Twenty years of WIC: a review of some effects of the program

A Review of Interventions to Increase WIC Enrollment and Participation

Our goal was to identify strategies aimed at increasing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment and participation rates. The WIC program provides many health benefits for pregnant women, mothers, and children. WIC offers nutrition education, formula, fruits and vegetables, and other food to pregnant and postpartum women and their children until they reach the age of five. Despite the availability of this program nationwide, enrollment and participation rates remain low across the country. Several states have tried various interventions to combat this deficiency of engagement with the goal of increasing WIC enrollment and participation. We conducted a scoping review to identify articles based on pre-specified inclusion and exclusion criteria. Two reviewers independently identified and screened articles. Subsequently, three reviewers independently extracted study details and outcomes related to WIC enrollment and participation rate changes. We included 14 studies reporting on 12 interventions from 3945 citations reviewed. Seven of these were published papers, while the others were final reports of USDA WIC Special Grant Projects. All the observed interventions had some success increasing WIC participation. Virtual interventions demonstrated the most success based on preliminary evidence. Successful interventions showed percentage gains in enrollment close to 8% and changes in participation over 9%. Overall, the literature surrounding WIC enrollment interventions reveal a mixed impact on improving participation. Many successful interventions involve an online or virtual engagement component which can provide educational resources on WIC benefits, nutrition, and living a healthy lifestyle.

WIC Participants' Perceptions of COVID-19-Related Changes to WIC Recertification and Service Delivery

Many Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics implemented alternatives to in-person service delivery in response to the COVID-19 pandemic, including virtual visits and electronic document sharing. The objective of this cross-sectional study was to describe WIC participants’ experiences with remote service delivery and recertification during the pandemic. Participants included mothers and infants who participated in a WIC-based intervention between June 2019-August 2020. All participants (N = 246) were invited to complete a follow-up survey between November 2020-February 2021; 185 mothers completed the survey. The survey assessed sociodemographics, employment, food security, experiences with remote WIC recertification and service delivery, and experiences with obtaining WIC foods during the pandemic. Average age for mothers was 29.2 ± 6.3 years and for infants was 17.7  ± .2 months; 80% (n = 147) identified as Hispanic. Approximately 34% (n = 62) of participants reported very low or low food security and 40% (n = 64) had difficulties buying WIC foods during the pandemic. Among participants who recalled providing documentation of income and address virtually, the majority felt comfortable providing information via email (60%) and text messaging (72%). Participants reported high levels of satisfaction with remote methods of service delivery, as well as overall satisfaction with the WIC program during the pandemic. While ~ 25% of study participants preferred for all WIC services to remain remote, 75% still desired at least some in-person contact with WIC staff after the pandemic. In conclusion, remote methods of WIC service delivery addressed existing barriers to WIC participation and were well-received by study participants.

Dietary Quality of Pregnant Women Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children

Few studies have examined the dietary intake of low-income pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The aim of this study was to assess the dietary quality of WIC-enrolled pregnant women and examine associations with maternal characteristics, nutrition knowledge, and key health indicators. Fifty-one WIC-enrolled pregnant women completed two sets of 3-day food records. Food records were analyzed for nutrient content, and diet quality was assessed using the Healthy Eating Index (HEI)-2015. Since an HEI score of less than 60 is indicative of the need to improve dietary quality, participants' HEI scores were divided into two categories: <60 and ≥60. The total mean HEI score of the cohort based on analysis of the first set of food records was 59.1 ± 12.5 (range 37.1-89.2), while the mean score for the second 3 days of food records was 56.8 ± 12.7 (range 30.0-89.0). The majority of participants did not consume the minimum recommended servings of whole vegetables. Those in the <60 HEI category consumed on average less than 50% of the recommended servings of whole fruits and whole grains. The diets of the majority of participants were high in saturated fat and sodium. More than one-third did not meet the recommendations for folate and iron intake, while less than half met the RDA for vitamin D. Choline intake was insufficient based on analysis of the first 3 days of food records. Our results indicate that the dietary quality of WIC-enrolled pregnant women requires improvement.

Maternal Compliance to Recommended Iron and Folic Acid Supplementation in Pregnancy, Sri Lanka: A Hospital-Based Cross-Sectional Study

Iron deficiency anaemia during pregnancy is a common public health problem that negatively affects maternal and newborn health. This study aims to identify the rate of maternal compliance with the recommended iron and folic acid (IFA) supplementation during pregnancy and to identify factors associated with maternal compliance and non-compliance. A hospital-based cross-sectional study was conducted among 703 women at 0-4 days postpartum. The prevalence of anaemia at the initial antenatal clinic (ANC) visit and at the third trimester were 20.8% and 44.9%, respectively. The rate of IFA supplementation compliance during pregnancy was 80.1%. Forgetfulness (66.9%) was the major reason for non-compliance, followed by side effects (15.7%). Maternal employment [OR (95%CI): 1.7 (1.00-2.89)], history of a low birth weight infant [OR (95%CI): 0.4 (0.19-0.9)] and history of anaemia [OR (95%CI): 0.4 (0.12-0.98] were significantly associated with maternal compliance with IFA supplementation. Only 26.6% of the participants adhered to dietary recommendations during the period when IFA supplements were provided. The rate of maternal compliance with IFA supplementation was high. However, the prevalence of maternal anaemia during pregnancy was also high, which was presumably due to poor dietary compliance despite high IFA supplementation compliance.

A Qualitative Study of Breastfeeding and Formula-Feeding Mothers' Perceptions of and Experiences in WIC

OBJECTIVE

To explore Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants' perspectives about why formula-fed infants are less likely to be recertified at 1 year compared with breastfed infants.

DESIGN

Four focus groups of WIC mothers, stratified by language spoken (English or Spanish) and feeding mode (breastfeeding [BF] or formula-feeding [FF]).

SETTING

Two WIC sites within Los Angeles County, CA.

PARTICIPANTS

Mothers of 6- to 12-month-old infants (n = 31) in the WIC program.

PHENOMENON OF INTEREST

Mothers' perceptions of (1) how WIC supports BF and FF mothers; and (2) experiences of FF mothers in WIC, with a focus on how these experiences may affect desire to recertify their infant in WIC at age 1 year.

ANALYSIS

Thematic analysis of verbatim transcripts.

RESULTS

Mothers in all focus groups discussed the perceived positive value of BF support, food assistance, nutrition education, referrals, convenient WIC services, and social support from staff. Themes related to experiences of FF mothers included feeling judged for not BF, perceptions of WIC as a formula provider, and perceived difficulties obtaining formula. Mothers indicated that these experiences affected motivations to recertify.

CONCLUSIONS AND IMPLICATIONS

Although WIC provides important and effective support to low-income families, especially related to BF, some FF mothers may feel underserved with respect to support for their feeding decisions.

The effect of women, infant, and children (WIC) services on birth weight before and during the 2007-2009 great recession in Washington state and Florida: a pooled cross-sectional time series analysis

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to have positive effects in promoting healthy birth outcomes in the United States. We explored whether such effects held prior to and during the most recent Great Recession to improve birth outcomes and reduce differences among key socio-demographic groups.

METHODS

We used a pooled cross-sectional time series design to study pregnant women and their infants with birth certificate data. We included Medicaid and uninsured births from Washington State and Florida (n = 226,835) before (01/2005-03/2007) and during (12/2007-06/2009) the Great Recession. Interactions between WIC enrollment and key socio-demographic groupings were analyzed for binary and continuous birth weight outcomes.

RESULTS

Our study found beneficial WIC interaction effects on birth weight. For race, prenatal care, and maternal age we found significantly better birth weight outcomes in the presence of WIC compared to those without WIC. For example, being Black with WIC was associated with an increase in infant birth weight of 53.5 g (baseline) (95% CI = 32.4, 74.5) and 58.0 g (recession) (95% CI = 27.8, 88.3). For most groups this beneficial relationship was stable over time.

CONCLUSIONS

This paper supports previous research linking maternal utilization of WIC services during pregnancy to improved birth weight (both reducing LBW and increasing infant birth weight in grams) among some high-disadvantage groups. WIC appears to have been beneficial at decreasing disparity gaps in infant birth weight among the very young, Black, and late/no prenatal care enrollees in this high-need population, both before and during the Great Recession. Gaps are still present among other social and demographic characteristic groups (e.g., for unmarried mothers) for whom we did not find WIC to be associated with any detectable value in promoting better birth weight outcomes. Future research needs to examine how WIC (and/or other maternal and child health programs) could be made to work better and reach farther to address persistent disparities in birth weight outcomes. Additionally, in preparation for future economic downturns it will be important to determine how to preserve and, if possible, expand WIC services during times of increased need.

TRIAL REGISTRATION

Not applicable, this article reports only on secondary retrospective data (no health interventions with human participants were carried out).

Child Consumption of Whole Fruit and Fruit Juice Following Six Months of Exposure to a Pediatric Fruit and Vegetable Prescription Program

Public health recommendations suggest limiting child consumption of fruit juice in favor of whole fruit due to juice’s high sugar content, lack of fruit fiber, and potential for excess intake. However, replacing juice with whole fruit may be particularly challenging for low-income and minority children, who report the highest intake of 100% juice. To address access and affordability challenges among low-income children, researchers partnered with pediatricians in an urban food desert community, to introduce a fruit and vegetable prescription program (FVPP) that provided a $15 prescription for fresh produce to every child during each office visit. Participating vendors included a farmers’ market and local mobile market. This study assessed changes in daily consumption of total fruit and whole fruit among 108 pediatric patients following six months of exposure to the FVPP. Child-reported mean daily intake of whole fruit increased significantly from the baseline to the 6-month follow-up (p = 0.03): 44% of children reported an increased intake of at least ¼ cup per day, and 30% reported an increased intake of at least ½ cup per day. Changes in total fruit intake (including fruit juice) were not significant. Results suggest a pediatric FVPP may have meaningful impacts on children’s dietary behaviors, particularly with regard to the intake of whole fruits.

Association of Special Supplemental Nutrition Program for Women, Infants, and Children With Preterm Birth and Infant Mortality

IMPORTANCE

Nearly 4 in 10 expectant mothers in the United States received Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits during pregnancy between 2011 and 2017. Despite public support for the program, empirical evidence of the success of the program varies substantially.

OBJECTIVE

To assess the association of WIC program participation during pregnancy by low-income expectant mothers covered by Medicaid with infant mortality by gestational age at birth and by maternal race/ethnicity in comparison with their counterparts who did not receive WIC benefits.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from January 1, 2011, to December 31, 2017, from US live birth certificates. Data were from 11 148 261 expectant mothers who delivered live births in states that have implemented the 2003 revision of the US live birth certificate and whose insurance coverage and receipt of WIC benefits were recorded on the birth certificates. Data analysis was performed from June 2019 to October 2019.

EXPOSURES

Receipt of WIC benefits during pregnancy.

MAIN OUTCOMES AND MEASURES

The first outcome was gestational age at birth: extremely preterm (<28 weeks), very preterm (28-32 weeks), moderate-to-late preterm (32-37 weeks), and normal term (≥37 weeks) births. The second outcome was death within the first year of life.

RESULTS

Among the 11 148 261 expectant mothers who delivered live births between 2011 and 2017 and were covered by Medicaid during pregnancy, the modal age at delivery was 20 to 24 years, the predominant race/ethnicity was non-Hispanic white (4 257 790 [38.2%]), and 8 145 770 (73.1%) received WIC benefits during pregnancy. The proportion of expectant mothers covered by Medicaid who also received WIC benefits decreased from 2011 to 2017 (79.3% to 67.9%; P < .001). The odds of preterm birth compared with normal term birth were lower among expectant mothers covered by Medicaid who received WIC benefits during pregnancy compared with their counterparts who did not receive WIC benefits during pregnancy (adjusted proportional odds ratio, 0.87; 95% CI, 0.86-0.87). The odds of mortality within 1 year of birth were lower for infants whose mothers were covered by Medicaid and received WIC benefits during pregnancy compared with those who did not receive WIC benefits during pregnancy (adjusted odds ratio, 0.84; 95% CI, 0.83-0.86).

CONCLUSIONS AND RELEVANCE

This study found that receipt of WIC benefits among expectant mothers with Medicaid coverage was associated with lower risk of preterm birth and infant mortality.

Recovery From Malnutrition Among Refugee Children Following Participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) Program in Massachusetts, 1998-2010

OBJECTIVES

(1) To examine patterns of catch-up growth and anemia correction in refugee children younger than 5 years after participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) program, and (2) to identify factors associated with recovery from growth abnormalities.

DESIGN

Records on 1731 refugee children younger than 5 years who arrived in Massachusetts between 1998-2010 were matched to WIC program records and then restricted to 779 children who had at least 2 WIC visits. Kaplan-Meier curves and Cox proportional hazards models were used to examine how sex affected time to recovery from malnutrition and anemia. Factors associated with recovery were analyzed in SAS using multivariate logistic regression.

SETTING

Massachusetts.

PARTICIPANTS

Refugee children younger than 5 years on arrival, who visited a WIC program at least twice between 1998 and 2010.

MAIN OUTCOME MEASURES

(1) Proportion of children who recovered from low height-for-age (stunting), low weight-for-age, low weight-for-height (wasting), and anemia; (2) odds ratios for factors associated with recovery; and (3) Kaplan-Meier curves showing recovery over time from low height-for-age, low weight-for-age, and low weight-for-height.

RESULTS

The number of WIC visits was associated with recovery from stunting, wasting, low weight-for-age, and anemia; results reached statistical significance for stunting (odds ratio [OR] = 8.64; 95% confidence interval [CI], 2.25-33.19), low weight-for-age (OR = 5.28; 95% CI, 1.35-20.73), and anemia (OR = 6.50; 95% CI, 2.69-15.69). Female sex was associated with recovery from stunting, wasting, and low weight-for-age, whereas male sex was associated with recovery from anemia; the associations were statistically significant between female sex and stunting (OR = 9.14; 95% CI, 1.93-43.29), wasting (OR = 14.78; 95% CI, 1.57-138.85), and low weight-for-age (OR = 4.29; 95% CI, 1.09-16.79).

CONCLUSIONS

Children who remained engaged in WIC may recover better from malnutrition than children with fewer WIC visits, although there are limitations to the available data.These findings suggest that those working with refugee families should prioritize outreach toward initiating and maintaining WIC program enrollment for eligible refugee children.

Association of Maternal Eligibility for the Deferred Action for Childhood Arrivals Program With Citizen Children's Participation in the Women, Infants, and Children Program

This study examines the association of maternal eligibility for Deferred Action for Childhood Arrivals (DACA) immigration program with participation of citizen children in the Women, Infants, and Children (WIC) health care and supplemental nutrition program.

Child access to the nutritional safety net during and after the Great Recession: The case of WIC

Because children disproportionately live in poverty, they are especially vulnerable during economic crises, making the social safety net a key buffer against the effects of economic disadvantage on their development. The Great Recession of 2007-2009 had strong and lasting effects on American children and families, including striking negative effects on their health environments. Understanding access to the health safety net during this time of increased economic need, as well as the extent to which all children-regardless of age, income or race/ethnicity-share in the increased use of transfer programs, is therefore important in identifying the availability and accessibility of government assistance for those in need. Focusing on the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program because of its strong effects on child development, we use longitudinal data from the Survey of Income and Program Participation (SIPP) to examine change and stability in children's WIC enrollment before, during and after the recession. Specifically, we examine: 1) whether children's WIC enrollment increased alongside changing family income, and 2) the extent to which changes in participation were shared by all subpopulations, regardless of age, income, and race/ethnicity. Analyses reveal that WIC participation among eligible children increased leading up to, during, and after the Great Recession, suggesting that the program was responsive to increasing economic need. Examining the distribution of WIC enrollment across demographic groups largely reveals a pattern of stable inequality in access and "take up." Children born to poorer and less-educated mothers were more likely to be enrolled prior to the recession, and these differences remain mostly constant during and after the recession. Eligible Hispanic children had consistently higher enrollment, particularly among those in families with foreign-born mothers. The findings suggest that not all eligible children equally enroll in WIC, but that these differences have not been drastically exacerbated by macroeconomic instability.

Nutrition for Multiples

In 2012 there were 135,943 infants of multiple pregnancies born in the United States, nearly a 2-fold increase since 1980, with twins accounting for 96% of all multiple births. To date, most perinatal morbidities associated with multiple births have proven resistant to technological or pharmaceutical interventions. Maternal nutrition can have a profound effect on the course and outcome of multiple pregnancy, with the goal of achieving optimal intrauterine growth and birthweights, and minimizing prenatal and perinatal complications for the mother and her children.

'Fit Moms/Mamás Activas' internet-based weight control program with group support to reduce postpartum weight retention in low-income women: study protocol for a randomized controlled trial

BACKGROUND

High postpartum weight retention is a strong independent risk factor for lifetime obesity, cardiovascular disease, and type 2 diabetes in women. Interventions to promote postpartum weight loss have met with some success but have been limited by high attrition. Internet-based treatment has the potential to overcome this barrier and reduce postpartum weight retention, but no study has evaluated the effects of an internet-based program to prevent high postpartum weight retention in women.

METHODS/DESIGN

Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m(2) or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures.

DISCUSSION

Fit Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (identifier: NCT01408147 ) on 29 July 2011.

Early childhood WIC participation, cognitive development and academic achievement

For the 22% of American children who live below the federal poverty line, and the additional 23% who live below twice that level, nutritional policy is part of the safety net against hunger and its negative effects on children's development. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides steadily available food from the food groups essential for physical and cognitive development. The effects of WIC on dietary quality among participating women and children are strong and positive. Furthermore, there is a strong influence of nutrition on cognitive development and socioeconomic inequality. Yet, research on the non-health effects of U.S. child nutritional policy is scarce, despite the ultimate goal of health policies directed at children-to enable productive functioning across multiple social institutions over the life course. Using two nationally representative, longitudinal surveys of children-the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) and the Child Development Supplement (CDS) of the Panel Study of Income Dynamics-I examine how prenatal and early childhood exposure to WIC is associated in the short-term with cognitive development, and in the longer-term with reading and math learning. Results show that early WIC participation is associated with both cognitive and academic benefits. These findings suggest that WIC meaningfully contributes to children's educational prospects.

Evaluating the initial impact of the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on dietary intake and home food availability in African-American and Hispanic families

OBJECTIVE

The present study assessed the impact of the 2009 food packages mandated by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dietary intake and home food availability in low-income African-American and Hispanic parent/child dyads.

DESIGN

A natural experiment was conducted to assess if the revised WIC food package altered dietary intake, home food availability, weight and various lifestyle measures immediately (6 months) following policy implementation.

SETTING

Twelve WIC clinics in Chicago, IL, USA.

SUBJECTS

Two hundred and seventy-three Hispanic and African-American children aged 2-3 years, enrolled in WIC, and their mothers.

RESULTS

Six months after the WIC food package revisions were implemented, we observed modest changes in dietary intake. Fruit consumption increased among Hispanic mothers (mean = 0·33 servings/d, P = 0·04) and low-fat dairy intake increased among Hispanic mothers (0·21 servings/d, P = 0·02), Hispanic children (0·34 servings/d, P < 0·001) and African-American children (0·24 servings/d, P = 0·02). Home food availability of low-fat dairy and whole grains also increased. Dietary changes, however, varied by racial/ethnic group. Changes in home food availability were not significantly correlated with changes in diet.

CONCLUSIONS

The WIC food package revisions are one of the first efforts to modify the nutrition guidelines that govern foods provided in a federal food and nutrition assistance programme. It will be important to examine the longer-term impact of these changes on dietary intake and weight status.

Use of food labels, awareness of nutritional programmes and participation in the special supplemental program for Women, Infants and Children (WIC): results from the National Health and Nutrition Examination Survey (2005-2006)

Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts are focusing on the revamping of nutritional labels to make them easier to read and use for the consumer. The study aims to assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programmes by low-income women including those participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey 2005-2006. Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the USDA Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.91], the health claims information (OR 0.54, 95% CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95% CI 0.20-0.97) in comparison with WIC eligible non-participants. Any intervention to improve use of nutritional labels and knowledge of the USDA's nutritional programmes needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants in comparison with eligible non-participants.

Impact of fruit and vegetable vouchers and dietary advice on fruit and vegetable intake in a low-income population

BACKGROUND/OBJECTIVES

Lower-income subgroups consume fewer servings of fruit and vegetables (FVs) compared with their more advantaged counterparts. To overcome financial barriers, FV voucher delivery has been proposed.

SUBJECTS/METHODS

In a 12-month trial, 302 low-income adults 18-60 years old (defined by evaluation of deprivation and inequalities in health examination centers, a specific deprivation score) were randomized into two groups: dietary advice alone ('advice'), or dietary advice plus FV vouchers ('FV vouchers') (10-40 euros/month) exchangeable for fresh fruits and vegetables. Self-reported data were collected on FV consumption and socioeconomic status at baseline, 3, 9 and 12 months. Anthropometric and blood pressure measurements were conducted at these periods, as well as blood samples obtained for determination of vitamins. Descriptive analyses, multiple linear regression and logistic regression were performed to evaluate the impact of FV.

RESULTS

Between baseline and 3-month follow-up, mean FV consumption increased significantly in both the 'advice' (0.62±1.29 times/day, P=0.0004) and 'FV vouchers' groups (0.74±1.90, P=0.002), with no difference between groups. Subjects in the FV vouchers group had significantly decreased risk of low FV consumption (<1 time/day) compared with those in the advice group (P=0.008). No change was noted in vitamin levels (vitamin C and β-carotene). The high number of lost-to-follow-up cases did not permit analysis at 9 or 12 months.

CONCLUSION

In the low-income population, FV voucher delivery decreased the proportion of low FV consumers at 3 months. Longer-term studies are needed to assess their impact on nutritional status.

Why nutritional iron deficiency persists as a worldwide problem

The earliest studies of food iron absorption employing biosynthetically incorporated radioisotopes were published in the 1950s. Wheat flour has been fortified with iron in Canada, the United Kingdom, and the United States since the 1940s. However, half a century later, nutritional iron deficiency (ID) is estimated to affect 1.5-2 billion people worldwide. The reasons for the apparently limited impact of health and nutrition policies aimed at reducing the prevalence of ID in developing countries are complex. They include uncertainty about the actual prevalence of ID, particularly in regions where malaria and other infections are endemic, failure of policy makers to recognize the relationships between ID and both impaired productivity and increased morbidity, concerns about safety and the risks to iron-sufficient individuals if mass fortification is introduced, and technical obstacles that make it difficult to add bioavailable iron to the diets of those at greatest risk. It is, however, likely that the next decade will see a marked reduction in the prevalence of ID worldwide. More specific assessment tools are being standardized and applied to population surveys. The importance of preventing ID during critical periods of the life cycle is receiving increased attention. Innovative approaches to the delivery of bioavailable iron have been shown to be efficacious. The importance of integrating strategies to improve iron nutrition with other health measures, and economic and social policies addressing poverty as well as trade and agriculture, are receiving increasing consideration.

Zinc and iron deficiency and their interrelations in low-income African American and Hispanic children in Atlanta

BACKGROUND

Information about the zinc status of low-income minority children in the United States is lacking.

OBJECTIVE

The objective was to determine the prevalence of zinc deficiency and anemia and their interrelation among low-income African American and Hispanic preschool children.

DESIGN

This was a cross-sectional study in which a prospective 3-d food diary was completed, and hemoglobin, serum ferritin, zinc, copper, and C-reactive protein concentrations were measured. Children with elevated C-reactive protein concentrations were excluded from analysis.

RESULTS

Of 292 children recruited, 280 (mean +/- SD age: 2.5 +/- 1.2 y) qualified for analysis. One hundred forty-six (52%) children were African American and 134 (48%) were Hispanic; 202 (72%) were enrolled in the Women, Infants, and Children nutrition program. A low serum zinc concentration (<10.7 mumol/L) was present in 34 (12%) children, and 37 (13%) were anemic (hemoglobin < 110 g/L). African American (odds ratio: 3.47; 95% CI: 1.51, 7.96) and anemic (odds ratio: 2.92; 95% CI: 1.24, 6.90) children had an increased risk of zinc deficiency. Serum zinc correlated with hemoglobin (r = 0.24, P < 0.001). Children with a height/length less than the fifth percentile had significantly lower mean serum zinc concentrations than those with a height/length greater than the fifth percentile (12.4 +/- 1.8 compared with 13.0 +/- 2.2 micromol/L; P < 0.001). In a multiple logistic regression model, African American race-ethnicity was associated with zinc deficiency (odds ratio: 0.26; P = 0.02). The main sources of iron and zinc in the diets were meat products and cereals.

CONCLUSIONS

The prevalence of zinc deficiency and anemia was high in this population of low-income minority children, especially among African Americans. Further investigation of the incidence of zinc deficiency and the ability of anemia to screen for it is warranted.

Household food insecurity is a risk factor for iron-deficiency anaemia in a multi-ethnic, low-income sample of infants and toddlers

OBJECTIVE

The present study examines the relationships of household food security status with Fe deficiency (ID) and Fe-deficiency anaemia (IDA) among children less than 3 years of age, and associated factors that contribute to ID and IDA.

DESIGN

Cross-sectional study and chart review. The US Food Security Survey Module was administered to adult caregivers as part of the Children's Sentinel Nutrition Assessment Project (C-SNAP). Haematological data were obtained from medical records.

SETTING

A large metropolitan medical centre in Minneapolis, Minnesota, USA.

SUBJECTS

A multi-ethnic sample of 2853 low-income children aged <36 months who received care at the medical centre.

RESULTS

Among the caregivers, 23.3 % reported low household food security and 11.6 % reported very low household food security (VLFS). After controlling for background factors, children from households with VLFS were almost twice as likely to have IDA than were children from households with high or marginal food security (OR = 1.98, 95 % CI 1.11, 3.53); the corresponding associations for ID were not statistically significant.

CONCLUSIONS

The prevalence of IDA in early childhood is significantly larger in low-income infants and toddlers living in VLFS households. Asian, Hispanic and African-American children have elevated prevalences of ID and IDA. Breast-feeding may be associated with elevated ID and IDA, while participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may be protective for ID.

Participants' comments on changes in the revised special supplemental nutrition program for women, infants, and children food packages: the Maryland food preference study

The Institute of Medicine recommended changes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages to help families from diverse populations establish more healthful dietary patterns. A cross-sectional study conducted during summer 2007 included interviews and focus groups with 223 WIC participants throughout Maryland. The objectives were to examine participants' responses to food package changes, to identify racial/ethnic differences, and to assess costs. All participants (100%) consumed fruits and vegetables. They preferred fresh for taste, but many endorsed canned and frozen for convenience and cost. Most women (56%) and children (69%) consumed whole milk and did not want reduced-fat milk. Few participants (13%) consumed soy products and most were uninterested in future consumption. Participants endorsed whole-wheat bread as more healthful and reported that they (59%) and their children (51%) would increase consumption if provided by WIC. Non-Hispanic participants preferred peanut butter over beans, Hispanic participants reported that they (44%) and their children (57%) would consume more beans (substituting for peanut butter) if provided by WIC. There were few differences in preferences between African-American and white participants. Hispanics differed from non-Hispanics in preference for beans and dislike of frozen and canned vegetables, suggesting the importance of choices. The proposed food packages were cost-neutral, except when extensive substitutions with soy products were allowed. By providing fruits and vegetables, reduced-fat options, and increased opportunities for nutrition education, the revised food packages may reduce the risk of obesity among low-income women, infants, and children.

Nutritional iron deficiency

Iron deficiency is one of the leading risk factors for disability and death worldwide, affecting an estimated 2 billion people. Nutritional iron deficiency arises when physiological requirements cannot be met by iron absorption from diet. Dietary iron bioavailability is low in populations consuming monotonous plant-based diets. The high prevalence of iron deficiency in the developing world has substantial health and economic costs, including poor pregnancy outcome, impaired school performance, and decreased productivity. Recent studies have reported how the body regulates iron absorption and metabolism in response to changing iron status by upregulation or downregulation of key intestinal and hepatic proteins. Targeted iron supplementation, iron fortification of foods, or both, can control iron deficiency in populations. Although technical challenges limit the amount of bioavailable iron compounds that can be used in food fortification, studies show that iron fortification can be an effective strategy against nutritional iron deficiency. Specific laboratory measures of iron status should be used to assess the need for fortification and to monitor these interventions. Selective plant breeding and genetic engineering are promising new approaches to improve dietary iron nutritional quality.

Prepregnancy weight, inappropriate gestational weight gain, and smoking: Relationships to birth weight

This study was designed to test predictors of infant birth weight based on categories of prepregnancy body mass index (BMI), gestational weight gain, and smoking. Data were collected retrospectively from records of 233 mother-infant pairs enrolled in the Siouxland Women, Infants, and Children (WIC) Program in Sioux City, Iowa. Prepregnancy BMI and gestational weight gain were coded according to Institute of Medicine guidelines. Smoking behavior was coded based on reported smoking during the last 3 months of pregnancy. Multiple regression analysis was used to test predictors of infant birth weight. Forty-two percent of women gained more weight than recommended, and 16% gained less than recommended. Based on prepregnancy BMI, women were classified as underweight (12%), overweight (16%), or obese (31%). Twenty-four percent of mothers reported smoking late in gestation. Higher birth weight was predicted by prepregnancy obesity (+144 g). Lower infant birth weight was predicted by lower (-162 g) and higher (-153 g) than recommended weight gain, and by lower (-299 g) and higher (-168 g) levels of smoking. Depression of birth weight among women who gained excess weight may relate to inadequate early weight gain or pregnancy complications. More research is needed regarding physiological consequences of these maternal factors and their associated demographic risk factors.

Nutrition in multiple gestations

Multiple pregnancies represent a state of magnified nutritional requirements, resulting in a greater nutrient drain on maternal resources and an accelerated depletion of nutritional reserves. Maternal weight gain to 20 weeks and between 20 and 28 weeks has the greatest effect on birthweight in twin and triplet pregnancies, particularly among underweight women. Parity, which most likely represents a higher proportion of body fat, has a positive effect on pregnancy outcome, with an average 7 to 10 days longer gestation for multiparous versus nulliparous women. In addition to being the nutrients most often lacking in a woman's diet, calcium, magnesium, and zinc have been identified as having the most potential for reducing pregnancy complications and improving outcomes.

Perceptions of health status and play activities in parents of overweight Hispanic toddlers and preschoolers

Childhood overweight among lower socioeconomic, Hispanic children has increased. Interviews regarding health status and play patterns were conducted with 76 predominantly Hispanic mothers of overweight toddlers and preschoolers served by Women, Infants, and Children (WIC). Most participants believed their child was healthy and half were unconcerned about their child's weight. Most parents reported having a safe place to play and access to a playground, although gender differences were found. Access to an outside play area was related to amount of active play activities. Children watched an average of 1.7 hours per day of television. Health professionals must partner with parents to address childhood obesity.

Erythrocyte folate and its response to folic acid supplementation is assay dependent in women

Optimizing folate status requires continued monitoring of erythrocyte (RBC) folate and folate intake. The accuracy of RBC folate assays remains a concern. Therefore, we measured RBC folate with 4 different assays, examined the interassay correlations, and compared RBC folate with folate intake as measured by an abbreviated folate-targeted food/supplement screener. The screener had 21 questions (19 diet, 2 supplement) and measured usual and customary intakes of dietary folate equivalents (DFEs). Our design was a 4 x 2 x 2 factorial, 4 assays in pregnant and nonpregnant women before and after each group received a folic acid supplement (1814 nmol/d) for 30-60 d. Folate assays included L. casei, chemiluminescence, GC-MS, and radioassay (RA). Baseline RBC folate levels ranked low to high by assay (mean +/- SE) were as follows: 1155 +/- 44 nmol/L (L. casei) < 1390 +/- 43 nmol/L (chemiluminescence) < 1531 +/- 39 nmol/L (GC-MS) < 1727 +/- 55 nmol/L (RA) (P < 0.0001). Supplementation raised RBC folate levels (mean +/- SE) as follows: 138 +/- 63 nmol/L (chemiluminescence) < 267 +/- 64 nmol/L (GC-MS) = 285 +/- 75 nmol/L (L. casei) < 351 +/- 87 nmol/L (RA). Pregnant women had higher RBC folate than nonpregnant women using chemiluminescence and RA. Interassay correlations (r) ranged from 0.4679 to 0.8261 (P < 0.001). Correlations of RBC folate with folate intake ranged from 0.2676 to 0.4622 (P < 0.0004). We conclude that RBC folate levels are assay dependent, as is the definition of optimized status; there continues to be a need for an accurate assay of RBC folate. RBC folate correlated with total folate intake using a folate-targeted food/supplement screener.

Relationship of child-feeding practices to overweight in low-income Mexican-American preschool-aged children

OBJECTIVE

The purpose of this research was to examine the relationship of child-feeding practices and other factors to overweight in low-income Mexican-American preschool-aged children.

DESIGN

Cross-sectional survey with anthropometric measurements of mothers and target children. Trained bilingual staff interviewed the parents to collect data on child-feeding strategies, food patterns, child's health history, parental acculturation level, food insecurity, and other household characteristics. Subjects and setting Complete data were available from 204 low-income Mexican-American parents residing in California with at least one child aged 3 to 5 years. Outcomes measured Risk of overweight was defined as body mass index (BMI) (measured as weight [in kilograms]/height [in meters](2)) >/=85th percentile and overweight was defined as BMI >/=95th percentile. The Student t test, chi(2) test, and logistic regression were used.

RESULTS

Three variables were positively related to risk of overweight: birth weight (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.11 to 4.82), mother's BMI >/=30 (OR, 2.05; 95% CI, 1.11 to 3.79), and juice intake (OR, 2.33; 95% CI, 1.09 to 4.98). Being enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children was negatively related to risk of overweight (OR, 0.40; 95% CI, 0.21 to 0.75). Additional variables related to overweight were monthly income >$1,500 (OR, 2.33; 95% CI, 1.00 to 5.42) and child takes food from the refrigerator between meals (OR, 0.32; 95% CI, 0.13 to 0.76).

CONCLUSIONS

The results of this study suggest that biological and socioeconomic factors are more associated with overweight in Mexican-American preschool-aged children than most of the self-reported child-feeding strategies.

Nutrient intakes and food choices of infants and toddlers participating in WIC

OBJECTIVES

To examine the nutrient intakes, foods consumed, and feeding patterns of infants and toddlers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Cross-sectional telephone survey, including 24-hour dietary recalls of infants' and toddlers' food and nutrient intakes, as reported by parents or other primary caregivers.

SUBJECTS

National random sample of 3,022 children ages 4 to 24 months who participated in the 2002 Feeding Infants and Toddlers study. Sample sizes by age were infants 4 to 6 months: 265 WIC participants, 597 nonparticipants; infants 7 to 11 months: 351 WIC participants, 808 nonparticipants; and toddlers 12 to 24 months: 205 WIC participants, 791 nonparticipants.

STATISTICAL ANALYSES PERFORMED

We used Statistical Analysis Software (version 8.2) to examine the breastfeeding status, infant feeding patterns, and foods consumed; the personal computer version of the Software for Intake Distribution Estimation to estimate mean usual intake of food energy and of key nutrients targeted by the WIC program; and methods recommended by the Institute of Medicine to assess nutrient adequacy.

RESULTS

Infants participating in WIC were less likely than nonparticipants to have ever been breastfed or to be currently breastfeeding, and they were more likely to be consuming formula. Mean usual nutrient intakes exceeded the adequate intake for WIC participants, and the percentage with inadequate nutrient intake was less than 1%. Reported mean energy intakes exceeded mean energy requirements, with the largest discrepancy observed for WIC participants. Sizeable proportions of WIC and non-WIC infants and toddlers did not consume fruits and vegetables on the recall day.

APPLICATIONS

WIC providers should focus nutrition education on appropriate infant and toddler feeding patterns, should continue to reinforce their message of the importance delaying the use of cow's milk until 1 year of age, and should stress the importance of fruit and vegetable consumption.

Growth pattern of overweight preschool children in the Siouxland WIC program

Demographic, nutritional, and anthropometric data were collected from 134 preschool children enrolled in the Siouxland Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). All children were diagnosed as overweight between the ages of 8 months and 3 years. Weight and length/height z-scores were calculated for birth measurements and for postnatal measurements up to 3 years. The main hypothesis involved stability of weight and length/height z-scores between successive WIC visits. Average changes in z-scores between measurements were calculated and tested for significance using paired t-tests. Multiple regression analysis was used to test relationships between changes in weight z-scores and demographic/nutritional characteristics. The overweight group had a higher percentage of Hispanic children than the total Siouxland WIC population. Overweight children were also significantly different in terms of birthweight, monthly household income, number in the house, and mother's education level. The children displayed a large average increase in weight z-scores between birth and 8 months (P < 0.001). Weight z-scores also increased significantly between 12 and 30 months. Length z-scores increased significantly between 18 and 30 months but remained lower than weight z-scores. Initial weight, sex of child, breastfeeding, and household size were significantly related to changes in weight z-scores among overweight children. Results of recent studies suggest that rapid weight gain in infancy may increase the risk of overweight during later childhood.

Nutritional assessment of pregnant women enrolled in the Special Supplemental Program for Women, Infants, and Children (WIC)

OBJECTIVE

To evaluate nutrient intake from dietary sources for 95 pregnant women enrolled in the Special Supplemental Program for Women, Infants, and Children (WIC).

SUBJECTS/SETTING

Women were recruited from Minneapolis and St Paul area WIC clinics between January and June 1999. Based on estimates from the WIC clinics, the study was described to 159 (63%) of the 251 potentially eligible women. Of these 159 women, 107 (67%) completed the in-person interview. Ninety-five (89%) were included in the nutrition analysis.

METHODS

Each woman completed a 1-hour in-person interview that included a questionnaire, anthropometric measurements, and a venous blood sample. A shortened Block 98 food frequency questionnaire was used to assess dietary intake. Serum ferritin was measured for 86 women. Means, medians, and standard deviations of dietary intake were explored as well as body mass index distributions. Additionally, the percentage of women consuming less than two thirds of the recommended dietary allowance (RDA) for certain nutrients was calculated.

RESULTS

Overall, the women reported consuming only 85% of the RDA for energy. The average percentage of energy from fat was higher than recommended (37% vs 30%). The most notable nutrient shortfall was iron; 90% of the women reported consuming less than 2/3 of the RDA. Additionally, serum ferritin analysis classified 22% of the women with iron-deficiency anemia (<12 mg/L).

CONCLUSIONS

Interventions should be designed to decrease fat consumption and increase iron intake among pregnant WIC participants to meet dietary recommendations.

[Dietary recommendations for pregnant women affected with phenylketonuria]

Prevention of embryopathy due to maternal phenylketonuria is possible thanks to a maternal-specific low-phenylalanine diet, which has to be started before conception and followed during the whole gestation. The setup of this diet implies knowing the recommended dietary allowances for normal pregnant women as well as for women with nutritional deficiencies. Women with phenylketonuria must be considered at risk for nutritional imbalance for two main reasons. First, most adult women with phenylketonuria have been on a vegetarian diet for many years without protein substitutes or medical control. Secondly, the strict diet for pregnant women with phenylketonuria may induce anorexia or nutritional deficits if it is not well tolerated or understood. Protein, iron, calcium, selenium, vitamin B 12 and caloric intakes are the most sensitive parameters. Close cooperation with an experienced medical and dietician team is required.

Client satisfaction with the nutrition education component of the California WIC program

Past evaluation research has documented improved nutritional outcomes resulting from participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). However, these evaluations have not examined the program from the clients' perspective, nor have they examined the independent effect of the nutrition education component. The purpose of this study was to quantitatively and qualitatively examine client satisfaction with the nutrition education component of the California WIC program. The methodology consisted of two phases. During phase I of the study (the quantitative component), participants completed Client Satisfaction Surveys immediately following attendance of one nutrition class. During phase II (the qualitative component), four focus groups were conducted. All subjects were participants in the California WIC program. Client Satisfaction Surveys were completed by 2138 participants, and the focus groups included 29 participants. Results from both phases of the study indicated that client satisfaction with the nutrition education component of the California WIC program was high. Between 80% and 95% of participants responded positively to five satisfaction questions, and focus group participants unanimously agreed that the nutrition education was an essential component of the program. Hispanic participants were more likely than non-Hispanic Caucasians, Asians, or African Americans to respond positively to three of the five satisfaction questions. For two of the questions, the frequency of positive responses increased as age increased and decreased as education level increased. A small segment of clients reported some dissatisfaction by responding negatively to one or more of the satisfaction questions (4% to 20% of respondents). Some suggestions for improvement were made by survey respondents. Identification of some WIC participants who are not completely satisfied with the nutrition education that they have received, paired with differences in satisfaction across demographic variables, suggests the need for a personalized approach to WIC nutrition education.

Early postnatal growth of low birthweight infants in the WIC program

Patterns of early postnatal growth were analyzed among low birthweight infants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Infants were divided into four groups according to their neonatal status: (1) term, normal birthweight (NBW); (2) term, low birthweight (LBW); (3) moderately preterm LBW; and (4) very preterm LBW. Comparison of mean weight and length z-scores indicated that term NBW and very preterm LBW infants were at or near the national reference averages at 8, 12, and 18 months. Term LBW and moderately preterm infants were lighter and shorter than the other two study groups at each visit. Term LBW and moderately preterm infants displayed evidence of catch-up growth during the study period. Catch-up growth was defined as a decrease in the percentage of infants below the 10th percentile for weight. The effect of neonatal body proportions on postnatal growth was investigated in term LBW infants. The infants were divided into two groups based on their ponderal index (PI) at birth (low PI and proportionate PI). Comparison of weight and length z-scores indicated that both groups of term LBW infants improved in z-scores between birth and the first visit (approximately 8 months). However, infants with evidence of asymmetric intrauterine growth restriction (low PI) continued to improve in weight and length z-scores, whereas those with symmetric growth restriction (proportionate PI) remained lighter and shorter.

A comparison of perspectives on breastfeeding between two generations of black American women

PURPOSE

To determine differences in breastfeeding perspectives between two generations of black American women with and without access to governmental food assistance programs (i.e., WIC).

DATA SOURCES

Descriptive, comparative study of a convenience sample of 118 black American women in their childbearing years and beyond conducted in a primary rural health care clinic serving an indigent population.

CONCLUSIONS

A significant difference was found between breastfeeding perceptions and rate among younger black American women on WIC program and their mothers without access to these programs. The availability of free formula through WIC programs has partially influenced the rate of breastfeeding among the young black American women. The other significant influencing factor was public embarrassment at breastfeeding.

IMPLICATIONS FOR PRACTICE

An extensive educational campaign is needed in order to influence the public's perceptions of breastfeeding as an embarrassment. The success of programs such as WIC must be measured beyond the first six months of an infant's life.

Consumption of foods from the WIC food packages of Chinese prenatal patients on the US west coast

OBJECTIVE

To assess consumption of foods from food packages provided by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) among 80 Chinese prenatal WIC recipients living in Oakland or San Francisco, Calif.

DESIGN

During a single interview, a food frequency questionnaire was used to assess WIC food consumption by the prenatal patients for the period before and after receipt of WIC vouchers.

SETTING

The study was conducted at Asian Health Services, Oakland, and the Chinatown Public Health Center of the San Francisco Department of Public Health in California.

SUBJECTS

Eighty low-income Chinese prenatal women with limited education and limited ability to speak English, aged 21 to 43 years, with gestational stages of 15 to 38 weeks.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics (frequency and percent distribution) were used to report the findings of the study.

RESULTS

Subjects reported that before receiving WIC vouchers, milk, eggs, and juice were the only foods in their WIC food package that had been consumed frequently (> 5 times/week) in their daily diet. Other WIC foods, including cheese, peanut butter, dried beans, and hot and cold cereals, were consumed infrequently (0 to 1 time/month). Subjects reported that with the availability of WIC vouchers, milk, eggs, and juice remained frequently consumed with 81% to 100% of monthly supply as the most prevalent reported consumption rate. Dried beans and hot and cold cereals were also consumed frequently. Cheese remained poorly consumed (0% to 20% of the monthly supply). As many as 74 of 80 subjects stated that they had shared foods from their own WIC package, except milk, with their families. The use of any WIC foods provided to other children in the family was not assessed in this study.

APPLICATIONS

Data from this study indicate that most WIC foods were well used by Chinese prenatal patients. The most notable exception was cheese, which was poorly consumed. The ready consumption of milk by pregnant Chinese WIC recipients in this study suggests that milk may be readily consumed by these women, even though it is atypical of the Asian diet. The WIC food package for Chinese prenatal patients may be improved by omitting cheese and substituting more milk and/or foods such as tofu and dark green leafy vegetables.

Severe iron deficiency anemia in young children

We retrospectively characterized clinical features of 55 patients with severe nutritional iron deficiency anemia. Anemia was commonly discovered in the absence of related complaints. Forty percent of patients were of Southeast Asian ancestry. Most were treated successfully with iron therapy alone; 8 required transfusion.