Impact
of the WIC
Program
on the Iron Status
of Infants
Virginia
Miller,
MPH,
MS
Sheldon
Swaney,
BA, and
Amos
Deinard,
MD
From The Bureau of Maternal and Child Health and Public Health Statistics, Minneapolis
Health Department, and Department of Pediatrics and School of Public Health, University
of Minnesota, Minneapolis
ABSTRACT. The WIC Program (Special Supplemental
Food Program for Women, Infants and Children) was
initiated in the early 1970s to improve the nutritional
status of pregnant women, lactating women, and children
from birth to 5 years of age who were at risk for nutri-tionally related health problems. Better hematologic
sta-tus of a group of preschool-aged infants who were enrolled
in the WIC Program from birth, as compared with
an-other group of similar age and socioeconomic status from the pre-WIC Program era, suggests that participation in the WIC Program will help limit the development of iron depletion or iron deficiency anemia in young children, an
important consideration in view of the deleterious
he-matologic and nonhematologic effects that have been attributed to those conditions. Pediatrics 1985;75:100-105; WIC Program, iron status, infants.
The WIC Program (Special Supplemental Food Program for Women, Infants and Children, Public Law 92-433) was first authorized for fiscal year
1973. The purpose of the legislation, to be
admin-istered by the Department of Agriculture, was to
fund agencies to distribute either coupons, which
could be redeemed for specific foods, or the specific
foods, themselves, to populations at risk for
nutri-tionally related health problems.’ Those groups that were at risk included pregnant women, lactat-ing women, and children from birth to 5 years of age.
The purpose of this report is to consider the contribution that enrollment in the WIC Program
may make in helping to limit the development of
Received for publication April 30, 1984; accepted Aug 18, 1984.
Reprint requests to (A.S.D.) Department of Pediatrics, Box 85 Mayo, University of Minnesota Hospitals, 420 Delaware St SE, Minneapolis, MN 55455.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the
American Academy of Pediatrics.
iron depletion or iron deficiency anemia in young children. This is an important consideration in view
of the deleterious hematologic2’3 and
nonhema-tologic4’5 effects that have been attributed to iron
deficiency and iron deficiency anemia in young
children.
SUBJECTS AND METHODS
Patient Population
Patients whose hematologic data were analyzed for the study were receiving comprehensive health care at the Children and Youth Project Clinic, Bureau of Maternal and Child Health, Minneapolis Health Department, Minneapolis.
The Children and Youth and Maternity and In-fant Care Projects have always served patients of low socioeconomic status. Indeed, the demographics of those enrolled in the Bureau’s projects have changed little over the past 1#{189}decades. Demo-graphic data of those enrolled in the projects in
1973 to 1974 and in 1977, the two periods from
which children were studied, were comparable with respect to age distribution of new Children and Youth Project registrants, ethnicity of active Chil-dren and Youth Project case load (black, white, native American), age distribution of active Chil-dren and Youth Project case load, initial trimester
in which maternity care was initiated, age of mother
at time of enrollment in the Maternity and Infant Care Project, out-of-wedlock status on enrollment
in the Maternity and Infant Care Project, maternal
educational status, median number of months since
last pregnancy, and nulliparous status (Table 1).
For the city as a whole, unemployment (an indicator of the state of the economy) averaged 4.6% and 3.4% for the periods 1973 to 1974 and 1977,
702 (49.5%)
452 (31.9%)
264 (18.6%)
68.6%
22.5%
4.8%
4.1%
479 (9.2%)
1,993 (38.3%) 2,735 (52.5%)
51.9% 37.2%
10.1%
17.6% 19.8%
61.6% 1.0% 59.3%
41.7%
16.4 41.1% 40.2%
17.2
TABLE 1. Demographics of Populations from Which Study Groups Were Drawn
1973-1974 1977
Age distribution of new Children and Youth Project registrants
<1 yr 853 (42.0%)
1-4 yr 745 (36.7%)
5 yr 433 (21.3%)
Ethnicity of Children and Youth Project active caseload
White 75.7%
Black 15.1%
Native American 5.2%
Asian/other 4.0%
Age Distribution of active Children and Youth Project caseload
<lyr 628 (10.1%)
1-4 yr 2,473 (39.8%)
5yr 3,117(50.1%)
Initial trimester in which maternity care was initiated
1st trimester 45.9%
2nd trimester 40.0%
3rd trimester 14.1%
Age of mother at time of enrollment in Maternity and Infant Care Project
<18 10.7%
18-19 25.1%
20-34 62.9%
:35 1.3%
Out-of-wedlock status on enrollment in 57.6%
Maternity and Infant Care Project
Maternal educational status (< high school)
Median no. of months since last pregnancy
No prior pregnancies 53.6%
Design
A comparison of the hematologic status of a group of preschool-age infants from the pre-WIC Program era and another group of infants of similar age and socioeconomic status who had been en-rolled in the WIC Program from birth was under-taken in order to ascertain whether a reduction in the percentage of children classified as being iron depleted or anemic could be documented if they had been enrolled in the WIC Program from birth.
For the pre-WIC Program sample, two sets of data were analyzed. The first consisted of hemato-crit and serum ferritin concentration values col-lected during 1973 to 1974 on infants 6 and 9 months of age who were participating with their
mothers in a longitudinal study of the relationship
of maternal iron status to childhood iron status. Three hundred mothers were randomly selected in
1973 from the Bureau’s Maternity and Infant Care
Project clinic and enrolled in this longitudinal
study. Informed consent was obtained in every case
after the study design had been explained in detail. At birth, all of the infants were enrolled in the Children and Youth Project. The design of the longitudinal study called for each infant to be tested at 6 and 9 months of age. Blood samples were obtained when the infant was visiting the clinic for comprehensive, well-child care. A dietary history was obtained for every infant at these clinic visits.
After hematologic sampling had been completed on all infants at 9 months of age, they or their lactating
mothers were enrolled in the WIC Program. The
second set of data was limited to hematocrit values compiled from laboratory records of all (863)
pa-tients 9 through 23 months of age who were seen
in the Children and Youth clinic for comprehensive, well-child care in 1973 to 1974. The hematocrit values were generated during the course of enrolling this group of 863 infants into the WIC Program for
the first time. No infant who had participated in
the longitudinal study was included in this compi-lation.
For the post-WIC Program sample, hematocrit and serum ferritin concentration values, compiled from the laboratory records of 1,039 infants 6
through 23 months of age who received
comprehen-sive, well-child care in the Children and Youth clinic during 1977, were analyzed. All had been enrolled in the WIC Program from birth, either as primary recipients or as infants of lactating women. Specific dietary histories were obtained on these infants every 6 months at the time of WIC Program recertification.
Hematologic Assays
Serum ferritin concentration was used to
mea-sure iron status. The assay was performed
TABLE 2. Serum Ferritin Concentration Values for 6- and 9-Month-Old
(Pre-WIC) and After (Post-WIC) the WIC Program
Infants Before
Ferritin Concentration (ng/mL) Total
<10.0 10.0-19.9 20.O
No. % No. % No. %
Infants aged 6 mo*
Pre-WIC 33 20.5 50 31.1 78 48.4 161
Post-WIC 2 0.7 37 13.0 246 86.3 285
Infants aged 9 mo*
Pre-WIC 87 43.3 53 26.4 61 30.3 201
Post-WIC 3 1.6 37 19.1 153 79.3 193
* x2= P< .005.
TABLE 3. Hematocrit Values for 6- and
After (Post-WIC) the WIC Program
9-Month-Old Infants Before (Pre-WIC) and
Hematocrit (%) Total
<33.0 33.0-35.9 36.O
No. % No. % No. %
Infants aged 6 mo*
Pre-WIC 44 20.8
Post-WIC 33 14.0
Infants aged 9 mo5
Pre-WIC 41 20.2
Post-WIC 37 23.8
63 29.9
64 27.1
68 33.5
48 31.0 104 139
94 70
49.3 58.9
46.3 45.2
211 236
203 155
* x2 is not statistically significant.
Miles et al,7 using a two-site radioimmunometric
assay (New England Nuclear, Boston). Values of
<10 ng/mL indicated unequivocal iron depletion;
values of 10 to 19 ng/mL indicated mild hypoferri-tinemia; values of 20 ng/mL represented intact iron stores.
Microhematocrit, always measured on a capillary blood specimen according to the standard tech-nique, was used to determine the anemic state. Values of <33% indicated anemia; values of 33.0% to 35.9% represented the low-normal (“borderline”)
state; values of 36% indicated the high-normal
state.
Data Analysis
Pearson’s
x2
analysis was used to compare thedistribution of children in the pre- and post-WIC Program samples for several groupings of ferritin concentrations and hematocrit values. Interest cen-tered on whether it could be shown that a smaller percentage of infants of different ages from the post-WIC Program period than from the pre-WIC Program period were iron depleted or anemic. Hence, descriptive statistics for hematologic mea-surements and other statistical analyses (eg, t test) were not performed.
RESULTS
Hematologic
The number of infants 6 and 9 months of age from the pre- and post-WIC Program periods in
each of the ferritin concentration and hematocrit
percentage groups is depicted in Tables 2 and 3. At
both age levels,
x2
analysis confirmed that thefer-ritin concentration differences were statistically
significant (P < 0.005) (Table 2). However, with
regard to hematocrit percentage, at neither age level did
x2
analysis reveal statistically significant differ-ences (Table 3).The number of infants from the pre- and post-WIC Program periods in each of the hernatocrit groups for infants of three different ages (9 through 11 months, 12 through 17 months, and 18 through 23 months) is depicted in Table 4. For each age group,
x2
analysis revealed the differences to be statistically significant (P < 0.005). Although noferritin data are available for infants 9 through 23 months of age from the pre-WIC Program period, data from the post-WIC Program period revealed that, of 571 infants, only 22 infants (3.9%) were severely hypoferritinemic, whereas 456 infants
(79.9%) had intact iron stores.
Dietary
TABLE 4. Hematocrit
After (Post-WIC) the
Values for Infants
WIC Program
(Three Age Groups) Before (Pre-WIC) and
Hematocrit Value (%) Total
<33.0 33.0-35.9 36.O
No. % No. % No. %
Infants aged 9-11 mo*
Pre-WIC 18 9.4 96 49.7 79 40.9 193
Post-WIC 12 7.5 50 31.3 98 61.2 160
Infants aged 12-17 mo*
Pre-WIC 44 14.1 111 35.7 156 50.2 311
Post-WIC 9 3.0 95 31.9 194 65.1 298
Infants aged 18-23 mo*
Pre-WIC 23 6.4 144 40.1 192 53.5 359
Post-WIC 2 1.9 22 21.4 79 76.7 103
* x2= P < .005.
of iron-containing foods were included in their gen-eral diet. For infants enrolled in the WIC Program, dietary assessments, conducted each time WIC Pro-gram recertification occurred (every 6 months), confirmed that these infants were consuming the iron-fortified formula and cereal and vitamin C-fortified juice for which specific coupons were rou-tinely provided. Review of WIC Program certifica-tion data for this period revealed that <5% of the WIC Program recipients were breast-feeding women. The remainder were infants who were bot-tle-fed and, thus, primary recipients of the WIC Program food package.
DISCUSSION
Health professionals have had longstanding con-cern about childhood iron deficiency and iron defi-ciency anemia.2’3’8 It has been recognized for some time that iron deficiency affects all age groups and all socioeconomic levels of society.9” In addition to the deleterious hematologic effects that iron deficiency is known to have, more recently similar
effects of a nonhematologic nature have been
stressed, including the impact that iron deficiency
and iron deficiency anemia have on cognitive-be-havioral development.’222
Iron deficiency or iron deficiency anemia is more common among youngsters during infancy and early childhood, times when important aspects of brain development occur. Because the CNS is de-velopmentally vulnerable in early childhood, iron deficiency or iron deficiency anemia during that period may produce long-lasting (perhaps irrevers-ible) CNS changes that become manifest as aber-rations in cognitive functioning.’5’23 Unfortunately, determination of iron depletion or iron deficiency
in the absence of anemia in clinical practice is
limited by the fact that most physicians still rely on measurement of hemoglobin concentration or hematocrit percentage to detect the child who is hematologically at risk.
Intake of calories and essential nutrients must, therefore, be adequate to maximize the physical and mental development of children. The WIC Program was initiated in the early 1970s in response to the recognition that there were many pregnant and postpartum women, as well as infants and preschool-aged children, who were considered to be nutritionally “at risk” because of insufficiency of income. The program has provided infants with iron-fortified formula (12 mg of iron per liter) to 12 months of age, iron-fortified cereal from 6 to 12 months, and vitamin C-fortified juice from 6 months to 12 months. Children 1 to 5 years of age are given milk, adult (iron-fortified) cereal, eggs, vitamin C-fortified or citrus juice, cheese, and dried beans. Lactating women are given milk, cheese, cereal (iron-fortified), eggs, vitamin C-fortified or
citrus juice, and dried beans. Over the past decade,
the program has become a large nutrition program, exceeded at the present time only by the Food Stamp Program and the School Nutrition Pro-gram.24 Despite the fact that the WIC Program today reaches approximately 2.8 million mothers and children, it is estimated, nevertheless, that only between 25% and 30% of eligible recipients nation-wide are enrolled, with eligibility being based on economic factors (<185% of poverty) (Minnesota Department of Health, WIC Program, personal communication, 1983). In recent years, the WIC Program has fared better financially than some other health and social service programs.
Nonethe-less, although funding rose from $960 million in
is shifted to state responsibility through the Mater-nal and Child Health Block Grant Program.
To date, in only a limited number of studies has the nutritional effectiveness of the WIC Program been described in quantitative terms. A 1974 Louis-iana study showed mean hemoglobin-hematocrit values to be significantly higher and the percentage of anemic children to be significantly lower among children receiving food supplements for 1 year than among children receiving similar health services but no food supplements.25 Edozian et al26 con-ducted a medical evaluation study of the WIC Pro-gram in 1976 and documented, among WIC Pro-gram participants, an increase in the hemoglobin concentration and a reduction in the prevalence of anemia, the main effect occurring during the first 6 months of participation. In a study of WIC Pro-gram participants in Kentucky, Weiler et al’ found the WIC Program to be effective in correcting nu-tritional anemia in infants whose hemoglobin con-centration at the time of enrollment in the program was less than the corresponding mean for age, but ineffective in increasing hemoglobin concentration in those infants whose hemoglobin concentration at the time of enrollment was comparable to mean-for-age values. Most recently, Pearson and Win-dom27 have reported their observations on the ben-eficial impact that participation in the WIC Pro-gram had on hemoglobin status of inner-city pre-school-aged children in New Haven.
The present study, in which serum ferritin con-centration and hematocrit percentage were mea-sured in a group of children in 1973 to 1974, before the WIC Program was available but at a time when iron-fortified formulas and cereals were
commer-cially available if they could be afforded, and in
1977, when all children studied had been enrolled since birth in the WIC Program (ie, had, since birth, the quasifinancial means to acquire foods that were commercially available but otherwise unaffordable) reveals that enrollment of children in the WIC Program was associated with a reduction in the percentage of infants 6 and 9 months of age who were found to be iron depleted (Table 2) and with a reduction in the percentage of infants 9 through
23 months of age who developed iron deficiency
anemia (Table 4). The percentage of infants 9 through 23 months of age from the pre-WIC Pro-gram period who were anemic was consistent with known incidence data on anemia in infants.
This study differs from preceding evaluations of the WIC Program by considering the impact that participation in the WIC Program may have on limiting iron depletion as well as preventing the development of anemia. That participation in the WIC Program had no demonstrable effect on
hem-atocrit level (Table 3) in infants 6 and 9 months of age is not surprising because iron deficiency anemia does not usually begin to become evident until late in the first year of life, with peak incidence occur-ring in the second year of life (Table 4). Although serum ferritin concentration data are not available in our data base on older children from the pre-WIC Program period, the data suggest that WIC Program participation will help to minimize the development of depleted iron stores in those age groups. One report from the Nutrition Canada Sur-vey from the early 1970s revealed that 30% of children 0 to 4 years of age had a high probability and 50% had a moderate probability of being iron depleted. Such percentages are clearly greater than those calculated in the present study from post-WIC Program ferritin data.
It is recognized that evaluating food supplemen-tation programs is a complex matter. The patient or, in this case, the parent must be able to describe accurately the foods eaten and whether dietary supplementations beyond the WIC Program were used. These are factors over which there was no control. But, because of the similarity of the popu-lations from the two time periods, it is presumed that the reporting was as accurate in 1973 to 1974
as it was in 1977. Other factors (eg, improved diet
exclusive of the WIC Program contribution, more readily available over-the-counter iron-fortified children’s vitamin-mineral preparations) may have contributed to the observed improvement in he-matologic status. However, to attribute the im-proved hematologic status exclusively to these or other factors, to the exclusion of WIC Program participation, would be inappropriate. In view of the effect that iron deficiency and iron deficiency anemia have been shown to have on cognitive func-tioning in young children,’222 that depletion of iron
stores can be minimized, at least in part, by
partic-ipation in the WIC Program is an important con-sideration for without iron depletion there can be no iron deficiency or iron deficiency anemia. The findings reported herein underscore the importance of maintaining the viability of the WIC Program so that it will continue to benefit those who are deemed to be at nutritional high risk.
ACKNOWLEDGMENTS
This study was supported by grants MC-R-270179 and
MC-R-270401 from the Bureau of Community Health
Services, grant 775-0513 from the Ford Foundation, and
by funds from General Mills, mc, Pillsbury Company,
Ross Laboratories, Gerber Products, and the Graduate School, University of Minnesota.
The authors acknowledge the technical assistance of
EDWARDS’
TIME/EFFORT
LAW
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Effort X Time = Constant
A. Given a large initial time to do something, the initial effort will be small. B. As time goes to zero, effort goes to infinity.
Corollary:
If it weren’t for the last minute, nothing would get done.
Submitted by Dr Warren Bosley
