Framework for Dietary Risk Assessment in the

WIC Program: Interim Report

__________________________________________________________________________________

Committee on Dietary Risk Assessment in the WIC Program

Food and Nutrition Board

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS

Washington, D.C.
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v

COMMITTEE ON DIETARY RISK ASSESSMENT IN THE WIC PROGRAM

VIRGINIA A. STALLINGS (Chair), Division of Gastroenterology and Nutrition, The

Children’s Hospital of Philadelphia, Pennsylvania

TOM BARANOWSKI, Department of Pediatrics, Baylor College of Medicine, Houston, Texas

YVONNE BRONNER, Masters of Public Health and Doctor of Public Health Program, Morgan

State University, Baltimore, Maryland

LAURA E. CAULFIELD, Division of Human Nutrition, Johns Hopkins University, Baltimore,

Maryland

EZRA C. DAVIDSON, JR., Primary Care, Charles R. Drew University of Medicine and

Science, Los Angeles, California

THERESA O. SCHOLL, Department of Obstetrics and Gynecology, University of Medicine

and Dentistry of New Jersey, Stratford

CAROL W. SUITOR, Nutrition Consultant, Northfield, Vermont

ROBERT C. WHITAKER, Division of General and Community Pediatrics, Children’s

Hospital Medical Center, Cincinnati, Ohio

Staff

Romy Gunter-Nathan, Study Director

Kimberly Freitag, Research Assistant

Shelley Goldberg, Senior Project Assistant

Geraldine Kennedo, Project Assistant
vi

FOOD AND NUTRITION BOARD

CUTBERTO GARZA (Chair), Division of Nutritional Science, Cornell University, Ithaca,

New York

ALFRED H. MERRILL, JR. (Vice Chair), Center for Nutrition and Health Sciences, Emory

University, Atlanta, Georgia

ROBERT M. RUSSELL (Vice Chair), Jean Mayer U.S. Department of Agriculture Human

Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts

VIRGINIA A. STALLINGS (Vice Chair), Division of Gastroenterology and Nutrition, The

Children’s Hospital of Philadelphia, Pennsylvania

LARRY R. BEUCHAT, Center for Food Safety and Quality Enhancement, University of

Georgia, Griffin

BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins School of Hygiene

and Public Health, Baltimore, Maryland

FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts at

Amherst

ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville

SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical

Center at Dallas

SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of

Pennsylvania, Philadelphia

LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action

Center, Washington, D.C.

ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research

Center, Seattle, Washington

A. CATHARINE ROSS, Department of Nutrition, The Pennsylvania State University,

University Park

ROBERT E. SMITH, R.E. Smith Consulting, Inc., Newport, Vermont

STEVE L. TAYLOR, Food Processing Center, University of Nebraska-Lincoln

Staff

Allison A. Yates, Director

Gail E. Spears, Administrative Assistant

Gary Walker, Financial Associate
vii

Acknowledgments

Many individuals volunteered significant time and effort to address and educate the

committee at its workshop and public meeting. Workshop speakers included Jean Anliker, Ph.D.,

R.D. of the University of Maryland; Valerie Tarasuk, Ph.D. of the University of Toronto;

Cutberto Garza, M.D., Ph.D. of Cornell University; Kristin Marcoe, M.B.A., R.D. of the United

States Department of Agriculture; Amy Subar, Ph.D., M.P.H., R.D. of the National Cancer

Institute; Gladys Block, Ph.D. of the University of California, Berkeley; Graham Colditz, M.D.,

Dr.P.H. of Harvard University; Anna Maria Siega-Riz, Ph.D. of the University of North

Carolina; Jill Leppert of the North Dakota State Department of Health; Amanda Watkins, M.S.,

R.D. of the Arizona Department of Health Services; Ann Barone of the Rhode Island Department

of Health; Carol Rankin, M.S., R.D., L.D. of the Mississippi Department of Health; Bob

Greenstein of the Center on Budget and Policy Priorities, Washington, D.C.; and Lynn Parker of

the Food Research and Action Center, Washington, D.C.

In addition, the following organizations provided oral testimony to the committee during

its public meeting: National Association of WIC Directors and the Food and Nutrition Service,

United States Department of Agriculture.

The report was also reviewed in draft form by individuals chosen for their diverse

perspectives and technical expertise, in accordance with procedures approved by the NRC’s

Report Review Committee. The purpose of this independent review is to provide candid and

critical comments that will assist the institution in making its published report as sound as

possible and to ensure that the report meets institutional standards for objectivity, evidence, and

responsiveness to the study charge. The review comments and draft manuscript remain

confidential to protect the integrity of the deliberative process. We wish to thank the following

individuals for their review of this report: Janet Allen, M.A., R.D., North Central Florida

Maternal & Infant Care Project, WIC; Barbara A. Dennison, M.D., Associate Professor of

Clinical Pediatrics, Columbia University and Attending Pediatrician and Research Scientist,

Research Institute, Bassett Healthcare; Dr. Bernard Dreyer, Associate Chair of Pediatrics,

Department of Pediatrics, New York University and Bellevue Hospital Center; Gail G. Harrison,

Ph.D., Professor and Chair, Department of Public Health and Community Health Science, UCLA

Center for Human Nutrition; Maxine Hayes, M.D., M.P.H., Assistant Secretary of Community &

Family Health, Washington State Department of Health and University of Washington School of

Medicine; and Michele Lawler, Public Health Analyst, Department of Health and Human

Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Although the reviewers listed above provided many constructive comments and

suggestions, they were not asked to endorse the conclusions or recommendations nor did they

see the final draft of the report before its release. The review of this report was overseen by

Richard E. Behrman, M.D., J.D., Vice President for Medical Affairs, Lucile Packard Foundation

for Children’s Health, appointed by the Institute of Medicine, who was responsible for making

certain that an independent examination of this report was carried out in accordance with

institutional procedures and that all review comments were carefully considered. Responsibility

for the final content of this report rests entirely with the authoring committee and the institution.
viii
ix

Contents

_______________________________________________________________________________________________

SUMMARY 1

ASSESSING DIETARY RISK AMONG WIC PROGRAM APPLICANTS 3

APPENDIXES

A. Workshop Agenda and Presentations A-1

B. Literature Search B-1
1

Assessing Dietary Risk

Among WIC Program Applicants

______________________________________________

Summary

The Food and Nutrition Board of the Institute of Medicine (IOM), part of the National

Academies, was asked to evaluate the use of various dietary assessment tools and to make

recommendations for the assessment of inadequate or inappropriate dietary patterns. These

assessments should accurately identify dietary risk of individuals and thus eligibility for

participation in the Special Supplemental Nutrition Program for Women, Infants, and Children

(WIC). The Committee on Dietary Risk Assessment in the WIC Program was appointed for the

2-year study and directed to develop an interim report which was to include (1) a framework for

assessing inadequate diet or inappropriate dietary patterns, (2) a summary of a workshop on

methods to assess dietary risk, and (3) the results of literature searches conducted to date.

This interim report includes these three components. Building on the approach used in the

1996 IOM report, WIC Nutrition Risk Criteria, the framework proposed by the committee

identifies characteristics of dietary assessment tools that can identify dietary patterns or

behaviors for which there is scientific evidence of increased nutrition or health risk in either the

short or long-term. The proposed framework consists of eight characteristics that a food intake

and/or behavior-based tool should have when used to determine eligibility to participate in WIC

programs. In order to be considered useful and effective, tools should:

• use specific criteria that are related to health, growth, or disease

• allow prioritization within the category of dietary risk

• have acceptable performance characteristics

• be suitable for the culture and language of the population served

• be suitable for the skill level of the population served

• be appropriate for age and physiological condition

• be responsive to operational constraints

• be standardized across states/agencies.
2

This interim report also includes authored summaries of the presentations at the

workshop (Appendix A), along with the results of literature searches conducted in the initial

phase of the study (Appendix B).

The committee’s review of dietary assessment tools currently in use in WIC agencies has

not been exhaustive, but it did not find any tools that have all eight characteristics. The

committee’s final report will provide recommendations for tools to assess dietary risk in

potential WIC participants and give the scientific basis for those recommendations. It will also

address the remaining tasks requested by the Food and Nutrition Service of the U.S. Department

of Agriculture (see tasks 2 through 6 in the box).

BOX 1 Scope of Work for Assessing Inadequate Diets or Inappropriate Dietary Patterns to

Ascertain Eligibility to Receive WIC Services Based on Dietary Risk

1. Propose a framework for assessing dietary risk among WIC program applicants, focusing

on “Failure to Meet Dietary Guidelines” as a risk criterion;

2. Identify and prioritize areas of greatest concern when the U.S. Dietary Guidelines are

incorporated into WIC programs;

3. Examine the use of food-based and behavior-based approaches in assessing “Failure to

Meet Dietary Guidelines” requirements;

4. Evaluate possible approaches for use specifically in the WIC setting;

5. Provide specific cut-offs for establishing WIC eligibility using the identified approaches;

and

6. Identify needed research and tools necessary to implement the approaches identified as

having the greatest potential for identifying those at nutrition risk.
3

Assessing Dietary Risk

Among WIC Program Applicants _____________________________________________________________________________________________

BACKGROUND

Dietary risk is one of several categories of nutrition risk criteria used, together with low

income, to establish eligibility for program benefits from the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC). Dietary risk refers to dietary deficiencies that

impair or endanger health, such as inadequate dietary patterns assessed by a 24-hour dietary

recall, dietary history, or food frequency checklist (7CFR Subpart C, Section 246.7(e)(2)(iii)).

WIC eligibility based on the category of dietary risk is intended to prevent the occurrence of

malnutrition or other overt problems of dietary origin due to suboptimal dietary patterns, and

result in improved outcomes in terms of the health of the pregnant woman, mother, fetus, infant,

and young child.

In the event that a WIC agency has reached its maximum caseload given funding

constraints, nutrition risk criteria provide the basis for a priority system in which program

applicants can be placed on an eligibility waiting list. As openings become available, applicants

from the waiting list may enter the program according to priority level. In general, priority is first

accorded to individuals with nutrition risk conditions detectable by biochemical or

anthropometric measurements, followed by other documented medical conditions, dietary risk,

and lastly, homelessness or migrancy (IOM, 1996). Pregnant women, lactating women, and

infants (birth to 12 months) are given priority over children (>12 months through 5 years), and

children are given priority over nonlactating postpartum women. The current seven-level priority

system can be found in Table 1. Many states have set subpriority levels within these seven

priority categories.

The federal definition for dietary risk focuses on underconsumption of essential nutrients.

However, the health risks associated with unbalanced dietary patterns, overconsumption, and

excess body weight call for an expanded definition of dietary risk—one that considers balance

and moderation in food intake. Data suggest that high weight for height is a significant and
4

TABLE 1 WIC Priority System

Priority

I Pregnant and breastfeeding women and infants at nutrition risk as demonstrated by

anthropometric or hematologic measurements or by other documented nutrition-related

medical condition.

II Infants up to 6 months of age of mothers who participated in WIC during pregnancy or who

would have been eligible to participate under Priority I documented medical condition. This

priority may also be assigned to a breastfeeding mother of an infant who is classified as

Priority II.

III Children at nutrition risk, as demonstrated by anthropometric or hematological assessment or

other documented medical condition. At State option, this priority can also include high-risk

postpartum women.

IV Pregnant and breastfeeding women and infants at nutrition risk as demonstrated by

inadequate dietary pattern. At State option, this priority can also include homeless and

migrant pregnant and breastfeeding women and infants and high-risk postpartum women.

V Children at nutrition risk because of inadequate dietary pattern. At State option, this priority

can also include homeless and migrant children and high-risk postpartum women.

VI Postpartum women, not breastfeeding, at nutrition risk either medical or dietary criteria

unless they are assigned to higher priorities at State discretion. At State option, this priority

may also include homeless and migrant postpartum women.

VII Previously certified participants likely to regress in nutritional status without continuation of

supplemental foods. At State option, this priority can also include homeless and migrant

participants.

growing concern among women and children enrolled in WIC (Mei et al., 1998; USDA, 2000).

This is consistent with recent CDC reports that obesity rates among children and adolescents

have doubled over the past 20 years (Troiano and Flegal, 1998)

Dietary risk includes two major types of risk through which individuals may become

eligible for participation in the WIC program. Inadequate diet as a risk criterion includes

reported food intakes that are identified to be potentially low in nutrients. Inappropriate dietary

pattern includes descriptors of dietary intake or habits, developmentally or age-inappropriate

patterns of feeding, and the ingestion of specific inappropriate substances. Dietary inadequacy

has been defined (IOM, 1996) as food or nutrient intake insufficient to meet a specified

percentage of the Recommended Dietary Allowances (RDAs) (NRC, 1989) for one or more

nutrients. Determination of inadequate diets usually involves estimating nutrient intakes using

some method of dietary recall or food frequency, and then comparing the intake with a specified

percentage of the RDAs for the individual (often between 70 and 100 percent of the RDA) (IOM,

1996). Examples of inappropriate dietary patterns include inappropriate infant or child feeding

practices, pica, high caffeine intakes, and reported food intakes that do not meet one or more of

the Dietary Guidelines for Americans (USDA/DHHS, 2000). The latter may include consumption of less than the recommended number of servings from food groups of the Food Guide

Pyramid, unsupplemented vegan diets, or other highly restrictive diets.

In 1998, approximately 49 percent of all WIC enrollees (47 percent of women, 13 percent

of infants, and 68 percent of children over the age of 1 year) were certified for participation on

the basis of dietary risk, either alone or in conjunction with other nutritional risks
5

(USDA/DHHS, 2000). While many applicants to the WIC program are eligible for program

benefits based on identification of other nutrition risks, for some dietary risk is the only nutrition

criterion upon which they can be certified as eligible for program benefits.

EVOLUTION OF NUTRITION RISK CRITERIA

From the inception of the WIC program, state agencies were permitted to develop

nutrition risk criteria using broad federal guidelines to determine a participant’s eligibility for the

program. However, prompted by concern over the variation among state agencies in determining

eligibility, in 1989 Congress mandated a review of nutrition risk criteria and the priority system.

In 1993, the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture

(USDA) contracted with the Food and Nutrition Board (FNB) of the Institute of Medicine (IOM)

to conduct a comprehensive scientific assessment of the nutrition risk criteria for use as

eligibility criteria in the WIC program. In 1996, an FNB committee released its

recommendations in the report WIC Nutrition Risk Criteria: A Scientific Assessment (IOM,

1996). With regard to the dietary risk classifications, the committee reviewed three major

categories: inappropriate dietary patterns, inadequate diets, and food insecurity. The committee

found clear health and nutrition risks associated with selected inappropriate dietary patterns.

They concluded that individuals with these inappropriate dietary patterns had high

potential to benefit from participation in the WIC program. The committee also found evidence

to support the use of dietary patterns that fail to meet the Dietary Guidelines as an indicator of

both health risk and health benefit in the WIC program. Consequently, it recommended the use

of the 1995 U.S. Dietary Guidelines for Americans (USDA/DHHS, 1995)1

 as a risk criterion for

identifying inappropriate diets for women and children over 2 years of age (Table 2). The

committee did not, however, find evidence for an effective method to assess an individual’s

usual intake in comparison with the Dietary Guidelines, nor did it specify cut-off points.

The 1996 FNB committee recommended discontinuing the use of the criterion

inadequate diets. Although it concluded that individuals in this category would benefit greatly

from the supplemental food provided through participation in the WIC program, it also

concluded that currently available assessment tools have inherent limitations that make them

unacceptable for determining which income-eligible individuals consume inadequate diets.

Lastly, with regard to food insecurity, the committee concluded that those at risk would

likely benefit from participation in the WIC program. However, while the committee

recommended that food insecurity be included as a risk criterion, they found insufficient

scientific evidence on which to select a cut-off point to identify those most likely to benefit.

Following the release of the FNB committee’s report, the National Association of WIC

Directors (NAWD) and FNS established a collaborative partnership—the Risk Identification

and Selection Collaborative (RISC)—to address recommendations of the IOM report and to

develop standardized and scientifically sound nutrition risk criteria. Their intent was to achieve

 1

Earlier this year a revised report, Dietary Guidelines for Americans, 2000 (USDA/DHHS, 2000),

was released (see Table 2). While structured differently, the new guidelines are similar in content to the

1995 guidelines, with the exception of an additional guideline regarding food safety.
6

TABLE 2 Dietary Guidelines for Americans

AIM FOR FITNESS...

• Aim for a healthy weight.

• Be physically active each day.

BUILD A HEALTHY BASE...

• Let the Pyramid guide your food choices.

• Choose a variety of grains daily, especially whole grains.

• Choose a variety of fruits and vegetables daily.

• Keep foods safe to eat.

CHOOSE SENSIBLY...

• Choose a diet that is low in saturated fat and cholesterol and moderate in total fat.

• Choose beverages and foods to moderate your intake of sugars.

• Choose and prepare foods with less salt.

• If you drink alcoholic beverages, do so in moderation.

SOURCE: USDA/DHHS, 2000.

greater consistency among state and local WIC agencies. Through multiple subcommittees, the

joint NAWD/FNS Workgroup developed three lists of nutrition risk criteria: criteria that are

allowed, criteria that are not allowed, and criteria that are in need of future review. RISC was

created to address criteria still in need of review and to provide ongoing review. FNS released a

final policy memorandum that described over 100 allowable nutrition risk criteria along with cutoffs/thresholds. These criteria were implemented as of April 1, 1999 (FNS, 1998). While state

agencies are allowed to establish more restrictive cut-offs/thresholds, the final policy

memorandum of allowable nutrition risk criteria provides for a reasonable degree of consistency

from state to state and some flexibility to meet local priorities (FNS, 1998).

The list of official allowable nutrition risk criteria contains 18 dietary risk criteria (Table

3). Inadequate diet and inappropriate diet (failure to meet Dietary Guidelines) are included

among the 18, however these are the only two criteria for which definitions, cut-off values, and

priority levels have not been officially set. While priority levels for types of participants have

been assigned for these two categories (see Table 4), definitions and cut-off values have not

been. States are still given discretion within broad federal guidelines to define dietary risk,

choose tools to assess it, and set their own cut-off points when using those tools.

CHARGE TO THE COMMITTEE

For the aforementioned reasons, FNS/USDA contracted with the FNB/IOM to appoint a

committee of experts to review the scientific basis for methods currently employed in the

assessment of individuals for eligibility to the WIC program based on dietary risk. The

committee’s task is to evaluate the use of various dietary assessment tools and to make

recommendations for the assessment of inadequate or inappropriate dietary patterns. These

assessments should accurately identify dietary risk of individuals and thus eligibility for
7

TABLE 3 Dietary Risk Assessment Criteria Allowed for WIC Program Certification

400 Inadequate/Inappropriate Nutrient Intake

401 Failure to Meet Dietary Guidelines

402 Vegan Diets

403 Highly Restrictive Diets

410 Other Dietary Risk

411 Inappropriate Infant Feeding

412 Early Introduction of Solid Foods

413 Feeding Cow’s Milk During First 12 Months

414 No Dependable Source of Iron for Full-Term Infants at 6 Months of Age or Later

415 Improper Dilution of Formula

416 Feeding Other Foods Low in Essential Nutrients

417 Lack of Sanitation in Preparation/Handling of Nursing Bottles

418 Infrequent Breastfeeding as Sole Source of Nutrients

419 Inappropriate Use of Nursing Bottles

420 Excessive Caffeine Intake (Breastfeeding Woman)

421 Pica

422 Inadequate Diet

423 Inappropriate or Excessive Intake of Dietary Supplements Including Vitamins, Minerals, and

Herbal Remedies

424 Inadequate Vitamin/Mineral Supplementation

425 Inappropriate Feeding Practices for Children

participation in WIC. More specifically, during its deliberations, the committee is charged with

the following tasks:

1. Propose a framework for assessing dietary risk among WIC program applicants,

focusing on “Failure to Meet Dietary Guidelines” as a risk criterion.

2. Identify and prioritize areas of greatest concern2 when the U.S. Dietary Guidelines are

incorporated into WIC programs.

3. Examine the use of food-based and behavior-based approaches in assessing “Failure

to Meet Dietary Guidelines” requirements.

4. Evaluate possible approaches for use specifically in the WIC setting.

5. Provide specific cut-offs for establishing WIC eligibility using the identified

approaches.

6. Identify needed research and tools necessary to implement the approaches identified

as having the greatest potential for identifying those at nutrition risk.

Although asked to focus on “Failure to Meet Dietary Guidelines” as the type of dietary

risk, the final report may consider other possible criteria where evidence substantiates an

increased risk due to food choices and practices, including criteria related to food insecurity.

 2

Given that the U.S. Dietary Guidelines include a number of specific recommendations, the intent of

this component of the task is to determine which of the Dietary Guidelines recommendations are most

important and relevant to include in assessing dietary risk specific to the WIC population.
8

TABLE 4 Dietary Risk Criteria Without Standard Definitions and Cut-off Values

INADEQUATE DIET*

Definition/cut- Based on definition currently in use by State agency

off value

Participant Category Priority

Category and Pregnant Women IV

priority level Breastfeeding Women IV

Nonbreastfeeding Women VI

Infants IV

Children V

Justification To be provided by State agency

References To be provided by State agency

INAPPROPRIATE DIET: FAILURE TO MEET DIETARY GUIDELINES*

Definition/cut- Based on definition currently in use by State agency

off value

Participant Category Priority

Category and Pregnant Women IV

priority level Lactating Women IV

Nonlactating Women VI

Children V

Justification To be provided by State agency

References To be provided by State agency

*While recommended for use as an allowed risk criterion for the WIC program by the IOM, this criterion

is referred to the Risk Identification and Selection Collaborative (RISC) for long-term research. NAWD

and FNS concur in the following recommendations: (1) to merge this criterion with 422, “Inadequate

Diet”, and (2) to eliminate the use of identified specific nutrient deficiencies until a valid assessment tool

for both criteria is defined. NAWD and FNS agree with IOM’s recommendation for research to develop

practical and valid assessment tools for identification of inadequate diets or inappropriate dietary patterns.

Dietary adequacy will be considered a high priority for further research. It may take years to develop the

necessary practical and valid assessment tools and related definitions/cut-off values. Therefore, unlike

other criteria that are being referred to RISC, “Inadequate Diet” and “Failure to Meet Dietary Guidelines”

will not be subject to the April 1, 1999 expiration date.

SOURCE: FNS, 1998.

SOURCES OF INFORMATION

To assist the committee in its deliberations, a workshop on Dietary Risk Assessment in

the WIC Program was held on June 1, 2000, in Washington, D.C. Eight experts on various
9

aspects of dietary assessment, four state WIC representatives whose states use different

assessment methods and serve demographically diverse population groups, and two public policy

experts gave formal presentations. Additionally, four attendees provided comments in response

to an open invitation for such input to the committee. The workshop agenda and summaries of

presentations can be found in Appendix A. The committee also conducted a search of the

literature. A listing of references that the committee found to be of potential use can be found in

Appendix B.

METHODS/TOOLS TO IDENTIFY DIETARY RISK

Dietary assessments are used not only to establish eligibility in the WIC program, but

also as a basis for the individualization of nutrition education and food packages. For this reason,

dietary intakes are generally assessed for most WIC applicants regardless of whether or not they

have already met eligibility requirements based on nutrition risk criterion other than dietary risk.

In 1998, 86 percent of state agencies had policies that required obtaining dietary intake

information from all participants (USDA, 2000). The characteristics of the tools used in the

assessment of dietary intake necessary for certification may differ, however, from those

necessary for dietary counseling.

Currently, a few states use dietary assessment methods with a published research base.

Many use methods developed or adapted by state and local WIC agencies that appear to have

been less well studied. Most states define dietary risk as failure to consume a minimum number

of servings from one or more food groups represented in the Food Guide Pyramid, which they

interpret as indicating inadequate diet. Approximately 82 percent of states use 24-hour recalls

and/or food frequency/food item checklists in their assessments of dietary intake (USDA, 2000).

The following summaries provide overviews of some of the more common methods of

assessing usual dietary intake that have been used in research settings in which significant time is

usually available for interviews and follow-up questioning. In some cases, these methods have

been adapted for use in WIC programs, but the committee found few reported studies of their

validity in this setting.

Food Frequency Questionnaires

Food frequency questionnaires (FFQs) are designed to obtain information on the

frequency of consumption of selected foods over a defined period. In WIC, the period of time

usually ranges from 1 week to 1 month. The number and choice of foods depends on the

objective of the FFQ. For example, the FFQ might focus on important sources of only one or two

nutrients, or it might be comprehensive and attempt to obtain an accurate picture of overall

nutrient intake. Thus, the number of foods listed may vary greatly. Ideally, FFQs list foods

individually rather than in groups because it can be very difficult for the respondent to estimate a

combined frequency of intake of foods (e.g., the combined frequency of intake of apples,

applesauce, and pears). The time interval over which the respondent is asked to report usual

consumption can vary from “not stated” to “the last year,” “last month,” or “last week.” Each

time interval has implications for accuracy of memory and for the reliability of the assessment of
10

usual diet. Averaging usual intake over time may be difficult for some participants (Cullen et al.,

1999).

Some FFQs attempt to obtain portion size information, whereas others simply assume a

specified portion size. The portion size might be a standard measurement (e.g., 1/2 cup), or it

might be chosen to reflect a median portion size found in a nationwide survey. Often FFQs are

designed to be self-administered. If the client can read and follow the directions, and if the

results are computerized, data collection and processing can be achieved quickly and at relatively

low cost. If interviewer administration is required, the process may be time consuming, but the

interviewer does not have to be highly trained. FFQs lack the detail that is characteristic of diet

recalls or records, and they provide no information about meal and snack patterns. However,

they may provide more information about the variety of foods usually consumed (e.g., vegetables

and fruits) than do 24-hour diet recalls.

The validity of FFQs is usually determined by correlating estimates of nutrient intake

with nutrient-intake estimates obtained from a set of diet recalls or prospectively collected diet

records. The correlation coefficients for intake of specific nutrients between FFQ and diet

records or recalls (after adjustment for within-person variability) are usually 0.5 to 0.7 for FFQs

used in epidemiologic studies (e.g., Block et al., 1990; Friis et al., 1997; Willett et al., 1987).

Another method of assessing the performance of FFQs is to compare the FFQ’s classification of

nutrient intake by quintile with that obtained by a set of diet recalls or records. Typically, there is

considerable disagreement in the results obtained by the two methods (e.g., Friis et al., 1997).

Little evidence is available concerning the ability of FFQs to estimate intake correctly when

servings of foods or food groups (rather than nutrients) are the units of comparison (Thompson,

et al., 2000).

24-hour Recall

For a 24-hour recall, the client is asked to remember all food, beverages, and supplements consumed within the past 24 hours. Typically, the recall is obtained by an interviewer who

is a registered dietitian or, at a minimum, a person who has been trained intensively to use this

method. Often the recall is obtained face-to-face but sometimes is obtained by telephone. To

improve accuracy, the interviewer probes the informant to help remember every eating occasion,

including snacks and extra beverages, and to obtain descriptions of the method of food

preparation and brand name of the products. For example, if an informant reports drinking a cup

of coffee (decaffeinated or with caffeine), a standard probe would be made for the use of

lightener (cream, nondairy creamer, milk [whole, 2 percent, 1 percent, skim]) and sweetener

(sugar, honey, saccharine, aspartame). Food models, household measures (bowls, cups,

teaspoons, tablespoons), fast food or other commercial containers, and two-dimensional food

pictures are often used to help the informant estimate portion size. The interviewer can collect

data on unusual foods and special recipes and, with few exceptions, can accommodate the diets

of most informants.

A single research quality dietary recall usually requires 20 minutes for the interview

(Thompson and Byers, 1994). Although time demands imposed upon the informant are relatively

small, memory demands can be difficult for many, especially without probing. Because the recall

is interviewer administered, literacy is not a major issue.
11

A major disadvantage of the single diet recall is that it does not assess usual intake. This

is because individual diets vary by day of the week, season of the year, and from day to day.

Consequently, multiple averaged 24-hour recalls are needed to estimate the usual food or nutrient

intake of individuals. Moreover, detailed quality control for achieving accuracy involves a

protocol for administering the recall and for the training and periodic retraining of the

interviewers and data coders. Data coding, data entry, and data analysis are usually more

expensive than those entailed with the food frequency method.

Estimates of nutrient intake from a single 24-hour recall are poorly correlated with

nutrient intake estimates obtained from a set of diet records, from weighed intakes, or from

intakes recorded by independent observers (Bingham, 1991). Small, but statistically significant,

correlations (r~0.2) have been found between dietary (averaged 24-hour recalls) and circulating

micronutrients (e.g., dietary folate and serum folate [Huber et al., 1988; Scholl et al., 1996]).

Overweight adults and adolescents tend to have greater under-reporting than normal weight

individuals (Briefel et al., 1997). Studies of adults have shown that energy intake estimated from

24-hour recalls is under-reported when compared with expenditure estimated by doubly labeled

water (Johnson et al., 1998; Kroke et al., 1999; Sawaya et al., 1996; Tran et al., 2000), but this

may not be true for all population groups (Harrison et al., 2000).

Diet Records

Diet records are intended to provide quantitative and descriptive information about all

foods and beverages consumed over a specified time, usually several days. Good record keeping

requires substantial training of the client or caregiver—a time-consuming process. Food records

have many of the characteristics of diet recalls (e.g., a single day’s record does not provide a

sound basis for estimating usual intake, and coding of records may be time consuming, but

unusual foods can be included). If recorded faithfully at the time the food is eaten, food records

minimize the problem of memory, but they may change eating behavior. Invariably, the staff

member needs to spend time interviewing the client to clarify entries or check on potentially

missing items.

Diet History

The term diet history generally refers to any comprehensive measure of usual intake. It is

typically composed of a detailed interview to establish usual consumption patterns. The

interview usually begins with a 24-hour recall that is expanded by probing to gather information

regarding day-to-day and seasonal variation. The second phase of the interview involves

completion of an FFQ that includes questions on portion size. Finally, clients are asked to keep a

record of everything consumed for a 72-hour period.

Diet histories allow the practitioner to gather information on a wide variety of nutrients,

foods consumed over time, and eating patterns. The combined use of several methods allows the

detection and clarification of discrepancies in reporting. The disadvantages of diet histories are

those inherent in the separate methodologies of 24-hour recalls and food frequencies.

Specifically, recall bias may result from faulty memory or poor conceptualization by the client

and interviewer bias may result from inadequate or inappropriate probing. Proper training of
12

interviewers minimizes these effects. However, the use of multiple assessment methods is time

consuming.

Behavioral Approaches in Assessing Dietary Intake

The above dietary assessment methods focus on determining what and/or how much of a

food or nutrient a WIC client consumes. In comparison, a behavioral approach to diet assessment

can be viewed as examining the context of eating—where, when, and how. For example,

behavioral questions might determine such things as the frequency of eating at restaurants

(where), eating quickly versus slowly (how), or eating between meals or skipping breakfast

(when). Such questionnaires can also seek to determine the whys behind food consumption (e.g.,

eating when bored or feeding a toddler to calm fussiness).

Eating is a complex motivated behavior with multiple social, emotional, and

environmental determinants. What or how much an adult or child eats (or an adult offers to a

young child to eat) is the result of a complex sequence of decisions. These decisions are not

usually consciously deliberated and can be affected by contextual factors, such as eating during

social gatherings; the cost, convenience, or familiarity of certain foods; or cues to eating from

emotional states such as loneliness. Contextual factors that motivate the what and how much

aspects of diet may be easier to recall, less susceptible to various types of reporting bias, and

might be the most appropriate targets for dietary counseling (Kristal et al., 1990). All of these

would be practical advantages of a behavioral approach to assessing dietary risk.

There are several examples of behavioral approaches. A behavioral screening

questionnaire focused on dietary fat (Kristal et al., 1990) assessed practices associated with

dietary fat intake, such as “How often do you take the skin off chicken?” and “How often do you

drink skim or low-fat instead of regular milk?” People who frequently ate at fast food restaurants

tended to consume more dietary saturated fat (Clemens et al., 1999).

Another example relates to the feeding of preschool children. Birch and coworkers

reported that when parents used food as a reward in feeding preschool children (Birch et al.,

1980) or restricted access to food (Fisher and Birch, 1999a), children may have overeaten and

become overweight (Birch and Fisher, 2000; Fisher and Birch, 1999a, 1999b).

FRAMEWORK FOR ASSESSING DIETARY RISK

Through deliberations, the Committee on Dietary Risk Assessment in the WIC Program

developed a framework for evaluating possible methods to assess dietary risk among WIC

program applicants. Building on the approach used in the 1996 WIC report, the committee set as

an overall goal: an assessment tool that can identify dietary patterns for which there is (1)

scientific evidence of nutrition or health risk in either the short or long-term, and (2) evidence of

the ability to benefit from WIC participation for individuals with a given risk. The evaluation

framework consists of characteristics that a food or behavior-based tool should have to be

considered useful and effective in the WIC setting. At this point, the committee has not ruled out

the possible inclusion of some type of assessment of nutrient intakes or of aspects of food

security as part of this framework. The eight characteristics are as follows:
13

1. The tools use specific criteria that are related to health, growth, or disease.

Ideally, any risk criterion adopted for inappropriate dietary patterns should be predictive

of the individual’s risk of short-term or long-term health problems or growth problems, or of

developing a dietary deficiency. It also should predict the likelihood that the individual would

benefit from the WIC food package and/or nutrition education. For children ages 2 to 5 years and

for pregnant, lactating, and nonlactating postpartum women, the 1996 IOM report suggested

using the indicator “failure to meet Dietary Guidelines” (IOM, 1996). To be current, this would

involve using the consensus document Dietary Guidelines for Americans (USDA/DHHS, 2000)

as a reference.

Although the Dietary Guidelines were not developed to serve as criteria that are directly

predictive of optimal health or growth, they were based on extensive review of the literature and

deliberations by an expert committee—the Dietary Guidelines Advisory Committee. That

committee’s intent was to promote good health of Americans through use of the entire set of

guidelines—priority was not given to just one or a few of them. Neither the 1996 IOM report nor

the report of the Dietary Guidelines Advisory Committee makes recommendations for cut-off

points for determining when the guidelines have not been met.

Useful screening tools based on Dietary Guidelines need to determine how an

individual’s intake compares with an appropriate cut-off point based on those guidelines. For

such vulnerable populations as pregnant and lactating women and children ages 2 to 5 years,

should the criterion be a dietary intake that fails to meet any one of the guidelines, or should it be

more stringent? Should the criterion used differ for the three categories of women served by

WIC? Should there be an emphasis on “too much” along with “not enough”?

Assessment tools need to identify shortfalls or excess intake depending on the criterion or

criteria selected as most predictive of risk and benefit for the target population. The criteria

(indicators and their cut-off points) need to be specified clearly for the tools, along with the

rationales.

Because the criteria must be related to health, growth, or disease, they must be tailored to

subgroups served by WIC. For example, an indicator to determine “failure to meet Dietary

Guidelines” may not be appropriate for children younger than 2 years of age since Dietary

Guidelines were developed only for people 2 years and older. Criteria to identify what

constitutes an inappropriate diet for this younger age group still need to be related to risk of

health, growth, or development problems.

2. The tools allow prioritization within the category of dietary risk.

Currently, funding for the food grant portion of WIC is sufficient to meet current

participation levels, and all who apply and meet eligibility criteria receive the food assistance

component of WIC. When resources for WIC are insufficient to serve all those eligible, a tool

needs to allow the prioritization of risk within the dietary risk category. The goal should be to

ensure that those at greatest dietary risk and those most likely to benefit are served first. To meet

this goal, a set of criteria should be established that have different degrees of stringency

reflecting different degrees of risk. Where the prioritized criteria are established, the committee

will give the rationale for the prioritization developed.
14

3. The tools have acceptable performance characteristics.

All instruments should be held to two performance criteria: validity and reliability

(Windsor et al., 1994). Validity addresses whether one is really measuring what was intended.

For example, 24-hour dietary recalls are intended to measure dietary intake for the previous 24-

hour period, but several recent studies have revealed that as much as 30 percent of foods reported

by children were not eaten the previous day (Baxter et al., 1997). Foods reported but not eaten

are called intrusions or phantom foods (Domel et al., 1994). An instrument that systematically

mismeasures something (e.g., overestimates consumption by including a large number of

phantom foods) is biased and considered a validity issue. Reliability concerns whether applying

the same instrument twice (or more times) provides the same results. Reliability thereby

indicates the degree of random error in dietary assessment. Random error could be caused by the

respondent or interviewer being upset at the time of assessment, excessive noise during

assessment, the vagaries of memory, a person’s inability to properly average intake to provide a

desired response on an FFQ, etc.

One source of random error that has received substantial attention in dietary assessment

is intraindividual variability—that is, variation in an individual’s intake from day to day (Nelson

et al., 1989). In most dietary assessment research, the investigator intends to measure a person’s

usual intake. However, research has demonstrated that a person’s food intake varies substantially

from day to day (Nelson et al., 1989). The major problems with measures that contain substantial

amounts of error (low reliability) are that estimates of true values may be substantially off the

mark, and correlations with other variables will be attenuated (i.e., they will be lower than

correlations obtained if measures without error were available) (Traub, 1994).

One method for minimizing intraindividual variability in dietary data is to collect many

days of dietary intake and average the data. The number of days needed to attain a usually

desired level of reliability of 0.8 or higher varies by the nutrient or food group to be measured

(IOM, 2000; Nelson et al., 1989). Although the errors of individuals in a group tend to cancel

each other out and leave an unbiased estimate of the true value for the group, the error terms for

any single member of that group remain if only a single day’s intake has been obtained.

Assessing diets with sufficient accuracy to characterize an individual’s intake generally requires

either multiple days of assessment (IOM, 2000) or a lengthy questionnaire. When using these

dietary assessment procedures for group assessment, researchers have generally been willing to

tolerate a substantial amount of error, for which they could partially compensate by increasing

the number of participants in their research or using statistical correction procedures, called

corrections for attenuation (Traub, 1994).

Error in the assessment of an individual for certification in the WIC program (that is,

misclassification error), however, has more serious consequences: truly eligible individuals may

not be classified as eligible for the services (less than perfect sensitivity), or individuals not truly

eligible for the services may receive them (less than perfect specificity). Policy makers and the

public must decide how much and what type of misclassification error they are willing to tolerate

when certifying people to receive or not receive federally funded WIC services. The extent to

which specific cut-offs recommended in the final report misclassify individuals (see Chapter 3 of

the 1996 IOM report for further discussion) will be considered by the committee in its

deliberations; recommendations derived will be provided in the final report along with the

rationale used by the committee.
15

Given concerns about reliability and validity, all tools used to determine WIC dietary risk

should undergo testing for these performance criteria. If a WIC agency uses several tools for the

same client category, their relative ability to ascertain dietary risk accurately should also be

addressed.

4. The tools are suitable for the culture and language of the population served.

The WIC program serves a multiethnic, multicultural, heterogeneous population. Forty

percent of WIC participants are Caucasian, 31 percent are Latino, 24 percent are African

American, 3 percent are Asian or Pacific Islander, and 2 percent are American Indian or Alaskan

Native. The percentages of non-Caucasians and the diversity of cultures are expected to increase.

Diversity in heritage, geography, foods consumed, and culture translates into diversity in dietary

patterns and practices. To assess dietary intake and patterns effectively, dietary assessment tools

need to be developed with each specific culture in mind. Thus, many WIC agencies are likely to

require several or even many different dietary assessment tools to serve their population mix.

Language translation alone will not provide an acceptable tool for a different culture because the

types of foods consumed, the portion sizes, food combinations, and the way foods and eating are

conceptualized are likely to differ. Thus, the rigorous process of development and validity and

reliability testing is recommended for all dietary assessment tools designed for small target client

subpopulations regardless of how small the unique target client subpopulation may be.

Effective administration and use of tools with different cultural groups is likely to require

special training, but this topic is not within the charge to this committee. The committee is aware

that little information exists regarding successful adaptations of dietary assessment instruments

for use in different cultures whose members wish to avail themselves of WIC services. Thus, the

final report will develop recommendations to assist in ascertaining dietary risk in such subgroups

when the scientific basis is sparse.

5. The tools are suitable for the skill levels of the population served.

Due to time constraints of WIC staff, asking the client to fill out a questionnaire is a

reasonable option. However, dietary assessment tools are complex by nature. Self-administration

of the forms may not be a legitimate option for providing quality services in some WIC agencies

for several reasons: the questionnaire may be too complex, the task itself is complex, and some

clients have limited literacy and/or limited familiarity with completing forms (including scanable

forms). It is also possible that oral administration of a questionnaire may be superior to written

administration for obtaining the desired information in some settings or client groups. Thus, the

method of administration is a fundamental consideration for the development and selection of

appropriate dietary assessment tools for the WIC program. Pilot testing with WIC clients can

help develop user-friendly tools that are appropriate for the WIC client.

6. The tools are appropriate for age and physiological condition.

Several subgroups are served in the WIC program: pregnant, breastfeeding, and

nonbreastfeeding women and teenagers, along with their infants and children. When assessing

dietary risk, consideration needs to be given to the different nutritional goals and appropriate

feeding patterns for these groups. For example, appropriate feeding patterns change continually
16

throughout the first 2 years of life. In infants 0 to 6 months of age who are not exclusively

breastfed, many state agencies focus on caregiver behaviors such as the proper and sanitary

preparation of infant formula, and on discouraging additions, such as cereal, to the infant’s

bottle. Beginning at 4 to 6 months of age, issues related to the transition from breast or formula

feeding to a mixed diet of appropriate texture and consistency become important. For toddlers,

the appraisal may relate to the transition from pureed foods to family foods and to self-feeding.

Also, questions at this stage about hand-to-mouth activity often lead to the subsequent

identification of children with pica who are at risk of exposure to environmental lead from the

ingestion of nonfood substances. Therefore, the need for specialized tools for each client

subgroup must be considered in the development of appropriate tools for assessing dietary risk in

the WIC program.

7. The tools are responsive to operational constraints.

Time constraints for both staff and participants necessitate the use of an assessment tool

that can be administered, scored, and interpreted rapidly. It is imperative that the tools under

consideration take into account the variety of skills and knowledge levels of the competent

professional authorities (CPAs) who assess dietary intake in the WIC setting. CPAs are often

paraprofessional staff who have received basic nutrition training. Whether CPAs are

paraprofessional or professional, the assessment tools they use need to be linguistically and

culturally appropriate for different population groups served by WIC clinics.

A tool should provide consistent results regardless of the staff member who administers

it. Subjective measures in scoring should be avoided to eliminate administrator bias.

Furthermore, the tool should be constructed in a manner so as not to influence the client.

Features that may influence responses inappropriately include scoring mechanisms placed

directly on a self-administered form and phrasing that invites desirable or favorable responses

rather than accurate ones.

Additional points that need to be considered include the impact of the tool(s) on the

systems used by the WIC agency, and of expected future changes to the system, such as

automation or computerization.

8. The tools are standardized across states/agencies.

To some degree, tools used to determine eligibility for WIC participation based on

dietary risk need to be standardized across state agencies for each of the physiological groups

served by WIC. While differences in culture and language preclude the use of a single tool in all

settings or even in a single setting, some form of standardization needs to occur to ensure equal

access to program benefits regardless of the individual’s place of residence or cultural

background. Moreover, if federal funding for the program is limited, standardization needs to

ensure that individuals at greatest risk and with potential to benefit are served first.

Framework Summary

The eight criteria for tools to be used to identify dietary risk have many dimensions and

must take into account numerous constraints. It may be that the environment in which the WIC
17

program operates precludes the use of tools that have both greater predictive reliability and

greater sensitivity. The final report will address methods of dietary risk assessment in the context

of these constraints and of the scientific base available.

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component, and time interval between eating and reporting on accuracy of fourth-graders’

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Fisher JO, Birch LL. 1999b. Restricting access to palatable foods affects children’s behavioral

response, food selection, and intake. Am J Clin Nutr 69:1264–1272.

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(June 29, 1998). Supplemental Foods Program Division, Food and Nutrition Service, U.S.

Department of Agriculture, Alexandria, VA. Photocopy.

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IOM (Institute of Medicine). 2000. Dietary Reference Intakes: Applications in Dietary

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influence on the outcome of pregnancy. Am J Clin Nutr 63:520–525.

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Publishing Co.

A-1

Appendix A

Workshop Agenda and Presentations

Workshop on

Dietary Risk Assessment in the WIC Program

Thursday, June 1, 2000

National Academy of Sciences

Lecture Room

2101 Constitution Avenue, N.W., Washington D.C.

 8:00 a.m. Welcome and Introduction

Virginia Stallings, Committee Chair

 8:15 Overview of WIC Operational Issues and Practices which may Impact on

the Selection of Dietary Risk Assessment Methodology

Jean Anliker, University of Maryland A-3

8:45 Overview of Assessing Adequacy of Intake: Reliability and Sources of Error

Valerie Tarasuk, University of Toronto A-5

 9:30 Development of the Dietary Guidelines and their Application to the WIC

Population

Cutberto Garza, Cornell University A-7

10:00 Development of the Food Guide Pyramid and its Application to the WIC

Population

Kristin Marcoe, U.S. Department of Agriculture A-12

10:30 Break

10:45 Assessing Individuals Total Food Intake and Cognitive Aspects of Questionnaires

Amy Subar, National Cancer Institute A-17

11:30 Use of the Block Questionnaire in the WIC Program

Gladys Block, University of California, Berkeley A-19

12:15 p.m. Lunch

 1:00 Use of the Harvard Food Frequency Questionnaire in the WIC Population

Graham Colditz, Harvard School of Public Health A-22

 1:45 Assessing Dietary Intake and Risk During Pregnancy and Special Considerations

in Evaluating Intake in the Hispanic Population

Anna Maria Siega-Riz, University of North Carolina A-25

 2:30 Break
A-2

Workshop Agenda, continued

 2:45 Practical Issues in the Use of Various Tools in WIC Settings A-31

Jill Leppert, North Dakota State Department of Health; Amanda Watkins,

Arizona Department of Health Services; Ann Barone, Rhode Island

Department of Health; Carol Rankin, Mississippi Department of Health

 3:45 The Role of WIC in Assistance to the Poor and Food Insecurity as a

Predictor of Dietary Risk A-38

Bob Greenstein, Center on Budget and Policy Priorities; Lynn Parker,

Food Research and Action Center

 4:30 Open Discussion and Comments

 5:30 Adjourn
A-3

Overview of WIC Operational Issues and Practices which may Impact on the

Selection of Dietary Risk Assessment Methodology

Presented by Jean Anliker, Ph.D., R.D.

Adjunct Associate Professor

University of Maryland, Baltimore

Dietary assessment is an effective tool for identifying risk, tailoring interventions, and

testing the effects of nutrition education targeted to WIC participants. The Maryland WIC 5-ADay Promotion Program and the Maryland Food for Life Program, both funded by the National

Cancer Institute, are two programs in which dietary assessment instruments were developed and

utilized to evaluate program interventions. Both used trained peer educators to recruit program

participants and briefly explain questionnaire instructions. However, in order to avoid any

administrator bias, neither were permitted to help the participants in any capacity besides reading

difficulties. While the instruments were not validated in terms of comparing survey results to

actual food consumed, the experiences of both programs provide valuable insight into the

feasibility and challenges of conducting detailed dietary assessment in the WIC program.

The Maryland WIC Five-A-Day promotion program was a randomized cross-over design

with a 6-month intervention administered in 16 sites throughout Maryland. Eight sights were

selected to be intervention sites the first year; the other eight served as control sites. Their status

was reversed in the second year so that each site served as their own control. Subjects included

3,102 English-speaking women at least 18 years of age who were either pregnant, breast feeding,

or were mothers of children enrolled in WIC. Sites were chosen with different demographic

characteristics including rural and urban populations, as well as different racial and ethnic

profiles. The program had 5 objectives: The intervention group would show significantly greater

increases than the control group in (1) their knowledge about fruit and vegetable consumption;

(2) their attitudes about fruits and vegetables consumption; (3) their self efficacy for fruit and

vegetable consumption; (4) the stage of change for fruit and vegetable consumption; and (5) their

actual fruit and vegetable consumption.

Survey development incorporated focus groups, pilot testing, and cognitive testing prior

to initiation of its use in the study. The cognitive testing involved participants reading out loud

and verbalizing their thought processes as they answered questions. It was helpful in ensuring

that participants understood what was really being asked, and therefore, fine-tuning questions.

The standard National Cancer Institute seven-item fruit and vegetable frequency consumption

assessment was used along with a 35-item, 24-hour checklist for fruits and vegetables. The

survey also considered psychosocial variables, including self-efficacy, perceived barriers,

attitudes, social support, responsibility for food preparation and purchasing, and knowledge

relating to fruits and vegetables. The final survey was self-administered and took participants 15

to 30 minutes to complete. A $10 incentive was given to participants after the post-survey (8

months later) was completed.

Results of the study showed a significant difference, with a direct linear relationship

between fruit and vegetable consumption and program attendance. An increase in 0.13 servings

per day among the control group and increase of 0.56 servings per day in the intervention group

(p<0.002) were observed. Those who attended all sessions increased consumption by 1.25

servings per day. Other significant differences were seen in participant’s knowledge regarding
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the number of servings recommended for fruits and vegetables, attitudes about fruits and

vegetables, self-efficacy for fruit and vegetable consumption, and perceived social support.

The Maryland Food for Life Program was similar in design to the Five-A-Day program,

however only 10 sites were selected and the program intervention was 6 months rather than 8.

While final data analysis has not yet occurred, the food assessment methodology can be

described.

The food survey development for the Food for Life program included similar formative

research (cognitive and pilot testing) to that of the Five-A-Day program. In addition, Gladys

Block, Ph.D. served as a consultant in developing a food frequency instrument that would be

culturally appropriate for the program. Objectives for this program focused on lowering the

percentage of calories from fat, increasing dietary fiber, and increasing the number of servings of

fruits and vegetables. Hence, the survey instrument needed to evaluate dietary patterns rather

than just servings of fruits and vegetables. An 83-item food frequency instrument, capable of

generating a complete nutrient profile, was developed for this program. In addition, a

questionnaire was used to assess the fat levels of commonly eaten foods, stages of change for

fruit and vegetable consumption, as well as fat and fiber consumption.

The 83-item food frequency questionnaire included estimations of portion size. Serving

sizes were shown on the questionnaire and participants were asked to estimate their usual

servings as small, medium, or large. This self-administered questionnaire utilized computerscanned bubble sheets and took participants an average of 30 to 45 minutes to complete. A $20

incentive was given to participants after the final survey was completed.

Data generated by the food frequency assessment instrument was vast. Profiles of

nutrient data included calories, protein, fat, carbohydrate, cholesterol, fiber, vitamins, and

minerals. Servings of food groups from the food guide pyramid were also generated. The data

generated could be used not only for evaluation, but was enormously valuable for identifying

target behaviors for interventions, both at the individual and population level.

Experience with both of these programs lead to the following conclusions regarding

dietary assessment in WIC programs: (1) WIC participants will complete food surveys, even

surveys that take 15 to 45 minutes to complete; (2) literacy was not a common problem; 80

percent of the participants had high school education and in only a few instances were peer

educators asked to help with reading; (3) food survey questions were well understood; (4) dietary

data can be a useful tool in tailoring nutrition education; (5) trained peer educators can collect

dietary data; and (6) self-administered forms which can be computer scanned work very well.

The forms were scanned by the computer at the university, but having scanners on site in the

WIC clinics would likely be feasible.
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Assessing Adequacy of Intake: Reliability and Sources of Error

Presented by Valerie Tarasuk, Ph.D.

Associate Professor, Department of Nutritional Sciences

Faculty of Medicine, University of Toronto

Applying dietary assessment techniques to appraise the adequacy of an individual’s

intake requires: (1) an estimate of the individual’s usual or habitual dietary intake over the time

period of interest and (2) an estimate of the individual’s dietary requirements. Neither estimate is

straightforward.

The estimation of usual intake is complicated by the fact that individuals’ intakes vary

markedly from one day to the next. This variation is a function of environmental and biological

pressures on intake and measurement errors. Further, the level of day-to-day variation differs

across nutrients, depending on their concentrations in the foods that comprise the individual’s

diet. Classically, the highest variation is seen for vitamin A and the lowest is seen for energy.

An equation developed by Basiotis et al. (1987) can be used to determine the confidence

interval around an estimate of usual intake based on the assessment of actual intake on one or

more days. Using this equation, it can be demonstrated that the error term around an estimate of

usual intake for an individual decreases as the number of days of intake data increases. However,

the error term for estimates based on 1, 3, or even 7 days is very large, indicating that using a

limited number of days to assess dietary risk for an individual is hugely problematic.

The difficulty in estimating individuals’ usual intakes is compounded by the fact that the

precise magnitude and nature of day-to-day variation differs substantially between people.

Further, data from low-income women seeking food assistance in Toronto suggest that issues of

day-to-day variation are probably even more pronounced in the target group for WIC. Intakes

become even more erratic when economic constraints are added to everyday environmental and

biologic influences. Because day-to-day variation comes from multiple sources that vary among

individuals, it is likely impossible to strategize data collection in such a way as to eliminate this

source of error in the estimation of individuals’ usual intakes. Although there are statistical

techniques to estimate within-person variation and adjust for its effects on intake estimates in

large population studies, these methods are not appropriate for use at the level of individuals.

Other potential sources of error in the estimation of individuals’ usual intakes include

systematic under- or overreporting, proxy reporting, social desirability, and errors in the

assumptions made regarding food composition and nutrient bioavailability. Underreporting

appears to be pervasive in dietary intake surveys, affecting an estimated 10 to 45 percent of

samples. It has been associated with a number of factors, but appears to be a particular problem

among women with high body weight. There is also some evidence that children or young adults

are less prone to underreporting, and that individuals with lower socioeconomic status,

education, and literacy levels are more likely to underreport. It is unclear exactly what is being

underreported although there is some data to suggest that the reporting of fat, sugar, and alcohol

may be particularly problematic. In contrast to this, some studies have suggested that individuals

may be likely to overreport on the consumption of foods perceived to be healthful, particularly if

they had been engaged in interventions designed to improve healthful intake.

Usual intake can be estimated from the measurement of actual intake over a limited

number of days (using dietary recalls or records). Alternatively, a food frequency questionnaire
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can be used. However, neither method yields an estimate of usual intake without error. This is

well illustrated by a study of Crawford et al. (1994) in which a small sample (n=58) of 9–10

year-old girls had their lunch time intake observed and were asked to report their intake by one

of three methods: 24-hour recall, 3-day food record, or 5-day food frequency. Median percent

error between observed and reported intake by the different assessment methods (see Table 1)

indicates that while the particular nature of the errors differed, all three methods measured intake

with error.

TABLE 1 Median Percent Error Between Observed and Reported Intake from Lunch, by Method*

24-hour recall

(n=19)

3-day food record

(n=20)

5-day food frequency

(n=19)

Energy 19 12 28

Protein 19 14 26

Carbohydrate 26 16 33

Fat 39 20 23

*Percent Error = 100 × (| observed - reported |) / observed.

SOURCE: Crawford et al., 1994.

Lastly, the problem of measurement is compounded by the difficulty in interpreting

comparisons of intake estimates with dietary standards or nutrient requirement estimates.

Individuals differ from one another in their dietary requirements. Thus, if an individual’s usual

intake of some nutrient falls below a particular reference value, for example, it cannot be

assumed that the intake is inadequate to meet her requirement for that nutrient. Nonetheless, the

lower an individual’s usual intake is, the greater the probability that the intake is inadequate to

meet her needs. Both the between-person variation in nutritional requirements and the error

inherent in our estimation of individuals’ usual intakes need to be considered when applying

dietary assessment methods to determine nutritional risk.

References:

Basiotis PP, Welsh SO, Cronin FJ, Kelsay JL, Mertz W. 1987. Number of days of food intake

records required to estimate individual and group nutrient intakes with defined confidence. J

Nutr 117:1638–1641.

Crawford PB, Obarzanek E, Morrison J, Sabry ZI. 1994. Comparative advantage of 3-day food

records over 24-hour recall and 5-day food frequency validated by observation of 9- and 10-

year old girls. J Am Diet Assoc 94:626–630.
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Development of the Dietary Guidelines for Americans and

their Application to the WIC Population

Presented by Cutberto Garza, M.D., Ph.D.

Professor, Division of Nutritional Sciences

Cornell University

By law, the dietary guidelines represent the basis for federal policy and are used to guide

nutrition information, education, and interventions. While the food guide pyramid is one of the

major tools used for consumer education, the dietary guidelines, which incorporate the food

guide pyramid, are developed to be used as a policy instrument. The guidelines are quite relevant

to this committee’s task, in that the guidelines form the basis of federal food and nutrition

education programs.

The development of the new Dietary Guidelines for Americans was a very complex

exercise which relied heavily on available consensus documents. Contributing to the complexity

was incorporating all age groups from age 2 and older, all socioeconomic groups, both genders,

and multiple physiological states. In addition, the information needed to be reduced in such a

way as to be understandable to the average consumer, and yet be scientifically accurate.

 In developing the dietary guidelines, it was necessary to come up with generic

information when, in fact, the basis for it was questionable in terms of the available science.

Most difficult has been the nearly complete lack of usable data on the nutrient needs of infants,

children, adolescents, pregnant and lactating women—the groups that the WIC program deals

with. While the DRIs are currently being revised, the information gaps in the estimation of

average requirements by life stage and gender have been very difficult to come by. For this

reason, it is important to understand that there is an enormous amount of scientific judgment that

goes into the development of these guidelines. But yet, the best scientific information for

developing the dietary guidelines was available to this last guideline committee—more so than to

other committees who worked on previous versions of the guidelines.

 The first “dietary goals” were issued by the McGovern report and were released in 1977.

The work of the Senate select committee was very controversial. Nutrition scientists were, quite

literally, almost killing each other over whether the science was adequate enough for these

dietary goals to be set. History would suggest that, in fact, the Senate committee was quite wise

in their recommendations on the whole. Most of them are quite relevant today and have since

been borne out by the additional science.

 In 1979, the American Society for Clinical Nutrition brought together a panel that was to

review the relationship between dietary practices and health outcomes. Their findings were

incorporated in the Surgeon General's report on health promotion and disease prevention. These

were then the basis of the 1980 guidelines issued jointly by the Department of Health and Human

Services (DHHS) and the United States Department of Agriculture (USDA). While it was

primarily a federal effort, some external individuals were involved as well. In 1983,

nongovernment scientists were selected to review and make the recommendations to USDA and

DHHS about the first edition. Today, it is an external group which reviews the wide breadth of

information for all ages and income groups and then advises the government. Ultimately, the

guidelines are issued jointly by USDA and DHHS based on the recommendations of the external

group.
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 The dietary guidelines are to be based on current knowledge about how dietary intake

may reduce the risk of major chronic diseases and how a healthful diet may improve nutrition.

The basis is not just deficiency diseases, but in fact, the emphasis is on how dietary patterns can

be used to both avoid deficiency and also achieve other health outcomes that are believed to be

related to diet and dietary patterns. There is now a public law that requires publication and

revision of the guidelines at least every 5 years.

 The guidelines serve five very broad objectives. The first is to assist consumers in

making dietary choices—choices which are most likely to promote well-being and avoid or

postpone the onset of diet-related chronic diseases. This presents some challenges given the

paucity of data in terms of nutrient requirements of children and pregnant or lactating women.

When one adds to this the relationship between diet, nutrient-specific recommendations, and

chronic disease, one has to rely almost exclusively on epidemiological data. This type of data is

great for hypotheses and associations, but in terms of causality, it presents some challenges.

 The remaining objectives of the guidelines are: to assist federal, state, and local agencies

in the development, implementation, and formulation of regulatory policies and programs; to

assist health care providers in primary disease prevention efforts; and lastly, to guide other

domestic and international for-profit and not-for-profit organizations in the implementation of

nutrition and health goals.

 In developing the new dietary guidelines, the number of guidelines increased from seven

to ten and are now grouped under the categories of Aim for Fitness, Build a Healthy Base, and

Choose Sensibly (see Table 1).

TABLE 1 Dietary Guidelines for Americans

AIM FOR FITNESS...

• Aim for a healthy weight.

• Be physically active each day.

BUILD A HEALTHY BASE...

• Let the Pyramid guide your food choices.

• Choose a variety of grains daily, especially whole grains.

• Choose a variety of fruits and vegetables daily.

• Keep foods safe to eat.

CHOOSE SENSIBLY...

• Choose a diet that is low in saturated fat and cholesterol and moderate in total fat.

• Choose beverages and foods to moderate your intake of sugars.

• Choose and prepare foods with less salt.

• If you drink alcoholic beverages, do so in moderation.

Aim for Fitness. Under this heading are the guidelines Aim for a healthy weight and Be

physically active each day. These guidelines are just as relevant to pregnant or lactating women

and young children over the age of 2 as they are for any other age group. While there are no

specific recommendations as to what a healthy weight should be for a pregnant woman, weight is

discussed for a general adult population. The advice regarding physical activity is relevant to

pregnant and lactating women.
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 Build a Healthy Base-Let the Pyramid guide your food choices is the second group of

guidelines and represents somewhat of a tautology. The pyramid is supposed to reflect the

guidelines and the guidelines are saying to follow the pyramid. Under this guideline is a section

of particular relevance to pregnant womenUse of dietary supplements. The guideline

committee felt that it was very difficult for pregnant women to meet the iron requirements for

pregnancy and for this reason a statement was added to this effect. The other point that this

guideline makes is for folate. Women who are pregnant or who are at risk for becoming pregnant

should choose foods that are fortified in folate or take a folate supplement. It was felt that, given

present levels of supplementation, if women were judicious in their food choices, a supplement

would not be necessary.

 Choose a variety of grains daily, especially whole grains. This guideline is of relevance

to the WIC population because of the concern regarding folate intake for pregnant women. When

the U.S. fortification policy and consumption patterns were looked at, the guideline committee

came to the conclusion that it was necessary to put the emphasis on whole grains because many

grains are not fortified and without the emphasis, women could be put at risk of folate deficiency

and birth defects.

 Another reason whole grains were emphasized was recent epidemiological data

suggesting that whole grains can be, for reasons we do not yet understand, associated with

significant reductions in cardiovascular disease risk. The reason for using the word especially

was that the grains group was the food group for which Americans have the largest gap between

consumption patterns and recommendations. By using the word especially, the development

committee hoped to emphasize grains and increase public attention to this area.

 Whole grains were separated from Choose a variety of fruits and vegetables because

dietary patterns based on grains, fruits, and vegetables appear to be associated with the highest

reductions in disease risk. Consumers have treated these groups as interchangeable when, in fact,

benefits from these nutrients are significantly distinct. By separating the groups, it was intended

to point out that they are not interchangeable.

 Keep foods safe to eat is the other new guideline and is the second guideline where

pregnancy is specifically mentioned. The committee felt very strongly that if a recommendation

is made for a healthy diet, it had to be safe as well. One could not divorce microbiological safety

or other contaminants in the food supply from a healthful diet. So these were not nutrient

guidelines but food-based dietary guidelines. Obviously, women may be at risk if they are not

following food safety guidelines, and they may benefit from WIC, to the extent that WIC

incorporates this into their educational materials. Pregnant women, along with the elderly, young

children, and immune-compromised groups are at the highest risk for certain food-borne

pathogens.

 The third group, Choose Sensibly, is the most complicated of all the guidelines. The

difficulty stems from the guideline Choose a diet that is low in saturated fat and cholesterol

and moderate in total fat. Because the emphasis has been placed on low-fat diets when most of

the concern was being driven by saturated fat, the message regarding dietary fats and cholesterol

was not being adequately translated by either industry or consumers. This guideline is

complicated because consumers are now being asked to differentiate between total fat, saturated

fat, polyunsaturated fats, monounsaturated fats, and trans-fats. While there is science to back this

up, trying to educate the public on these various types of fats will be an enormous challenge.

However, it is one that the committee felt was significant enough because most of the risk is
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related to saturated fats and trans-fats. The guideline committee 5 years ago did not have the

science that is available today on the issue of trans-fatty acids.

 The most controversial guideline, certainly in terms of public comment, was the guideline

Choose beverages and foods to moderate your intake of sugars. There was quite a bit of debate

among the development group about how the guideline should be worded. The controversy was

whether the word moderate or limit should be used. In addition, dietary intake trends indicated

that the highest level of increasing sugar consumption came from added sugars in beverages.

There was significant concern that many consumers didn't recognize beverages as a source of

sugarsthey were not foods in their minds. For this reason, the committee needed to also include

the word beverages in the guideline.

 The development committee needed to be very careful whenever the term moderation

was being used in terms of quantitating the advice. One of the major changes they tried to make

with the new guidelines was to make them more actionable. For example, the word moderate in

the total fat guidelinethe wording states to aim for a total fat intake of no more than 30 percent

of calories, but one does not need to go much beyond that. The committee felt that telling

consumers to moderate their intake was very difficult to put into action. On the other hand, there

were many others who felt that by using the term limit, the committee was going beyond what

the science provided. The committee’s rationale was that given the increasing rates of obesity in

this country, it is obvious that there is an energy balance problem. If consumers are asked to eat

more of certain products, they needed to be asked to eat less of other products. Consumers were

asked to limit their consumption of alcohol, fat, and sugar.

 The next guideline in this grouping, Choose and prepare foods with less salt has been

reworded but the message is essentially the same. The only difference is that there is now a

quantitative recommendation for salt intake.

 The third guideline in which pregnancy is specifically mentioned is If you drink

alcoholic beverages, do so in moderation. Throughout committee deliberations, it was clear that

there was no way to distinguish at what level of drinking would birth defects become a problem

or have other adverse effects in women. For this reason, pregnant women or those at risk of

becoming pregnant were asked not to drink alcohol at all.

 The other reason for the way the guideline is stated is because there are health benefits

associated with alcohol. It does not matter what form the alcohol is in (wine, beer, distilled), it is

the ethanol that appears to be the active agent. There is a significant reduction in risk to

cardiovascular disease that appears to operate via a reduction in platelet aggregation. Because it

is an acute effect, one does not obtain any benefits from a lifetime of drinking. Rather, if one is

interested in drinking for health benefits, there is no reason that drinking should begin at age 21

because the benefit does not become available until one is at risk for cardiovascular disease45

years of age for men and 55 years of age for women. It is also clear that, at least for women,

more than one drink a day increases risk for breast cancer. However, women should not be asked

to refrain from drinking alcohol because there are benefits as well as risks. For this reason,

postponing drinking until after the age of 55 if consuming it for health reasons seems the most

rational and prudent thing to do.

 Overall, the major changes in the guidelines are mainly the grouping of the

recommendations and the addition of guidelines on physical activity and food safety. Because

pregnancy is such a teachable moment, it is hoped that WIC provides an opportunity to impress

the point that physical activity is important for everyone. It is not just for women in other age

groups, men, or for those who need to lose weight. There are significant health benefits that
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physical activity provides. Physical activity permits individuals to increase food intake and

therefore increases the likelihood of getting all the nutrients needed from food. Other changes in

the 2000 guidelines include a separation of guidelines on grains from fruits and vegetables, a

shift from an emphasis on total fat to the reduction of specific types of fats, a recognition of the

trends in sugar intake, and greater specificity in the alcohol guidelines.

 The guidelines are quite applicable to the WIC population, but only after the age of 2.

The likely reason that everybody has shied away from the under 2 population is that trying to

look at nutrient-specific requirements is very difficult based on the data available for the first

year of life. However, focusing on women’s health in the WIC setting can be very beneficial and

advantage should be taken of this opportunity. In fact, it is scientifically appropriate to do so.

Pregnancy represents an ideal time to get women to focus on their health and enhance their

knowledge, behavior, and practices. In many households, women are the gatekeepers for health.

In addition, for many women, problems with overweight and obesity appear to begin during

pregnancy and the postpartum period.

 While the guidelines are very applicable to the WIC population in terms of defining an

inadequate diet, it is not likely possible to come up with a simple paradigm or algorithm for

compliance by looking at only a few of the guidelines. The grouping of guidelines were not

intended to be prioritized in any way; they all are relevant to good health. It is important to

remember that the risk is to long-term outcomes. For the individual, we have gone to some

lengths to ask people to look at their own family histories and their own risks. For example, if

one knows that there is no hypertension in their family history and no one has ever died of

stroke, then for that individual, perhaps the salt guideline under those conditions would not be as

important. Perhaps in this particular family history, everyone seems to be dying at the age of 50

from atherosclerosis. For this individual, paying attention to fat and physical activity or having

one drink a day once over the age of 40 may be more important to lowering this individual’s risk.

The guidelines could perhaps be prioritized in some way for each individual. However, from a

public health perspective, it is not likely possible.
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Development of the Food Guide Pyramid and

Its Application to the WIC Population

Presented by Kristin Marcoe, M.B.A., R.D.

Nutritionist, Center for Nutrition Policy and Promotion

U.S. Department of Agriculture

 The Food Guide Pyramid and the Food Guide Pyramid for Young Children are sciencebased food guidance. A food guide translates recommendations on nutrient intake into

recommendations on food intake. The Food Guide Pyramid and, subsequently, the Food Guide

Pyramid for Young Children were developed using a sound research process and were based on

a set of established philosophical goals. These philosophical goals included: (1) a food guide

should promote overall health; (2) it should be based on current nutrition research; (3) it should

be based on the total diet instead of a core or foundation diet; (4) it should be useful to a target

audience; (5) it should meet nutritional goals in a realistic manner; (6) it should allow flexibility

in how consumers meet nutritional goals; (7) it should be practical, hence varying numbers of

servings to meet different calorie and nutrient needs; and (8) it should be evolutionary.

 Nutrition goals for the food guide were originally based on the 1980 Recommended

Dietary Allowances (RDAs) for nutrients for which there are adequacy concerns such as calories,

protein, vitamins, and minerals. Also considered were the 1980 Dietary Guidelines for

Americans for fat and sugar—for which there are moderation concerns. Subsequent releases of

the RDAs and Dietary Guidelines have been used to update the food guide.

 The food groups were defined for the food guide by primarily considering the nutrient

content of a food, but also the usual use of a food in meals and how a food was grouped in earlier

food guides. In the most recent food guide, foods which were high in fat and added sugars and

low in nutrient density were put in a separate group, the tip of the pyramid, in order to highlight

the need to moderate intake of these food components. In addition, vegetables were separated

from fruits, and subgroups within the vegetables were used to emphasize nutrients and specific

food components.

 Serving sizes for the food groups were based on typical serving sizes reported in the U.S.

Department of Agriculture’s (USDA) food consumption surveys. Consideration was also given

to using common measures easily utilized by consumers, such as 1 cup. Nutrient content was

used to establish serving sizes in the milk group and for meat alternates in the meat group. Each

food in the milk group was assigned a serving size that would provide 300 mg of calcium, the

amount in 1 cup of skim milk. Amounts of meat alternates would provide approximately the

same amount of protein and minerals found in 1 oz of meat.

 Tradition dictated that serving sizes used in previous food guides will continue to be used

for some foods. For example, two slices of bread is the typical amount eaten at a single occasion,

yet one slice of bread is considered a serving. There was concern that if the serving size was

changed to two slices, it would reduce the minimum number of servings for grains from six to

three. This would have contradicted the philosophy of the Dietary Guidelines, which encourage

the consumption of more grains.

 In order to determine the nutrient profiles of each food group and subgroups, composites

were created using USDA food consumption survey data. Each profile represented the amounts

of nutrients one would expect to obtain from eating a serving of a food group or subgroup. The
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original Pyramid work used 1977–1978 Nationwide Food Consumption Survey data. The 1989–

1991 Continuing Survey of Food Intake by Individuals (CSFII) data was used to update the

original data. It was based on foods reportedly consumed by 11,488 individuals, 2 years and

older over 3 days. Sample weights were applied to provide estimates representative of the

population. Work is currently in progress to update the composites using 2-day weighted data

from the 1994–1996 CSFII and the Agriculture Research Service's Pyramid Servings Data in

conjunction with consumption data from this survey.

 For the initial update, composites for each food group and subgroup, such as dark-green

vegetables, were developed based on reported consumption of food items (i.e., cooked broccoli)

in the CSFII 1989–1991. USDA's Center for Nutrition Policy and Promotion developed a Food

Guide Servings Database for the CSFII 1989–1991. This database was used to convert grams of

foods consumed into numbers of food guide servings consumed. A composite of item groups

was then constructed, weighted by the numbers of servings of each reported by all individuals.

One food code was selected to represent each food item group in each of the composites.

 Nonfortified ready-to-eat and cooked breakfast cereals were used in both the whole grain

and enriched grain composites. In this way, the nutrient profiles of these composites do not overestimate the nutrients for those individuals who do not eat fortified breakfast cereals. Nutrients

added at standard enrichment levels, such as in enriched bread, were used in the composites.

Folate fortification was not mandated by the government at the time the 1989–1991 survey was

conducted, and was therefore not reflected in the nutrient profiles for grain products. However,

in the 1994–1996 work, nutrient values for folate were modified to bring them up to current

levels.

 Nutrient profiles for each composite were calculated using forms of food items lowest in

fat and added sugars. This reflected the philosophical goals that the food guide should be realistic

and allow maximum flexibility for users to select specific sources of fats and sugars within their

diets.

 To minimize sodium, the form of the food item with the lowest amount was used in the

composite. For most of the vegetable and cooked grain item groups, food codes were used which

specified “no salt added in preparation.” However, in a few cases, the salted form of the food

was used for vegetables based on 1989–1991 food supply data.

 Once a food code was selected to represent each of the food item groups in each of the

composites, grams and corresponding nutrient values of each were calculated for its portion of

the composite serving. Nutrient values were then summed across all item groups in the food

group or subgroup to determine the composite's nutrient profile per serving. The nutrient values

were derived from USDA's Survey Nutrient Database. Thus, each composite had a nutrient

profile which represented the most frequently consumed foods in that food group.

 A fat composite was developed to represent “discretionary” fat added to the diet above

the fat found in lean meats and the other forms of composite foods that were lowest in fat. For

example, the fat in cakes and margarine spread on bread are discretionary fats. The nutrient

profile for the fat composite was updated using proportions of animal and vegetable fats in the

food supply during 1989–1991.

 The numbers of servings for each food group and subgroup in the food guide were based

on nutrient adequacy and moderation. The numbers of servings required to meet the 1989 RDAs

for protein, vitamins, and minerals were determined. Since RDAs vary based on age, sex, and

pregnancy status, ranges in the numbers of servings of the food groups were set to cover the full
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range of nutrient needs. The higher number of servings is for individuals with greater caloric and

nutrient needs.

 Sample Food Guide Pyramid diet patterns for several caloric levels, including 1,600,

2,200, and 2,800 calories, were developed to reflect the range of food group servings. For

example, the minimum number of servings for each food group is based on a 1,600-calorie

pattern, while the maximum number of servings reflects a 2,800-calorie pattern. The greater

numbers of servings in the higher calorie diet patterns are for individuals with higher nutrient

and calorie needs, such as teenage boys, active men, and very active women. The lowest number

of servings is for sedentary women and older adults.

 Choosing a variety of foods from within each food group is important in obtaining the

expected levels of nutrients. This is particularly true for the vegetable group, where certain

subgroups (i.e., dark-green and deep-yellow vegetables, legumes) have been targeted for

increased consumption.

 Three whole grain servings in the patterns were based on the Food Guide Pyramid

recommendation to choose “several” servings a day of foods made from whole grains. There has

always been an emphasis on whole grains in Pyramid materials, and this continues to be

consistent with the Dietary Guidelines. For the meat alternates, the number of egg servings was

based on three eggs per week. This ensured that the cholesterol value across the patterns would

average 300 mg or less per day, based on the National Research Council's 1989 Diet and Health

report.

 Three servings from the milk group had been recommended in the past to meet the higher

calcium needs of pregnant or lactating women, teenagers, and young adults to age 24.

In light of the change in calcium requirements in the new DRIs, three servings from the milk

group are now recommended for older children and teenagers (children ages 9 to 18) and adults

over age 50. During pregnancy and lactation, the recommended number of milk servings is the

same as for nonpregnant women. This information appears in the newly-released Dietary

Guidelines 2000.

 As indicated previously, sample Food Guide Pyramid diet patterns were developed and

composites and their nutrient profiles used in these at three calorie levels that would meet

established goals for protein, vitamins, and minerals. Ranges in numbers of servings were used

to cover the varying needs of males and females 2 years of age and older. These patterns

included added or discretionary fat and added sugars. Discretionary fat was added to bring the

level of total fat in the three patterns to 30 percent of calories. Added sugars, represented as

teaspoons of sugar, were included to bring calories to the targeted levels. It should be

emphasized that the different amounts of sugar in the three patterns are not recommendations,

but merely indicate the calories, in teaspoons of sugar, needed to meet the targeted calorie levels

for each pattern.

 Analysis of the Food Guide Pyramid diet patterns have shown that the RDAs are

generally met. Nutrients that failed to meet the RDAs were iron and zinc. Iron is the main

nutrient for which adequacy is a concern, but only for individuals who have both high RDAs for

iron and who choose the minimum number of servings from the food groups. For example, a

female whose energy requirement is 2,200 calories per day may be choosing the minimum

amount of servings from each food group, and therefore, only consuming about 1,600 calories

per day. At this reduced calorie level, nutrient needs, especially iron and zinc, may not be met.

Therefore, these females would need to consume foods rich in iron or eat an iron-fortified

breakfast cereal in order to meet their nutrient needs.
A-15

 The diet patterns also meet the saturated fat goal of less than 10 percent of calories.

Cholesterol values in the 1989–1991 composites, being used in the patterns, are now lower than

what appear from the 1977–1978 composites. Sodium levels continue to fall below the 2,400 mg

recommendation. Total dietary fiber continues to range from 17 g in the 1,600-calorie pattern to

about 27 g in the 2,800-calorie pattern.

Food Guide Pyramid for Young Children

The Food Guide Pyramid for Young Children was developed using the same

methodology as was used for the original pyramid. The quantitative and qualitative research for

this project will be published in the next issue (this summer) of Family Economics and Nutrition

Review, a peer-reviewed journal of the USDA Center for Nutrition Policy and Promotion.

In order to meet the objective of adapting the original Food Guide Pyramid to a younger

audience, a literature search was first conducted to help decide on the target audience of 2–6-

year-olds. The philosophical and nutritional goals, developed for the original Pyramid, were reexamined and adapted for young children. Once the goals were set, discussions were held with

nutrition professionals who educate young children, parents and care-givers.

 Just as composites were developed for the original Pyramid, food group and subgroup

composites were developed based on reported food intakes of 1,053 children ages 2 to 6 years

over 3 days in the CSFII 1989–1991.

 The whole grains composite is an example of what was done for each of the food groups

and subgroups. The children obtained the bulk of their whole-grain servings from cereals, both

hot and ready-to-eat. Once the make-up of each of the food groups and subgroups was

determined via composites, the average quantity of food a child would eat at a single occasion

was calculated. The amounts reported for young children were 60 to 80 percent of those for all

individuals. This suggests that it is appropriate to continue to use the serving size estimate of

one-third smaller serving that was used previously in assessing nutrient levels in Food Guide

Pyramid patterns for young children. Two- to 3-year-old children eat two-thirds of a serving,

whereas the older or 4- to 6-year-old children have regular-sized servings.

 While a 1,300-calorie pattern was developed for 2 to 3 year olds, a 1,600-calorie pattern

was developed for 4 to 6 year olds. Although the REI for 4 to 6 year olds is 1,800 calories, food

consumption data reported for this age group in the CSFII 1989–1991 averaged 1,533 calories.

 Focus groups with parents indicated that parents were concerned that their children might

not be getting adequate nutrients from the amount of food that they were eating. It was important

to determine whether a diet pattern set closer to the level of calories that children reportedly eat,

based on their reported food choices, could meet their nutrient requirements. The 1,300-calorie

pattern represented the minimum number of servings per Food Guide Pyramid food group and

was calculated by reducing the 1,600-calorie pattern by one-third for all the food groups and

subgroups except milk, which remained 2 cups. This was to represent the smaller serving size

estimated for 2- to 3-year-old children.

 The nutrient levels in these patterns were compared to the RDA for 2 to 3 and 4 to 6 year

olds, as well as to actual nutrient intakes of these children from survey data. The goal was to

meet or exceed the RDA for nutrients, or to at least improve levels relative to actual

consumption. The 1,600-calorie pattern met all nutrient requirements for children age 4 to 6

years, except for vitamin E. The 1,300-calorie pattern provided the RDA for most nutrients for 2

to 3 year olds. The major exceptions were iron and zinc. When breakfast cereals fortified with
A-16

iron and zinc were included in the grain composites, the patterns did provide recommended

levels of these nutrients. In looking at the average actual consumption of servings in each of the

food groups and subgroups, it was evident that children were not consuming the recommended

numbers of servings from most food groups. Their diets could be improved by eating more darkgreen and deep-yellow vegetables, legumes, whole grains, and lean meat, poultry, and fish.

 Beyond the composites for children, analysis for other subpopulation groups, like

Hispanics and African Americans, have not yet been done, although this is possible if the sample

size is large enough in USDA's food consumption surveys.

 The food guide is based on nutrient recommendations such as the DRIs and Dietary

Guidelines. For this reason, as these are revised and released, the food guide recommendations

will be reassessed to make sure they meet the nutritional objectives. An article entitled

Reassessing the Food Guide Pyramid: Decision-Making Framework, written by Anne Shaw and

others at the Center for Nutrition Policy and Promotion will appear in the March/April 2000

issue of the Journal of Nutritional Education and serves as a good reference of the reassessment

process.

 Updating the nutrient profiles of the food group composites can also be done when there

are major changes in nutrient composition, like the fortification of certain grain products with

folate. By using updated composites in the Food Guide Pyramid diet patterns, and comparing

expected nutrient levels to nutritional objectives, it can be determined whether or not the patterns

meet objectives. If not, there are several options. Guidance could be individualized for selected

sex/age groups on choosing certain foods in food groups to help them meet higher nutrient

standards. The numbers of servings for a food group or subgroup could be modified. Another

possibility would be to create a new food group or subgroup to emphasize sources of a target

nutrient or food component, such as a separate tomato group if lycopene intakes continue to

generate interest, assuming serving recommendations were developed. Each proposed change

would need to be evaluated in terms of its effects on calories and other nutrients in the diet

patterns. In addition, consumer understanding of the Food Guide Pyramid and barriers to its use

must be monitored. Such research is currently being planned and through it, the USDA will

continue to have a tool that consumers can successfully use to meet their nutrient needs.
A-17

Assessing Individuals Total Food Intake and Cognitive

Aspects of Questionnaires

Presented by Amy Subar, Ph.D., M.P.H., R.D.

Research Nutritionist, Division of Cancer Control

National Cancer Institute

From a cognitive point of view, food frequency questionnaires (FFQs) can be difficult for

respondents to understand and complete. They require complex knowledge, skills, and

attentiveness with respect to food intake. Cognitive techniques can be used on all types of

instruments, whether they are self- or interviewer-administered, and would be useful in the WIC

population or any specific population.

This research describes the methods and results of three rounds of cognitive interviewing,

the purpose of which was to improve self-administered FFQs. Cognitive aspects having to do

with the wording, ordering, or anything that would ease the task and help respondents better

understand the questions were evaluated. The cognitive research was conducted with the help of

two cognitive psychologists, Jared Jobe and Albert Frederick Smith. The goal was to learn about

the cognitive strategies individuals use in responding to FFQs, identify the problems, modify and

test new questions, and design a cognitively improved questionnaire. The instrument that was

developed based on this cognitive testing was then to be evaluated with respect to response rates,

validation, calibration, and measurement error.

Using a Block questionnaire as the baseline instrument, 24 respondents in each of three

phases were enlisted. While an effort was made to recruit a diverse group of respondents in terms

of socioeconomic level and ethnic diversity, individuals with major literacy issues were not

included. The respondents were asked to think aloud as they completed the instrument. In this

way, the researcher could hear what the respondents were thinking as they formulated their

answers to each question. Mistakes and misunderstandings could be heard as the instrument was

completed. Doing pilot testing in this way versus discussing questions, thoughts, or problems

after completion of the instrument has advantages in that interviewers hear and see problems

with question, wording, layout, and understanding for each individual question as it is answered.

In some cases, such problems might not be remembered at the end of a long task. Each interview

took, on average, 2 hours per respondent.

Following the interviewing, the researchers pooled findings and discussed common

problem areas. The interviewing uncovered a series of both subtle and generic issues in

responding to FFQs having to do with wording, layout, design, and order. Specific examples of

problem areas had to do with respondents having difficulty with not having a response category

of “never” separated from “a few times per year,” responding to portion size questions referred

to as “small,” “medium,” and “large,” responding to frequency of intake for seasonal foods, and

responding to line items which included one or more foods not typically eaten as substitutes for

one another (for example, tomatoes and tomato juice). Although averaging intake over 1 year is

not particularly easy, it does provide the best picture of usual intake. Asking about shorter time

frames such as the past month or week may be easier but may not best represent long-term usual

intakes. Many of the stumbling blocks for respondents are simple things that can be easily

changed helping respondents to easily get through the process of completing the instrument.

Although most of the innovations incorporated into the new instrument based on the cognitive

testing would likely make completing the questionnaires easier for respondents, the next
A-18

important area of research was whether or not such innovations would lead to better food group

and nutrient intake estimates.

Findings from the cognitive testing led to the development of a new FFQ at the National

Cancer Institute, the Diet History Questionnaire (DHQ), which was validated using a checklist

approach, to assess frequency of intake in the past month. Three studies were conducted or are in

the process of being conducted to validate it to see if, in fact, the cognitive improvements would

prove to be valuable in validation studies. Findings from the Checklist Validation Study show

that most, but not all of what were considered cognitive improvements incorporated in the DHQ

were superior. Many of the changes made to the instrument based on the cognitive testing

showed significant improvements over the Block instrument as compared to reference data from

the past month. In a few areas, the data showed that the changes were not improvements. In some

cases, even if accuracy was no different, the cognitively improved questions were retained if the

investigators felt strongly that they were easiest for the respondents to answer. Based on the

findings of the Checklist Validation Study, the DHQ was further modified.

Further piloting compared response rates and data completeness between the DHQ and a

standard FFQ in a sample of participants from a clinical screening trial. Response rates were

identical for both FFQs. A significantly lower proportion of respondents skipped or missed

portion size and supplement questions on the DHQ versus the standard FFQ. These findings

suggest that intensive cognitive interviewing is beneficial in the development of dietary

assessment instruments and would be beneficial in developing a dietary assessment tool to be

used in the WIC setting.
A-19

Use of the Block Questionnaire in the WIC Program

Presented by Gladys Block, Ph.D.

Professor, Department of Public Health and Health Policy Management

University of California, Berkley

This study was designed as a validation study for the Block Food Frequency

Questionnaire (Block FFQ) and the Harvard Food Frequency Questionnaire (Harvard FFQ). The

questionnaires were self-administered and had both geographic and ethnic variation. Full length

questionnaires with manual scoring systems were tested. Subjects consisted of WIC participants

of African American, Caucasian, and Hispanic origin. Seven hundred fifty-seven pregnant,

lactating, and nonpregnant women, and children ages 1 to 4 completed the study. There was

equal distribution across the three ethnic groups and throughout WIC clinics of California, Ohio,

Texas, and New York. Intake was examined for protein, iron, calcium, vitamins A and C, and

energy.

Participants in WIC clinics were randomized to receive either the Harvard or Block FFQ

(see Table 1). The questionnaires, which were self administered at baseline, were offered in

English or Spanish. Then, over the next month, three telephone interviews took place using the

Minnesota NDS system. At the conclusion of the 1-month time period, a self-administered

questionnaire was repeated at the WIC clinic.

Results among the women indicated identical caloric intake and no significant differences

in the mean nutrient intakes between the Harvard and Block FFQ. Among the children, there

were significant differences in the mean nutrient intakes by recall data in protein (47.5 g

[Harvard] vs. 52.0 g [Block]; p = 0.04) and calcium (876 mg [Harvard] vs. 893 mg [Block]; p =

0.06). Data were recorded for the length of time for completion of the FFQ, the amount of

assistance required, and the time for the WIC staff member to perform manual scoring.

While these tools were originally developed for epidemiological study, in this study they

were used to determine eligibility for the WIC program. Both are long instruments designed to

calculate an extensive list of nutrients. For this reason, the time for completion and evaluation is

TABLE 1 Usability in WIC Settings

Criterion Ethnic Group Harvard Block

Time for respondent to complete

FFQ (median in minutes)

White

African American

Hispanic

6.0

8.0

10.5

8.0

9.0

13.5

Amount of assistance required

(1=none, 2=little, 3=some,

4=much) (mean)

White

African American

Hispanic

1.5

2.0

1.9

1.6

2.1

2.0

Median Mean Median Mean

Time for aide to perform manual

scoring (minutes)

FFQ-1 (baseline) 3.0 3.9 3.0 3.8

FFQ-2 (endpoint) 3.0 3.2 3.0 3.4
A-20

overestimated since the instruments are more extensive than what would be needed in a WIC

clinic.

Nutrient intake recalls were examined and compared to both the Harvard and Block

FFQs. Both the Harvard and Block FFQ were found to significantly overestimate intakes of

protein, calcium, vitamin A, and vitamin C. The Harvard FFQ also overestimated energy intake

and the Block FFQ overestimated iron intake. While both instruments were found to

overestimate various nutrient intakes, the Block FFQ tended to overestimate less often than the

Harvard FFQ.

Pearson correlations were performed on the Harvard and Block FFQ between the FFQ

and three 24-hour recalls (see Table 2). Correlations below 0.40 were considered inconclusive.

The Block FFQ tended to have a higher correlations for African American and Caucasian WIC

participants. Both instruments had low correlations with three 24-hour recalls in children and

Hispanic women, and therefore seemed to be no more reliable than chance.

TABLE 2 Validity Coefficients of the Harvard and Block Food Frequency Questionnaires

Mean Nutrient Intake by Recall Data Harvard Block

Hispanic Women

 Energy (kcal) 0.19 0.14

 Protein (g) 0.13 0.09

 Vitamin A (RE) 0.4 0.15

 Vitamin C (mg) 0.28 0.17

 Iron (mg) 0.28 -0.01

 Calcium (mg) 0.18 0.15

Black Women

 Energy (kcal) 0.18 0.53

 Protein (g) 0.22 0.46

 Vitamin A (RE) 0.00 0.28

 Vitamin C (mg) -0.36 0.32

 Iron (mg) 0.02 0.40

 Calcium (mg) 0.27 0.46

White Women

 Energy (kcal) 0.27 0.44

 Protein (g) 0.33 0.53

 Vitamin A (RE) 0.28 0.62

 Vitamin C (mg) 0.33 0.20

 Iron (mg) 0.27 0.47

 Calcium (mg) 0.40 0.56

Children

 Energy (kcal) 0.13 0.14

 Protein (g) 0.19 0.15

 Vitamin A (RE) 0.28 0.03

 Vitamin C (mg) 0.10 0.19

 Iron (mg) 0.01 0.15
A-21

One possible explanation for the poor outcomes seen in the Hispanic population could be

attributed to the level of education. While all of the African American respondents had greater

than a ninth grade education, 35 percent of the Hispanic respondents and 1.4 percent of

Caucasian respondents had less education than the ninth grade. In addition, the FFQs were

designed for African American and White women’s cognitive capabilities, not Hispanics. This is

an important area to pursue, given that various cultures answer questions in different ways.

Cross-classification is a better measure than correlation because correlations are

influenced by a number of factors, including the range of distribution. The questionnaires and the

diet recall were divided into quartiles by 3-day averages, then cross-tabulated. For the African

American and Caucasian participants, the agreement was 28 percent. The cross-tabulation

approach worked better for the Block FFQ and did not work at all for the Hispanic participants

Manual scores were examined for the Block FFQ to determine if this method was able to

identify a group with low intake (or high intake). Based on the average of three 24-hour recalls,

low true intake levels were observed in the low quartile of the manual score method in the WIC

nutrients. With the manual scoring system it is possible to move the cut point. For example, if

individuals who are getting less protein than the recommended level need to be identified, the cut

point could be moved down. Another example would be to move the calcium cut-off point in

order to identify individuals with intake under 800 mg, or less than the RDA. To accomplish this,

the cut point could be moved. Unfortunately, this approach would not be valid for the Hispanic

WIC population or in children.

Use of a FFQ is difficult in WIC children. Women who had 24-hour responsibility for the

nutrition of their children were asked to report the food intake for their children. No significant

correlations in FFQ and diet recall were found. Using short simple screening questions may be a

more effective method for evaluating dietary risk in children. For example, questions such as

“Did you give your child any fruit last week?” or “How many days a week did you give your

child any fruit?” There will be problems in justifying the scientific validity, but in terms of

common sense, one could say if it is less than seven for any of these, then there should be a

concern for that child.

In terms of Hispanic participants, similar problems exist. Correlations were found to be

poor for both instruments. Since the Block FFQ was not designed to contain Hispanic food

choices, it is not currently a good choice for this population. The instrument would need to be

modified for a Hispanic population. Because of problems with education level, interviewing

respondents rather than providing participants with questionnaires that need to be self

administered may help. Overall, the Block questionnaire appears to be an instrument that works

in the African American and Caucasian population when using the manual score methodology.
A-22

Use of the Harvard Food Frequency Questionnaire in the WIC Program

Presented by Graham Colditz, M.D., Dr.P.H.

Professor of Medicine

Harvard School of Public Health

The Harvard Food Frequency Questionnaire (HFFQ) is a self-administered tool in which

a client makes reference to a 4-week time period in contrast to a 1-year reference period that

many other FFQs use. It was originally developed as a 60 item questionnaire for nurses in

response to a request from the National Cancer Institute. It has since been expanded to include

approximately 120 items. In the mid-1980s, the questionnaire was modified and implemented for

use in pregnant and lactating women. Later, it was also modified for use in children 1 to 5 years

of age. Most of the development for use in children included input from local WIC participants

in Boston.

The HFFQ is currently available in both English and Spanish and can be administered in

a paper format as well as a computerized direct entry format. It is comparable to other FFQs,

except for the length of the reference period. It is simple and tends to have less items than other

FFQs. Responses can be manually entered by either the participant or staff in a WIC setting and

can provide instant computer-generated printouts. Computerized scoring systems are optimal to

manual scoring methods because they can provide tailored feedback.

The development of the list of foods and portion sizes for the HFFQ is based on data

from the Continuing Survey of Food Intake by Individuals. It has been designed with substantial

input from clinics in Massachusetts as well as U.S. Department of Agriculture (USDA)-funded

focus groups and clinics in North Dakota. The Harvard nutrient database is used. Although this

database is primarily based on USDA data, it is additionally supplemented for some nutrients.

While it contains data on more than 80 nutrients, the WIC Clinic computerized version focuses

on nutrients specifically focused on in the WIC program. The database is continually updated.

For example, when the food supply was fortified with folate, the values for folate were updated

for all foods in the HFFQ. One limitation of the instrument is the focus on nutrients rather than

whole foods and food patterns. This is an area that is currently being reexamined.

The computerized direct entry version was developed and pilot tested in Massachusetts

with feedback from WIC providers and clients. The instrument is in a menu-driven format with

on-screen directions. This set-up allows for branching. For example, if a client fills in that she

does not drink milk, she does not have to get the next set of questions regarding milk

consumption. This makes the overall process more efficient. Another advantage of direct entry is

that there is not the opportunity for clients to skip lines. In contrast, in the old grid system, one

could go across the rows when marking answers and put two marks on the same line. Another

advantage is a significantly lower error rate on the computerized entry version compared to the

pencil and paper version. Hence, there is less likely to be gross overestimation. It is also efficient

in terms of the provider’s time. The participant can complete the HFFQ prior to meeting with the

WIC counselor and the allotted time can be used for nutrition counseling, rather than completing

the assessment. The disadvantages to this process include the equipment cost and space

requirements in addition to a paper copy needed for backup in the client record.
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Several validation studies using the HFFQ have been performed in pregnant women and

children. In 1999, Blum and colleagues conducted a validation study using the HFFQ in White

and Native American children. Suitor and colleagues (1989) conducted a validation study on

Caucasian, African American, and Hispanic women. The analysis consisted of WIC nutrients

only. In 1999, Wei and colleagues used the same data, expanded the range of nutrients in the

analysis, and used an alternative approach to error correction for intra-individual variation in

day-to-day diet, based on three 24-hour recalls. A summary of the correlation coefficients found

in these studies can be found in Table 1.

TABLE 1 Summary of Validation Studies Performed on the Harvard Food Frequency Questionnaire

Tools and Sample

References Children Pregnant Women

Number of Nutrients

for which Average

Correlation was

Derived

Average

Pearson

Correlation

Coefficient

Children’s HFFQ

Blum et al., 1999 X 19 0.55a

1–2 years 0.57

3–5 years 0.55

Native American 0.56

Caucasian 0.52

Women’s HFFQ

Suitor et al., 1989 X 8 0.5a,b

Wei et al., 1999 X 26 0.47b

a

 Adjusted for within person variation.

b

 Adjusted for energy intake and within person variation.

Recent data indicate that the HFFQ can be used for determination of WIC eligibility

based on dietary risk. In a completed, but not yet published, study by Rodan and colleagues, an

80-item version of the HFFQ is compared to a 31-item version of a Massachusetts FFQ. The

HFFQ uses a reference period of 4 weeks and the Massachusetts questionnaire a time period of 1

week. Ninety-six percent of women found the HFFQ easy to use and can complete it

independently within 9–12 minutes. The HFFQ identified 95 percent of these women as being at

nutritional risk compared to 85 percent based on the Massachusetts questionnaire. Only 6

percent, however, were found to be eligible for WIC based solely on dietary risk. In children, the

HFFQ identified 98 percent to be at nutrition risk compared to 94 percent based on the

Massachusetts questionnaire; 49 percent were eligible for WIC based solely on diet.

In summary, WIC programs in several states have implemented the HFFQ and there is

growing evidence from validation studies that indicate its performance in WIC settings is

comparable to that of a research tool. It is conceptually superior to a 24-hour recall because

WIC’s focus is to measure long-term intake. The ease of use has also been documented by

studies in Massachusetts. While measurement of biochemical markers would be the best

validation of the HFFQ, unfortunately this has not been done and is not practical at this time. The

printout that the client receives from the HFFQ includes both nutrients and food groups and this
A-24

output can easily be used for nutrition counseling. In addition, if the HFFQ is administered

repeatedly, research has indicated that it could be used to evaluate change in diet over time. In

the future, there is also the potential to use the data for surveillance and program planning.

References:

Blum RE, Wei EK, Rockett HR, Langeliers JD, Leppert J, Gardner JD, Colditz GA. 1999.

Validation of a food frequency questionnaire in Native American and Caucasian children 1 to

5 years of age. Matern Child Health J 3:167–172.

Suitor CJ, Gardner J, Willett WC. 1989. A comparison of food frequency and diet recall methods

in studies of nutrient intake of low-income pregnant women. J Am Diet Assoc 89:1786–1794.

Wei EK, Gardner J, Field AE, Rosner BA, Colditz GA, Suitor CW. 1999. Validity of a food

frequency questionnaire in assessing nutrient intakes of low-income pregnant women.

Matern Child Health J 3:241–246.
A-25

Assessing Dietary Intake in the Hispanic Population

Presented by Anna Maria Siega-Riz, Ph.D.

Assistant Professor of Nutrition and Maternal and Child Health

University of North Carolina School of Public Health

Over the last 10 years, the Hispanic population has increased more than 50 percent. The

majority of the increase has occurred in individuals of a Mexican, Central South, and South

American origin. Hispanic children are the second largest group of children in the country. The

Mexican-American subgroup is the largest (60 percent) of the Hispanic population; however, the

second largest Hispanic subpopulation (23 percent) cannot be classified as Mexican, PuertoRican, or Cuban. This reinforces the concept that one dietary assessment tool cannot serve

everyone within a state or across a nation. There are four main considerations when examining a

dietary assessment tool. These are language, educational level, cultural practices, and dietary

culture.

It is usually not appropriate to use a translator as an interpreter in the public health

setting. It is more useful to utilize a person who is linguistically and culturally competent in the

area of Hispanic attitudes and practices when administering a dietary assessment and providing

other WIC services. Although there are no studies available that validate the accuracy of the

information reported by an interpreter at a WIC clinic, it would not be uncommon that the

viewpoint of the interpreter may be expressed or the participant’s responses may be filtered. This

is an especially important consideration when translating participants’ views of food voodoos or

taboos or breast feeding attitudes and practices, which are very much an everyday occurrence in

the WIC program.

Based on national data, Hispanics have the lowest rates of high school degrees. The

majority of native-born Hispanics have less than 8 years of formal education. Many of the

available food frequency questionnaires (FFQs) require thinking on an abstract level. It is

difficult for individuals with minimal education to understand an FFQ, especially when asked

about the frequency of consumption of a particular food when it is not in the context of a meal.

This is not only true for Hispanics, but for anyone with a low level of education.

When providing health services to the Hispanic population, there are many cultural issues

that present challenges. Often, a Latina woman has strong viewpoints that have been passed

down from generation to generation, such as “the family is always first.” The woman may

provide her family with the advice and services provided to her by WIC, while neglecting

herself. Another strong cultural issue is conflict with authority figures and social desirability. For

example, a Hispanic woman may not disclose in-depth answers to an interviewer for fear that the

interviewer would think less of her because of her inability to provide for her family.

Different subgroups of Hispanics have different food consumption patterns. One dietary

assessment tool can not adequately assess all Hispanics living in America today. None of the

existing dietary assessment tools have been designed to capture the dietary habits of different

subgroups of Hispanics. In an ethnically diverse population, the 24-hour recall or a food diary

would be the preferred methods of assessing dietary intake because they are open ended and

allow the individual to report the foods they are consuming as opposed to selecting from a

restricted food list. These methods may be limiting as the database of foods in computerized

programs may not contain the ethnic foods consumed or the WIC provider may not be
A-26

knowledgeable with regard to the ethnic foods and their composition.

Among some Hispanic populations, particularly migrant workers, environmental factors

such as nonexistent or inadequate housing can cause high intra-individual variability of dietary

intake. Limited income also has the potential to decrease the variety of the foods. Income is

variable from month to month and can affect dietary intake. In summary, in order to conduct

dietary assessments in the Hispanic population, it is recommended that the WIC program

promote and support the attitudes, behaviors, knowledge, and skills necessary for staff to work

respectfully and effectively with clients.

Bibliography:

The National Coalition of Hispanic Health and Human Services Organizations. 1998. Delivering

Preventive Health Care to Hispanics: A Manual for Providers. Washington D.C.: The

National Coalition of Hispanic Health and Human Services Organizations.

Sanjur D. 1995. Hispanic Foodways: Nutrition and Health. Needham Heights, Mass.: Allyn &

Bacon.
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Differences by Socio-demographic Characteristics in Diet Quality

Among Pregnant Women

Presented by Anna Maria Siega-Riz, Ph.D.

Assistant Professor of Nutrition and Maternal and Child Health

University of North Carolina School of Public Health

A Diet Quality Index for Pregnancy (DQI-P) was developed using data from the

Pregnancy, Infection, and Nutrition (PIN) cohort (n > 3000) in central North Carolina. The goal

was to develop a composite that reflected current nutritional recommendations for pregnancy as

well as the Food Guide Pyramid (Shaw et al., 1999). Dietary intake was assessed during the

second trimester using a Food Frequency Questionnaire. The DQI-P includes eight components:

percent of recommended servings of grains, vegetables, and fruits based on the Food Guide

Pyramid, percent of dietary reference intakes (DRI) for folate, calcium, and iron (NRC, 1989;

Yates et al., 1998), percent of energy from fat based on the Dietary Guidelines, and dietary

variety score based on the Food Guide Pyramid (Shaw et al., 1999; USDA/DHHS, 2000). Scores

range from 0 to 80 with each component contributing 10 points.

The DQI-P differentiates diets both quantitatively and qualitatively. The mean score for

the population was 51. Higher amounts of grains, vegetables, and fruits and other DQI-P

components were associated with an increasing DQI-P score. High intakes of nutrients not

measured on the DQI-P, such as vitamin A and vitamin C, were also associated with high DQI-P

scores. One drawback of the study was that the food frequency questionnaire underestimated

intake of grains.

Sociodemographic characteristics of the women were also examined. There was no

difference in mean score based on ethnicity, however several significant differences were found

based on sociodemographic factors. Women who were nulliparous, over 20 years of age, over

350 percent of the poverty level, and had at least a high school education had significantly higher

overall scores. Non-Hispanic black women consumed more grains compared to non-Hispanic

white women. Vegetables consumption was higher among non-Hispanic blacks, women over 20

years of age, over 350 percent poverty, and women with some college education. Fruit

consumption was higher in nulliparous and non-Hispanic black women. Women who had

incomes less than 185 percent of the poverty level, were nulliparous, younger than 30 years of

age, non-Hispanic black, and had less than a college education had greater intakes of iron. These

results may reflect nutrition counseling that these women received. Non-Hispanic white women

who had higher incomes, were greater than 30 years of age, and were better educated tended to

consume diets lower in fat. Compared to their counterparts, non-Hispanic black and nulliparous

women had higher dietary variety scores. There were no differences found in sociodemographic

characteristics for calcium, folate, or diet variety.

Establishing tertiles as cut points for the DQI-P may be useful. Women who were in the

lowest tertile had a mean diet quality score of 37. This equated to meeting 60.2 percent of the

Recommended Dietary Allowance (RDA) for folate, 40.7 percent the RDA for iron, consuming

36.5 percent of energy from fat, as well as not meeting the recommended intakes for fruits,

vegetables, and grains. Another approach to the DQI-P would be to examine women who do not

achieve two-thirds of the recommendations on any six of the components. This would be
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equivalent to a mean diet quality score of 35.

In the population of pregnant women examined, the DQI-P was qualitatively and

quantitatively differentiated. It has also been reproduced in later research. An advantage of using

the DQI-P is that it assesses overall variation in diet as opposed to assessing one nutrient. It also

can be used in a computerized assessment. The DQI-P may be a useful public health tool for

evaluating the overall diet quality of pregnant women.

References:

NRC (National Research Council). 1989. Recommended Dietary Allowances, 10th ed.

Washington, D.C.: National Academy Press.

Shaw A, Fulton L, Savis C, Hogbin M. 1999. Using the Food Guide Pyramid: A resource for

nutrition educators. Available at: http://www.nal.usda.gov/fnic/Fpyr/guide.pdf. Accessed

November 30, 1999.

USDA (United States Department of Agriculture)/DHHS (Department of Health and Human

Services). 2000. Nutrition and Your Health: Dietary Guidelines for Americans, 5th ed. USDA

Home and Garden Bulletin No. 232.

Yates AA, Schlicker SA, Suitor CW. 1998. Dietary Reference Intakes: The new basis for

recommendations for calcium and related nutrients, B vitamins, and choline. J Am Diet Assoc

98:699–706.
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The Frequency of Eating During Pregnancy and Its

Effect on Preterm Delivery

Presented by Anna Maria Siega-Riz, Ph.D.

Assistant Professor of Nutrition and Maternal and Child Health

University of North Carolina School of Public Health

The 1990 Institute of Medicine report, Nutrition During Pregnancy, recommended that

pregnant women eat nutritious snacks and small to moderate-sized meals at regular intervals in

order to meet the increased nutritional needs during pregnancy (IOM, 1992). This has been

translated into a recommendation of three meals and at least two snacks per day. Several studies

have examined eating frequency and results indicate that eating three to six meals per day

improves glucose tolerance and lipid and lipoproteins profiles in pregnant women.

In order to identify meal patterns of pregnant women and investigate the relationship

between these meal patterns and preterm delivery, an analysis was performed using data from

pregnant women (n=2,065) in the Pregnancy, Infection, and Nutrition Study (Siega-Riz et al., in

press). Meal patterns were created from the reported number of meals (breakfast, lunch, and

dinner) and snacks consumed per day during the second trimester, as well as having the women

characterize the times of meals and snacks on a 24-hour time clock. In accordance with the

IOM’s recommendations, an optimal meal pattern was defined as three meals and two or more

snacks.

Seventy-two percent of women were found to meet this recommendation. These women

had the lowest rates of preterm births. The highest rates of preterm birth were associated with

women who had erratic eating patterns. Women who did not meet the IOM recommendation had

a 30 percent higher risk of preterm delivery (adjusted odds ratio [AOR]=1.30, 95 percent

confidence interval [CI]=0.96, 1.76). Women who consumed meals/snacks less frequently than

recommended were found to be slightly heavier prior to conception, were older, and had a lower

total energy intake. While there was no difference in risk found to be associated with gestational

age, women delivering after premature rupture of the membranes (AOR=1.87, 95 percent

CI=1.02, 3.43) had a higher risk than those who delivered following preterm labor (AOR=1.11,

95 percent CI=0.65, 1.89).

The above mentioned study supports previous animal model work, which has shown an

association between frequency of eating and preterm delivery (Binienda et al., 1989; Fowden et

al., 1994). Experimentally induced fasts during late gestation have been found to stimulate

intrauterine prostaglandin production, uterine contractions, and preterm delivery. In one study,

pregnant sheep who were fasted for 12 to 48 hours in the last half of pregnancy were found to

experience hypoglycemia and an increase in prostaglandins leading to uterine contractions and

subsequent preterm delivery. In another study, effects of a 16-hour extended overnight fast in

pregnant women and nonpregnant women found that only the pregnant women experienced

hypoglycemia, hypoinsulinemia, and ketonemia (Metzger et al., 1982).

Given the results of these studies, the eating frequency of pregnant women (n=1,494) in

the Pregnancy, Infection, and Nutrition Study using reported meal and snack times was evaluated

(Herrmann et al., in press a). The usual time period without food (including an overnight fast)

was found to range from 2 to 24 hours. Thirteen percent of the women fasted 3 to 8 hours per

day, 58 percent fasted 9 to 12 hours per day, and 29 percent fasted 13 to 24 hours per day. While

controlling for age, income, race, pregravid body mass index, and caloric intake, multivariate
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logistic regression analysis indicated that the risk for preterm birth was highest among women

who fasted 13 hours per day compared to women who fasted 8 hours per day (AOR=3.2, 95

percent CI=1.1–9.7). These results suggest an association between fasting during the second

trimester of pregnancy and preterm delivery.

In order to better understand the relationship between fasting and preterm labor, levels of

corticotropin-releasing hormone (CRH), which can serve as an indicator of stress during

pregnancy and have been associated with preterm delivery were studied (Herrmann et al., in

press b). To investigate the relationship between fasting, CRH and gestational age in pregnant

women, 24-hour food recalls and CRH were measured in 688 pregnant women at 18 to 20, 28 to

30, and 35 to 36 weeks. Women who fasted for more than 13 hours the day prior to plasma CRH

analysis were found to have an elevated level of CRH as compared to women who did not fast.

Lastly, women who skipped meals and snacks were found to be at a higher risk for preterm birth

even after total caloric intake and other factors were considered. Measuring meal and snack

intake, as well as the timing of meals and snacks, may be a very simple public health tool that

can be used to evaluate the prenatal diet and could easily be incorporated into assessments of

dietary risk for WIC eligibility.

References:

Binienda Z, Massmann A, Mitchell MD, Gleed RD, Figueroa JP, Nathaielsz PW. 1989. Effect of

food withdrawl on arterial blood glucose and plasma 12, 14-dihydro-15-keto-prostaglandin

F2α concentrations and nocturnal myometrial electromyographic activity in the pregnant

rhesus monkey in the last third of gestation: A model for preterm labor? Am J Obstet Gynecol

160:746–750.

Fowden AL, Ralph MM, Silver M. 1994. Nutritional regulation of uteroplacental prostaglandin

production and metabolism in pregnant ewes and mares during late gestation. Exp Clin

Endocrinol 102:212–221.

Herrmann T, Siega-Riz AM, Hobel CJ, Aurora C, Dunkel-Schetter C. In press a. Fasting during

pregnancy increases risk for elevated maternal corticotropin releasing hormone

concentrations.

Herrmann T, Siega-Riz AM, Savitz DA, Zhou H, Thorp J. In press b. Fasting during pregnancy

and preterm birth.

IOM (Institute of Medicine). 1992. Nutrition During Pregnancy and Lactation: An Implementation Guide. Washington D.C.: National Academy Press.

Metzger BE, Vileisis RA, Ravnikar V, Freinkel N. 1982. Accelerated Starvation: and the skipped

breakfast in late normal pregnancy. Lancet 2:588–592.

Siega-Riz AM, Herrmann T, Savitz DA, Thorp J. In press. The frequency of eating during

pregnancy and its effect on preterm delivery. Am J Epidemiol.
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Practical Issues in the Use of Various Tools in WIC Settings

Presented by Jill Leppert

Nutritionist, North Dakota WIC Program

North Dakota Department of Health

The state of North Dakota has used the Harvard Food Frequency tool since 1993 to assess

dietary risk in all participants. It is used for certification and recertification of women and

children. Prior to the adoption of this tool, the state used both the 24-hour diet recall and a food

frequency method. Concerns over time constraints, repetition, and lack of consistent results

prompted a search for a better tool. The goal was to streamline the process, have a better tool that

was easy for paraprofessionals to use, and could be used in a variety of settings. In addition, the

tool needed to provide enough information to be used to assess both eligibility and serve as a

basis for nutrition education.

The Harvard tool provided all of the information needed. The printout provides the

number of servings eaten each day in all food groups, the number of servings of vitamin A foods,

vitamin C foods, simple sugar foods, and fats. In addition, it provides the percent Recommended

Dietary Allowance, calories, and a breakdown of the percentage of fat, carbohydrate, and

protein. The information was all computerized. Given that the staff was comfortable with

computers and they were available in all the agencies, it was a good match.

The tool was piloted in three sites. After 3 months, results were very positive. The tool

takes the client approximately 5–7 minutes to complete and it takes staff approximately 2–3

minutes to enter the data in the computer. This then provides an immediate 3-page printout with

the information mentioned above. Paraprofessionals were easy to train in terms of administering

the tool and interpreting the results. Clients liked the new tool and found it easy to fill out.

Approximately 90 percent of clients do a very good job in completing the form. Approximately 3

percent of clients were not able to fill out the previous food frequency tool and this same group

has similar limitations with this tool. The other 7 percent do not take the time to fill out the

questionnaire because they are either rushed or uninterested. However, this would be the case

with any tool that was used.

With the time saved in using the Harvard tool, more time was available for nutrition

education. Clients liked the printouts they received and seemed to be more engaged in the

nutrition education. They felt confident in the results received because they had been computer

generated. Using the client education page has worked out well. Clients find the food groups to

be helpful and appreciate receiving the information. They seem to like computer-generated

information about themselves. North Dakota is currently in the process of updating its computer

system and the new technology will work well. In a new program, nutrition risk codes could be

recognized by the computer and automatically identify individuals at risk, which will further

decrease errors.

In North Dakota, the average WIC family has 3.9 people. Sixty-seven percent of families

have both the mother and father present. Sixty-nine percent have either one or both parents

employed full-time. Sixty-six percent of the participants are Caucasian, 15 percent Native

American, 5 percent Hispanic, 3 percent black, and less than 1 percent Asian. Fifty-seven percent

of the families have incomes below 100 percent, 20 percent have incomes between 100 and 133,

and 23 percent have incomes between 133 and 135. Forty-seven percent of WIC mothers have a
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high school education. Twenty-four percent have less than a high school education, and 29

percent have more than a high school education.

It is difficult to estimate the number of WIC participants who are at dietary risk for a

number of reasons. Primarily, it is an issue of coding and priority. Only the five highest priority

codes are listed in the computer. Since dietary risk codes are not high priority (level 4, 5, or 6)

they often do not make it into the computer. Eighty-three percent of pregnant women are priority

level one. Typical priority one clients would be those who are underweight, overweight, anemic,

or had a previous poor pregnancy outcome. Only 17 percent are priority four; however not all

priority four clients are eligible based on dietary risk. Priority four also includes conditions such

as migrancy, homelessness, transfer of certification, and inadequate vitamin intake. For children,

approximately 36 percent are coded as priority three (overweight, underweight, anemic, or other

specific health problem). Dietary risk is priority five. While 64 percent of children are coded as

priority five, this includes other conditions such as inappropriate use of bottle or other

inappropriate feeding practice.

Overall, there is an exceedingly small number of income eligible individuals who are not

certified for the program because they lack nutrition eligibility—perhaps 1 percent. While

Congress did not set up the WIC program this way, it would best if the risk assessment were

divorced from the eligibility criteria. While assessment is important for nutrition education, it

would be best if eligibility were based on income alone. Lastly, when it does come to selecting

and approving a tool for dietary assessment, it would be best if two or three different tools were

approved that the states could choose between.
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Practical Issues in the Use of Various Tools in WIC Settings

Presented by Amanda Watkins, M.S., R.D.

Nutritionist, Arizona WIC Program

Arizona Department of Health Services

To date, Arizona has used a food frequency questionnaire for dietary assessment. The

state is currently in the process of automating the WIC program and in an effort to incorporate

diet assessment into the automation process, Arizona reviewed numerous tools and decided to

have a new food frequency questionnaire created. The Arizona Department of Health Services

has contracted with Dr. Douglas Terrin of the University of Arizona to create a short food

frequency tool that could be validated. This tool unfortunately did not prove to be valid and it

was recommended that it not be used for certification purposes. For this reason, the state of

Arizona is back at square one.

After reviewing many options, the current tool decided on is a 24-hour recall, adapted

from a tool used by a local agency. It is a paper tool that utilizes the food guide pyramid. All age

groups and types of clients can be assessed using one form. The community nutrition worker

(CNW) shades in each serving of a food group eaten. Thus, the tool may be used for nutrition

education as well. While the tool can be self administered (the participant fills out what they eat

on top and the CNW does the evaluation on the bottom), the most common method in Arizona is

for the tool to be completed through an interview process, as there is a high percentage of

Hispanics and literacy does tend to be a problem.

Dietary assessment is not mandatory in Arizona. If another risk is determined which

qualifies an individual for the program, a dietary assessment does not need to be performed.

Only when the certifier is unable to find a valid risk do they proceed with dietary assessment.

Thus, Arizona has a low rate of certification for dietary risk. The decision for not making dietary

assessments mandatory is not completely clear; it may be because of the controversy over which

tools are truly valid and it is very seldom that an individual qualifies on dietary risk alone.

Generally, if an individual is not eating properly, chances are that they will qualify for another

reason such as anemia, underweight, overweight, or other risks. The feeling among many clinics

is that given the validity of the assessments, do not go there unless necessary.

Sixty-two percent of Arizona’s WIC population is Hispanic. Approximately 30 percent

are non-Hispanic whites, 5 percent are African American, 2 percent are Native American, and 1

percent are Asian. The Native American population appears low because there are actually three

separate programs in Arizona: Arizona WIC program, the Navajo Nation WIC program, and the

Intertribal Council of Arizona WIC program. The Navajo Nation program and the Intertribal

Council of Arizona WIC programs are the two programs that certify and service the majority of

the Native American WIC population.

To address the needs of the Hispanic population, the dietary assessment tool is in English

on one side and in Spanish on the other. In addition, the combination foods list contains popular

Mexican fare. The most important way that the Arizona program meets the needs of the Hispanic

population however is that the majority of the staff are not only bilingual, they themselves are

Mexican-American, live in the same community, and many of them have been WIC participants

themselves. The CNWs are truly their peers. They not only perform the certifications, they also

perform the dietary assessments, and in most cases also provide the nutrition education. The
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CNWs are required to have a GED or high school diploma. The majority have had no other

nutrition education other than what they have received through WIC training. For this reason, the

staff drives the requirements we have for a dietary assessment tool.

Based on different focus and working groups of state and local WIC agency staff, several

things need to be considered in designing a dietary assessment tool. In order to be useful to the

state of Arizona, it needs to be fast and easy to administer—3 minutes would be ideal. A new

enrollment appointment is allotted approximately 20 minutes. In this time period quite a bit

needs to get done (blood work, income documentation, height, weight, health history questions,

etc.). In addition, the clinic flow needs to be kept in mind. Diet assessments are only performed

if no other risks are found. Results of the assessment must be able to be converted into portion

sizes according to the U.S. Department of Agriculture Food Guide Pyramid, be used for dietary

counseling, measure changes in dietary patterns, be easily incorporated into Arizona's automated

system and, preferably, be a food frequency questionnaire. Ideally, the tool would be one which

would be interviewer administered and information obtained would be input into the computer

by the CNW. The ideal tool has yet to be created.
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Practical Issues in the Use of Various Tools in WIC Settings

Presented by Ann Barone, LDN

Nutritionist, Rhode Island WIC Program

Rhode Island Department of Health

In the state of Rhode Island, the dietary risk assessment process has been in a state of

revision. While a 24-hour recall and food frequency tool continue to be used, the food frequency

tool is now based on the food guide pyramid rather than being nutrient based. In addition, some

of the required servings have been adjusted (e.g., calcium serving size and protein requirements

for children). Other changes were made in terms of combining groups such as inadequate intake

of fruits and vegetables.

In determining the tool to be used for Rhode Island, assessment tools were collected and

examined from many states. A committee of WIC agency nutritionists from around the state

examined the tools and determined what was needed for the Rhode Island population. The food

guide pyramid is the base of the tool. An assessment tool was modified for each group (e.g.,

pregnant, breastfeeding, and children), including 1–2 year olds.

In Rhode Island, every person who applies for WIC has a dietary assessment performed.

An average WIC appointment takes approximately 30 minutes per participant. The tools are

administered by a nutritionist, who has a minimum of a bachelor’s degree. Completing both a

24-hour recall and a food frequency does not leave much time for education. Together, the

assessment and evaluation take approximately 15 minutes. It is the same individual who

performs the assessment that does the education.

Approximately 20 to 30 percent of the population in Rhode Island is Hispanic and less

than 5 percent is African American. There is a fairly large Portuguese population in one part of

the state. Thirty-seven percent of participants qualify for WIC based on dietary risk alone. Only a

very small percentage of individuals who apply for the WIC program are not deemed eligible.

Staff will generally find some reason why an individual qualifies. In terms of dietary risk, if an

individual is short a serving or over by a serving, they are eligible based on dietary risk.
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Practical Issues in the Use of Various Tools in WIC Settings

Presented by Carol Rankin, M.S., R.D., L.D.

Nutritionist, Mississippi WIC Program

Mississippi State Department of Health

In Mississippi, the tools used to assess dietary risk are basic, but provide the information

needed to determine whether an applicant is at nutritional risk. Three separate forms are used for

dietary assessment of women, infants, and children. A food frequency tool is on all forms and a

24-hour recall is on all except for the form for the infant. There is a section for inappropriate

feeding practices as well, which are used as talking points for the counselor and can be checked

off to indicate risk. The dietary assessment is used for both determination of eligibility and

nutrition education.

For infants, food frequencies are checked against the recommendations. If any group is

missing or there are two inappropriate food groups, then the infant is certified based on

inappropriate diet. Inappropriate feeding practices are broken down for the different ages: 0 to 3

months, 4 to 5 months, 6 to 9 months, and lastly, 10 to 12 months. The dietary assessment forms

for women and children include both the food frequency and the 24-hour diet recall. Children are

divided into age groups of 1 to 3 years of age and 3 to 5 years of age.

The tools used for nutrition assessment were chosen in order to fulfill U.S. Department of

Agriculture (USDA) and Mississippi WIC requirements for the specific populations served.

Accepted dietary guidelines, food guide pyramid recommendations, and other established

feeding practices such as American Academy of Pediatrics recommendations were considered. In

addition, two other factors contributed to the selection of the nutrition assessment tools: ease of

obtaining usable information in a format for busy clinics and ease of use by nonnutrition

professionals.

Additional nutrition assessments are used for pregnant women and infants who are

enrolled in the perinatal high-risk and infant services program. This is a program where a team of

health professionals case manage high-risk, Medicaid-eligible patients. The team consists of a

nutritionist, nurse, and social worker. The pregnant woman is followed through 60 days

postpartum and the infant until 1 year of age. All of these patients also qualify for the WIC

program. The nutrition assessment for these special populations is more in-depth, requiring

additional calculations of calorie levels, growth parameters, and questions about food security

and preparation. The WIC nutrition staff use the information in determining WIC eligibility and

in order to provide nutrition education targeted to the needs of the patient.

The forms may appear complicated, but once training is received the forms are simple to

use. They are used by paraprofessionals, nurses, and lactation specialists. It takes about 10

minutes to complete one of the dietary assessment forms. There is then an additional 5 to 10

minutes for nutrition education. Mississippi WIC sites do not currently have computers but are

expected to within the next 1 to 2 years.

High risk applicants and those who are certified based on inappropriate dietary intake

receive a diet history during every clinic visit. All other clients should get a nutrition assessment

at least once per year. If an individual is certified based on another type of risk, they may not

receive a dietary assessment. However, if an individual meets no other risk and does have a
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dietary assessment, it is rare that they would not be certified. According to USDA figures, 22

percent of WIC clients in Mississippi qualify for the program based on dietary risk.
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The Role of WIC in the Framework of Overall Assistance to the Poor

Presented by Robert Greenstein

Executive Director, Center on Budget and Policy Priorities

Washington D.C.

It has been suggested by many over the years that additional nutrition criteria on which

eligibility is based be done away with. However, for several reasons, the WIC program has

continued to operate, thrive, and produce significant positive health outcomes with program

eligibility based on both income and nutrition criteria.

Overall, research on the impact of the WIC program on diet and health over the last

quarter century has shown striking results in terms of its impact on birth outcomes and lowering

the incidence of low birth weight. In 1992, the General Accounting Office (GAO) did an

evaluation synthesis in which it concluded that the WIC program reduced the incidence of low

birth weight by 25 percent and very low birth weight by 44 percent (USGAO, 1992). While these

figures are not precise due to questions on selection bias and other matters, when looking at the

body of research as a whole, it is pretty clear that the findings are robust and the that the

direction is strong in terms of the significance of effects on reducing the incidence of low birth

weight. Overall, the research has led to findings that low-income women who receive WIC

during pregnancy have better birth outcomes than low-income women who do not.

The WIC program also appears to reduce the incidence of anemia in children.

Researchers at the Centers for Disease Control (CDC) compared the anemia levels of infants and

children at the time of initial enrollment in WIC to their anemia level at the time of WIC followup visits. Significant reductions in anemia rates were found for most age groups of infants and

young children in most years for which data were examined. Researchers reported that the

prevalence of anemia was consistently higher for children seen at initial visits than for those seen

at WIC follow-up visits (Yip et al., 1987). Barbara Devaney and others who have looked at the

data from CDC have concluded that the evidence is pretty strong in terms of the WIC program’s

anemia-reducing effects (Devaney, 1998).

An area that until recently was the most controversial was whether or not WIC improved

the diets of children. Findings from the national WIC evaluation of the mid-1980s found very

strong effects in reducing the frequency of low intakes of certain nutrients among infants and

children (Rush et al., 1988). While no one was quite sure what to make of the findings because

the study had been marred by significant selection bias problems, Devaney and others noted that

the selection bias problems were more likely to understate, rather than overstate, WIC's effects

because the control group was better off than the treatment group (Devaney, 1998). Nevertheless,

the problems were significant enough to cast doubt on the findings that WIC improved the diets

of children. In the last 3 years, however, this has changed in part because of a better controlled

study by Rose, Habicht, and Devaney (Rose et al., 1998). These researchers found that WIC had

significant effects in increasing preschoolers intakes of ten nutrients, including iron, zinc, and

vitamin E. These three nutrients are among the four most frequently deficient in the diets of lowincome preschoolers. The increases in WIC participants in iron and zinc were particularly large.

Within the past month, a new study was released by Oliveira and Gunderson of the

Economic Research Service (Oliveira and Gunderson, 2000). This study, which uses data from

the 1994 to 1996 Continuing Survey of Food Intake by Individuals (CSFII), found that
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participation in WIC significantly increases children's intake of iron, folate and vitamin B6. With

the addition of this study, there is now a body of evidence that, when looked at together, suggests

that WIC both reduces anemia and improves diets among children. In particular, WIC apparently

reduces the incidence of low intakes of particularly important nutrients such as iron among low

income children. In addition, a review of the literature conducted and published by Leighton Ku

of the Urban Institute, prior to the study by Oliveira and Gunderson, found similar results (Ku,

1999). While noting that there are holes in the research, Ku concluded that taken as a whole, it is

hard to think of any public program with so consistent a body of positive research findings.

At the Center for Budget and Policy Research, the gamut is covered when it comes to

means tested benefit programs at both federal and local levels (e.g., health, income, supports,

housing programs). Research is constantly being reviewed and evaluated. Some programs are

found to be less effective, others are found to be more effective, and some are found to need

various changes. However, there is not another means-tested program for which the literature of

efficacy approaches that of the WIC program. WIC is an important remedial and preventive

program.

Inadequate dietary pattern as a nutrition risk criteria to determine eligibility for WIC has

been described as being applied in an imprecise and sometimes loose manner. However, to some

degree, policy makers have known that inadequate dietary pattern was imprecise and loosely

applied and, to some degree, that is the kind of criteria they have wanted. At two points, in the

late 1970s and again in the mid-1980s, policy makers gave serious consideration to eliminating

nutrition risk as an eligibility criterion for pregnant women or for pregnant women and infants.

Ultimately, this was not done for a few reasons, which could largely be put under the heading of

optics. There was very much a sense on the part of both policy makers and state WIC directors

that if income was the only eligibility criterion, it would lead to the perception of WIC as merely

another welfare program as opposed to a health program. It was felt that this would be damaging

to WIC's political viability, its image in the community, its effectiveness in reaching working

families who do not want to be on welfare, and lastly, that it might result in some agencies

paying less attention to providing the dietary, nutrition, and other health information and

counseling needed.

The decision not to drop the nutrition risk criteria was aided by the fact that in exploring

the elimination of the nutrition risk criteria, policy makers found that hardly any pregnant

women who met the income criteria and applied for the program were turned away because of

not meeting the nutritional risk criteria. This is what many policy makers wanted. A nutrition

assessment could be performed and the image of a health program rather than a welfare program

would be maintained, and yet low income individuals for whom there would be a preventive

value would not be denied entry into the program. This raises an important question for this

committee: How can the necessary information be collected in an effective manner while

avoiding a significant narrowing of the criteria that could possibly make a few million

individuals who are currently eligible for WIC, ineligible? 

Shrinking the eligible pool of individuals for WIC by narrowing the eligibility criteria

would seem reasonable if this meant opening slots for needier individuals. However, while this

may have been the case some years ago, it is not the case now. WIC actually has as much money

right now as it needs to serve virtually everybody who walks in the door and applies. The

program has substantial amounts of carry-over funding. It has been funded for the last 3 or 4

years by the Congress to serve between 7.4 and 7.5 million women, infants, and children and

each year it has served 7.3 million individuals. Last year, there was close to $200 million of
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available WIC funds that were unspent and carried forward to the following year. While there

sometimes are occasional problems of a few months when there is too much money in a given

state and not enough money in another, it can not be said that substantial numbers of people are

trying to get into WIC and are turned away.

Another argument for narrowing the eligibility criteria would be if one thought that the

eligibility criteria was too loose and that money could be better spent on other important

functions. There are a few problems with this argument. The first is that narrowing the eligibility

criteria could weaken WIC’s effectiveness as a preventive program. People who meet the income

test but do not immediately meet one of the more rigorous nutritional risk screens could be

denied WIC, only to meet the nutritional screen subsequently if their nutritional status

deteriorates. In addition, the current budgetary situation is not one of deficits that threaten the

economy. Rather, the picture is one of growing surpluses. In the next 4 weeks, both OMB and

the Congressional Budget Office (CBO) will release new budget forecasts that place the new

surplus estimate, outside Social Security, at more than $1.5 trillion over the next 10 years. In

other words, OMB and CBO are about to double the size of the surpluses they projected only 4

months ago. Congress already is preparing to start expending more money on both the tax and

the spending side. A plethora of tax bills that cost significant sums is starting to move through

the House and Senate, the latest of which would ultimately reduce revenue $50 billion a year by

eliminating the estate tax, even though that tax applies to the estates only of the wealthiest 2

percent of people who die in the United States. The point is that if one were to narrow

significantly the eligibility criteria for WIC, the result would simply be fewer people served and

a reduction in WIC funding levels. Where would the money saved go? These days, a bigger tax

cut would be the likely outcome.

The idea of WIC becoming an entitlement program is politically a nonstarter. As

previously mentioned, there are currently WIC funds available that are not being spent, and

participation in the program has dropped by 3 percent since its peak in 1996. In 1996–1997, WIC

participation reached its peak of approximately 7.4 million participants. Now participation is 7.2

million. (In comparison, food stamp participation has dropped 40 percent since 1994.) The drop

in WIC participation is likely due primarily to the economy; there are fewer numbers of lowincome individuals now. In addition, in all assistance programs, the working poor have a lower

participation rate than the welfare poor.

Making WIC an entitlement was considered by policy makers in the late 1970s and mid1980s. It was not something that proved to be a viable option politically then. It is even less

likely to be considered a viable option now, given the more conservative Congress today. The

chance that it would be seriously considered is near zero.

It is important to look at what improvements can made in the nutritional risk criteria,

particularly if such improvements can improve information for WIC clinics and provide

participants with more effective counseling and other services. However, one would hope that

the Committee on Dietary Risk Assessment in the WIC Program keeps the Hippocratic oath in

mind if it considers options that could significantly narrow the pool of low-income women,

infants, and children who are eligible for WIC. The principal effect of such an approach would

be fewer low-income individuals being provided with WIC benefits and services and more

money made available for tax cuts likely to accrue primarily to relatively high-income

individuals.
A-41

References:

Devaney B. 1998. Commentary. In Rossi PL, ed, Feeding the Poor. Washington, D.C.: AEI

Press.

Ku L. 1999. Debating WIC. The Public Interest Spring:108–112.

Oliveira V, Gunderson, C. 2000. WIC and the Nutrient Intake of Children. Food and Rural

Economics Division Research Report No. 5. Washington, D.C.: Economic Research Service,

U.S. Department of Agriculture.

Rose D, Habicht JP, Devaney B. 1998. Household participation in the Food Stamp and WIC

programs increases the nutritional intakes of preschool children. J Nutr 128:548–555.

Rush D, Sloan NL, Leighton J, Alvir JM, Horvitz DG, Seaver WB, Garbowski GC, Johnson SS,

Kulka RA, Holt M. 1988. The National WIC Evaluation: Evaluation of the Special

Supplemental Food Program for Women, Infants, and Children. V. Longitudinal study of

pregnant women. Am J Clin Nutr 48:439S–483S.

USGAO (United States General Accounting Office). 1992. Early Intervention: Federal

Investments Can Produce Savings. Washington, D.C.: U.S. Government Printing Office.

Yip R, Binkin NJ, Fleshood L, Trowbridge FL. 1987. Declining prevalence of anemia among

low-income children in the United States. J Am Med Assoc 258:1619–1623.
A-42

Food Insecurity as a Predictor of Dietary Risk

Presented by Lynn Parker, M.S.

Director of Child Nutrition Programs and Nutrition Policy

Food Research and Action Center, Washington D.C.

In considering how food insecurity applies to WIC, it is important to understand the

history of where this concept came from. The idea of measuring food insecurity started in the

United States in the 1980s during the period of recession when there were major cut backs in

federal nutrition programs. Many more people were coming in for emergency food assistance

and service providers began to document enormous jumps in need. Concerns, however, were

discounted by policy makers and there was a strong desire around the country to convince them

that a hunger problem not only existed, but was increasing, and had negative consequences for

the country.

The Food Research and Action Center, working in partnership with the Connecticut

Association for Human Services, developed a systematic approach to studying the problem of

hunger among families with children, which was called the Community Childhood Hunger

Identification Project (CCHIP). It was the first time a group attempted to develop an objective

measurement of hunger that could be used in a national survey (Wehler et al., 1995). Hunger was

defined as food insufficiency due to constrained resources, not voluntary hunger, but involuntary

hunger because of not enough money to buy food. A survey was developed for families with

children under the age of 12. It consisted of a series of eight questions and based on the results,

families were categorized as hungry, not hungry, or at risk of hunger. This type of survey was

needed as it would not have been feasible to measure blood levels of nutrients or to administer

24-hour recalls. These measures would have been incredibly time consuming, extremely

expensive, and would have required a level of training on the part of interviewers that would not

have been feasible with the type of community groups involved.

Results from the surveys showed that a highly significant number of children were

hungry and that families were food insecure. In addition, a relationship was found between

hunger and reported infections, fatigue, irritability, headaches, and ear infections and colds

among kids. We also found that parents are the first to be hungry and children are the last. This

has come through again and again in national surveys. When children are found to be food

insecure, it is a very severe problem in the family.

We also learned that who the interviewer is and who the respondent is can affect the

response. There appeared to be a difference in response because our interviewers were paraprofessionals who were trained to carry out the survey. Parents may not be as truthful if they are

afraid their child will be taken away if they admit to a government interviewer that they cannot

feed them. In addition, individuals living in rural areas were less likely to admit that they were

hungry than those who lived in urban areas.

At the same time that the CCHIP survey was being used, work was also being done by

researchers at Cornell University, and the Life Sciences Research Office (LSRO) came out with

definitions on how to define hunger, food security, and food insecurity (see Box 1). Also during

this time, the Nutrition Monitoring Act was signed into law. The Act had a provision in it that

required the federal government to develop some kind of measure of food insufficiency. In 1994,
A-43

BOX 1 LSRO Definitions on How to Define Hunger, Food Security and Food Insecurity

Food security—Access by all people at all times to enough food for an active, healthy life.

Food security includes at a minimum: (1) the ready availability of nutritionally adequate and

safe foods, and (2) an assured ability to acquire acceptable foods in socially acceptable ways

(e.g., without resorting to emergency food supplies, scavenging, stealing, or other coping

strategies.)

Food insecurity—Limited or uncertain availability of nutritionally adequate and safe foods or

limited or uncertain ability to acquire acceptable foods in socially acceptable ways.

Hunger—The uneasy or painful sensation caused by a lack of food. The recurrent and

involuntary lack of access to food. Hunger may produce malnutrition over time. Hunger, as

the recurrent and involuntary lack of access to food which may produce malnutrition over

time, is discussed as food insecurity in this report.

Hunger, in its meaning of the uneasy or painful sensation caused by lack of food, is in this

definition a potential, although not necessary, consequence of food insecurity. Malnutrition is

also a potential, although not necessary, consequence of food insecurity (Wehler et al.,

1995).

the Department of Health and Human Services, United States Department of Agriculture, and the

Census Bureau got together and developed what is now the food security module, which is an

annual part of the Current Population Survey. The population survey is given out to

approximately 58,000 households monthly (Hamilton et al., 1997). The food security module has

been included in the population survey for one month of the year, every year since 1995. (In

1998, results showed that 19 million adults and 12 million children were in households classified

as food insecure.) There are several categories of food insecurity based on severity. Even

individuals who are classified as “food secure” may still have indicated on the survey that they

worry about food running out or that the food they bought did not last. The questions on the

survey are listed in the typical order in which they may be answered affirmatively (Table 1). The

conservative nature of this measure is evident here.

Results indicated that approximately 10 percent of the households surveyed were

considered food insecure—two-thirds of them without hunger and one-third with hunger.

Households that were more likely to be found food insecure were those with children,

households headed by single females, and black or Hispanic households. Inner city and rural

families were also more likely to be food insecure than suburban households and food insecurity

ran higher in the southern and western parts of the United States than it was in any other regions

of the country.

Questions from the food insecurity module or various combinations of them are now

being included or are in the process of being included in several national surveys such as the

National Health and Nutrition Examination Survey, the Continuing Survey of Food Intake by

Individuals (CSFII), and the National Behavior and Knowledge Survey. Shortly, there will likely

be good research data to answer questions regarding food insecurity and how it relates to dietary

behavior and nutritional status.
A-44

In 1996, the report from the IOM Committee on the Scientific Evaluation of WIC

Nutrition Risk Criteria found limited evidence to evaluate the causal links between food

insecurity and nutrition and health risk. They also found insufficient scientific evidence to select

a cut-off point for WIC eligibility based on food insecurity. However, they did recommend use

of the food insecurity measure at some point.

TABLE 1 Response Profile By Category (Percentage of Households in Each Food Security Category

Answering Each Question Affirmatively)

Food Security Status

Questions

(in order of increasing severity) Food

Securea

Food

Insecure,

without

Hungerb

Food

Insecure,

with

Moderate

Hungerc

Food

Insecure,

with

Severe

Hungerd

Q53 Worried food will run out 5.0 89.5 97.2 99.1

Q54 Food bought didn’t last 2.3 80.9 98.1 99.4

Q55 Adult not eat balanced meals 1.9 75.4 94.9 98.5

Q58 Child fed few low-cost foods 2.3 63.4 91.0 100.0

Q24 Adult cut size or skipped meals 0.4 36.8 93.1 99.1

Q56 Couldn’t feed child balanced meals 0.3 41.2 77.4 95.5

Q32 Adult eat less than felt they should 0.3 34.4 90.3 98.8

Q25 Adult cut size or skipped meals, 3+

months

0.1 20.0 77.2 94.6

Q57 Child not eating enough 0.1 15.5 53.5 96.2

Q35 Adult hungry but didn’t eat 0.1 8.3 57.5 94.3

Q38 Adult lost weight 0.0 2.8 30.5 71.7

Q40 Cut size of child’s meals 0.0 2.1 24.2 70.7

Q28 Adult not eat whole day 0.0 2.4 20.7 87.6

Q47 Child hungry 0.0 1.7 20.0 72.9

Q29 Adult not eat whole day, 3+ months 0.0 0.8 11.6 80.6

Q43 Child skipped meal 0.0 0.6 8.1 56.4

Q44 Child skipped meal, 3+ months 0.0 0.2 4.7 43.6

Q50 Child not eat for whole day 0.0 0.1 1.4 18.1

Number of households in sample (unweighted)e 39,736 3,254 1,326 331 a No or minimal indicators of food insecurity evident.

b Multiple indicators of food insecurity, but no or minimal indicators of resource-constrained hunger

evident for household members.

c

Multiple indicators of resource-constrained hunger evident for adult household members.

d Multiple indicators of resource-constrained hunger evident for children in household and/or indicators

of severe adult hunger.

e For questions applicable only to households with children, the unweighted sample in the four groups

is: 14,192, 1,934, 655, and 133.
A-45

There have been a number of studies showing an association between food insecurity and

dietary risk in terms of nutritional inadequacy in a number of nutrients. Recent research by

Dixon et al. (in press) showed low fasting levels of vitamin E and C in relationship to food

insecurity. This was the first time a biochemical measure has been related to food insecurity. It

has also been interesting to note that the research has shown a deeper and broader impact of food

insecurity on nutrient levels in women than was originally thought. Cristofar and Basiotis (1992)

looked at data from the CSFII for women aged 19 to 50 and children 1 to 5. They were able to

demonstrate a relationship between food security status and nutrient intakes for women. While

they did not see a strong relationship with children, it was not surprising given the demonstrated

protective factor placed on children (i.e., adults apprear to sacrifice eating first before allowing

their children to eat less or go hungry.) Kendall, Olson, and Frongillo (1996) used the RadimerCornell Hunger and Food Insecurity measure and found a relationship between food insecurity

and a lower consumption of fruits and vegetables and lower levels of vitamin C, potassium, and

fiber in the diet. They also saw much more disordered eating patterns in food insecure

households. Rose and Olivera (1997) also demonstrated that in all nutrients looked at, adult

women who were food insufficient did worse in terms of nutritional adequacy. Tarasuk and

Beaton (1999) have also shown similar results using a slightly altered survey in Canada.

Dr. Christine Olson (2000) recently reported on a relationship between food insecurity

and body mass index (BMI). She found that women who were food secure and women who were

food insecure with hunger had, on average, very similar BMIs that were not indicative of obesity.

The women who were food insecure without hunger were much more likely to be obese. She

theorizes that food deprivation may lead to over-eating at times when food insecure people do

have enough food or have enough money to buy food. If an individual is very poor, chronically

food-deprived, and lacking the opportunity to overeat, the individual will have a lower BMI.

However, if the individual is going through the constant ups and downs of having enough and

not having enough to eat, it may lead them to adopt unhealthy eating habits that can lead to

obesity. Dr. Olson’s conclusion was that ending health disparities related to chronic disease will

require ending food insecurity.

There have also been a number of studies looking at the impact of food insecurity on

psychosocial indicators in school-aged children. Associations have been found with increased

depression, anxiety, and inattentiveness in class. There is also research showing an impact on

children’s ability to learn, explore, and interact with their environment.

Overall, the research is important to consider in terms of the WIC program. WIC has

been very successful at being a preventive program. Many of the people who come to the WIC

clinic may be food insecure one day and not the next. They tend to go in and out of poverty. It

may be as little as one child needing a new coat that could lead the family to go for a few weeks

with less food than needed. It is important to remember what food insecurity looks like in these

families. There has been work done on adapting the food insecurity survey to make it shorter. It

may be possible to build only one or two questions into the dietary assessments in WIC settings.

A few food insecurity questions would be helpful. Just as dietary assessment questions help to

guide nutrition counseling, food insecurity questions could lead a nutritionist to recognize when

a family may need other assistance programs such as food stamps, Temporary Assistance to

Needy Families, Medicaid, or emergency food. Using these questions, the nutritionist could

assist in increasing the food security in a family as well as helping them improve their diet.
A-46

References:

Cristofar SP, Basiotis PP. 1992. Dietary intakes and selected characteristics of women age 19–50

and their children ages 1–5 years by reported perception of food sufficiency. Nutr Ed 24:53–

58.

Dixon LB, Radimer K, Winkeeby M, Krebs-Smith S. In press. Differences in foods, dietary

nutrients, and serum nutrients between food insufficient and food sufficient low income

adults, NHANES III, 1988–1994.

Hamilton WL, Cook JT, Thompson WW, Burron LF, Frongillo EA, Olson CM, Wehler CA.

1997. Household Food Insecurity in the United States in 1995: Summary Report of the Food

Security Measurement Project. Washington, D.C.: Food and Consumer Service, U.S.

Department of Agriculture.

Kendall A, Olson CM, Frongillo EA. 1996. Relationship of hunger and food insecurity to food

availability and consumption. J Am Diet Assoc 96:1019–1024.

Rose D, Oliveira V. 1997. Nutrient intakes of individuals from food insufficient households in

the United States. Am J Public Health 87:1956–1961.

Tarasuk V, Beaton GH. 1999. Women’s dietary intakes in the context of household food

insecurity. J Nutr 129:672–679.

Olson CM. 2000. Presentation at the National Nutrition Summit, Food Insecurity and the Health

of Working Americans, May 30, 2000, Washington, D.C.

Wehler CA, Scott IS, Anderson JJ, Summer L, Parker L. 1995. Community Childhood Hunger

Identification Project: A Survey of Childhood Hunger in the U.S. Washington, D.C.: Food

Research and Action Center.
B-1

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