Women, infants and children program prenatal participation and dietary intakes

Women, infants and children program prenatal participation and dietary intakes

NUTRITION RESEARCH, Vol. 7, pp. 451-459, 1987 0271-5317/87 $3.00 + .00 Printed in the USA. Copyright (c) 1987 Pergamon Journals Ltd. All rights reserv...

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NUTRITION RESEARCH, Vol. 7, pp. 451-459, 1987 0271-5317/87 $3.00 + .00 Printed in the USA. Copyright (c) 1987 Pergamon Journals Ltd. All rights reserved.

WOMEN, INFANTS AND CHILDREN PROGRAM PRENATAL PARTICIPATION AND DIETARY INTAKES E.S. Farrior, Ph.D., R.D.* and C.H. Ruwe, M.S., R.D.** School of Home Economics, East Carolina University, Greenville, North Carolina and Wilson-Greene District Health Department, Wilson, North Carolina

ABSTRACT In order to assess the diets of pregnant women before and after nutrition services (WIC supplemental foods and/or nutritional counseling), initial and subsequent dietary recalls were collected from 217 low-income women who were receiving prenatal care and WIC services at the Wilson-Greene District Health Department. Paired t-tests were used to compare the initial recall to the subsequent recall. Results were significant (P <0.009) increases in mean nutrient composition, in mean nutrient composition as a percentage of the RDA and in mean nutrient composition per 1,000 kilocalories for subsequent recalls. The only exceptions were mean carbohydrate intake and mean nutrient composition per 1,000 kilocalories for fat and carbohydrate. These results indicated that positive changes were observed in the diets of pregnant women after having received nutrition services. KEY WORDS :

dietary assessment, nutritional status, pregnancy, WIC

INTRODUCTION

The Special Supplemental Food Program for Women, Infants and Children (WIC) was authorized for the purpose of improving the health of persons nutritionally at risk. Nutrition education and provision of supplemental foods are the key components of the program. Both components are designed to correct nutritional deficiencies common in the population at risk. The food package is intended as a supplement to be consumed in addition to the normal diet to meet energy and nutrient needs. The pregnant woman who consumes an equal amount of the WIC foods throughout the month should meet lO0 percent of the Recommended Dietary Allowances for thiamin, niacin, riboflavin, vitamins A, BI2, C, and D, calcium and iron (1). Because of the cost of this program, data on the effectiveness of this program are needed to guarantee continued funding from the federal government. Data which show the beneficial aspects of good nutrition to the outcome of pregnancy are available (2-8). Results of these studies can be summarized as indicating that a nutritionally adequate diet during pregnancy tends to *Evelyn Farrior, PhD, RD, School of Home Economics, East Carolina University, Greenville, NC 27834 **Carol H. Ruwe, MS, RD, Department of Nursing, Atlantic Christian College, Wilson, NC 27893

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E.S. FARRIORand C.H. RUWE

decrease problems during pregnancy (i.e. inadequate weight gain and anemia) and improve the outcome of pregnancy (i.e. birth weight and gestational age). One or two studies (9-10) have indicated that nutrition may not play a dramatic role in pregnancy outcome. Assuming a correlation exists between nutrient intake and pregnancy outcome, researchers have attempted to document factors which result in positive behavior changes related to diet during pregnancy. Hunt and associates (Ii) demonstrated that diets of low incomepregnant women of Mexican decent could be improved by nutrition education alone. Further, their score on a nutrition quiz was significantly higher (P <0.005) than scores of the control group who received no nutrition education. Edozien, et al. (2) reported improvements in dietary intakes of protein, calcium, phosphorus, iron, thiamin, riboflavin and ascorbic acid between initial WIC program enrollment and a follow-up visit. Endres et al. (1) compared WIC to non-WIC participants and reported increased consumption of all nutrients measured except vitamin E by WIC participants but no difference in nutrient density of the diets consumed by the two groups. Bailey et al. (12) reported that WIC participants consumed higher (P <0.05) amounts of B 6 and iron than similar non-participants; while no differences were reported for folacin, energy and protein. Intakes of B 6 and folacin for both groups were well below the RDA. Further data are needed to support the idea that women who receive WIC services do improve their nutrient intakes as a result of either food supplements or counseling or both. Questions addressed by this paper are: 1. Do WIC services affect nutrient intakes of pregnant women? 2. Do WIC services affect the nutrient density of diets consumed by pregnant women? 3. How do nutrient intakes of pregnant women compare to the Recommended Dietary Allowances (RDA) before and after WIC services?

METHODS

Twenty-four hour dietary recalls of pregnant women before nutrition intervention were compared to twenty-four hour recalls completed after receipt of WIC program benefits to describe the diets of pregnant women after nutrition intervention services. Population and Sample The current study was based on data collected from low-income clients living in Wilson County who received prenatal care at the Wilson-Greene District Health Department from January 1980 through December 1981. The population of pregnant women served by the agency consisted of 81 percent black, 17 percent white, and 2 percent Hispanic. Clients interviewed had family incomes at or below 125 percent of poverty guidelines asdefined by the Office of Management and Budget. (For example, in 1981 the annual gross income of a family of four could not exceed $8,450.) After an explanation of the study by a nutritionist, all subjects verbally agreed to participate in the study and were assured that the information would remain confidential. The study was approved by the Wilson-Greene District Health Department. Migrant farmworkers attending the prenatal clinic were excluded from the study because of the uncertainty of obtaining a follow-up recall. Initial recalls were obtained from a total of 378 women as a part of their routine prenatal care. Of that total, 161 were not included in the study sample due to the lack of subsequent recalls. Transfers to high-risk clinics, relocation to other counties, women entering the clinic late in pregnancy

WIC AND DIETARY INTAKES

453

(third trimester), and the conclusion of the study accounted for the difference in number of persons providing initial recalls and subsequent recalls. The final study sample was 217. Table I describes the age and participation in food assistance of the 217 subjects. More than half (57.1% or 124) of the subjects were in the age group of 19 to 50+ years. Less than 5 percent were iI to 14 years of age. The remainder of the subjects were in the 15 to 18 age group (39.2% or 85). TABLE i Information on the 217 Pregnant Subjects

Number of Subjects

Percentage

Age (years) 11-14 15-18 19-50+

8 85 124

3.7 39.2 57,1

Assistance Food Stamps yes Food Stamps no

98 119

45.2 54,8

23 194

10.6" 89.4

WIC yes WIC no * No longer than 4 months.

Food assistance was received by slightly less than half (45.2% or 98) of the subjects. Twenty-three (i0.6%) of the subjects had received WIC supplemental foods before admission to the study but none had received foods for longer than four months. Those receiving WIC foods had applied for WIC benefits before enrolling in the prenatal clinic. At the conclusion of the study, the length of WIC participation varied among the women. The largest proportion (55.3%) had received services for 2 to 3 months. Over 75 percent of the subjects had received services for 2 to 5 months, while fewer than 15 percent had received services for less than 2 months (Table 2). TABLE 2 Number of Months Subjects Participated in WIC

Time

0-i 2-3 4-5 6-10

Number of Subjects

31 120 56 i0

Percentage

14.3 55.3 25.8 4.6

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E.S. FARRIOR and C.H. RUWE

Instruments and Data Collection Data were collected by three trained nutritionists using a computerized system called Nutrient Dietary Data Analysis System (NDDA) developed at Southern Illinois University at Carbondale. Data collection began during the client's first prenatal visit which consisted of a nurse interview, biochemical assessment, physical examination by a certified nurse-midwife or physician, interviews with the health educator and social worker, and referral to the nutritionist. During the initial visit with the nutritionist, a 24-hour dietary recall was obtained according to NDDA protocol and recorded in the client's medical record. (If a client consumed foods which were not listed on the machine readable form, the NDDA protocol was followed in recording substitute foods or supplying nutrient composition for inclusion in the analysis.) A dietary assessment was performed and nutrition counseling provided. Nutrition counseling, although directed to specific needs of individuals, supplied information on the types and amounts of foods a pregnant woman should consume in order to meet the RDA for a pregnant woman. Clients were screened for WIC eligibility (financial and nutritional risk status). For those determined eligible, the nutritionist prescribed the WIC food package and food vouchers were issued. A typical monthly food package for a pregnant woman consisted of 7 gallons of whole, skim or low-fat milk (cheese could be substituted for milk), 36 ounces iron-fortified cereal, 276 ounces of fruit juice, and 2 dozen eggs. The package supplied up to 800 kilocalories, 40 g protein and I00 percent of the RDA of thiamin, riboflavin, niacin, vitamins A, B19 , C, and D, calcium and iron per day if equal quantities of the foods were-~onsumed over a one month period (i). A follow-up visit with the nutritionist was planned for all clients 8 to 12 weeks after the first visit. During the subsequent visit, a second 24-hour dietary recall was obtained. The average weeks pregnant was 1 8 • weeks at the first recall and was 30 ~ 6.3 at the second recall. The average time between recalls was 12 weeks. Data Analysis Upon concluding the study, a summary report of data collected during both the initial recall and the subsequent recall was supplied by the NDDA Laboratory. Data supplied for each time period were mean values for protein, fat, carbohydrate, thiamin, riboflavin, niacin, folacin, vitamin A, vitamin B6' vitamin BI2' vitamin C, vitamin D, vitamin E, calcium, phosphorous, iron, magneslum, zinc, and energy, mean nutrient intake per I000 kilocalories, and mean nutrient and dietary energy intakes as a percentage of the RDA. Using paired t-tests, the initial recall of each client was compared to the client's subsequent recall to determine if differences existed in the diets after having received nutrition services. In order to control for mean nutrient intake values being affected by increased kilocaloric intake, the mean nutrient intake per lO00 kilocalories was calculated for each nutrient and paired t-tests were used to determine if any differences in nutrient density existed between the initial recall and subsequent recall of each client. Paired t-tests were also used to determine if mean nutrient or energy intakes as a percentage of RDA were different. A probability level of P <0.009 was used to determine significance. Quality of diet was evaluated by comparing nutrient intakes to the RDA for pregnant women. A nutrient intake of 68 percent of the RDA was considered marginally adequate since the RDA represents the estimated average requirement plus two standard deviations to cover 98 percent of the healthy population.

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WIC AND DIETARY INTAKES RESULTS

When the mean nutrient composition of the initial recall was compared with the subsequent recall for each patient, significant (P <0.009) increases w e r e observed in the subsequent recall for protein, fat, thiamin, riboflavin, niacin, folacin, vitamin A, vitamin B6, vitamin B12 , vitamin C, vitamin D, vitamin E, calcium, phosphorous, i~on, magnesi~, zinc, and energy. No significant increase was observed for carbohydrate intake (Table 3). TABLE 3 Nutrient Composition of Diets before and after Nutrition Services

Nutrient

Ist visit mean

Energy (kcal) Protein (gm) Fat (gm) Carbohydrate (gm) Thiamin (mg) Riboflavin (mg) Niacin (mg) Folacin (mcg) Vitamin A (IU) Vitamin B6 (rag) Vitamin BI2 (mcg) Vitamin C (mg) Vitamin D (IU) Vitamin E (IU) Calcium (mg) Phosphorous (mg) Iron (mg) Magnesium (mg) Zinc (mg)

1750.6 + 668.5* 6 3 . 4 ~- 26.8 70.8 + 32.1 220.3 + 94.2 1.3 + 0.9 1.8! 1.4 16.6 • 10.9 158.9 • 179.9 4026.1 + 5581.4 0.6 + 0.9 2.1 + 2.9 89.4 + 90.0 1 2 6 . 5 • 199.7 5.6 + 9.8 593.5 • 415.8 961.I • 456.7 12.3 • 9.3 145.7 + 100.4 5.4 ~ 4.0

2nd visit mean

1931.1 + 771.3t 78.5 ~m 32.4~ 77.2 + 37.3~ 234.8 + 98.1 1.7 + 1.2t 2.3 ~ 1.7t 21.1 • 15.8t 280.8 • 329.2t 6343.1 + 7367.6t I.i + 1.5T 3.8 + 4.9t 136.0 + ll6.0T 2 1 8 . 8 • 321.6t 10.4 + 20.5t 797.2 ~ 538.7t ll90.O • 563.7T 16.4 ~ 13.5T 177.7 + 102.3~ 7.2 • 4.0t

* Standard deviation t P< 0.009 In order to control for increases in mean nutrient intake simply as a result of increased kilocaloric consumption, the data were analyzed for mean nutrient intake per I000 kilocalories. Significant (P <0.009) increases in nutrient intake for the subsequent recall were reported for all nutrients and energy except for fat and carbohydrate (Table 4). The mean nutrient and dietary energy intakes for each reported recall were compared to and expressed as a percentage of the RDA. A significant (P <0.009) increase in all nutrients and energy was reported for the subsequent recalls (Table 5). However, reported dietary energy intakes failed to meet the RDA for pregnancy. At the initial visit, the women were consuming 73.6 percent of the RDA for energy as compared to 81.2 percent at the second visit. Initially, theonly reported nutrient values which met or exceeded lO0 percent of the RDA were riboflavin, niacin and vitamin C. Intakes of these

E.S. FARRIOR and C,H. RUWE

456

nutrients increased at the subsequent recall. Protein, thiamin, and vitamin A met between 68 and i00 percent of the RDAinitially and at the subsequent recalls reported values exceeded the RDA. Phosphorus met between 68 and i00 percent of the RDA initially and although level of intake increased, the intakes did not reach lO0 percent. Intakes of BI2, vitamin E and iron were between 68 and lO0 percent of the RDA initially and subsequently were in the same range, despite increased intakes.

TABLE 4 Nutrient Composition per I000 Kilocalories of Diets before and after Nutrition Services

Nutrient

Ist visit mean

Protein (gm) Fat (gm) Carbohydrate (gm) Thiamin (mg) Riboflavin (mg) Niacin (mg) Folacin (mcg) Vitamin A (IU) Vitamin B6 (mg) Vitamin BI2 (mcg) Vitamin C (mg) Vitamin D (IU) Vitamin E (IU) Calcium (mg) Phosphorous (mg) Iron (mg) Magnesium (mg) Zinc (rag)

2nd visit mean

36.8 + I0.I* 39.8 ~ i0.0 126.7 + 26,5 0.8 • 0.5 1.O! 0.7 9.7 + 5.8 94.7 • I10.7 2339.4 ! 3151.3 0.4 • 0.5 1.2 + 1.7 52.1 + 52.9 70.4 + i15o5 3.2 + 5,8 329.6 • 174.7 546.8 + 152.7 7.3 + 5.3 83.1 + 46.9 3.1 + 1.9 - -

41.3 39.4 122.4 0.9 1.2 11.2 150.7 3366.2 0.6 2.0 72.0 118.4 5,3 409.2 618.4 8.7 93.8 3.9

+ lO. It ~ 8.2 + 24.4 • 0.6t • 0.Sf + 7.6t • 168.4t • 3747.9t • 0.St + 2,6~ + 60.5t + 174.8t + 9.7f • 211.7+ + 162.8f + 6.6~ + 38.5t + 1.9t m

* Standard deviation t P< 0.009 Despite the benefits of nutrition services, reported values for folacin, vitamin Ba, vitamin D, calcium, magnesium, and zinc did not meet 68 percent of the RDA both at the initial and subsequent recall, even though significant (P <0.009) increases were observed. It should be noted, however, the data base for certain nutrients in some foods may have been incomplete. All foods consumed were coded on the form and nutrient analysis was performed based upon available data. It is probable that values for zinc, magnesium, vitamin B.~, IZ and folacin are affected, and the reported intakes for these nutrients are lower than actually consumed (12). DISCUSSION Our 217 subjects were from low income households and from a rural area. In contrast, Edozien's et al. (2) 1435 subjects were 91.6 percent from urban areas and from low income households. His findings of increased total nutrient consumption by 299 women after three months of WIC program participation for protein, calcium, phosphorus, iron, thiamin, riboflavin, and Vitamin C agree

457

WIC AND DIETARY INTAKES

with our results. However, he did not find the increased energy, Vitamin A, niacin and folacin intakes which we reported. He further reported intakes below I00 percent of the RDA for energy, protein, calcium, Vitamin A, thiamin, riboflavin, and niacin. Iron was below 68 percent of the RDA. Our results differed from Edozien's et al. (2) for protein, Vitamin A, thiamin, riboflavin, and niacin which exceeded lO0 percent of RDA at follow-up and calcium which was consumed at less than 68 percent of the RDA at follow-up. Energy and iron intakes compared to the RDA were similar.

TABLE 5 Comparison of Intake by Percentage of RDA before and after WIC Services

Nutrient

1st visit mean

Energy (kcal) Protein (gm) Thiamin (mg) Riboflavin (mg) Niacin (mg) Folacin (mcg) Vitamin A (IU) Vitamin B6 (mg) Vitamin B12 (mcg) vitamin c (mg) Vitamin D (IU) Vitamin E (IU) Calcium (mg) Phosphorous (mg) Iron (mg) Magnesium (mg) Zinc (mg)

73.6 84.7 90.0 112.0 104.9 20.0 80.9 24.7 51.4 112.2 25.2 46.7 43.9 71.2 53.7 32.4 26.9

+ 28.0* + 35.7 + 59.7 • 87.3 + 68.9 • 22.5 • I18.8 + 33.9 • 72.5 + 112.5 + 40.6 + 81.9 • 30,6 ~ 34.2 + 40.4 + 22.3 ~ 19.9 m

m

2nd visit mean

81.2 104.9 166.6 144.3 133.6 35.3 127.4 41.1 95.5 170.7 42.5 86.6 59.4 88.9 70.9 39.5 36.1

+ + + + + • • + • + + + • • + + ~

32.5# 43.3~ 83.4t 107.4# 99.2t 41.2~ 147.5t 57.0t 123.4~ 145.6T 58.6~ 170.8t 41.4t 43.8~ 57.6~ 22.8~ 20.0~

* Standard deviation P< 0.009

Endres et al. (I) compared intakes of 115 pregnant women on WIC for six months to 651 applying for WIC. Sixty-one percent of the subjects were from rural and 39 percent were from urban areas. WIC participants consumed a significantly (P <0.05) higher percentageof the RDA for all nutrients except Vitamin E compared to non-WlC participants. Our findings of all nutrients consumed at a significantly (P <0.009) higher level after WIC services were in agreement. Nutrients which were not consumed by the WIC participants in Endres' et al. (1) study at lO0 percent of the RDA were: energy, Vitamin B. 2, Vitamin D, calcium, and iron. Nutrients consumed by WIC participants a~ less than 68 percent of the RDA were: folacin, Vitamin B6, Vitamin E, magnesium, and zinc. Our results were similar except Vitamln D and calcium which were consumed at less than 68 percent of the RDA and Vitamin E which was below lO0 percent of the RDA. In examiningthe nutrient density of the reported diets of the WIC population compared to non-WIC, Endres et al. (i) reported a significant (P <0.05) increase only for thiamin. In contrast, our study indicated the

458

E.S. FARRIOR and C.H. RUWE

nutrient density of the diets increased significantly (P <0.09) for protein, thiamin, riboflavin, niacin, folacin, vitamin A, vitamin B6, vitamin Bl~ , vitamin C, vitamin D, vitamin E, calcium, phosphorus, iron, magnesium, an~ zinc. The significant (P <0.009) increases in the above nutrient densities suggest that nutrition intervention may have been a factor in improving the quality of the diets of pregnant women in the current study. Our study results of significantly (P <0.009) increased intakes of B , iron, folacin, energy and protein may be compared to those of Bailey et a~. (12) who reported that 4 1 W I C participants at the 30th week of pregnancy consumed significantly (p <0.05) more B 6 and iron than 37 control subjects. However, Bailey et al. (12) reported no difference in energy, protein or folacin intakes. Nutrients consumed by the subjects in this study at less than 68 percent of the RDA even after intervention were: folacin, vitamin B~, vitamin D, calcium, magnesium, and zinc. Endres et al. (I) reported th~se sa~ne nutrients to be consumed at levels below 68 percent of the RDA with the exceptions of vitamin D and calcium which were consumed at levels above 68 percent of the RDA. Likewise, Bailey et al. (12) reported WIC participant conshmption of vitamin B~ and folacin to be below 68 percent of the RDA for pregnant women. T~ese levels of intakes are comparable to the levels re~orted here and provide evidence that B~ and folacin should be supplied in food packages and/or supplements and That nutrition counseling should stress C~nsumption of foods which provide these nutrients. Overall, positive changes were observed in the diets of th~ subjects after having received nutrition services as a part of prenatal care. Those positive changes were for all nutrients studied except fat and carbohydrate. Positive changes were not limited to total intakes but included nutrient density and percentage of the RDA. The supplemental food and nutrition counseling may have been factors in the improved dietary intakes of pregnant women in this current study. Emphasis needs to be placed on improving consumption of calcium rich foods supplied in the food package and improving folacin , vitamin B6, vitamin D, magnesium, and zinc intakes either through addition of appropriate foods to the package, counseling and/or supplements. REFERENCES (i) Endres JM, Sawicki M, Casper JA. Dietary assessment of pregnant women in a supplemental food program. J. Am. Diet. Assoc. 1981; 79: 121-6. (2) Edozien JC, Switzer BR, Bryan RB. Medical evaluation of the special supplemental food program for women, infants, and children. Am. J. Clin. Nutr. 1979; 32: 677-92. (3) Kennedy ET, Kotelchuck M. The effect of WIC supplemental feeding on birth weight: a case-control analysis. Am. J. Clin. Nutr. 1984, 40: 579-85. (4) Kennedy ET, Gershoff S, Reed R, Austin JE. Evaluation of the effect of WIC supplemental feeding on birth weight. J. Am. Diet. Assoc. 1982; 80: 220-27. (5) Kotelchuck M, Schwartz JB, Anderka MT, Finison KS. WIC participation and pregnancy outcomes: Massachusetts statewide evaluation project. Am. J. Public Health 1984; 74: 1086-92. (6) Lechtig A, Habicht JP, Delgado H, Klein RE, Yarbrough C, Martorell R. Effect of food supplementation during pregnancy on birthweight. Pediatrics 1975; 56: 508-20.

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(7) Metcoff J, Costiloe P, Crosby WM, Dutta S, Sandstead HH, Milne D, Bodwell CE, Majors SH. Effect of food supplementation (WIC) during pregnancy on birth weight. Am. J. Clin. Nutr. 1985; 41: 933-47. (8) Stockbauer JW. Evaluation of the Missouri WIC program: prenatal components. J. Am. Diet. Assoc. 1986; 86: 61-7. (9) Rush D, Stein Z, Susser M. A randomized controlled trial of prenatal nutritional supplementation in New York City. Pediatrics 1980; 65: 683-97. (lO) Adams SO, Barr GD, Huenemann RL. Effect of nutritional supplementation in pregnancy. J. Am. Diet. Assoc. 1978; 72: 144-7. (ii) Hunt IF, Jacob M, Ostergard NJ, Masri G, Clark VA, Coulson AH. Effect of nutrition education on the nutritional status of low-income pregnant women of Mexican descent. Am. J. Clin. Nutr. 1976; 29: 675-84. (12) Bailey LB, O'Farrell-Ray MS, Mahan CS, Dimperio D. Vitamin Bg, iron and folacin status of pregnant women. Nutr. Res. 1983; 3: 783-93~ Accepted for publication January 28, 1987.