Kathleen M. Rasmussen, ScD, RD Meinig Professor of Maternal and Child Nutrition Division of Nutritional Sciences, Cornell University Ithaca, NY PDF Free Download

At what point is not meeting the recommendations for consumption of a food group a problem at the population level? Experience with redesigning the WIC food packages Kathleen M. Rasmussen, ScD, RD Meinig Professor of Maternal and Child Nutrition Division of Nutritional Sciences, Cornell University Ithaca, NY 14853

Committee to Review WIC Food Packages: Statement of Task Review and assess the WIC food packages... Recommended changes should be consistent with the 2015 Dietary Guidelines for Americans and the Dietary Reference intakes How does one use these criteria together? What does it mean if the results are discordant?

Use of the DRI Well-established way of planning diets for groups

Estimating the proportion of individuals below the EAR Actual From: Otten JJ, et al., eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: National Academies Press, 2006.

Decision tree for planning diets From: IOM. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academy Press, 2000.

Calculation of adequacy of nutrient intake using data from NHANES NHANES dataset (24-h recall, 1-2 d) Via food composition database Distribution of daily nutrient intake v. DRIs Proportion below DRI (EAR or AI) for a nutrient

Nutrients with evidence of inadequate intake in the diets of WIC-participant subgroups Nutrient Pregnant, BF, or PP Women, 19 to 50 years Children 2 to less than 5 years Calcium Copper Iron Magnesium Zinc Vitamin A Vitamin D Vitamin E Vitamin C Thiamin Riboflavin Niacin Vitamin B6 Folate Protein From: K.M. Rasmussen, et al., eds. Review of WIC Food Packages Interim Report. Washington, DC: National Academies Press, 2015.

Challenges with these data on nutrient intake Aside from the adequacy of the NHANES data... Women are known to underestimate their intake and consume diets that are not nutrient-dense This could account for so many nutrients being consumed in inadequate amounts The data are still hard to believe because women in WIC receive generous food packages These currently meet more than one-half of women s daily requirements for many nutrients!

Use of the DGA No established way of planning diets for groups

What does it mean to be aligned with the DGA? There are 2 practical meanings that are relevant to the WIC Program The food packages cover all or nearly all of the food groups and subgroups Within historical precedent and the constraint for the food packages to be cost-neutral The food packages provide the opportunity for participants to meet the DGA recommendations But this depends on the quality of the home diet It may be difficult to achieve this with a supplement when the home diet is poor

Use of indicators of adequacy of intake based on nutrients or food groups: data from NHANES Via FPED NHANES dataset (24-h recall, 1-2 d) Via food composition database Daily intake of USDA food groups USDA food groups Distribution of daily nutrient intake Proportion not meeting the DGA for a food group v. DGA recommendations v. DRIs Proportion below DRI (EAR or AI) for a nutrient

Food groups with evidence of intakes below and above amounts recommended in the DGAC 2015 Report in the diets of WIC-participant subgroups Food Group P, BF, or PP Women, 19 to 50 years Children 2 to less than 5 years Intakes Below Recommended Amounts Total fruit Total vegetables Dark green Total red and orange Beans and peas Total starchy Other vegetables Total grains Whole grains Total protein foods Seafood Nuts, seeds, and soy Total dairy Oils Intakes Above Recommended Amounts Solid fat Added sugars From: K.M. Rasmussen, et al., eds. Review of WIC Food Packages Interim Report. Washington, DC: National Academies Press, 2015.

Challenges with the data on consumption of food groups They align poorly with the data on nutrient consumption for children What could cause this discrepancy?

Energy and nutrient levels in nutrientdense food patterns: 1600-kcal (older woman, child > 3 y old) Pattern type Source Amount Goal or limit (%) Energy (kcal) Pattern 1595 100 Protein (g) RDA 82 178 Fiber (g) (14 g/1000 kcal) AI 25 110 Vitamin A (μg RAE) RDA 754 108 Vitamin C (mg) RDA 100 133 Vitamin B 12 (μg ) RDA 6.6 275 Calcium (mg) RDA 1189 99 Iron (mg) RDA 14 179 Zinc (mg) RDA 13 160 Potassium (mg) AI 2961 63 Sodium (mg) UL 1522 66 From: Britten P, et al. J Acad Nutr Dietet 2012;112:1648.

Challenges with the data on consumption of food groups They align poorly with the data on nutrient consumption for children but not for women Children consume relatively large amount of highly fortified foods (e.g. breakfast cereals), which give them high nutrient intakes Children are often picky eaters and are poor consumers of a wide range of food groups (e.g. vegetable subgroups, legumes, seafood) This is one way to account for the observed discordance in these measures of adequacy.

Now what? At what point should the committee be concerned with below-recommended intakes of food groups?

Challenges with these data on food-group intake Measurement of food-group and nutrient intake have the same problems with the adequacy of the background data on dietary intake However, the consequences of being above or below a recommended intake a food group are unknown Analogous to the situation when the DRI is an AI There is no expected distribution of food intakes on which to rely and, thus, it is hard to know what proportion of the population below the recommended amount is too high

Decision tree for planning diets From: IOM. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academy Press, 2000.

Considering low intakes of nutrients and food groups together: WIC example

Conclusions: what we did We calculated the proportion below the recommendation for a given food group and created priority groups based on these proportions We treated these priority groups for food groups similarly to those for nutrients with our decision tree in terms of how we addressed each identified priority However, 25% of a population with an inadequate nutrient intake probably means something different than a 25% of a population with a less-than-recommended intake of food group

Bottom line It makes sense to expect federal nutrition programs to align their offerings with the DGA However, at present we lack a validated way to accomplish this alignment Better science is needed before aligning food packages with the DGA can be done with the same assurance as planning nutrient intakes for groups

Conclusions This analysis explains how comparison of the dietary intakes of the same individuals to the DRIs and DGA food groups could produce such difference inferences However, it leaves the decision about how to use them (e.g. on or the other or in combination) to the committee

Challenges with the data on consumption of food groups They align poorly with the data on nutrient consumption for children, but not for women It may be hard for people to meet these high nutrient densities (some nutrients are well above the RDA) because: Diets must move from nutrient-poor to nutrient-rich This requires a change in food preferences (not easy do do!) to be sustainable And, for many people, overall intake must decrease for better health

Conclusions Assessment and planning of diets for groups relies heavily on data on dietary intake (for better or worse) However, these data are interpreted differently when determining whether intakes of nutrients or food groups are too low Nationally, we don t have dietary data on nationally representative samples of all population subgroups of interest

2005 USDA food pattern Source: Britten P, et al. J Acad Nutr Dietet 2012;112:1648.

2010 USDA food pattern Source: Britten P, et al. J Acad Nutr Dietet 2012;112:1648.

Estimating the proportion of individuals below the EAR When we count those who do not achieve the DGA dietary pattern for their caloric needs, we are identifying those at the turquoise bars. For some nutrients, this will be more than half of the population --even with few (top) or no (bottom) individuals with intakes below the EAR (top). From: Otten JJ, et al., eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: National Academies Press, 2006.

Is prevalence <5%? Yes STOP: no action Is prevalence >50%? Yes No Is prevalence 10-50%? Yes No No Is prevalence 5-10%? Yes Proposed decision tree given the prevalence of nutrient inadequacy among WIC women and children Consider action; HIGH priority Does the nutrient have known health consequences for the WIC population? Yes Consider action; MEDIUM priority Does WIC currently offer foods that provide a useful amount of this nutrient? Consider action; LOW priority Yes Is redemption adequate? No Yes ACTION: Consider substituting a preferred form Enhance nutrition education STOP: No change in food package No STOP: no action No Could this inadequacy be addressed by increasing the CVV? Yes ACTION: Consider increasing the value of the CVV No No WIC solution: move on to next nutrient inadequacy No Are there foods not currently in WIC that could be added to address this inadequacy? Yes Is adequate consumption likely? Yes Is this food available in useful forms and at a reasonable price? Yes ACTION: Consider adding this food or using it as an alternative to current foods No No STOP: No change in food package KMR 160104

Is prevalence only <5%? Yes STOP: no action No Is prevalence >50%? Yes No Is prevalence 10-50%? Yes No Is the prevalence 5-10%? Yes Proposed decision tree with identified nutrient inadequacy Consider action; HIGH priority Consider action; MEDIUM priority Consider action; LOW priority Does the nutrient have known health consequences for the WIC population? No STOP: no action Yes Does WIC currently offer a useful amount of this nutrient? No Is there already a rich food source in WIC? N o Could this inadequacy be addressed by increasing the CVV? Yes Yes Yes Enhance nutrition education Is redemption adequate? Consider increasing the value of the CVV Yes STOP: No change in food package Encourage consumption by intended beneficiary No Consider substituting a preferred form No No WIC solution: move on to next nutrient inadequacy No Are there foods not currently in WIC that could be added to address this inadequacy? Yes Is adequate consumption likely? No Yes Is this food available in useful forms and at a reasonable price? No Yes Consider adding this food or using it as an alternative to current foods STOP: No change in food package KMR 151222

Use of indicators of adequacy of intake based on nutrients or food groups: data from NHANES Via FPED NHANES dataset (24-h recall, 1-2 d) Via food composition database Daily intake of USDA food groups USDA food groups Distribution of daily nutrient intake v. DGA recommendations v. DRIs Proportion not meeting the DGA for a food group Summarized across food groups as HEI How to use these together to decide what is limiting and what should change? Proportion below DRI (EAR or AI) for a nutrient Summarized across nutrients as NBDI

Uses of DRIs for assessing intakes of individuals DRI EAR RDA AI UL Suitable uses Use to examine the probability that usual intake is inadequate Usual intake at or above this level has a low probability of inadequacy Usual intake at or above this level has a low probability of inadequacy Usual intake above this level may place an individual at risk of adverse effects from excessive nutrient intake

Micronutrients with Evidence of Intakes Exceeding the Tolerable Upper Intake Level (UL) in the Diets of WIC Participant Subgroups Nutrient Copper P, BF, or PP Women, 19 to 50 years FF Infants 6 to less than 12 months Children 1 to less than 2 years Children 2 to less than 5 years Iron Selenium Sodium 12

DRI and DGA: using them together to make policy decisions

From: IOM. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academy Press, 2000.

Uses of DRIs for assessing intakes of groups DRI EAR RDA AI UL Suitable uses Use to estimate the prevalence of inadequate intakes within a group Do not use for assess intakes of groups Mean usual intake at or above this level implies a low prevalence of inadequate intakes Use to estimate the percentage of the population at potential risk of adverse effects from excessive nutrient intake

Uses of DRIs for assessing the diets of groups Typically involves comparing usual nutrient intakes with nutrient requirements to assess the prevalence of inadequacy Proportion below the EAR is preferred Alternatively, compare the mean and median with the AI If less than the AI, no inference about the prevalence of inadequacy is possible Proportion above the UL is also of interest

Uses of DRIs for planning diets Goal: to optimize the prevalence of diets that are nutritionally adequate without being excessive For individuals: To achieve intakes that are close the RDA or the AI For groups: To determine the usual intake distribution that results in a low prevalence of intakes that are inadequate or at risk of being excessive

Uses of DRIs for planning diets For individuals RDA: Aim for this intake AI: Aim for this intake UL: Use as a guide to limit intake; chronic intake of higher amounts may increase the risk of adverse effects For groups EAR: Use in conjunction with a measure of variability of the group s intake for the mean intake of a specific population

Nutrients for which mean usual intake falls below the adequate intake (AI) in the diets of WIC-participant subgroups Nutrient P, BF, or PP Women, 19 to 50 years FF Infants 0 to 6 months Children 1 to less than 2 years Children 2 to less than 5 years Potassium Choline Fiber From: K.M. Rasmussen, et al., eds. Review of WIC Food Packages Interim Report. Washington, DC: National Academies Press, 2015. 11

V From: USDA/US DHHS. Dietary Guidelines for Americans 2010. Available at: www.dietaryguidelines.gov.