NEW JERSEY WIC SERVICES STATEWIDE NUTRITION EDUCATION PLAN

Transcription

1 NEW JERSEY WIC SERVICES STATEWIDE NUTRITION EDUCATION PLAN FFY 2004 James E. McGreevey Governor Clifton R. Lacy, M.D. Commissioner

2 TABLE OF CONTENTS NEW JERSEY POPULATION...1 OVERVIEW...1 STATEMENT OF THE PROBLEM...2 DEMOGRAPHIC CHARACTERISTICS OF WIC PARTICIPANTS IN NEW JERSEY...3 THE FEMALE POPULATION...5 Age...6 Ethnicity...7 PEDIATRIC POPULATION...8 Age...8 Ethnicity...9 Ethnicity of Infants...10 Ethnicity of Children...11 ASSESSMENT OF NEEDS...12 INDICATORS OF NEGATIVE PREGNANCY OUTCOMES...12 Low Birthweight...13 Infant Mortality...15 INDICATORS OF PRENATAL RISK FACTORS...15 Maternal Low Hemoglobin/Hematocrit...15 Maternal Smoking During Pregnancy...19 Maternal Substance Use During Pregnancy...19 Maternal Enrollment Into The WIC Services...20 INDICATORS OF PEDIATRIC RISK FACTORS...21 Low Height for Age (Short Stature)...22 High Weight For Height (Overweight)...24 Low Weight for Height (Thinness/Underweight)...26 Low Hemoglobin Levels Among the Pediatric Population...28 SUMMARY...30 BREASTFEEDING PROMOTION AND SUPPORT...33 Breastfeeding Women...33 Breastfeeding Infants...34 Assessment of Needs...36 FFY 2002 STATEWIDE NUTRITION EDUCATION PLAN EVALUTION...39 Statewide Participant Feedback Results for: Goal Goal Goal Goal Goal Goal Goal Goal

3 TABLE OF CONTENTS (Continued) FFY 2003 STATEWIDE NUTRITION EDUCATION PLAN...63 Goal Lesson(s): Iron...67 Goal Lesson(s): Pregnancy...73 What You Need Every Day...74 The Weight Facts...75 Building A Healthy Baby...78 The Importance of Folic Acid...79 Strategies for The Common Complaints of Pregnancy...80 Goal Lesson(s): Sweet Tooth...85 Cholesterol...89 Fat...93 Fruits and Vegetables...95 Fast Food Calcium Goal Your Baby s First Year Goal Oral Health Goal Smoking and Pregnancy Goal Prenatal Breastfeeding Class Goal Lets Get Physically Active...149

4 NEW JERSEY POPULATION OVERVIEW Section 17 of the Child Nutrition Act of 1966, as amended states in part, that substantial numbers of pregnant, postpartum and breastfeeding women, infants and young children from families with inadequate income are at increased risk with respect to their physical and mental health because of inadequate nutrition or health care or the combination. Congress therefore, authorized the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to prevent and improve the nutritional status of this population during the critical times of growth and development and to prevent the occurrence of health problems including substance abuse. WIC benefits are delivered through 18 local agencies with 165 clinic and mobile sites through out New Jersey. WIC benefits include: 1. Assessment of participants nutritional status using Anthropometric and hematological measures. 2. Provision of individual/group counseling education and nutrition care plans for the high-risk participants. 3. Provision of targeted nutrition education to participants for informed health and dietary choices and patterns. 4. Promotion and support of breastfeeding. 5. Provision of supplemental nutritious and wholesome foods to WIC participants. 6. Referrals to healthcare, substance abuses treatment and other social services 1. Specifically, Federal Regulation [246.11b(1)(2) mandates nutrition education to be designed to accomplish the following two broad goals: Stress the relationship between proper nutrition and pregnancy outcome/good health, with special emphasis on the nutritional needs of low-income pregnancy, postpartum, and breastfeeding women, infants and children less than five years of age. 1 WIC Program Consolidated Regulation (2000) pg

5 Assist WIC participants who are at nutritional risk to adopt a positive change in food habits, resulting in improved nutritional status and in the prevention of nutrition related problems through optimal use of supplemental and other nutritious foods. Provision of nutritious supplemental food packages and nutrition education are conducted within the ethnic, cultural and geographic preferences of the participants with consideration to the educational and environmental limitations experienced by the participants. STATEMENT OF THE PROBLEM Prenatal nutrition is critically important to healthy pregnancy outcomes. Many experts identify nutrition as an integral component of comprehensive prenatal services. Women with low incomes are more predisposed to inadequate nutrient intakes. To improve the nutrient intakes of low-income pregnant women, WIC services provide checks for food packages with target nutrients. Studies have shown that participation in a nutrition intervention program such as WIC improves birth outcomes. New Jersey WIC Services conducted a study in 1997 evaluating the impact of WIC prenatal participation on selected birth outcomes and costs associated with infant hospitalization up to 60 days post delivery. The study population was Medicaid participants. Study results showed that for every dollar spent on prenatal WIC Services, Medicaid saved $5.60 for White not Hispanic and approximately $9.60 for Black not Hispanic newborns, in hospitalization costs or treatment for with medical conditions. The study results also demonstrated that WIC prenatal participation contributes to fewer infants weighing less than 2500 grams at birth, fewer days in hospital stay and lower infant mortality rates 2. Inadequate nutrition retards normal growth, lowers resistance to infections and adversely affects optimal mental and physical functioning of infants and children. In addition to promoting normal growth, development, and health, provision of WIC nutrition services to infants and children with acute or chronic conditions may produce cost savings by decreasing medical care costs. Birth weight is a variable most frequently used in assessing pregnancy outcomes due to its relationship to infant mortality, morbidity, and increased health care costs. Many researchers 2 The impact of WIC Prenatal WIC participation on Medicaid Cost for Hospitalization of Infants up to 60 days Post Delivery. New Jersey WIC Program Technical Report,

6 have identified adequate nutrition as an important determinant in modifying low birth weight. Other determinants of low birth weight are maternal medical or behavioral risk factors. Risk factors most frequently examined in association with low birth weight are smoking, substance abuse during pregnancy and low hemoglobin concentration. To assess how the incidence of low birth weight is distributed in a given population, maternal age, ethnicity and medical/behavioral risk factors are examined. Therefore, nutrition alone is not sufficient to reduce the prevalence of low birth weight. 3, 4 DEMOGRAPHIC CHARACTERISTICS OF WIC PARTICIPANTS IN NEW JERSEY The Special Supplemental Nutrition Program provides nutrition education, nutritious foods, social and healthcare referrals to low-income pregnant, postpartum and breastfeeding women, infants and children up to five years of age. Total monthly enrollment into the WIC Program ranged from 139,429 to 149,903 with average of monthly enrollment of 144,489. Demographic characteristics of WIC Services population are described by WIC status, age, and ethnicity. Such characteristics are meaningful and useful in monitoring trends, describing incidence and prevalence rates of health and nutritional problems and for comparisons of service coverage for WIC participants. The New Jersey WIC Management Information Summary Report 5 for the year 2001 showed that 148,962 women, infants and children participated in WIC services. Of the 148,962 that enrolled in WIC services, 38,284 were women, 41,088 infants and 69,590 were children five years and under. Figure I shows WIC Services enrollees by their WIC status. 3 Centers for Disease Control. Pregnancy Nutrition Surveillance System (PNSS) United States, Centers for Disease Control, Nutrition Status of Minority Children-United States, Mortality Morbidity Report 1987; 36: The New Jersey WIC Management Information summary Report,

7 Fig. I WIC Services Participants in 2001 By status (N=148,962) INFANTS (41,088) 28% WOMEN (38,284) 26% CHILDREN (69,590) 46% Examination of the WIC Enrollees for showed that of the 148,962 that participated in WIC Services, 44,995 were Black, 65,912 were Hispanic, 26,614 were White, 5,020 were Asian and 6,421 were categorized as an ethnicity termed Other. Figure II shows the ethnicity of the WIC population. Fig. II WIC Service Participants in 2001 By Ethnicity (N=148,962) OTHER (6,421) 4% WHITE (26,614) 18% HISPANIC (65,912) 45% BLACK (44,995) 30% ASIAN (5,020) 3% 6 New Jersey WIC Services WIC Enrollees Report, January

8 THE FEMALE POPULATION WIC Services provides services primarily to women of childbearing age. WIC Services categorizes the women of childbearing age into three statuses- pregnant, breastfeeding and nonbreastfeeding. The WIC Enrollees report showed that the female population that participated in WIC Services in 2001 was thirty eight thousand, two hundred eight four. Of the 38,284 women that participated in WIC Services, were pregnant, 12,971 breastfeeding and 8,476 nonbreastfeeding. Figure III shows the percentage of the Female population by their WIC Services Status. Fig. III Female Population in WIC Services in 2001 By Status (N=38,284) Nonbreastfeeding (8,476) 22% Pregnant (16,337) 44% Breastfeeding (12,971) 34% 5

9 Age Age is the most powerful factor that affects the distribution of any health condition and a good predictive factor for mortality according to Duncan 7. Epidemiological studies on incidence of birth outcomes among pregnant women have repeatedly shown a variation relative to age 8. The WIC Enrollees Report showed that of the 38,284 women that participated in the WIC Services in 2001, 5,323 (14%) were 19 years or less; 28,814 (75%) were between the ages of 20 to 34; 4,107 (15% were between the ages of 35 to 44; and 40 (< 1%) were above the age of 45 years. Figure IV shows the percentage of the Female Population in the WIC Services in 2001 based on age. Fig. IV Female Population in WIC Services in 2001 By Age (N=38,284) Yrs. (4,107) 11% < 19 Yrs. (5,323) 14% Yrs. (28,814) 75% Note: The Percentage of Female Population above 45 is < 1% and, therefore, did not show on the chart. 7 Duncan, D.F. Epidemiology: The Basis of Disease Prevention and Health Promotion, p Fretts, R.C., Schmittdiel, J; Mclean, F.H, Usher, R.H., and Goldman, M.B> (1995) Increased Maternal Age and the Risk of Fetal Death. New England J. of Medicine 333:

10 Ethnicity The influence of ethnicity is confounded in genetic, economic, social and cultural factors. Researchers also report that when other factors contributing negatively to birth outcomes are held constant, race has implications regarding variations in incidences and prevalence of disease and/or birth outcomes 9,10. Of the 38,284 women enrolled in WIC Services during 2001, 10,688 (28%) were Black; 17,783 (46%) Hispanic; 6,805 (18%) White; 1,374 (4%) Asian and 1,634 (4%) were categorized as an ethnicity termed Other. Based on ethnicity only, more of the Hispanic female population participated in WIC Services in the year Figure V shows the ethnicity of the female population enrolled in WIC Services in Fig. V Women Population in WIC Services In 2001 By Ethnicity (N=38,284) Asian (1,374) 4% Other (1,634) 4% White (6,805) 18% Hispanic (17,783) 46% Black (10,688) 28% 9 Stein, A., et al. Social adversity, Low Birthweight and Pre-Term Delivery, British Medical Journal (1987) pp Friis, R.H. and Sellers, T.A., Epidemiology for Public Health Practice, (1996) pp

11 PEDIATRIC POPULATION Age In New Jersey WIC Services, the pediatric population consists of infants and children up to age five. The New Jersey WIC Enrollees Report showed that WIC Services served 110,678 pediatric children (birth-five years) population in The pediatric population represents 74.3% of the total New Jersey WIC Services enrollees. Of the 110,678 pediatric populations in WIC Services in 2001, 37% (41,088 out of 110,678) were under 12 months, 37% (41,046 out of 110,678) were one to three years, and 26% (28,544 out of 110,678) were three to five years of age. For the pediatric population, WIC Services served significantly more children 63% (69,590 out of 110,678) than infants, 37% (41,088 out of 110,678). Fig. VI shows the breakdown of the pediatric population birth to five year olds. Fig. VI Pediatric Population in WIC Services in 2001 By Age (N=10,678) 12 to 35 months (41,046) 37% 35 to 59 months (28, % < 12 months(41,088) 37% 8

12 Ethnicity Of the 110,678 pediatric population that New Jersey WIC Services served, 18% (19,809 out of 110,678 records) were White, 31% (34,307 out of 110,678 records) Black, 44% (48,128 out of 110,678 records) Hispanic, 3% (3,746 out of 110,678 records) Asian, and 4% (4,688 out of 110,678 records) were Other. Figure VII shows the percentage of pediatric ethnicity. Fig. VII Pediatric Population in WIC Services in 2001 By Ethnicity (N=110,678) Asian (3,746) 3% Other (4,688) 4% White (19,809) 18% Hispanic (48,128) 44% Black (34,307) 31% 9

13 Ethnicity of Infants The New Jersey WIC Services served 41,088 infants in the year The ethnicity of the infant population in the WIC Services was as follows: 13,114 (32%) were Black, 17,749 (43%) were Hispanic, 7,008 (17%) were White, 1,332 (3%) were Asian, 1,884 (5%) were categorized as Other. Figure VIII shows the ethnicity of infants who participated in WIC Services in Fig. VIII Infant Population in WIC Services in 2001 By Ethnicity (N=41,088) Asian (1,332) 3% Other (1,884) 5% White (7,008) 17% Hispanic (17,749) 43% Black (13,114) 32% 10

14 Ethnicity of Children The population of children (one-five years) served by WIC Services in the year 2001, was 69,590. Of the 69,590, 21,193 (30%) were Black, 30,379 (45%) Hispanic, 12,801 (18%) were White, 2,313 (3%) were Asian and 2,904 (4%) were categorized as Other. Figure IX shows the breakdown of the child population in WIC Services in 2001, by ethnicity. Fig. IX Children Population in WIC Services in 2001 By Ethnicity (N=69,590) White(12,801) 18% Asian (2,313) 3% Other (2,904) 4% Hispanic (30,379) 45% Black (21,193) 30% 11

15 ASSESSMENT OF NEEDS To assess the needs of WIC Services population, data from PNSS and PedNSS were used. The PNSS data are used to monitor variations in the prevalence of nutrition problems and behavioral risks among WIC population that contribute to negative outcomes. The PedNSS data provides data that indicates prevalence of nutrition related problems among the pediatric population participating in the WIC Program. Needs assessment in this document focused on those factors that indicate or contribute to poor health status and negative pregnancy outcomes among the women and pediatric population. The factors contributing to negative outcomes are grouped into three broad headings: 1. Indicators of Negative Pregnancy Outcomes, 2. Prenatal Risk Factors, and 3. Pediatric Indicators Planning, development and implementation of targeted intervention programs are based on the results of the needs assessment. In WIC Services such intervention includes, but is not limited to, the provision of supplemental food vouchers, nutrition education and referral to health and social services. INDICATORS OF NEGATIVE PREGNANCY OUTCOMES Studies have indicated several factors that influence pregnancy outcomes. The identified factors that influence pregnancy birth outcomes ranged from maternal demographic characters to medical risk factors. Scholl, Hediger, Fischer and Shearer (1992) reported that maternal iron deficiency is associated with low birth weight and poor gestational weight gain 11. However, Kim, Hungerford, Yip, Kuester, Zyrkowski and Trowbridge (1992) showed that prevention or treatment of low hemoglobin concentration during pregnancy improves pregnancy outcomes, especially low birth weight 12. Birth outcomes reviewed in this document were those found to be associated with maternal nutrition, behaviors and selected medical conditions. Measures of birth outcomes in New Jersey that were summarized in this document were low birth weight and infant mortality. When appropriate, a comparison in the prevalence rate by ethnicity and age were made. 11 Scholl, T.O., Hediger, M.L., Khoo, C.S., Healey M.F., and Rawson. N.L (1991) Maternal Weight Gain, Diet and Infant Birth Weight: Correlations during Pregnancy, J. of Clinical Epidemiology 44: Kim, I., Hungerford, D.W., Yip, R, (1992) Pregnancy Nutrition Surveillance System- United States, MMWR 1992,41 (ss-7):

16 Low Birthweight Standard definition of low birth weight is birth weight that is less than 2500gr 5.5lbs. Low birth weight is a risk factor associated with neonatal mortality. 13 While Survival of low birth weight infants have improved, low birth weight infants are still more likely to have long-term developmental impairment, neurological disorders and other related disabilities. 14 One of the National Health Objectives is to reduce the prevalence rates of low birth weight to 5 per 100 live births by the year In New Jersey, the objective is to reduce low birth weigh to 6.0 per 100 live births by New Jersey Health Statistics (1998) showed the statewide prevalence rate for low birth weight was 7.8 per 100 live births. Prevalence rate for low birth weight among Whites was lowest at 6.3 while that of Blacks was 13.9 per 100 live births. The prevalence rate of low birth weight for Hispanics and Asians were 7.3 and 7.9 per 100 live births. 16 The prevalence rate of low birth weight for all ethnicities are still above the national health objectives for A study of the impact of WIC prenatal participation on selected birth outcomes among Medicaid recipients was conducted using 1992 WIC and Medicaid linked data files. Results of the study showed the prevalence rates of low birth weight among non-wic Medicaid recipients was 11.7 per 100 live births a rate almost double the rates of 6.3 for the WIC- Medicaid participants Ventura, S.J.; Kimberly, M.A.; and Martin J.A. (1998) Births and Deaths: United States, 1996 Preliminary Data. Monthly Vital Statistics Report, vol. 46(1) supplement 2. National Center for Health Statistics. 14 Paneth K.A. (1995) The Problem of low birth weight. Future Child 5: Healthy People 2010 Objectives: Draft for Public Comment-Maternal, Infant and Child Health (12-22). 16 Department of Health and Senior Services/Center for Health Statistics: New Jersey Health Statistics 1998 Highlights. 17 The Impact of WIC Prenatal WIC Participation on Medicaid Costs for Hospitalization of Infants up to 60 days Post Delivery. New Jersey WIC Program Technical Report

17 Fig. X Prevalence Rates of Low Birth Weight Statewide and Nationwide PedNSS Data for % Prevalence Rates by 1000 live births % 7.4% 14.1% 13.5% 8.4% 8.7% 7.9% 10.3% 13.8% 10.0% 9.1% Hispanic Black White Asian Other Overall Ethnicity Statewide Nationwide New Jersey 2000 PedNSS data indicated that the statewide prevalence rates of low birth weight for all ethnic groups were 10.0% (11,120 out of 111,204 records). The prevalence rates of low birth weight for Hispanic PedNSS population was 7.5% (3,432 out of 45,754 records), 14.1%(4,578 out of 32,469 records) was noted for Black, 8.4% (1,762 out of 20,981 records) for White, 23.0% (270 out of 1,172 records for Asian and 10.3% (552 out 5,355 records for Other PedNSS population. The prevalence rates of low birth weight among the Black and Other PedNSS population were the highest. The PedNSS data showed that the Nationwide prevalence rates of low birth weight among the PedNSS population was 9.1%, a rate that is slightly lower than the New Jersey s statewide prevalence rate of 10.1%. The nationwide prevalence rates of low birth weight for White PedNSS population was 8.7% ( out of 2,600,731 records), 13.5% (182,475 out of 1,351,66 records) for Black, 7.4% (93,792 out of 1,267,453 records) for Hispanic, 7.9% (13,276 out of 168,044 records) for Asian and 13.7% (27,994 out of 203,237 records for Other PedNSS population. Unlike New Jersey PedNSS data on variation by ethnicity, Black and Other had the highest prevalence rate. 14

18 Infant Mortality Infant mortality is an important measure of health status of a population. Infant mortality reflects the state of maternal health, quality, availability, quantity and accessibility to primary health care for pregnant women and infants. The New Jersey Center for Health Statistics (1998) data shows that infant mortality rate in New Jersey is 6.4 deaths per 1000 live births. The data also showed that the infant mortality rate for White was 4.1 deaths per 1000 live births, 12.7, 6.0 and 6.4 per 1000 live births for Blacks, Hispanic and Asian respectively. The New Jersey WIC study on the impact of prenatal WIC participation on selected birth outcomes among Medicaid recipients showed that the prevalence rates of infant mortality rate among Black infants in non-wic Medicaid recipients group was 22.3 per 1000 live births and the rates for Black infants WIC Medicaid group was 6.7 per 1000 live birth. The target in the national health objectives for 2010 is to reduce infant mortality rate to no more than 5 deaths per 1000 live births. 18 The target for New Jersey as stated in the Healthy New Jersey 19 is to reduce infant mortality rate to 4.3 by the Infant mortality rate for New Jersey, WIC participants and non- WIC Medicaid recipients still exceed the target in the national health objectives and in the health New Jersey INDICATORS OF PRENATAL RISK FACTORS Maternal Low Hemoglobin/ Hematocrit Measurement of hemoglobin/hematocrit concentrations in the blood is used to screen for iron deficiency. Diets low in iron or insufficient absorption of dietary iron, poor utilization of iron and/or blood loss during pregnancy contribute to lower hemoglobin/hematocrit concentrations. Scholl, Hediger and Shearer (1992) reported that maternal blood iron deficiency is associated with preterm delivery, low birth weight, infant mortality and poor gestational weight gain. 20 It should be noted that while low hemoglobin/hematocrit levels are major indicators for anemia, hemoglobin/hematocrit tests are not widely used to differentiate the various types of anemia. Kim, Hungerford, Yip, Kuester, Zyrkowski and Trowbridge (1992) showed that prevention or 18 Healthy People 2010 Objectives: Draft for Public Comment- Maternal, Infant and Child Health(12-22). 19 Health New Jersey 22010: A Health Agenda for the First Millennium,vol.1pg Scholl, T.O., Hediger, M.L., Fischer, R.L. and Shearer, J.W. (1992) Anemia vs. iron deficiency. Increased risk of pre-term delivery in a prospective study. Am. J. of Clinical Nutrition 55:

19 treatment of low hemoglobin/hematocrit concentration during pregnancy improves pregnancy outcomes especially the occurrence of low birth weight. 21 The CDC established cut off values for hemoglobin/hematocrit concentration varies for the three trimesters of pregnancy and adjusted for altitude and smoking behavior of the pregnant women. The established cut-off values for hemoglobin/hematocrit concentrations are 11.0gm/dl&33.0%, 10.5gm/dl &32.0%, and 11.0gm/dl &33.0% for the first, second and third trimester of pregnancy for non-smokers. Using the CDC s standard definition, the statewide prevalence rate of low hemoglobin/hematocrit concentrations was 20.9% (3,518 out of 16,841 records) of the 1999 New Jersey Pregnancy Nutrition Surveillance System (PNSS) population. Examination of ethnic-specific New Jersey PNSS data regardless of the trimester of pregnancy showed the prevalence rates of low hemoglobin/hematocrit concentrations for Black was 29.6% (1,544 out of 5,209 records), 17% (1,191 out of 6,995 records) for Hispanics and 15.1% (518 out of 3,433 records) for White. The prevalence rates of low hemoglobin/hematocrit concentrations for Asian and Other were 23.0% (119 out of 518 records) and 21.6% (148 out of 686 records) respectively. Figure XI shows the prevalence rates of low hemoglobin/hematocrit by ethnicity among the 1999 PNSS population. Fig. XI Prevalence Rates of Low Hemoglobin/Hematocrit 1999 PNSS Population by Ethnicity 29.6% Prevalence Rates by Percentages % 21.6% 20.9% 17% 15.1% Black Hispanic White Asian Other Overall Ethnicity 21 Kim, I., Hungerford, D.W., Yip, R, Kuester, S.A., Zyrkowski, C., and Trowbridge, F.L. (1992) Pregnancy Nutrition Surveillance System-United States, Morbidity Mortality Report Weekly 41 (ss-7)

20 The statewide prevalence rates for low hemoglobin/hematocrit concentrations for 1999 PNSS for each pregnancy trimester were 9.0% (303 out of 3,368 records), 16.8% (741 out of 4,412 records) and 37.4% (920 out of 2,459 records) respectively. Figure XII showed that the proportion of PNSS population with low hemoglobin/hematocrit concentration was highest during the third trimester and that the PNSS population has increased risk for anemia as the pregnancy trimester increase. The increase in the percentage of PNSS population with low hemoglobin/hematocrit concentration could be an indication that the PNSS population is more likely to participate in the New Jersey WIC Services as the pregnancy trimester increase. 4000% Fig. XII Prevalence of Low Hemoglobin/Hematocrit by Pregnancy Trimester among 1999 PNSS Population 37.4% 3500% 3000% 2500% 2000% 16.8% 1500% 1000% 9% 500% 0% 1st Trimester 2nd Trimester 3rd Trimester The prevalence rates of low hemoglobin/hematocrit concentrations by first, second and third trimesters of pregnancy respectively for Black PNSS population in 1999 were 16.3% (217 out of 1,328 records), 24.1% (523 out of 2,170, and 47.0% (804 out of 1,711 records). The 1999 Hispanic PNSS population had prevalence rates of low hemoglobin/hematocrit concentrations by first, second and third trimesters of pregnancy respectively of 7.5% (157 out of 2,090 records), 13.7% (413 out of 3,013 records) and 32.8% (621 out of 1,892 records) while the by trimester rates for White PNSS population were 4.1% (37 out of 892 records), 11.0% (150 out of 1,359 records) and 28.0% (331 out of 1,182 records). The by trimester prevalence rate of low hemoglobin/hematocrit concentration for the 1999 Asian PNSS population was 21.6% (24 out of 111 records), 20.4% (45 out of 221 records) and 26.9% (50 out of 186 records) and the rates for Other were 26.0% (6 out of 23 records), 21.4% (110 out of 513 records) and 21.3% (32 out 17

21 of 150 records). As figure XIII shows the prevalence rates of low hemoglobin/hematocrit was substantially higher during the third trimester of pregnancy in spite of ethnicity. The trimester prevalence rates for the PNSS population grouped as Other were almost the same for the second and third trimesters. Fig. XIII Prevalence Rates 0f Low Hemoglobin/Hematocrit By Pregnancy Trimesters and Ethnicity 1999 NJ PNSS Population % % 28% 32.8% 21.6% 26.9% 26% % 11% 13.7% 20.4% 21.4% 21.3% % 7.5% 0 Black White Hispanic Asian Other Ist Trimester 2nd Trimester Third Trimester 18

22 Maternal Substance Use During Pregnancy Substance use during pregnancy includes the use of cocaine, crack, cigarettes, alcohol and other psychoactive substances. Uses of these substances during pregnancy contribute significantly to such negative birth outcomes as low birth weight and premature delivery. In New Jersey, some prenatal clinics in the inner cities have used a urine test as a screening tool for substance use among pregnant women. The result of the urine test was used to estimate that 20% of the pregnant women have similar demographic characteristics as WIC participants. 22 Use of substances during pregnancy is associated with increased risks for infant mortality, low birth weight, growth abnormalities, mental retardation and fetal alcohol syndrome. It is estimated that the economic costs due to medical and service provision to infants exposed to substances during the prenatal period ranged from $75 million to $9.7 billion each year. Smoking doubles the risk of low birth weight and is a major contributing factor in 20 to 40 percent of low birth weight among infants born in the United States. Smoking and other substances use are among the most important preventable contributory risk factors of low birth weight. A woman who stops the use of substances, including cigarettes, when she discovers that she is pregnant reduces her risk of negative pregnancy outcomes. Also, empirical data on passive smoking suggests that nonsmoking pregnant women who inhale cigarette smoke in the environment have increased risk of low birth weight. 23 Maternal Smoking During Pregnancy Among the PNSS prenatal population examined for smoking in 1999, 9.7% (1,714 out of 17,731 records) reporting smoking during pregnancy. Among the 1,714 recorded as smoking during pregnancy, Figure XIV illustrated that 51% (869 out of 1,714 records) were White, 32% (540 out of 1,714 records) were Black, and the lowest percentage 1% (18 out of 1,714 records) were Asian, 14% (246 out of 1,714 records) were Hispanic and 2.4% (41 out of 1,714 records) were Others. 22 Straton, K., Howe, C. and Battaglia (1996) Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention and Treatment, National Academy Press, Washington, DC. 23 Centers for Disease Control: Pregnancy Nutrition Surveillance System (PNSS) User s Manual 1993, pp 1-9, Atlanta, GA. 19

23 Fig. XIV Smoking During Pregnancy Among PNSS Population in 2000 By Ethnicity (N=1714) Other 2% (41out of 1714) Asian 1% (18 out of 1714) Black 32% (540 out of 1714) White 52% (896 out of 1714) Hispanic 14% (246 out of 1714) Examination of PNSS data for 1999 relative to age showed that the prevalence rates of smoking during pregnancy was higher for prenatal population ages years at 78.9% (1,352 out of 1,714 records) compared to 19.5% (335 out of 1,714 records) for those years old. Maternal Enrollment Into The WIC Services An important factor in improving birth weight, reducing the risk of prematurity, low birth weight and neonatal mortality is early enrollment and consistent use of appropriate prenatal services including WIC Services. Early enrollment in the WIC Program is necessary for participants to maximize benefits associated with WIC prenatal participation, which includes supplemental food packages, nutrition education and referral to healthcare. Of the 17,707 records of PNSS examined for prenatal enrollment into the WIC Program in 1999, 15.7% (2,780 out of 17,707 records), 47.2% (8,364 out of 17,707 records) and 37% (6,563 out of 17,707 records) were enrolled during the first, second and third trimesters of pregnancy, respectively. Fig. XV shows the pattern of enrollment into WIC Services based on trimester of pregnancy. 20

24 The percentage of the 1999 PNSS population who enrolled in the WIC Program during the first and second trimester (early) by ethnicity showed that 21.5% (475 out of 2,207 records) were White, 23.9% (790 out of 3,300 records) were Black, 25.8% (1,255 out of 4,872 records) were Hispanic, 28.5% (70 out of 316 records) were Asian, and 24% (30 out of 125 records were Other. The percentage of the PNSS prenatal population between the ages of years enrolled in the WIC Program in the first and second trimesters was higher. Fig. XV Enrollment in WIC Services by Trimester of Pregnancy 1999 PNSS Population (N=17,707 Records) 9,000 8,000 8,364 7,000 6,000 6,563 5,000 4,000 3,000 2,000 2,780 1, st Trimester 2nd Trimester 3rd Trimester INDICATORS OF PEDIATRIC RISK FACTORS Assessing and monitoring the growth of infants and children both in New Jersey and in the nation is fundamental to early detection and prevention of adverse effects of abnormal growth and development. The age-specific assessment of pediatric risk factors for growth includes periodic measurement of height and weight. According to the CDC, growth rates below the 5 th percentile and above the 95 th percentile on the NCHS growth reference is an indicator of poor nutrition status for a prolonged period. The growth and weight status of the PedNSS population is assessed by height and weight with reference to age. The ratio of height to weight relative to age is expressed in percentile values using the NCHS/CDC reference growth chart. Abnormal pediatric growth among the PedNSS is grouped as "Low Height for Age" and "High Weight for Height." Besides the growth rate, the hematological status of the pediatric population is periodically assessed to determine the hemoglobin/ hematological concentration 21

25 in the blood. Low hemoglobin/ hematological concentration in the blood indicates dietary iron deficiency and/or poor assimilation of dietary iron. Below are the results of the growth and hematological assessments of the pediatric population. 24 Low Height For Age (Short Stature) The New Jersey Pediatric Nutrition Surveillance System (PedNSS) 2000 data showed that the statewide prevalence rates of low height-for-age (short stature) was 10.1% (11,107 out of 109,967 records). The comparisons of the prevalence rates of low height for age by ethnicity among New Jersey PedNSS population showed that Black PedNSS population had the highest at 12.6% (4,530 out of 35,957 records). The prevalence rates for low height for age among New Jersey White PedNSS population was 10.4% (2,172 out of 20,883 records), Hispanics 8.2% (3,703 out of 45,155 records), Asian 9.7% (259 out of 2,670 records), and 9.2% (490 out of 5,302 records) for Other. Fig. XVI shows the prevalence rates for low height for age by ethnicity among the New Jersey PedNSS population. Prevalence Rates by Percent % Fig. XVI Rates of Low Height For Age New Jersey 2000 PedNSS Population by Ethnicity 10.4% 8.2% 9.7% 9.2% 10.1% Black White Hispanic Asian Other Statewide Ethnicity Age-specific variation in the prevalence rates of low height for age among New Jersey PedNSS population existed. The prevalence rates of low-height for age among New Jersey PedNSS population who are 0-11 months was 10.8% (7,378 out of 68,312 records), 9.6% (3,664 out of 38,171 records) for months and 3.2% (112 out of 3,484 records) for those months. 24 Centers for Disease Control, CDC Surveillance Summaries. Morbidity and Mortality Weekly Report (MMWR), Vol. 41 (Supplement 7), p 9, Atlanta, GA,

26 The prevalence rates for low height for age decrease as the New Jersey PedNSS population age increases. The prevalence rates of low height for age for the National PedNSS population were 8.2% (521,097 out of 6,354,846 records). Data on the prevalence rates of low height for age among the various ethnic groups of the National PedNSS population showed that Black PedNSS population was 9.4% (138,956 out of 1,478,256 records), 8.0% (225,383 out of 2,817,282 records) for White, 7.3% (118,228 out of 1,619,567 records) for the Hispanic, 8.8% (18,472 out of 209,904 records) for Asian and 7.3% (16,881 out of 229,837 records) for "Others." Similar to New Jersey, the national data for low height for age for Black PedNSS population was the highest. Figure XVII shows the comparison of prevalence rates of low height for age by ethnicity with the national and statewide data. Fig. XVII Low Height for Age Among 2000 PedNSS Population Comparison of the National and Statewide Prevalence Rates by Ethnicity % Prevalence Rates by Percentage % 8.2% 7.3% 10.4% 8% 9.7% 8.8% 9.2% 7.3% 10.1% 8.2% 0 Black Hispanic White Asian Other Overall Ethnicity Statewide Nationwide The national data showed that the prevalence rates for low height for age was 11.3% (245,968 out of 2,176,711 records) for PedNSS population below 12 months, 9.2% (130,756 out of 1,421,260 records) noted for those between age 12 and 23 months and 5.0% (127,566 out of 2,551,310 records) for those between 25 and 48 months. Similar to New Jersey PedNSS population prevalence rates for low height for age decreases as the age increases. 23

27 High Weight For Height (Overweight) The definition of overweight used in this document was based on NCHS growth chart, which defined overweight in pediatric population as a ratio of weight to height above the 95 th percentile. According to Hill & Trowbridge (1998), prevalence of overweight among United States pediatric population has tripled between 1971 and Pediatric overweight/obesity is associated with development of unfavorable health outcomes including increased risk for adult obesity in the United States population and has become a major public health priority (Healthy People 2010). Health professionals are concerned when the prevalence rates of overweight among PedNSS population exceeds 5%. It is predicted that about one-half of these children whose ratio of weight to height fell above the 95 th percentile (overweight) on the NCHS growth reference are more likely to become obese adults. 25 In 2000, the statewide prevalence rates of high weight for height among the PedNSS population was 13.9% (14,157 out of 101,847 records). In figure XVIII the prevalence rates of high weight for height by ethnicity shows that New Jersey Hispanic PedNSS population had the highest rate at 14.9% (6,259 out of 42,004 records). The prevalence rates of high weight for height for the New Jersey White PedNSS population was 13.6% (2,711 out of 19,932 records), 13.4% (4,350 out of 32,464 records) for Blacks, 11.1% (279 out of 2,514 records) for Asian and 11.2% (553 out of 4,928 records) for Other. 25 Centers for Disease Control: Pregnancy Nutrition Surveillance System (PNSS) User s Manual 1994, pp 1-7, Atlanta, GA. 24

28 Prevalence Rates by Percentage Fig. XVIII Prevalence of High Weight for Height among New Jersey 2000 PedNSS Population By Ethnicity 14.9% % 13.6% 13.9% 11.1% 11.2% Black Hispanic White Asian Other Overall Ethnicity Comparison of age-specific variations in the prevalence rates of high weight-for-height among the New Jersey PedNSS population was 11.2% (6,742 out of 39,171 records) for 12 to 23 months) and 9.9% (345 out of 3,484 records) for those 25 to 36 months. The prevalence rates of high weight for height among the national PedNSS population was 11.1% (661,152 out of 5,956,328 records). The highest prevalence rate of high weight for height was for the national Hispanic PedNSS population at 14.2% (213,559 out of 1,503,934 records). The prevalence rates for high weight for height for national PedNSS population Other was 13.8% (27,994 out of 203,237 records). The prevalence rates of high weight for height for the National Black PedNSS population was 10.3% (140,462 out of 1,363,711 records), 9.6% (258,301 out of 2,690,631 records) for Whites and 10.4% (20,261 out of 194,815 records) for Asian. Figure XIX shows a comparison between the national and the statewide prevalence rates for high weight among the PedNSS population by ethnicity. The overall statewide prevalence rate of high weight for height for height for PedNSS population (13.9%) exceeded that of the national PedNSS population (10.2%). Similar to New Jersey, the nationwide Hispanic PedNSS population has the highest prevalence rate for high weight for height. Comparison of high weight for height by age of the National PedNSS population 2000 showed that those less than 12 months old had prevalence rates of high weight for height of 9.7% (183,000 out of 1,866,601 records), 14.6% (206,838 out of 1,416,695 records) for 12 to 24 months and 9.8% (249,479 out of 2,545,699 records) reported for those between age 25 and 36 months. 25

29 Fig. XIX High Weight for Height Among 2000 PedNSS Population Comparison of the National and Statewide Prevalence Rates By Ethnicity Prevalence Rates by Percentage % 13.6% 14.2% 13.4% 13.8% 13.9% % 11.2% 11.1% % 10.4% 9.6% Black Hispanic White Asian Other Overall Ethnicity Statewide Nationwide Low Weight For Height (Thinness/Underweight) Determination of low weight for height is based on the ratio of height and weight on the NCHS growth curve. Pediatric populations that are considered thin and underweight are those weights for height fell below the 5 th percentile on the NCHS growth chart. The Centers for Disease Control set acceptable prevalence rates for low weight for height at 5%. The 5% cut off point was based on data from pediatric populations examined during famine or war. The famine or war based rates for low weight for height being used, as a cut off point is an indication of serious mal-nourishment for infants and children. Low weight for height is an indicator of insufficient caloric intake and probable serious underlying health problems. The PedNSS data for 2000 showed that the statewide prevalence rate of low weight for height among PedNSS infants and children in New Jersey was 2.8% (2,852 out of 101,847 records). Figure XX shows the comparison by ethnicity with the highest prevalence rate 3.7% (1,201 out of 32,464 records) of low weight for height among New Jersey Black PedNSS population. The prevalence rates of low weight for height among New Jersey Hispanic PedNSS population was 2.2% (924 out of 42,004 records). Among the White, Asian and Other PedNSS population, the prevalence rates of low weight for height were 2.1% (419 out of 19,932 records), 3.0% (75 out of 2,514 records) and 3.9% (193 out 5,003 records) respectively. 26

30 Fig. XX Prevalence Rate of Low Weight for Height among New Jersey 2000 PedNSS Population By Ethnicity 3.7% 3.9% 4 Prevalence Rate in Percentages % 2.1% 3% 2.8% Black Hispanic White Asian Other Overall Ethnicity The age-specific prevalence rates comparison for low weight in the New Jersey PedNSS population below 24 months was higher at 2.8% (2,760 out of 98,363 records) than for those between the ages of 2 to four years with 2.1% (73 out of 3,484 records). The nationwide prevalence rates of low-weight for height for the PedNSS population in 2000 were 2.3% (136,995 out of 5,956,328 records). The nationwide Black and Asian PedNSS population each had prevalence rates for low weight for height 3.1% (42,275 out of 1,363,711 records) and 3.0% (5,845 out of 194,815 records) respectively. The prevalence rates for low weight for height for White PedNSS population was 2.1% (56,503 out of 2,690,631 records) and for Hispanics 1.9% (28,575 out of 1,503,934 records). Figure XXI shows a comparison of the statewide and national prevalence rates of low weight for height among PedNSS population by ethnicity. The national prevalence rates of low weight for height among PedNSS population (2.6%) was slightly lower that the statewide rate (2.8%). The prevalence rates for low weight for height for Other and Black PedNSS populations were the highest among national and statewide PedNSS population. Age-specific prevalence rates for low weight for height for the national PedNSS population below 24 months was 2.8% (91,545 out of 3,303,296 records) relative to the 1.7% (43,277 out of 2,545,699 records) for the PedNSS population who were two to four years old. 27

31 Fig XXI Low Weight for Height among 2000 PedNSS Population Comparison of National and Statewide Prevalence Rates By Ethnicity Prevalence Rates in Percentages % 3.7% 3.2% 3% 3.0% 2.8% 2.8% 2.3% 2.2% 2.1% 2.1% 1.9% Black Hispanic White Asian Other Overall Ethnicity Statewide National Low Hemoglobin Levels Among The Pediatric Population Measurement of hemoglobin concentrations in the blood is used to screen for iron-deficiency in the PedNSS population. It should be noted that low hemoglobin level is a major determinant of iron deficiency anemia in children. However, hemoglobin tests are not widely used to differentiate types of anemia. The CDC established cut-off values for hemoglobin concentration for the PedNSS population ranged from 12.0 to The cut off value is below the 95% confidence interval for healthy, well-nourished individuals of the same demographic characteristics. In 2000, based on hemoglobin measurement only, the statewide prevalence rates of low hemoglobin concentration for New Jersey PedNSS population was 20.5% (1,040 out of 5,072 records). Figure XXII shows the variation by ethnicity in the prevalence rates of low hemoglobin concentration among New Jersey PedNSS data for The prevalence rates for low hemoglobin concentration were higher for statewide Black PedNSS population at 28.1% (5,370 out of 19,112 records). White PedNSS population had a prevalence rate of low hemoglobin concentration of 23.1% (2,376 out of 10,287 records), 21.9% (5,304 out of 24,217 records) for Hispanic, 23.0% (270 out of 1,172 records) for Asian and 22.2% (549 out of 2,469 records) for Others. 28

32 Fig. XXII Prevalence Rates of Low Hemoglobin among New Jersey 2000 PedNSS Population By Ethnicity Prevalence Rates in Percentages % 23.1% 21.9% 23% 22.2% 20.5% Black Hispanic White Asian Other Overall Ethnicity Age specific prevalence rates of low hemoglobin concentration for New Jersey PedNSS population younger than 24 months was 22% (506 out of 2,264 records) and 19% (536 out of 2,808 records) for those between the ages of two to five years. The prevalence rates of low hemoglobin concentration among the national PedNSS population in 2000, was 16.4% (574,085 out of 3,500,517 records). The national Black PedNSS population had the highest prevalence rates for low hemoglobin concentration at 23.2% (206,709 out of 890,988 records). The prevalence rate of low hemoglobin concentration for national White PedNSS population was 12.7% (198,800 out of 1,565,360 records), 15.7% (132,506 out of 843,989 records) for Hispanic, 18.2% (17,943 out of 98,587 records) for Asian, and 17.1% (17,457 out of 101,593 records) for Others. Figure XXIII shows the comparison of the overall and ethnic specific prevalence rates of low hemoglobin concentration for national and the statewide PedNSS population. The overall prevalence rates low hemoglobin concentration among New Jersey PedNSS population (20.5%) was higher than the nationwide overall rate (19.3%). Similar to New Jersey, the prevalence rates of low hemoglobin concentration for Black PedNSS population was the highest. 29

33 Prevalence Rates in Percentages Fig. XXIII Low Hemoglobin among 2000 PedNSS Population Comparison of the State and The National Prevalence Rate By Ethnicity % % 21.9% 15.7% 23.1% 12.7% 23% 18.2% 22.2% 17.1% 20.5% 16.4% 0 Black Hispanic White Asian Other Overall Ethnicity Statewide Nationwide The nationwide prevalence rates of low hemoglobin concentration among PedNSS population were 18.0% (2,241 out of 12,505 records) for those less than 23 months and 16.1% (2,155 out of 13,382 records) for those that were 24 to 48 months old. To address the high prevalence rates of low hemoglobin concentration among New Jersey PedNSS population, the New Jersey WIC Services prescribes only iron-fortified formula to all non-breastfed WIC infants from birth to 12 months of age. SUMMARY WIC Services includes risk assessment, provision of food vouchers for obtaining supplemental nutritious food items, nutrition education and referral to pertinent health and social services. Each of these components of WIC Services could contribute to early detection of factors that influence pregnancy/birth outcomes and the health and nutrition status of program participants. Enrollment into WIC Services is based on income and presence of nutritional and medical risk factors. In 2001, 148,962 women, infants and children met the criteria for participation in the WIC Services, of which, 45% were Hispanic, 30% Black, 18% White, 3% Asian and 4% from the ethnicities grouped as Other. A large percentage (74%) of WIC Services' population were infants and children. Pregnancy and pediatric nutrition surveillance systems (PNSS and PedNSS) continue to provide data used to monitor factors that specifically contribute to negative birth outcomes and indicate poor health status among WIC Services' participants. The 30

34 PNSS and PedNSS data also provides data to assess variations and disparities in the health status and birth outcomes of WIC Services' participants by age and ethnicity. In 1999, PNSS data showed that: 1. Proportion of women with behavior risk factors such as smoking and alcohol use during pregnancy was relatively low. However, the largest proportion of women who reported smoking during pregnancy was Whites, followed by Blacks and Hispanics. 2. Low hemoglobin concentration during the prenatal period was more prevalent among pregnant Black women and among those in the third trimester of pregnancy consistently across ethnicities in the PNSS population. 3. Most pregnant women, regardless of ethnicity enrolled in WIC Services during the second trimester of their pregnancy. However, a larger percentage of Hispanic and Black pregnant PNSS population enrolled in the program between the first and second trimester of their pregnancy. The 2000 PedNSS data showed: 1. The statewide prevalence of low height for age was relatively lower than the national rates. Black PedNSS infants had a higher prevalence rate for low height for age, while the Hispanic PedNSS infants had the lowest rates. Low height for age was also higher for infants and children below 24 months of age. 2. Prevalence rates for high weight for height were higher in the New Jersey PedNSS population compared to rates of the National population. The statewide ethnic group comparisons showed the prevalence rates for high weight were highest for the Hispanic and White Not Hispanic PedNSS population than the rates for Asian, Black Not Hispanic and Other. 3. Proportion of New Jersey PedNSS population with low weight for height was higher than the national proportion. The New Jersey Black PedNSS population had higher rates for low weight for height than the remaining ethnic groups in the PedNSS population. 4. Based on hemoglobin levels, prevalence of low hemoglobin concentration was disproportionately higher for New Jersey Black PedNSS population and for infants and children below 24 months. 31