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i WIC Nutrition Risk Criteria: A Scientific Assessment Committee on Scientific Evaluation of WIC Nutrition Risk Criteria Food and Nutrition Board INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996
ii NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sci- ences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertain- ing to the health of the public. In this, the Institute acts under both the Academy's 1863 congres- sional charter responsibility to be an adviser to the federal government and its own initiative in iden- tifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Insti- tute of Medicine. This study was supported under contract no. 59-3198-3-044 from the Food and Nutrition Ser- vice, U.S. Department of Agriculture. Library of Congress Catalog Card No. 95-72317 International Standard Book Number 0-309-05385-4 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Wash- ington, D.C. metropolitan area) or visit the online bookstore at http://www.nas.edu/nap/online/. Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Insti- tute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
iii Committee On Scientific Evaluation Of Wic Nutrition Risk Criteria RICHARD E. BEHRMAN (Chair),* Center for the Future of Children, David and Lucile Packard Foundation, Los Altos, California BARBARA ABRAMS, School of Public Health, University of California, Berkeley A. SUE BROWN (through February 1995), Commission on Health Care Finance, Government of the District of Columbia, Washington, D.C. MARY ELLEN COLLINS, Brigham and Women's Hospital, Boston, Massachusetts CATHERINE COWELL, School of Public Health, Columbia University, New York, New York BARBARA DEVANEY, Mathematica Policy Research, Inc., Plainsboro, New Jersey LEON GORDIS,* School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland JEAN-PIERRE HABICHT, Division of Nutritional Sciences, Cornell University, Ithaca, New York K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver GAIL G. HARRISON, School of Public Health, University of California, Los Angeles JEAN YAVIS JONES, Congressional Research Service, Library of Congress, Washington, D.C. ROY M. PITKIN,* School of Medicine, University of California, Los Angeles ERNESTO POLLITT, Department of Pediatrics, University of California, Davis KATHLEEN M. RASMUSSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York EARNESTINE WILLIS, MACC Fund Research Center and Department of Pediatrics, Medical College of Wisconsin, Milwaukee Staff ROBERT EARL, Study Director (through November 1995) CAROL WEST SUITOR, Study Director (beginning November 1995) SANDRA A. SCHLICKER, Senior Program Officer (beginning November 1995) SHEILA A. MOATS, Research Associate KIMBERLY M. BREWER, Research Assistant (beginning September 1995) GERALDINE KENNEDO, Project Assistant * Member, Institute of Medicine
iv Food And Nutrition Board CUTBERTO GARZA (Chair), Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois, Urbana PERRY L. ADKISSON, â Department of Entomology, Texas A&M University, College Station LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis DENNIS M. BIER, USDA Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas FERGUS M. CLYDESDALE, Department of Food Science and Nutrition, University of Massachusetts, Amherst MICHAEL P. DOYLE, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver JANET C. KING, * USDA Western Human Nutrition Research Center, Presidio of San Francisco, California SANFORD A. MILLER, Graduate Studies and Biological Sciences, University of Texas Health Science Center, San Antonio ALFRED SOMMER, * School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland STEVE L. TAYLOR (Ex officio), Food Processing Center, University of Nebraska, Lincoln VERNON R. YOUNG,â Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge * Member, Institute of Medicine â Member, National Academy of Sciences
v Staff ALLISON A. YATES, Director (beginning July 1994) CATHERINE E. WOTEKI, Director (through December 1993) BERNADETTE M. MARRIOTT, Associate Director and Interim Director (through June 30, 1994) GAIL SPEARS, Administrative Assistant (beginning September 1994) MARCIA S. LEWIS, Administrative Assistant (through August 1994) JAMAINE L. TINKER, Financial Associate
ACKNOWLEDGMENTS vii Acknowledgments This report represents the collaborative efforts of many individuals, particularly the study committee and staff whose names appear at the beginning of this document. Completion of this study was a complex task and it required substantial dedication and effort by all those who participated in its completion. The committee wishes to acknowledge the assistance of the National Association of WIC Directors (NAWD) for furnishing volumes of information about nutrition risk criteria in use in state WIC programs. NAWD's president during the majority of the study, Alice Lenihan, was particularly helpful and supportive. The committee wants to express their appreciation of the input received from the entire WIC community, too numerous to mention by name, through public meetings, site visits, additional information about nutrition risk criteria, and informal communications. Drs. Robert Kuczmarski and Anne Looker of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, made presentations to the committee on upcoming data from the third National Health and Nutrition Examination Survey and revision of NCHS infant and child growth charts. Dr. Tiefu Shen of the Division of Nutritional Sciences, Cornell University, and Cyn O'Malley and Suzan Carmichael of the School of Public Health, University of California, Berkeley, provided substantial assistance with the development of the chapter on anthropometric risk criteria. This report was sponsored by the Food and Consumer Service, U.S. Department of Agriculture (USDA). Without their vision for the need to undertake this scientific assessment, this report would not have become a reality. The committee acknowledges their commitment to the WIC program
ACKNOWLEDGMENTS viii and their support of this project, particularly the support of project officers Jay Hirschman and Dr. Janet Tognetti Schiller. In addition, the committee recognizes other major informational contributions of several USDA staff: Donna Hines, Julie Kresge, Michele Lawler, Elaine Lynn, and Debra Whitford. The committee also wishes to express its appreciation to the staff of the Food and Nutrition Board of the Institute of Medicine, whose tireless efforts on our behalf were so critical to the committee's deliberations and the production of this report. Our appreciation goes to Robert Earl, who provided administrative support to the committee. The committee is especially grateful for the substantial efforts of Dr. Carol Suitor, who, with the assistance of Dr. Sandra Schlicker and Kim Brewer, worked closely with committee members to complete the analysis and finalize the report. The efforts of Sheila Moats, Geraldine Kennedo, Susan Knasiak, and Dr. Allison Yates on behalf of the committee are also deserving of our heartfelt thanks. RICHARD E. BEHRMAN, Chair Committee on Scientific Evaluation of WIC Nutrition Risk Criteria
CONTENTS ix Contents SUMMARY 1 Committee Process and Structure of the Report 3 Principles of Nutrition Risk Assessment 5 General Conclusions 7 Recommendations for Specific Nutrition Risk Criteria 9 Recommendations for Future Research and Action 20 1 OVERVIEW 23 Charge to the Committee 24 The WIC Program 25 Overview of the Report and the Committee Process 34 References 38 2 POVERTY AND NUTRITION RISK 41 Definition of Poverty 41 Prevalence of Poverty 43 Poverty and Nutrition Risk for Women 43 Poverty and Nutrition Risk for Infants and Children 45 Effects of WIC Program Participation 47 References 49 3 PRINCIPLES UNDERLYING THE NUTRITION RISK CRITE- 53 RIA FOR WIC ELIGIBILITY Principles of Nutrition Risk Assessment 53
CONTENTS x WIC Nutrition Risk Criteria 60 Priority System of the WIC Program 60 Summary and Implications 63 References 65 4 ANTHROPOMETRIC RISK CRITERIA 67 Use of Anthropometric Measures in the WIC Program 67 Maternal Anthropometric Risk Criteria 70 Prepregnancy Underweight 70 Low Maternal Weight Gain 73 Maternal Weight Loss During Pregnancy 79 Prepregnancy Overweight 80 High Gestational Weight Gain 84 Maternal Short Stature 87 Postpartum Underweight 89 Postpartum Overweight 92 Abnormal Postpartum Weight Change 96 Anthropometric Risk Criteria for Infants and Children 97 Low Birth Weight 97 Small for Gestational Age 100 Short Stature 104 Underweight 110 Low Head Circumference 114 Large for Gestational Age 117 Overweight 118 Slow Growth 123 Summary and Conclusions 125 References 128 5 BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 149 Criteria Related to Nutrient Deficiencies 154 Anemia 154 Failure to Thrive and Other Nutrient Deficiency Disease 159 Medical Conditions Applicable to the Entire WIC Population 166 Gastrointestinal Disorders 166 Diabetes Mellitus 169 Thyroid Disorders 170 Chronic Hypertension 172 Renal Disease 174 Cancer 175 Central Nervous System Disorders 177 Genetic and Congenital Disorders 179
CONTENTS xi Inborn Errors of Metabolism 181 Chronic or Recurrent Infections 183 HIV Infection and AIDS 185 Recent Major Surgery, Trauma, Burns, or Severe Acute Infec- 188 tions Other Medical Conditions 190 Conditions Related to the Intake of Specific Foods 192 Food Allergies 192 Food Intolerances 194 Conditions Specific to Pregnancy 195 Pregnancy at a Young Age 195 Pregnancy Age Older Than 35 Years 197 Closely Spaced Pregnancies 197 High Parity 200 History of Preterm Delivery 204 History of Postterm Delivery 206 History of Low Birth Weight 206 History of Neonatal Loss 207 History of Previous Birth of an Infant with a Congenital or 207 Birth Defect Lack of Prenatal Care 208 Multifetal Gestation 210 Fetal Growth Restriction 211 Preeclampsia and Eclampsia 213 Placental Abnormalities 214 Conditions Specific to Infants and/or Children 215 Prematurity 215 Hypoglycemia 217 Potentially Toxic Substances 218 Long-Term Drug-Nutrient Interactions or Misuse of Medica- 218 tions Maternal Smoking 220 Alcohol and Illegal Drug Use 226 Lead Poisoning 229 Summary 232 References 233 6 DIETARY RISK CRITERIA 251 Inappropriate Dietary Patterns 253 Dietary Patterns That Fail to Meet Dietary Guidelines for 253 Americans Vegetarian Diets 259 Highly Restrictive Diets 260
CONTENTS xii Inappropriate Infant Feeding 261 Inappropriate Use of Nursing Bottle 265 Inappropriate Diets in Children 268 Excessive Caffeine Intake 269 Pica 270 Inadequate Diet 272 Food Insecurity 279 Definition of Food Insecurity 279 Summary 283 References 283 7 PREDISPOSING NUTRITION RISK CRITERIA 295 Homelessness 297 Migrancy 304 Passive Smoking 309 Low Level of Maternal Education and Illiteracy 311 Maternal Depression 314 Battering 317 Child Abuse or Neglect 319 Child of a Young Caregiver 321 Child of a Mentally Retarded Parent 323 Summary 325 References 325 8 CONCLUSIONS AND RECOMMENDATIONS 335 General Conclusions 336 Recommendations for Specific Nutrition Risk Criteria 337 Recommendations for Future Research and Action 350 APPENDIXES A Participants at the First Public Meeting, May 19, 1994 353 B Participants at the Second Public Meeting, September 19â20, 1994 355 C WIC Program: Common Nutritional Risk Criteria 357 D Definitions of Yield and Sensitivity of Cutoff Points for Nutrition 359 Risk E Biographical Sketches 361 ACRONYMS 371 INDEX OF RISK CRITERIA 373
CONTENTS xiii List of Tables and Figures TABLES S-1 Nutrition Risk Criteria and Committee Recommendations 10 for the Specific WIC Population, by Category of Nutri- tion Risk, 1-1 WIC Program Participation by Subgroup and Federal Costs, 35 1974â1993, 3-1 Nutrition Risk Criteria Defined by WIC Program Regula- 61 tions, 3-2 The WIC Priority System, 62 4-1 Summary of Anthropometric Risk Criteria in the WIC Pro- 68 gram and Use by States, 4-2 Summary of Anthropometric Risk Criteria as Predictive of 70 Risk or Benefit Among Pregnant and Postpartum Women, 4-3 Summary of Anthropometric Risk Criteria as Predictive of 98 Risk or Benefit Among Infants and Children, 4-4 Summary of Anthropometric Risk Criteria and Committee 126 Recommendations for the Specific WIC Population, 5-1 Summary of Biochemical and Other Medical Risk Criteria 150 in the WIC Program and Use by States, 5-2 Summary of Broad Categories of Biochemical and Other 153 Medical Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children, 5-3 Cutoff Points for Anemia Used in the WIC Program and 158 Recommended Cutoff Points from the Centers for Dis- ease Control and Prevention and the Institute of Medicine for Women, Infants, and Children, 5-4 Summary of Medical Risk Criteria and Committee Recom- 160 mendations for the Specific WIC Population,
CONTENTS xiv 6-1 Summary of Broad Dietary Risk Criteria in the WIC Pro- 252 gram and Use by States, 6-2 Summary of Broad Dietary Risk Criteria as Predictive of 253 Risk or Benefit Among Women, Infants, and Children, 6-3 Summary of Broad Dietary Risk Criteria and Committee 266 Recommendations for the Specific WIC Population, 7-1 Summary of Predisposing Risk Criteria in the WIC Program 296 and Use by States, 7-2 Summary of Predisposing Risk Criteria as Predictive of Risk 297 or Benefit Among Women, Infants, and Children, 7-3 Summary of Dietary Risk Criteria and Committee Recom- 298 mendations for the Specific WIC Population, 8-1 Nutrition of Risk Criteria and Committee Recommendations 338 for the Specific WIC Population, by Category of Nutri- tion Risk, 8-2 Committee Recommendations for Changes in Risk Criteria, 347 FIGURES S-1 WIC program components, services, benefits, and projected 2 outcomes, 1-1 WIC program components, services, benefits, and projected 26 outcomes,