportedly consumed white potatoes (41.5 percent), other starchy vegetables (17.0 percent), deep yellow vegetables (16.0 percent), dark green vegetables (12.0 percent), and other vegetables (28.7 percent) (Deming et al., 2014). Vegetable intake contributed to less than 1 percent of energy intake of 2005–2012 NHANES 6–11.9-month-old infants (Grimes et al., 2015). For 12–23.9 month olds, total vegetable intake contributed to 3.2 percent of energy (Grimes et al., 2015).

Grains and Grain Products

Grains were present in the diets of 18.3 percent of 3-month-old IFPS II infants, primarily in the form of infant cereal (Grummer-Strawn et al., 2008). Similarly, infant cereals were the primary grain contributors in the diets of FITS 2008 infants 0–5.9 months old (Deming et al., 2014). In later infancy (6–11.9 months), non-infant cereals were present in the diets of 26.4 percent of infants, and crackers, pretzels, or rice cakes were being eaten by 39.4 percent of WIC-participating infants (Deming et al., 2014). In the 12–23.9 month group, 56.2 and 63 percent WIC participants were consuming grains in mixed dishes and non-infant cereals, respectively (Deming et al., 2014). For NHANES 2005–2012 infants 6–11.9 months of age, mixed grain-based dishes and breads, rolls, and tortillas each con-

tributed to 2.3 and 1.1 percent of total energy intake, respectively (Grimes et al., 2015). For 12–23.9-month-olds, mixed grain-based dishes; bread, rolls, and tortillas; crackers; ready-to-eat cereal; quick breads and bread products; and cooked cereals each contributed more than 1 percent of total energy intake (Grimes et al., 2015).

Meats and Meat Substitutes

Meat and meat substitutes were introduced to IFPS II infants at a median age of approximately 8 months (Grummer-Strawn et al., 2008). By 1 year of age, most IFPS II individuals were consuming meat, chicken, or combination dishes (93.8 percent) and eggs (59.2 percent), with fewer eating peanuts or peanut butter (25.1 percent), fish and shellfish (17.7 percent), and soy foods (5.8 percent). Point estimates of meat and meat substitute consumption among FITS 2008 WIC participants ages 0 to less than 6 months are imprecise due to sample size and because consumption of meats and meat substitutes was an uncommon event for this age group (Deming et al., 2014). In general, baby food meat was not commonly consumed (< 10 percent in any age group). On a given day, 23.5 percent of older WIC infants (6–11.9 months) and 71.9 percent of WIC children (12–23.9 months) consumed non-baby-food meat. Only 28.3 percent of children 12–23.9 months reportedly ate eggs on a given day. Among 2005–2012 NHANES 6–11.9-month-olds, meat and meat substitute food groups (e.g., poultry, plant-based protein foods) each contributed to less than 1 percent of total energy intake (Grimes et al., 2015). In contrast, 2005–2012 NHANES 12–23.9-month-olds reportedly consumed poultry, cured meats and poultry, eggs, mixed meat/poultry/seafood dishes, and plant-based protein foods (Grimes et al., 2015).

Dairy

For the majority of IFPS II infants, cow’s milk and milk products (excluding breast milk and infant formulas) were not present in their diets until late infancy, with the median age of introduction being approximately 10 months (Grummer-Strawn et al., 2008). By approximately 10.5 months of age, 17.3 percent of IFPS II infants were consuming cow’s milk. FITS 2008 found that approximately 13 percent of WIC participants 6–11.9 months old consumed cow’s milk on a given day (Deming et al., 2014). Cow’s milk was consumed on a daily basis by more than 80 percent of WIC participants 12–23.9-months-old, with the majority (59.2 percent) reportedly consumed whole milk. A greater proportion of WIC participants consumed reduced- or low-fat milk on a given day, compared to their non-WIC counterparts (31.8 versus 19.7 percent). Cow’s milk contributed to

3.1 percent and 22.4 percent of total energy intake of 2005–2012 NHANES infants aged 6–11.9 months and 12–23.9 months, respectively (Grimes et al., 2015). Among 12–23.9-month-olds, cheese, yogurt, and flavored milk contributed another 2.6, 1.7, and 1.3 percent of total energy, respectively (Grimes et al., 2015).

Desserts, Sweetened Beverages, and Savory Snacks

In the IFPS II cohort, fatty and sugared foods were present in the diet of nearly one-quarter of 9-month old infants (Grummer-Strawn et al., 2008). By 1 year of age, 14.6 percent were consuming sweetened drinks, and 52.2 percent were consuming candy, cookies, and cake. In the FITS 2008 sample, 22.7 percent of older WIC participants 6–11.9 months and 63.6 percent of WIC participants 12–23.9 months old consumed desserts and candy on a given day, but their consumption of these foods did not differ from that of nonparticipants (Deming, 2014). Differences did emerge for consumption of sweetened beverages and fruit-flavored drinks, however, with more WIC participants 12–23.9 months old consuming these on a daily basis (39.6 percent and 31.1 percent, respectively) compared to nonparticipants (22.0 percent and 16.6 percent, respectively). Consumption of carbonated sodas (sweetened or non-caloric was not specified) also appears to have been more common among WIC participants 12–23.9 months old, but the point estimate for nonparticipants was imprecise due to small sample sizes and low frequency of consumption (10.3 percent of WIC versus 1.8 percent of non-WIC). Approximately 18 percent of WIC participants 12–23.9 months old consumed salty snacks on a given day, which was comparable to nonparticipants. The 2005–2012 NHANES analysis found that sweet bakery products contributed 1.8 percent of the total energy intake of 6–11.9-month-olds (Grimes et al., 2015). Among 12–23.9-month-olds, sweet bakery products, sugar-sweetened beverages, savory snacks (e.g., potato chips, tortilla chips, popcorn, pretzels, snack mixes), candy, and other desserts each contributed more than 1 percent of total energy intake (Grimes et al., 2015).

Areas of Concern for Complementary Feeding

Based on the findings from IFPS II, FITS 2008, and the 2005–2012 NHANES analysis, the committee identified four areas of concern with respect to complementary feeding: (1) early introduction of complementary foods, (2) insufficient intake of iron-fortified foods and supplements among older infants, (3) early introduction of cow’s milk, and (4) consumption of foods of poor nutritional value. The committee’s reasons for concern are explained below.

It should be reiterated that data collection for IFPS II, FITS 2008, and

most of the presented NHANES analysis occurred prior to the full implementation of the WIC food package revisions. Some of the changes, such as not issuing complementary foods prior to an infant reaching 6 months of age, have the potential to affect the areas of concerns described below. Large datasets exploring the postrevision status of infants, however, do not currently exist.

Early Introduction of Complementary Foods

Of the 1,334 IFPS II mothers who provided complete data, 40.4 percent reported introducing solid food before their infant was 4 months of age (before 17 weeks; Clayton et al., 2013). This early introduction of complementary foods was half as common among breastfed infants (24.3 percent) compared to infants who were formula fed or mixed fed (52.7 percent and 50.2 percent, respectively). Women who introduced complementary foods early were more likely to be participating in the WIC program, according to Clayton et al. (2013). In another analysis of the IFPS II data that used different criteria and cutoffs, the estimated proportion of early introducers (before 15 weeks) was 21 percent, and early introduction of complementary foods was associated with lower maternal education (Fein et al., 2008b). The reported differences in proportion of early introducers may be due to differences in the cutoff ages of infants included in the respective studies. The FITS 2008 data also suggested that a portion of infants were receiving complementary foods before 4–6 months of age. Introduction of these foods appears to be delayed compared to FITS 2002 infants (Siega-Riz et al., 2010).

The early introduction of complementary foods may reflect early cessation of exclusive breastfeeding and has implications for infant weight gain. Gaffney et al. (2012) reported that the weight-for-age z-score of 691 IFPS II infants (primarily white) at 1 year of age was significantly higher in infants who received complementary foods before 6 months of age compared to those who received them at or after 6 months of age. Chapter 6 provides a summary of health outcomes associated with inappropriate infant weight gain.

Iron-Fortified Foods and Supplements

Healthy, full-term infants are typically born with sufficient iron stores for at least the first 4 months of life (AAP, 2014). The iron concentration of human milk, however, is relatively low and, although readily absorbed by the infant, can be insufficient to meet iron needs in the latter half of infancy. Inasmuch as iron deficiency can have potentially long-lasting neurocognitive effects (see Chapter 6 for a summary of health outcomes

associated with iron deficiency in infants), the American Academy of Pediatrics (AAP) recommends that infants who consume at least half of their daily feedings from human milk receive a 1 mg/kg/day iron supplement starting at 4 months of age, with the supplement eventually being displaced by iron-rich complementary foods (Baker and Greer, 2010; AAP, 2014).

Using IFPS II data, Dee et al. (2008) compared the intake of iron-rich foods among exclusively breastfed versus mix-fed, full-term infants and found that, by 6 months of age, 80 percent of mix-fed infants were consuming infant cereal and 14 percent were consuming meat. In contrast, nearly one-quarter of exclusively breastfed, full-term infants (23 percent) did not have a regular iron-rich food source in their diets. Iron supplementation among both exclusively breastfed and mix-fed infants was fairly uncommon, with less than 10 percent reporting using iron supplements at any given time during the survey.

Among FITS 2008 infants, which included infants of all breastfeeding intensities, Butte et al. (2010) found mean iron intake among 6–11-month-olds to be 15.8 mg/day, with 12 percent consuming inadequate iron (relative to the EAR of 6.9 mg/day). Among 12–23-month-olds inadequate iron uptake was not apparent. Based on the 2005–2012 NHANES analysis (Grimes et al., 2015), which did not include supplement use in the evaluation, the top foods that contributed to iron intake among 6–11.9-month-olds were infant formulas (44.8 percent), baby foods (43.1 percent), ready-to-eat cereals (3.1 percent), and grain-based mixed dishes (1.0 percent).

Early Introduction of Cow’s Milk

The early introduction of cow’s milk can affect the health of an infant. For example, a portion of infants experience significant increases in occult fecal blood loss when fed cow’s milk, with the response diminishing with age (Ziegler et al., 1990, 1999; Jiang et al., 2000). Furthermore, cow’s milk has a high protein, but low iron content. As such, it may displace foods with higher iron content in the early months of complementary feeding and thereby compromise an infant’s iron status. Some international guidelines for the introduction of cow’s milk into the diets of infants and young children suggest that a limited amount is permissible (usually 500 mL/day after 6 or 9 months of age), especially if accompanied by an iron supplement (Agostoni and Turck, 2011; FAO, 2013). The AAP, however, recommends that whole milk should not be introduced before 12 months of age (Baker and Greer, 2010; AAP, 2014).

Estimates from IFPS II, FITS 2008, and the 2005–2012 NHANES indicate that infants are being fed cow’s milk prior to 12 months of age. IFPS II results found that, at 10.5 months, 17.3 percent of infants had

consumed cow’s milk in the previous week (Grummer-Strawn et al., 2008). Overall, 25.9 percent of IFPS II infants had consumed cow’s milk prior to 10.5 months of age, a practice more common among mothers with lower education levels (Fein et al., 2008b). FITS 2008 data indicate that an estimated 13.3 percent of WIC infants aged 6–11.9 months consumed cow’s milk on a given day (Deming et al., 2014). For infants 6–11.9 months of age included in the 2005–2012 NHANES analysis, cow’s milk contributed 3.1 percent of total energy intake (Grimes et al., 2015).

Foods of Poor Nutritional Value

Results from IFPS II, FITS 2008, and the 2005–2012 NHANES indicate that desserts, sweetened beverages, and salty snacks are parts of the diets of children less than 24 months of age. These foods are typically energy-dense and nutrient-poor, and have little nutritive role in the diets of young children. Higher consumption of energy-dense, nutrient-poor foods has been associated with lower micronutrient intake in young children (Webb, 2006) and can help to establish taste preferences, which has implications for dietary patterns later in life (Beauchamp and Mennella, 2009; Mennella, 2014).

NHANES ANALYSIS: FOOD GROUP AND SUBGROUP INTAKES

In addition to evaluating NHANES findings reported in the literature (i.e., Grimes et al. 2015), the committee conducted its own analyses of NHANES data. The committee examined food intake data from the three analytical subgroups described in Chapter 3, namely 2005–2008 WIC participants, 2005–2008 income-eligible nonparticipants, and 2011–2012 low-income individuals, across relevant WIC age categories (pregnant, breastfeeding, and postpartum women, 19 to 50 years; formula-fed infants 0 to less than 6 months; formula-fed infants 6 to less than 12 months; children 1 to less than 2 years; and children 2 to less than 5 years). Too few breastfeeding infants with reported food intake were included in NHANES to estimate their usual intakes of foods for any survey years of interest. Mean usual intakes and intake distributions for the population subgroups analyzed here are presented in Appendix Q.

As mentioned in Chapter 4, the WIC identifier for the 2011–2012 NHANES dataset became available only after completion of these analyses. Therefore, it was not possible to compare food intakes among WIC participants before the 2009 food package changes occured to those after the changes were implemented. Moreover, only the 2005–2008 NHANES data were considered appropriate for comparison of WIC participants to WIC-

eligible nonparticipants.¹ All individuals who were income-eligible for WIC from NHANES 2011–2012 were analyzed as a proxy for WIC participants. In phase II, the WIC indicator will be applied to the NHANES 2011–2012 dataset so that, depending on the sample sizes in 2011–2012, intakes of WIC participants in 2011–2012 can be compared to those of income-eligible nonparticipants. With adequate sample sizes, WIC participant intakes can also be compared before and after the 2009 food package changes.

Food group and subgroup intakes among WIC participating women, infants, and children were evaluated relative to the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (2015 DGAC report) recommended intakes or other dietary guidance as appropriate. To estimate the distribution of dietary components consumed episodically (food groups and subgroups), the Statistical Program for Age-adjusted Dietary Assessment (SPADE), a method similar to the National Cancer Institute (NCI), was implemented. For all population subgroups for which the percentage below recommended food intakes could be calculated with reasonable precision, a population level prevalence of low intakes of 50 percent or more was considered of concern (see detailed explanation of these methods in Chapter 3).

WIC participant and eligible non-WIC participant subgroups were compared by t-test. One consequence of the small sample sizes is that the standard error values are large and thus only large differences among means can be detected.

Food Group Intakes of Pregnant, Breastfeeding, and Postpartum Women, 19 to 50 Years of Age

Food group and subgroup intakes for women compared to recommendations are presented in Table 5-4, with mean usual intakes and intake distributions presented in Appendix Q. No statistically significant differences between WIC participant and WIC-eligible nonparticipant subgroups were identified. For low-income women in the 2011–2012 NHANES dataset, the estimated percentage below recommendations data are not reliable because the population subgroup size was small and the variance was large.² Therefore, mean usual intake data are presented so comparisons can be made

__________________

¹ The 2009–2010 NHANES dataset spanned the period of time over which the 2009 food package changes were implemented. It was therefore not considered appropriate for either the pre- or post-food package change assessments. As noted in Chapter 3, separation of a 2-year dataset requires re-computation of population weights, which was beyond the scope of this study.

² For the analysis of episodically consumed foods, small samples add enormous challenges. Consequently, with the small sample sizes that were available for women, estimates of the proportion of usual intakes of foods below recommendations are less reliable. Estimates of mean food intake are, however, adequately precise and only these are presented for women.

TABLE 5-4 Food Group Intakes Compared to the DGAC 2015 Report Recommendations, Pregnant, Breastfeeding, or Postpartum Women 19 to 50 Years, NHANES 2005–2008 and 2011–2012

NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available; oz-eq = ounce-equivalents; SE = standard error; wk = week. Percentage of population below recommended intake not provided for the “All Low-Income 2011–2012” group because the sample size is too small to produce statistically reliable estimates. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

^a For women, the reference food intake pattern used was 2,200 kcals, which was the calculated Estimated Energy Requirement for WIC women in NHANES 2005–2008.

Population subgroup definitions are as follows:

^b WIC = All individuals reporting participation in WIC regardless of income level.

^c Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^d All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^e The sample size of this group is too small to produce statistically reliable estimates in these units.

^f For all NA notations, estimate could not be obtained because the Statistical Program for Age-adjusted Dietary Assessment (SPADE) requires more than two observations per group with two non-zero intakes in order to estimate a within-person variance.

^g Although all data here are compared to values presented in the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (2015 DGAC report), the Dietary Guidelines for Americans (DGA) in place at the time of the 2005–2008 NHANES survey (the 2005 DGA) did not include a red and orange vegetables subgroup.

^h For solid fats and added sugars, Recommended Intakes indicate an upper limit.

SOURCES: Intake data are from NHANES 2005–2008 and 2011–2012 (USDA/ARS, 2005–2008, 2011–2012). Reference values are the USDA food patterns from the 2015 DGAC report (USDA/HHS, 2015).

across subgroups of women. Estimates of “% below recommendations” was adequately precise for women in the 2005–2008 dataset; therefore these data are presented.

More than 50 percent of WIC participating women and WIC-eligible nonparticipating women in the 2005–2008 NHANES survey had low intakes of all food groups, with the exception of refined grains (0 to 6 percent) and meat, poultry, and eggs (45 to 46 percent). Nearly 100 percent of these women had low intakes of total vegetables and whole grains. Likewise, nearly all women in the 2005–2008 NHANES survey had low intakes of dark green vegetables (for WIC-participating women, not enough consumed foods from this group to generate reliable estimates), red and orange vegetables (95 to 98 percent), and starchy vegetables (84 to 98 percent). Very low intakes (i.e., 80–95 percent of the population subgroup below recommendations) were also evident for beans and peas, nuts, seeds and soy, total dairy, and oils.

Mean usual intake data were also compared across subgroups of women. There were small differences across these groups in food intake, but women in the 2011–2012 NHANES dataset consumed more total fruit, total vegetables (as well as dark green and red and orange), whole grains, total protein foods (including meat, poultry, and eggs; nuts, seeds, and soy), and total dairy compared to women in the 2005–2008 NHANES survey. Too few women in the most recent survey consumed beans and peas or seafood to generate estimates. Intake of WIC-eligible nonparticipating women was generally greater than that of WIC participating women, except for total fruit, red and orange vegetables, and beans and peas.

For WIC participating women from the 2005–2008 population subgroup, mean intake of solid fats was 37 g-eq per day, or more than twice the recommended limit of 18 g-eq per day. Their intake of added sugars was 23 tsp-eq per day (see Appendix Q, Table Q-2), which was approximately triple the recommended limit of 8 tsp-eq per day.

Food Group Intakes of Formula-Fed Infants Ages 0 to Less Than 6 Months

Mean food group and subgroup intakes for infants ages 0 to less than 6 months are presented in Table 5-5. Because the 2015 DGAC report recommendations do not apply to infants, adequacy of food intake could not be evaluated for this age group. Intakes are anticipated to be low, given that the AAP advises complementary feeding to begin between 4 and 6 months of age. No statistically significant differences between WIC participant and WIC-eligible nonparticipant subgroups were identified.

Comparing mean usual intakes across population subgroups of these children, differences were small with a few exceptions. Low-income chil-

TABLE 5-5 Mean Usual Food Group Intakes of Formula-Fed Infants 0 to Less Than 6 Months, NHANES 2005–2008 and 2011–2012

NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available; oz-eq = ounce-equivalents; SE = standard error; wk = week. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

Population subgroup definitions are as follows:

^a WIC = All individuals reporting participation in WIC regardless of income level.

^b Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^c All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^d For all NA notations, the estimate could not be obtained because the Statistical Program for Age-adjusted Dietary Assessment (SPADE) requires more than two observations per group with two non-zero intakes in order to estimate a within-person variance.

^e Solid fat was considered equivalent to saturated fat in this analysis.

SOURCES: Intake data are from NHANES 2005–2008 and 2011–2012 (USDA/ARS, 2005–2008, 2011–2012). Reference values are the USDA food patterns from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (USDA/HHS, 2015).

dren in the most recent survey consumed fewer total vegetables and total grains (whole grains and refined grains), and total fruit. For many food groups, estimates could not be generated because the minimum amount of data required for SPADE was not reached.

Food Group Intakes of Formula-Fed Infants Ages 6 to Less Than 12 Months

Mean usual intakes for older infants (ages 6 to less than 12 months) are presented in Table 5-6. As with the younger infants, there exists no recommended food group pattern on which to assess adequacy. Mean usual intake of infants based on NHANES 2011–2012 was higher compared to other infants for red and orange vegetables and oils. Intakes of WIC participating infants were comparable to those of WIC-eligible nonparticipating infants when data were available.

Food Group Intakes of Children 1 to Less Than 2 Years of Age

As was the case for infants, the 2015 DGAC report does not include recommended food patterns for children 1 to less than 2 years of age. For this reason, mean usual food group and subgroup intakes for children of these ages are presented in Table 5-7 (intake distributions are presented in Appendix Q). Across population subgroups, intakes of vegetables, whole grains, and seafood are among the smallest (although seafood intake could be estimated for only one group). Intakes of total fruit, total vegetables (including all vegetable subgroups except “other”), total grains (including whole and refined), total protein (including nuts, seeds, and soy) were higher for WIC-eligible nonparticipating children compared to WIC participants. WIC participants consumed slightly more total dairy than non-WIC children. Other differences between these two subgroups of children were even smaller.

Children ages 1 to less than 2 years consumed similar amounts of solid fats. Intake of added sugars was greater for nonparticipating, low-income infants than both WIC participants and low-income children in the most recent survey (NHANES 2011–2012).

Food Group Intakes of Children 2 to Less Than 5 Years of Age

The percentage of food group and subgroup intakes for children ages 2 to less than 5 years compared to the 2015 DGAC report recommendations are presented in Table 5-8. (As with the other age groups, mean usual intakes and intake distributions are presented in Appendix Q.) Overall differences across subgroups of children were small, and no differences

TABLE 5-6 Mean Usual Food Group Intakes of Infants 6 to Less Than 12 Months, NHANES 2005–2008 and 2011–2012

NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available; oz-eq = ounce-equivalents; SE = standard error; wk = week. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

Population subgroup definitions are as follows:

^a WIC = All individuals reporting participation in WIC regardless of income level.

^b Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^c All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^d For all NA notations, the estimate could not be obtained because the Statistical Program for Age-adjusted Dietary Assessment (SPADE) requires more than two observations per group with two non-zero intakes in order to estimate a within-person variance.

^e Solid fat was considered equivalent to saturated fat in this analysis.

SOURCES: Intake data are from NHANES 2005–2008 and 2011–2012 (USDA/ARS, 2005–2008, 2011–2012). Reference values are the USDA food patterns from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (USDA/HHS, 2015).

TABLE 5-7 Mean Usual Food Group Intakes of Children 1 to Less Than 2 Years, NHANES 2005–2008 and 2011–2012

NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available; oz-eq = ounce-equivalents; SE = standard error; wk = week. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

Population subgroup definitions are as follows:

^a WIC = All individuals reporting participation in WIC regardless of income level.

^b Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^c All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^d For all NA notations, the estimate could not be obtained because the Statistical Program for Age-adjusted Dietary Assessment (SPADE) requires more than two observations per group with two non-zero intakes in order to estimate a within-person variance.

^e Solid fat was considered equivalent to saturated fat in this analysis.

SOURCES: Intake data are from NHANES 2005–2008 and 2011–2012 (USDA/ARS, 2005–2008, 2011–2012). Reference values are the USDA food patterns from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (USDA/HHS, 2015).

TABLE 5-8 Food Group Intakes Compared to the DGAC 2015 Report Recommendations, Children 2 to Less Than 5 Years, NHANES 2005–2008 and 2011–2012

NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available; oz-eq = ounce-equivalents; SE = standard error; wk = week. There were no statistically significant differences between WIC and eligible, non-WIC subgroups.

^a For all children 1 to less than 5 years of age, recommended intakes were generated by weighting the 1,000 and 1,300 (averaged from 1,200 and 1,400 kcal patterns) kcal food patterns in a 1:3 ratio following the methodology applied in IOM (2011). This results in a food pattern equivalent to approximately 1,225 kcals, slightly under the Estimated Equivalent Requirement for children 2 to 5 years of age of approximately 1,300 kcals. Therefore, the “% below recommendations” may be similarly underestimated.

Population subgroup definitions are as follows:

^b WIC = All individuals reporting participation in WIC regardless of income level.

^c Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^d All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^e Although all data here are compared to values presented in the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (2015 DGAC report), the Dietary Guidelines for Americans (DGA) in place at the time of the 2005–2008 NHANES survey (the 2005 DGA) did not include a red and orange vegetables subgroup.

^f For solid fats and added sugars, Recommended Intakes indicate an upper limit.

^g Solid fat was considered equivalent to saturated fat in this analysis.

SOURCES: Intake data are from NHANES 2005–2008 and 2011–2012 (USDA/ARS, 2005–2008, 2011–2012). Reference values are the USDA food patterns from the report of the 2015 DGAC report (USDA/HHS, 2015).

were statistically significant. Intakes were particularly poor (80 percent or more below recommended intakes across all three subgroups of children) for total vegetables (and, within total vegetables, dark green vegetables and red and orange vegetables), whole grains, and seafood. For all other food groups, with the exception of refined grains, 30 to 40 percent or more of children had intakes below recommended amounts. Intakes of added sugars and solid fats exceeded the recommendations across subgroups of children. Mean added sugars intake among WIC participating children was 14 tsp-eq per day, approximately five times the recommended limit for the 1,000–1,300 kcal weighted diet³ (approximately 3 tsp-eq per day). Mean solid fat intake for this group was 29 g-eq per day, or approximately 7 times that recommended for this calorie level.

EVALUATION OF DIET QUALITY

Two indexes of diet quality were estimated for all three NHANES subgroups: the Healthy Eating Index-2010 (HEI-2010) as requested by USDA-FNS, and a second index, the Nutrient-Based Dietary Quality (NBDQ) index, created by the committee. The basis for the NBDQ is described in Chapter 3 and, because the NDBQ is nutrient based, the results are described in Chapter 4. HEI-2010 values were generated following the method described in Guenther et al. (2014) and as described in Box 3-2 and Appendix K. As

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³ To evaluate the diets of all children 1 to less than 5 years of age, the committee applied a weighted food pattern (a 1,000 kcal pattern weighted 1:3 with the average of 1,200- and 1,400-kcal patterns [see Chapter 3 for details]).

noted in Chapter 3, because it is based on the Dietary Guidelines for Americans (DGA) food patterns, which apply only to individuals ages 2 and older, the HEI-2010 was applied only to individuals in this age range.

Mean scores for the HEI-2010 are presented in Tables 5-9 and 5-10. Mean scores are presented for each of the 12 components that make up the HEI-2010 as well for the overall index (total score). To provide context, maximum potential scores are presented in the second column. The maximum score for the index as a whole is 100, and maximum scores for the various components range from 5 to 20. In all cases, including dietary components that should be consumed in moderation (i.e., sodium, refined grains, and empty calories), a higher score reflects better diet quality.

Mean HEI-2010 Scores of Pregnant, Breastfeeding, and Postpartum Women

Mean total scores for all subgroups of women were well below the maximum possible score of 100. There were no statistically significant differences between WIC participant and eligible non-WIC participant subgroups (see Table 5-9). Overall, scores were lowest, relative to the maximum possible score, for greens and beans, whole grains, fatty acids (healthy fats), and empty calories. These results are consistent with the analysis of food group intakes reported earlier in this chapter and with findings from the USDA-FNS (2015) Diet Quality of Young American Children report (which also included an analysis of the HEI-2010 for women).

Mean HEI-2010 Scores of Children 2 to Less Than 5 Years of Age

Mean HEI-2010 scores for children 2 to less than 5 years of age are presented in Table 5-10. On average, children had higher total scores for the HEI-2010 than women (see Table 5-9). Mean total scores for WIC-participating children in the 2005–2008 NHANES surveys were 8 points higher than the scores observed for women (59.8 versus 51.9), although still well below the maximum score of 100. WIC participating children and income-eligible nonparticipant children in the NHANES 2005–2008 surveys had virtually identical mean scores for the HEI-2010 overall (total score) and for its 12 components. Scores were lowest, relative to the maximum possible score, for greens and beans, whole grains, fatty acids (healthy fats), total vegetables, and seafood and plant proteins. Differences in scores between WIC-participating children and eligible nonparticipating children were not significant.

These results are consistent with the analysis of food group intakes reported earlier in this chapter. The results are also generally consistent with findings from the USDA-FNS (2015) Diet Quality of Young American

TABLE 5-9 Summary of Mean HEI-2010 Scores for Women Ages 19-50 Years

NOTES: HEI = Healthy Eating Index; N = sample size; SE = standard error. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

Population subgroup definitions are as follows:

^a WIC = All individuals reporting participation in WIC regardless of income level.

^b Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^c All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^d Includes any beans and peas not counted as Total Protein Foods.

^e Includes 100% fruit juice.

^f Includes all forms except juice.

^g Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages.

^h Beans and peas are included here (and not with vegetables) when the Total Protein Foods standard is otherwise not met.

ⁱ Includes seafood, nuts, seeds, and soy products (other than beverages) as well as beans and peas counted as Total Protein Foods.

^j Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs).

^k Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol is more than 13 grams/1,000 kcal.

SOURCES: USDA/ARS, 2005–2008, 2011–2012, 2014.

TABLE 5-10 Summary of Mean HEI-2010 Scores for Children Ages 2 to Less Than 5 Years

NOTES: HEI = Healthy Eating Index; N = sample size; SE = standard error. There were no statistically significant differences between WIC and eligible non-WIC subgroups.

Population subgroup definitions are as follows:

^a WIC = All individuals reporting participation in WIC regardless of income level.

^b Eligible Non-WIC = Low-income individuals who did not report participation in WIC.

^c All Low-Income = All individuals at ≤ 185 percent of poverty. At the time of analysis, the WIC indicator was not available for NHANES 2011–2012. Thus, the “All Low-Income 2011–2012” group serves as a proxy for current intakes of this population.

^d Includes any beans and peas not counted as Total Protein Foods.

^e Includes 100% fruit juice.

^f Includes all forms except juice.

^g Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages.

^h Beans and peas are included here (and not with vegetables) when the Total Protein Foods standard is otherwise not met.

ⁱ Includes seafood, nuts, seeds, and soy products (other than beverages) as well as beans and peas counted as Total Protein Foods.

^j Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs).

^k Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol is more than 13 grams/1,000 kcal.

SOURCES: USDA/ARS, 2005–2008, 2011–2012, 2014.

Children report. However, there were differences between the committee’s analysis and the USDA-FNS (2015) report for some of the component scores. Specifically, the USDA-FNS (2015) analysis found that WIC-participating children had significantly higher scores than WIC-eligible nonparticipant children for all three of the dietary components that should be consumed in moderation: sodium, refined grains, and empty calories. In the committee’s analysis, there were no significant differences between WIC children and income-eligible nonparticipant children for these components.⁴ One potential reason for the discrepant findings (both analyses are based on 2005–2008 NHANES data) is that the USDA-FNS results were age adjusted to account for differences in the age distribution of WIC participants and nonparticipants. The analysis conducted by the committee was not age adjusted. In addition, the food patterns databases applied were different between the USDA-FNS’s and the committee’s approach.

Similar to the pattern observed for pregnant, breastfeeding, and postpartum women, low-income children in the 2011–2012 NHANES survey had a notably higher total score on the HEI-2010 than either subgroup of children in the 2005–2008 NHANES surveys (62.0 versus 59.8). Differences for the component scores were mixed (some were higher in 2011–2012 and some were lower), but the main contributors to the higher total score in 2011–2012 were higher scores for fatty acids (healthy fats), whole grains, sodium, and empty calories.

CONSIDERATIONS FOR DATA INTERPRETATION

The committee recognized several potential limitations to interpreting the data presented in this chapter. Since the Institute of Medicine (2006) report, there has been only limited national-level work evaluating the food intake patterns of infants up to 24 months of age. The two nationally representative surveys summarized here (IFPS II and FITS 2008) were completed 8 or more years ago and may not adequately reflect current feeding practices. As noted previously, the committee anticipates that results of the WIC Infant and Toddler Feeding Practices Study will be available in phase II (Harrison, 2014).

Limitations to the nutrient intake analyses that were discussed in Chapter 4 are also applicable to the food intake analyses of NHANES data presented here. In addition, the food intake data include many zeros in a reported day’s intake and this feature of the data requires appropriate methods that account for the zero intakes in estimating the intake distributions (see Chapter 3). The sample sizes are smaller across population subgroups

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⁴ Although not reported in Table 5-10, tests of statistical significance were conducted for these comparisons.

in the food intake analysis compared to those for nutrient intake because (due to software requirements) individuals included in the sample must have 2 days of reported intake to estimate usual intakes of foods (reported intake could be zero on one or both days). In some cases, this results in sample sizes that are quite small. For example, the 2011–2012 low-income population subgroup of women includes only 29 individuals. The only software that does not require equal number of observations per person is the NCI software, but it failed to converge in several cases in these analyses.

In this report, a population-weighted approach was applied using SPADE. An alternative, simplified approach was applied in the Letter Report (IOM, 2015) to compare intake to recommendations. Also, in the Letter Report, PC Software for Intake Distribution (PC-SIDE) and the Iowa State University method were used instead of SPADE, and for different sample years and respondent selection criteria, so mean intakes and the comparisons to recommended intakes differ between the Letter Report and the analyses presented here.

Overall, comparisons to recommended food patterns presented in this report are similar to those in other studies. Most recently, Krebs-Smith et al. (2010) applied an approach similar to that used here to compare intakes to federal dietary recommendations using 2001–2004 NHANES data. Although the food groups were categorized differently then, most individuals in the U.S. population did not meet the recommended intakes for any food group except “total grains” and “meat and beans.” As the committee found in its analysis, energy intake from solid (saturated) fats and added sugars was excessive. Similar to the findings in this report and those of Krebs-Smith et al., (2010), the 2015 DGAC report indicated overall poor intakes of food groups that supply important nutrients.

The reliability and consistency of the HEI-2010 has been validated for prediction of diet quality (Guenther et al., 2014); however, the index has a few limitations. Consumers of beans and peas may have lower scores for “seafood and plant proteins” or “total vegetables” because the beans and peas are counted toward other groups first, then any “leftover” is counted as contributing to these groups. The HEI-2010 also does not account for physical activity or the appropriateness of energy intake. Therefore, an individual who consumes too much energy may have higher HEI scores than one consuming an appropriate level of energy but whom, as a result, has difficulty meeting the recommended food pattern. For example, individuals over the age of 8 with energy needs less than 1,600 kcal will have difficulty meeting nutrient requirements (Guenther et al., 2014). Although consuming DGA 2010 food patterns would result in a perfect score, the food patterns do not actually provide the recommended amounts of vitamins D or E, or potassium or choline (Guenther et al., 2014). The HEI-2010 does provide a validated way to compare diet quality across population groups.

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