Micronutrients with EARs

For nutrients with an Estimated Average Requirement (EAR), the committee ranked nutrients for action by the proportion of each WIC subpopulation with inadequate intakes. Nutrients with the highest proportion of inadequacy (e.g., >50 percent) for a particular population were considered first, followed by nutrients with lower proportions of inadequate intakes. In addition, the committee considered whether a nutrient was linked to a known health consequence for the specific WIC-participating population under review (see Table 5-1 for a compilation of nutrients with known health consequences). Nutrients not linked to known health consequences were considered of lower priority, although all nutrients for which inadequacy was evident in 5 percent or more of a subgroup were considered to some degree.

TABLE 5-1

Nutrient Inadequacies and Excesses Linked to Adverse Health Consequences Relevant to WIC-Participating Population Subgroups, Based on the Dietary Guidelines, Literature Review, and Other Expert Guidance.

Special Case: Vitamin E

As was the case with subgroups included in the committee's National Health and Nutrition Examination Survey (NHANES) analyses (see Chapter 4), low vitamin E intake appears to be ubiquitous in the general U.S. population (USDA/HHS, 2016). However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC-participating population, vitamin E was not considered a priority in the food package revisions and was not carried through the decision tree.

Nutrients with an AI

For nutrients with an Adequate Intake (AI) value, the committee first assessed whether mean intake of the nutrient was below the AI. If so, the committee then considered whether or not the nutrient was linked to a known health consequence for the specific WIC-participating population under review. Nutrients not linked to known health consequences were considered lower priority.

Energy from Carbohydrate, Protein, and Fat

Lowering or raising the proportion of energy from one dietary macronutrient affects the proportion of energy from the others. However, beyond recommending that intakes be within the acceptable macronutrient distribution range (AMDR), the DGA (USDA/HHS, 2016) did not include recommendations for energy from total fat, carbohydrates, or protein. Therefore, the proportions of these macronutrients in the food packages were not considered in developing the revised food packages. (See below for the committee's consideration of saturated fat.)

Saturated Fat and Added Sugars

Saturated fat and added sugars were evaluated along with other nutrients, not food groups, because they may occur in several different foods. The current food packages already provide foods that are limited in saturated fat (e.g., only low-fat or nonfat milk and yogurt are allowed in packages for participants over 2 years of age) and added sugars (e.g., ready-to-eat cereals, yogurt, and vegetables and fruits purchased with the cash value voucher (CVV) are allowed in the packages only if they do not exceed required limits). Despite these current limitations, the WIC food packages do contribute some of each nutrient to the diet. Therefore, as described below, they were retained as macronutrients possibly linked to adverse health consequences (see Table 5-1).

Nutrients for Which Intakes Were Excessive

When micronutrient intakes were above the Tolerable Upper Intake Level (UL) in more than 5 percent of a WIC subgroup, the approach applied was similar to what was used when intakes were below the EAR except that the upper ends of intake distributions were examined. For example, nutrients for which intakes exceeded the UL in greater than 50 percent of the subgroup were considered to be of higher priority.

For excess consumption of saturated fat and added sugars, the committee prioritized action according to the proportion of the WIC subpopulation exceeding 10 percent of energy from each (e.g., 5 to <10, 10 to <50, and ≥50 percent of the population).

Priority Nutrients Across Subgroups of Women and Children

Across subgroups of women (see Tables 5-2 through 5-4) and children (see Table 5-5), fiber, potassium, sodium, and added sugars were considered to be higher priority, with intakes of sodium, and added sugars being excessive. For all women (except for postpartum women) and children, excessive saturated fat intake was also a higher-priority (saturated fat is a middle priority for postpartum women). For breastfeeding women (see Table 5-4) and children ages 1 to less than 5 years (see Table 5-5), there were no additional higher-priority nutrients. Proposed actions to address low fiber and potassium intakes include increasing the CVV or requiring an option for canned legumes as a means of adding convenience and, therefore, promoting intake. Added sugars and sodium are already limited in WIC foods, but the committee reviewed the specifications for WIC foods to identify possibilities for further limiting these nutrients. Additional priority nutrients and potential actions for pregnant and postpartum, nonbreastfeeding women are outlined below.

TABLE 5-4

Nutrient Priorities and Preliminary Actions, Food Package VI, Postpartum Women.

TABLE 5-5

Nutrient Priorities and Preliminary Actions, Food Package IV, Children Ages 1 to Less Than 5 Years of Age.

Pregnant women Higher-, middle-, and lower-priority nutrients for WIC-participating pregnant women are presented in Table 5-2. In addition to the higher-priority nutrients described above, iron and choline were also identified as higher-priority nutrients for pregnant women. Iron requirements during pregnancy are higher than can be met by diet alone. Low choline intakes could be improved by provision of additional eggs or by increasing consumption of the dairy products already provided by the WIC program.

Postpartum women For postpartum women who are not breastfeeding (food package VI), calcium was identified as another higher-priority nutrient in addition to the nutrients mentioned above (see Table 5-4). Women receiving food package VI currently receive a greater-than-supplemental amount of calcium in this package. Therefore, strategies to improve intake of the calcium that is already provided are needed.

Priority Nutrients for Infants

No priorities were identified for younger (0 to less than 6 months of age) infants or for formula-fed older infants because either human milk or formula meets the nutrient needs of these groups. Given that the protein concentrations of infant formulas are regulated and considered safe by the U.S. Food and Drug Administration, excess intake of protein by formula-fed infants was not considered a priority. Both iron and zinc were considered priority nutrients for breastfeeding infants ages 6 to less than 12 months (see Table 5-6). However, because the amounts of these nutrients in the food package exceeded 100 percent of recommendations, the committee considered the need to decrease amounts of foods provided in the current infant packages and provide a more preferred form to promote intake.

TABLE 5-6

Nutrient Priorities and Preliminary Actions, Food Package II, Partially or Fully Breastfed Infants (Ages 6 to Less Than 12 Months).

Priority Food Groups Across Subgroups of Women

Across subgroups of women (see Tables 5-7 through 5-9), food groups of higher priority (75 percent or more of women consumed less than the recommended amount) included: dark green vegetables, total red and orange vegetables, beans and peas, other vegetables, whole grains, seafood, as well as nuts, seeds, and soy. The committee considered increasing the value of the CVV as a possible approach to addressing intakes of vegetables, including subgroups of vegetables.³ Inasmuch as legumes and peanut butter are already provided in greater-than-supplemental amounts in most food packages, the quantities of these foods were a target for reduction along with nutrition education or behavioral approaches to improve intakes. The committee also considered increasing the amounts or types of whole grains and adding fish to food packages where it is not currently provided as possible approaches to addressing lower-than-recommended intakes of these food groups. There were no additional higher-priority food groups identified for pregnant women. Additional higher-priority food groups for partially breastfeeding, fully breastfeeding, and postpartum subgroups of women are described below.

TABLE 5-7

Food Group Priorities and Preliminary Actions, Food Package V, Pregnant Women.

TABLE 5-9

Food Group Priorities and Preliminary Actions, Food Package VI, Postpartum Women.

Breastfeeding Women

Additional higher-priority food groups for breastfeeding women included total fruits, total starchy vegetables, total grains, and total protein foods (see Table 5-8). The committee considered increasing the value of the CVV as a means to increase intakes of fruits and providing a greater quantity and wider variety of grain options to increase intake of grains. For partially breastfeeding women, protein intake could be addressed by providing canned fish. For fully breastfeeding women, low total protein foods intakes could be addressed by including more preferred options or through nutrition education or behavioral approaches to improving intake of protein foods currently provided.

Postpartum Women

For postpartum women, the committee also considered total fruit, total vegetable, and total starchy vegetable intakes to be higher-priority food groups (see Table 5-9). Increasing the value of the CVV would likely lead to improved intakes of these food groups. Dairy intakes were also below recommended amounts, which may be addressed by allowing options for more preferred forms of dairy in place of milk.

Children Ages 2 to Less Than 5 Years

Food groups and subgroups for which intakes were below recommended levels in more than 75 percent of children ages 2 to less than 5 years included total vegetables, dark green vegetables, total red and orange vegetables, whole grains, seafood, as well as nuts, seeds, and soy (see Table 5-10). The potential actions to address consumption of foods in these food groups were the same as those identified for subgroups of women.

Children Less Than 2 Years of Age and Infants

Although the DGA do not cover individuals ages 2 years and younger, the committee evaluated foods in the packages for these participants in Chapter 3. The amount of juice provided in food package IV-A (which is provided to children ages 1 to 2 years) exceeds the lower end of the AAP recommended limit 4 to 6 ounces per day (see Table 3-10), and a reduction could be considered. Food package II for fully breastfed infants ages 6 to less than 12 months provides 150 percent of the AAP recommended amount of infant cereal, and 130 percent of the recommended amount of jarred infant food meat. This information suggests that reductions in juice, infant cereal, and jarred infant food meat could be considered.