Review of WIC Food Packages Improving Balance and Choice: Final Report (2017) / Chapter Skim
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4 Nutrient and Food Group Intakes of WIC Participants
4 Nutrient and Food Group Intakes of WIC Participants
Pages 157-214
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From page 157... ...
The chapter concludes with a summary of findings from the committee's evaluation. A description of how the committee applied this information to determine priorities for changes to the food packages is presented in Chapter 5.
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158 REVIEW OF WIC FOOD PACKAGES TABLE 4-1 Selected Nutrition-Related Health Risks Relevant to the WIC Population Nutrient or Food Component Associated Health Concern by WIC Subgroup Reference Iron Women: Iron deficiency and iron-deficiency IOM, 2001; AND, anemia are associated with fatigue, weakness, 2014; AHRQ, 2015 and tachycardia; risk of preterm labor, low body weight, and infant mortality are increased; maternal iron status is associated with iron status of the infant Infants: Breastfed infants older than 6 months of IOM, 2006; AAP, age are at risk of low iron intake 2014 Children: Iron is important for growth and AAP, 2014; Berglund cognitive development and Domellöf, 2014 Zinc Infants: Breastfed infants older than 6 months of IOM, 2006; Krebs age are at risk of low zinc intake; risk of intake et al., 2006; AAP, above the UL from formula or foods 2014 Folate Women: Inadequate folate intake can cause birth CDC, 2010a; defects including neural tube defects; may be Williams et al., 2015 particularly important for Hispanic women who consume nonfortified corn masa flour Vitamin D Women and infants: Low serum 25(OH) D has been IOM, 2011; inconsistently associated with several pregnancy AHRQ, 2014 and birth outcomes; vitamin D is important for calcium homeostasis and bone health in infants Choline Women and infants: Low maternal choline intake is Zeisel, 2013 associated with the risk of neural tube defects and orofacial cleft in infants Omega-3 Infants: Omega-3 fatty acid supplementation may AHRQ, 2016 fatty acids be associated with increased visual acuity Food Women (of reproductive age)
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. The review focused on health risks of population groups relevant to the WIC program that are not covered comprehensively in the DGA, namely pregnant women, breastfeeding women, infants, and children less than 2 years of age.
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Nutrient Intakes of WIC Participants Before and After the 2009 Food Package Changes As part of its first step toward evaluating whether the food packages meet the three criteria outlined in the introduction of this chapter, the committee evaluated the scientific literature and reports on nutrient intakes
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The committee identified three reports comparing nutrient intakes by infants or children before versus after the 2009 WIC food package revisions (see Table 4-3)
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SOURCES: As noted in the Reference column. Food Group Intakes of Women and Children Participating in WIC The Effect of the 2009 Food Package Revisions on Food Group Intakes Except for studies on breastfeeding, data characterizing the effect of the 2009 WIC food package changes on participants' food intake or health are sparse.
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data, two repeated cross- consumption of whole milk sections before and after revisions Whaley et al., California, approximately 3,000 Telephone surveys of randomly Increases in consumption of fruits, vegetables, 2012 pregnant or postpartum women sampled WIC families in September and whole grains and increased consumption and caregivers of children 2009 and March 2010 of reduced-fat milk, decreased consumption of whole milk Meiqari et al., Atlanta, Georgia, African- Questionnaires before package Children, but not mothers, significantly increased 2015 American mothers and eldest changes and 1 and 4 weeks after their intake of low-fat milk child, 46 children and 38 mothers 163 SOURCES: As noted in the Reference column.
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After its own independent review, the committee likewise concluded that the 2009 food package changes likely had some positive effects on intake. The Effect of Racial and Ethnic Differences on Food Purchasing and Consumption Among WIC Participants Findings from several reports 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; Di Noia et al., 2016)
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Some of the changes in the food packages, such as not issuing complementary foods before an infant reached 6 months of age, have the potential to affect some of these areas of concern. ANALYSIS OF THE NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY DATA: NUTRIENT ADEQUACY As a second step toward assessing the adequacy of nutrient and food intakes of the WIC-eligible population, the committee estimated nutrient intake adequacy based on recommended Dietary Reference Intakes (DRIs)
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. Full details on the methodology applied are described in Appendix J, and a description of the portion of data presented in this chapter can be found below in the section titled, "Nutrient and Food Group Intake Data Presented in This Chapter." This section highlights the following: • The committee's rationale for including in this chapter only nutri ent and food intake data for WIC participants after the 2009 food package changes (other results are available in Appendix J)
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For other subgroups, results presented in this chapter are limited to nutrient intakes after the 2009 food package changes (that is, NHANES 2011–2012 data) because any detected differences before and after 2009 cannot necessarily be attributed to changes in the food packages.
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Breastmilk intakes were not quantified for infants coded as breastfed, which posed a challenge for assessment of total nutrient intakes for these infants. Given that iron and zinc intakes are a concern for breastfed infants over 6 months of age, the committee analyzed intakes of these nutrients only for infants coded as breastfed.
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for both WIC and WIC-eligible subgroups, are available in Appendix J Challenges with Dietary Intake Assessment of Pregnant and Breastfeeding Women For this report, nutrient intakes of all women coded as "pregnant" in NHANES were compared to the DRIs for pregnant women and to a 2,600kcal food pattern.8 This corresponds to the energy needs of a pregnant woman in the second trimester of pregnancy and, thus, overestimates the needs of some pregnant women and underestimates the needs of others.
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, the prevalence of dietary nutrient inadequacy is the estimated proportion of reported intakes below the Estimated Average Requirement (EAR) ; the prevalence of excessive intakes9 is the estimated proportion of the population with intakes above the Tolerable Upper Intake Level (UL)
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14.3 (12.3) NOTES: αTOC = α-tocopherol; DFE = dietary folate equivalents; EAR = Estimated Average Requirement; N = sample size; RAE = retinol activity equivalents; SE = standard error.
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Approximately 68 to 78 percent of women had intakes of added sugars above recommended limits, whereas 50 to 79 percent of women had intakes of saturated fat above recommended limits. Mean reported energy intake was below the median Estimated Energy Requirement (EER)
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f Tsp-eq and gram limits shown for added sugars and saturated fat, respectively, are based on energy intakes of 2,600 (pregnant and breastfeeding) and 2,300 (postpartum)
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2,379 (33) Food pattern applied in the report 2,600 2,600 2,300 Usual Energy Intake Median 2,333 (67)
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) and also the current age categories for the WIC food packages for infants (see Chapter 1, Tables 1-2 and 1-3)
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138 (5) NOTES: αTOC = α-tocopherol; AI = Adequate Intake; DFE = dietary folate equivalents; EAR = Estimated Average Requirement; N = sample size; RAE = retinol activity equivalents; SE = standard error.
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SOURCES: IOM, 2002/2005; USDA/ARS, 2011–2012. TABLE 4-13 Estimated Energy Requirement and Reported Energy Intake, Formula-Fed, WIC-Participating Infants 0 to 12 Months of Age, NHANES 2011–2012 Mean kcal/d (SE)
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is published, and therefore the basis for evaluation of intakes is limited. As noted above, fiber, saturated fat, and added sugars were not evaluated for infants.
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Evaluation of Energy and Iron Provided in the WIC Food Packages for Fully Formula-Fed Infants Formula-fed infants ages 0 to 3 months of age receive 806 fluid ounces per month (537 kcal per day) as the full nutrition benefit11 or, if the powder form is provided, 870 fluid ounces as the maximum monthly allowance (MMA)
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Mean usual energy intakes and the corresponding EER values are presented in Table 4-20. Estimated mean energy intake of children participating
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4–5 6–11 FNBb fl oz/month 806 870g 884 624 FNB, formula onlyc kcal/d 537 580 589 416 FNB, formulab + foodsd kcal/d NA NA NA 583 median EERe kcal/d 617h 617h 617h 727i % of EER in the food package, % 87 94 96 57 formula only % of EER in the food package, % NA NA NA 23 food only % of EER in the food package, % NA NA NA 80 formula + foods Iron provided in FNB of mg/d 9.5 10.4 10.5 7.4 formulaf DRI Values AI or EAR for iron mg/d 0.27j 0.27j 0.27j 6.9k UL for iron mg/d 40 40 40 40 NOTES: AI = Adequate Intake Level; DRI = Dietary Reference Intake; EAR = Estimated Average Requirement; EER = Estimated Energy Requirement; FNB = full nutrition benefit; NA = not applicable; UL = Tolerable Upper Intake Level. a Unless otherwise indicated.
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0 Vitamin B12 0.7 mg 0.02 (0.06) 0 NOTES: αTOC = α-tocopherol; DFE = dietary folate equivalents; EAR = Estimated Average Requirement; N = sample size; RAE = retinol activity equivalents; SE = standard error.
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. Micronutrient Excess Among WIC-participating children 1 to less than 2 years of age, the prevalence of nutrient intakes exceeding the UL was more than 5 percent for sodium, zinc, copper, and retinol (see Table 4-21)
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Tsp-eq and gram limits shown for added sugars and saturated fat, respectively, are based on an energy intake of 1,300 kcal. The percent above 10 percent of energy is based on the limits corresponding to the actual energy intake reported.
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1,532 (9) Usual Energy Intake Median 1,284 (26)
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NOTES: N = sample size; SE = standard error; UL = Tolerable Upper Intake Level.
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Because dietary intakes were evaluated relative to the DGA food patterns, which are available only for adults and children 2 years of age and older, the committee's analysis of food intake by infants was limited to an assessment of intake of "meat, poultry, and seafood" (as a key source of the key nutrients iron and zinc) among older breastfed infants.
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15 Calories for other uses (COU) includes added sugars, added refined starches, solid fats, alcohol, or calories from consuming more than the recommended amount of food in a food group (USDA/HHS, 2016)
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70.4 (11.8) Added sugars <15.5/13.7 tsp-eq/dd 68.3 (5.1)
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Food Group Intake of Children Ages 1 to Less Than 2 Years Participating in WIC As was the case for infants, the DGA do not include recommended food patterns for children 1 to less than 2 years of age. Inasmuch as there is no comparator for adequacy, mean usual food group and subgroup intakes for children of these ages are presented in Table 4-26.
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The prevalence of excess intake was greater than 75 percent for added sugars and solid fats. Only intakes of total fruit and whole fruit; total grains; refined grains; and meat, poultry, and eggs met or exceeded the DGA recommended amounts in more than 50 percent of these children.
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Added sugars tsp-eq/d 9.59 (0.67) NOTES: c-eq = cup-equivalents; d = day; g-eq = gram-equivalents; N = sample size; NA = data not available because an inadequate number of individuals reported intake; oz-eq = ounce-equivalents; SE = standard error; tsp-eq = teaspoon-equivalents; wk = week.
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c Limits for solid fats and added sugars are based on an upper limit of 10 percent of energy for the 1,300-kcal food pattern.
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QUALITY OF WIC PARTICIPANTS' DIETS The committee was tasked with applying two different indexes to evaluate the diet quality of WIC participants: the healthy eating index–2010 (HEI–2010) and a second index of the committee's choosing.
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. h Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol is more than 13 grams/1,000 kcal.
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. h Calories from solid fats and added sugars.
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Evaluating WIC-Specific Data: The Challenge of Selection Bias Since the creation of the WIC program, it has been difficult to evaluate the effect of participation on any outcome. Because random assignment of individuals to study groups that either receive or do not receive WIC benefits is not considered ethical, experimental study design options suitable for causal inference are limited (e.g., random assignment of a WIC service area, delayed start of a new benefit)
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Nearly all studies reviewed for this report either compare WIC participants to a group of nonparticipants or compare WIC participation before and after the 2009 food package changes. The study designs for these comparisons are not only insufficient for causal inference, but they are likely also confounded by factors that result in the decision to participate in WIC.
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Strengths and Limitations of NHANES Data for This Analysis NHANES is the most comprehensive source of national survey data of individuals with information on both food intake and WIC participation 17 Propensity score matching controls for observed confounding variables that are included in the analysis. It does not address differences in observed factors that are not included nor unobservable factors that cannot be accounted for (Cook et al., 2008; Steiner et al., 2010)
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For example, the numbers of pregnant, breastfeeding, or postpartum women who are captured in NHANES are relatively small and the number eligible for and served by WIC is smaller still. Major challenges that were experienced by the committee included small sample sizes for some subgroups of the WIC population, limitations imposed by combining NHANES samples, inaccurate reporting of WIC participation and household income as well as caveats to interpreting micronutrient adequacy, energy intake, food intake, and diet quality.
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Reported WIC participation by these women may indicate instead that they have a child who is receiving WIC benefits. Income Reporting Identifying which low-income individuals in NHANES are eligible for WIC poses another challenge.
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. Estimating Energy Requirements and Energy Intake The Estimated Energy Requirements (EERs)
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Estimating Food Intake The sample sizes were smaller in the food intake analysis compared to those for nutrient intake. For example, the sample size for pregnant women was 165 for nutrient intake and 139 for intake of food groups.
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In addition, intakes of iron and zinc, as well as several B vitamins, were below recommended amounts in more than 5 percent of subgroups of women. Saturated fat, sodium, and added sugars intakes exceeded recommended amounts in a high proportion of WIC-participating subgroups, again in accordance with what was reported in the 2015–2020 DGA for the overall U.S.
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However, as discussed earlier in this chapter, the committee found it impossible to use NHANES data to link pre- versus post-2009 nutrient and food intake differences to changes in the WIC food packages. Considerations for the Design of Studies to Evaluate Effects of the WIC Food Packages In Appendix K, the committee proposes study designs that would facilitate evaluation of the effects of the WIC program on various outcomes.
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For example, a pilot study in which the CVV for children is increased and effects on child retention are evaluated; or USDA allowing an agency or state to match clinics on demographics and breastfeeding rates and then randomly assign clinics to implement various models of breastfeeding support. If testing of the food packages in this way is prohibited, providing a waiver to states allowing design of the food packages in the first 30 days would provide information about whether the choice to breastfeed is influenced by the food package.
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In some cases, these excessive intakes may be addressed with changes to the food packages. • Diet quality as measured by the HEI–2010 was similar to HEI– 2010 results for the total U.S.
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nutritional surveillance: National Health and Nutrition Examination Survey caloric energy intake data, 1971– 2010.
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1997. Dietary meth ods research in NHANES III: Under-reporting of energy intake.
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2014. The Healthy Eating Index-2010 is a valid and reliable measure of diet quality according to the 2010 Dietary Guidelines for Americans.
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2013. The effect of revised WIC food packages on Native American children.
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2016. Review of WIC food packages: Proposed framework for revisions: Interim report.
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: Revisions in the WIC food packages; Final Rule, 7 C.F.R.
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2012. Revised WIC food pack age improves diets of WIC families.
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