Health Status: Minnesota Children
Enrolled in WIC 1997 to 2006
Data presented in this report were gleaned from the Minnesota
WIC Program through the Pediatric Nutrition Surveillance
System (PedNSS).
Table of Contents
Pediatric Nutrition Surveillance System ......................................3
Demographic Characteristics .......................................................3
Pediatric Health Indicators
Low Birthweight .................................................................4
High Birthweight ................................................................5
Short Stature ......................................................................6
Underweight .......................................................................7
Overweight and Risk of Overweight ...................................8
Anemia ..............................................................................11
Breastfeeding ...................................................................12
Infant and child health advances and concerns .........................16
Pediatric Recommendations ......................................................16
References .................................................................................17
PedNSS Summary Report ~ Page 2
Pediatric Nutrition Surveillance System
The Pediatric Nutrition Surveillance System (PedNSS) is a child-based public health
surveillance system that monitors the nutritional status of low-income children in
federally funded maternal and child health programs. In Minnesota, PedNSS includes only
data from children enrolled in the Special Supplemental Food Program for Women
Infants and Children (WIC). Virtually all Minnesota WIC records are included in the
surveillance system. The national PedNSS includes data from other federally funded
programs in addition to WIC, but is the comparable national group. Data reported here
includes: birthweight, short stature, underweight, overweight, anemia, and
breastfeeding. Data are collected at the clinic level, aggregated to the state level, and
submitted to the Centers for Disease Control and Prevention (CDC) for analysis.
The goal of PedNSS is to collect, analyze, and disseminate surveillance data to guide
public health policy and action. PedNSS information is used to set priorities and plan,
implement, and evaluate nutrition programs. This report summarizes 2006 data and
highlights trends from 1997 through 2006 for Minnesota.
Demographic Characteristics
During 2006, the Minnesota WIC Program served an average monthly caseload of
129,066 participants. Among the children served during 2006, 48% were non-Hispanic
white children, 19% Hispanic children, 16% non-Hispanic black children, 7% Asian or
Pacific Islander children, 3% American Indian or Alaska Native children, and 6% were
children of multiple or unspecified races and ethnicities.
During 2000, the average monthly caseload was 90,093 participants. Among the
children served during 2000, 59% were non-Hispanic white children, 13% Hispanic
children, 15% non-Hispanic black children, 9% Asian or Pacific Islander children, and 4%
were American Indian or Alaska Native children (Figure 1).
Figure 1
Racial and ethnic distribution
among
among Minnesota
Minnesota WIC children
children aged
aged <5
<5 years
years for
for 2000
2000 and
and 2006
2006
Percentage
0
Minnesota
2006
10
20
30
40
50
60
70
80
90 100
White, not Hispanic
Black, not Hispanic
Hispanic
American Indian
Asian
Multiple
Minnesota
2000
2006 MN PedNSS Table 1C
PedNSS Summary Report ~ Page 3
Pediatric Health Indicators
Low Birthweight
The single most important factor affecting neonatal mortality, and a significant
determinant of postneonatal mortality, is low birthweight (< 2,500 grams). Lowbirthweight infants who survive are at increased risk for a variety of health problems,
including neurodevelopmental disabilities and respiratory disorders. In Minnesota during
2006, 7.4% of WIC infants were born at a low birthweight, compared with 9.4% of
infants in the National Pediatric Nutrition Surveillance system during 2005. One of the
Healthy People 2010 objectives (16-10a) calls for a reduction in the incidence of low
birthweight to no more than 5% of all live births.2
While the prevalence of low birthweight among Minnesota WIC infants is lower than that
of the National PedNSS population, prevalence is still above the goal established for
2010. Furthermore, prevalence of low birthweight has not consistently declined over
time, as shown in Figure 2 below. Variations were also observed among each of the
racial and ethnic groups. Of particular concern is the higher rate of low birthweight
among Black infants compared to all other racial and ethnic groups in Minnesota WIC.
This difference has persisted for many years.
Figure 2
Trends in prevalence of low birthweight* among children
enrolled in WIC in Minnesota 1997
1997 to
to 2006
2006 by
by race and
and ethnicity
ethnicity
Percentage
15
10
5
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
White
*
Black
Hispanic
< 2500 grams, among infants born during the reporting period.
Year 2010 target: reduce low birthweight to 5% of live births.
American Indian
Asian
Total
2006 MN PedNSS Table 18C
PedNSS Summary Report ~ Page 4
High Birthweight
High birthweight (> 4,000 grams) also puts infants at increased risk. Infants born at high
birthweight are at increased risk for birth injuries, such as shoulder dystocia, and death.
Of infants participating in Minnesota WIC in 2006, 9.1% were born at a high birthweight,
compared with 6.6% in the National PedNSS population (2005). High birthweight is one
of the health indicators in which Minnesota WIC infants fare less well than their national
peers.
The prevalence of high birthweight has decreased somewhat among Minnesota WIC
infants in the ten years from 1997 (10.4%) to 2006 (9.1%). As with low birthweight, the
risk of high birthweight is greater among some racial and ethnic groups than others. For
example, the rates of high birthweight are higher among Native American children than
among other children enrolled in WIC in Minnesota. This difference has persisted over
time (Figure 3).
Because high birthweight may be indicative of gestational diabetes, it is important to
monitor high birthweight. Gestational diabetes is associated with future health problems
for the child, in particular obesity and diabetes.
Figure 3
Trends in prevalence of high birthweight*among
children enrolled in WIC in Minnesota
1997
1997 to
to 2006
2006 by
by race
race and
and ethnicity
ethnicity
Percentage
20
15
10
5
0
1997
1998
1999 2000
2001 2002
2003
2004 2005
2006
Year
White
*
Black
Hispanic
> 4000 grams, among infants born during the reporting period.
American Indian
Asian
Total
2006 MN PedNSS Table 18C
PedNSS Summary Report ~ Page 5
Short Stature
Short stature (low length or height, for age) may reflect the long-term health and
nutritional status of a child or a population. Although short stature can be associated with
parent’s short stature, or with low birthweight, it can also result from growth retardation
due to chronic malnutrition caused by inadequate food intake, recurrent illness, or both.
In the Minnesota WIC population during 2006, 5.1% of children birth to age 5 were of
short stature, compared with 2.3% of U.S. children (unpublished data, Dr. Zuguo Mei,
CDC, 2003). However, the prevalence of short stature in Minnesota’s WIC population is
about what would be expected at a population level (5%), and nearly meets the Healthy
People 2010 objective (19-4) to reduce to 5%2 growth retardation among low-income
children less than 5 years of age.
The prevalence of short stature among all MN WIC children has declined over the past 10
years from 5.7% (1997) to 5.1% (2006). While there has been a slight decrease in short
stature among most racial and ethnic groups, among Asian or Pacific Islander children
the decrease had been dramatic until 2004 when the prevalence in this group increased
markedly (Figure 4). This corresponds to an influx of new Asian immigrants when the last
of the refugee camps in Laos were closed.
Figure 4
Trends in prevalence of short stature*among children
enrolled in WIC in Minnesota
among
among children
children aged
aged <5
<5 years,
years, by
by race
race and
and ethnicity
ethnicity 1997 to 2006
Percentage
15
10
5
0
1997
1998
1999 2000
2001 2002
2003
2004 2005
2006
Year
White
*
Black
Hispanic
American Indian
Asian
Total
< 5th percentile length or height-for-age, CDC Growth Charts, 2000.
Year 2010 target: reduce growth retardation (short stature) among low-income children under age five years to 5%.
2006 MN PedNSS Table 18C
* Short Stature is defined using the 2000 CDC growth chart percentiles of less than the
5th percentile length-for age for children younger than 2 years of age and less than the
5th percentile height-for-age for children 2 years of age or older.
PedNSS Summary Report ~ Page 6
Underweight
Data on underweight* children from birth to age 5 indicate that acute malnutrition
(inadequate calories) is not a public health problem in the Minnesota WIC population.
The prevalence of 3.0% among MN WIC children in 2006 is below the expected
prevalence of 5%. The prevalence of underweight for U.S. children in this age group is
4.8% (unpublished data, Dr. Zuguo Mei, CDC, 2003). The prevalence of underweight for
all Minnesota WIC children decreased from 4.2% in 1997 to 3.0% in 2006 (Figure 5).
The highest prevalence of underweight during 2006 was among Black children at 4.2%.
Additionally, during 2006, 5.2% of Black infants were underweight, which might be
associated with the higher rate of low birthweight in this group, and may also contribute
to the overall higher rate of underweight among Black children.
Figure 5
Trends in prevalence of underweight* among children
enrolled in WIC in Minnesota
among
among children
children aged
aged <5
<5 years,
years, by
by race
race and
and ethnicity
ethnicity 1997
1997 to
to 2006
2006
Percentage
10
5
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
White
*
Black
Hispanic
American Indian
< 5th percentile weight-for-length or BMI-for-age, CDC Growth Charts, 2000.
5% of children are expected to fall below the 5th percentile.
Asian
Total
2006 MN PedNSS Table 18C
* Underweight is defined using the 2000 CDC growth chart percentiles of less than the
5th percentile weight-for-length for children younger than 2 years of age and less than
the 5th percentile BMI -for-age for children 2 years of age or older.
† To calculate BMI (body mass index): Weight (kg) ÷ Stature (cm) ÷ Stature (cm) x
10,000 or Weight (lb) ÷ Stature (in) ÷ Stature (in) x 703.
PedNSS Summary Report ~ Page 7
Overweight and Risk of Overweight
The prevalence of overweight* in children and adolescents has reached epidemic
proportions in recent years. In Minnesota WIC children in 2006, the prevalence of
overweight among children birth to age 5 was 12.1%. Overweight in children younger
than age 2 does not pose the same risk as it does for children aged 2 and older, because
only a weak association has been found between the weight status of children less than
two years of age and adult obesity.3
Expert committees have recommended distinguishing between two levels of risk in
children aged 2 years or older: overweight is defined as a BMI-for-age >95th percentile,
and at risk of overweight as a BMI-for-age between the 85th and 95th percentiles.4-6
With the exception of white children, the prevalence of overweight by racial and ethnic
groups in the Minnesota WIC population is comparable to or greater than the prevalence
in these groups nationwide. American Indian children in the Minnesota WIC Program
have higher rates of overweight than American Indian children in the national sample
(Figure 6).
Figure 6
Prevalence of overweight* among children enrolled in
WIC in Minnesota 2006
among
among children
children aged 2 to 5 years, by race
race and
and ethnicity
ethnicity compared to
to National
National PedNSS
30
Percentage
25
20
15
10
5
Expected
rate 5%
0
White
Black
Hispanic American
Indian
MN WIC 2006
*
Asian
Multiple
Total
National PedNSS 2005
> 95th percentile weight-for-length or BMI-for-age, CDC Growth Charts, 2000.
5% of children are expected to fall above the 95th percentile.
2006 MN PedNSS Table 8C
* Overweight is defined using the 2000 CDC growth chart percentiles of greater than or
equal to the 95th percentile BMI-for-age for children 2 years of age or older.
PedNSS Summary Report ~ Page 8
In the Minnesota WIC population, the prevalence of overweight in children aged 2 to 5
years increased slightly but steadily between 1990 (8.3%) and 2004 (13.8%) (Figure 7).
However, beginning in 2005 the prevalence began to decline slightly: in 2005 13.3%,
and in 2006 13.1%, of Minnesota WIC children had BMI values ≥ 95th percentile for age
and gender. While the change is relatively small and the time period may be too short to
constitute a “trend”, this is a positive development, and has been observed in other
states. National PedNSS data for overweight children aged 2 to 5 years, has shown a
leveling off during this time frame.
Overweight in children is a concern for all race ethnic groups in Minnesota WIC, but is of
particular concern among American Indian children, in which 25.0% were overweight in
2006. The prevalence of overweight in American Indian children has been consistently
higher than in other groups, and the recent decrease in prevalence among other groups
has not been observed among American Indian children.
Figure 7
Trends in prevalence of at risk of overweight
Percentage
among
among children
children aged
aged 22 to
to <5
<5 years,
years, by
by race
race and
and ethnicity
30
25
20
15
10
5
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
White
*
Black
Hispanic
American Indian
> 85th-<95th percentile BMI-for-age, CDC Growth Charts, 2000.
10% of children are expected to fall between these percentiles.
Asian
Total
2006 MN PedNSS Table 18C
* Overweight is defined using the 2000 CDC growth chart percentiles of greater than or
equal to the 95th percentile weight-for-length for children less than 2 years of age and
greater than the 95th percentile BMI-for-age for children 2 years of age or older.
Similarly, in the Minnesota WIC population of children aged 2 to 5 years, the prevalence
of risk of overweight (85th to 95th percentile) increased from 15.5% in 1997 to 16.5% in
2006. Among American Indian children, the prevalence of risk of overweight was 23.9%,
in 2006. As is true with overweight, the prevalence of risk of overweight has been higher
among American Indian children than in all other groups.
PedNSS Summary Report ~ Page 9
Similar to the National PedNSS data, prevalence of overweight increases with increasing
age among children participating in Minnesota WIC (Figure 8). Children at 4 years of age
are more likely to be overweight than younger children. Because the association
between childhood overweight and adult overweight increases with children’s age, this
trend is particularly troublesome.
Figure 8
Prevalence of overweight and risk of overweight*
among children enrolled in WIC in Minnesota 2006
among
among children
children aged
aged 22 to <5 years,
years, by
by age
Percentage
40
30
20
10
0
2
3
4
Total-State
Total-Nation
Age (years)
Overweight
*
Risk of overweight
Overweight: > 95th percentile BMI-for-age; at risk of overweight: > 85th-<95th percentile BMI-for-age, CDC Growth
Charts, 2000. 15% of children are expected to fall above the 85th percentile (5% above the 95th percentile and 10%
between the 85th and 95th percentiles).
2006 MN PedNSS Table 8C
The “picture” of childhood overweight seen in both Minnesota and National PedNSS data,
is similar to that of all U.S. children aged 2 to 5 years. In previous editions of this report,
the rate of overweight was much greater among Minnesota children enrolled in WIC than
among all children in the U.S. However, more recently, the prevalence of overweight in
children enrolled in Minnesota WIC (13.1%) is less than that (13.9%) for all U.S. children
aged 2 to 5 years (from NHANES 2003 – 2004).7
PedNSS Summary Report ~ Page 10
Anemia
Anemia (low hemoglobin/hematocrit) is an indicator of iron deficiency, the most common
nutrient deficiency worldwide. Iron deficiency in children is associated with
developmental delays and behavioral disturbances. In 2006, the prevalence of anemia
among children in the Minnesota WIC program was 11.6%, compared with 2.8% for all
U.S. children the same age (unpublished data, Dr. Zuguo Mei, CDC, 2003). The highest
prevalence of anemia in both Minnesota WIC and National PedNSS population is in
children younger than 2 years of age.
In the National PedNSS population as a whole, the prevalence of anemia decreased from
1996 to 2005. More recently, the prevalence of anemia has increased. A similar trend
has been observed in the Minnesota WIC population. As with other health indicators, the
prevalence of anemia varies between racial and ethnic groups. Compared with other
racial/ethnic groups, Black children enrolled in the Minnesota WIC program have the
highest rate of anemia (Figure 8). Among Black or African American children in
Minnesota WIC, 19.8% are anemic compared to 8.4% of the White non-Hispanic
children.
Figure 8
Trends in prevalence of anemia* among children
enrolled in WIC in Minnesota 1997 to 2006
among children aged <5 years, by race and ethnicity
Percentage
25
20
15
10
5
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
White
*
Black
Hispanic
American Indian
Hb or Hct < 5th percentile, CDC MMWR vol. 47 (No. RR-3), 1998.
Asian
Total
2006 MN PedNSS Table 18C
* Anemia is defined using the CDC MMWR Vol. 47 (No. RR3), 1998 as hemoglobin or
hematocrit measures less then the 5th percentile. Children aged 1 to 2 years are
considered anemic if their hemoglobin (Hb) concentration is less than 11.0 g/dL or their
hematocrit (Hct) level is less than 33.0%; children aged 2 to 5 years are considered
anemic if their Hb concentration is less than 11.1 g/dL or their Hct level is less than
33.3%. 8
PedNSS Summary Report ~ Page 11
Breastfeeding
The benefits of breastfeeding -- nutritional, immunologic, allergenic, economic, and
psychologic -- are well known and widely recognized. As such, the Healthy People 2010
objective (16-19a-c) is to increase the proportion of children who were breastfed in the
early postpartum period (referred to as “ever breastfed”) to 75%; to increase the
proportion of children still breastfeeding at 6 months to 50%; and to increase the
proportion of infants breastfed at 1 year to 25%. In Minnesota in 2006, 71% of WIC
infants initiated breastfeeding. Of the infants who initiated breastfeeding, 32.6% were
breastfed for at least 6 months; and 19.2% were breastfed for at least 12 months.
National data from other sources indicate that, 70.1% of U.S. infants initiated
breastfeeding; 33.2% were still breastfeeding at 6 months, and 19.7% at 12 months.9
Breastfeeding initiation in Minnesota WIC infants is similar to rates nationally, and close
to the 2010 goal. In 2006, the rates of initiation among Hispanic and non-Hispanic Black
infants in Minnesota WIC met or exceeded the 2010 goals (Figure 9).
Figure 9
Percentage of infants ever breastfed* among infants
enrolled in WIC in Minnesota
2006
Percentage
by
by race
race and
and ethnicity
ethnicity
100
90
80
70
60
50
40
30
20
10
0
Year
2010
target**
White
Black
Hispanic American
Indian
State
Asian
Multiple
Total
Nation
* Among infants born during the reporting period.
** Increase the proportion of mothers who breastfeed their babies in the early postpartum period to 75%.
2006 MN PedNSS Table 9C
PedNSS Summary Report ~ Page 12
Among Minnesota WIC children, the prevalence of initiating breastfeeding has increased
from 57.6% in 1997 to 72.9% in 2006. Increasing rates of breastfeeding initiation are
evident among all racial and ethnic groups (Figure 10).
Figure 10
Trends in the percentage of MN WIC infants
ever breastfed*
2006
Percentage
by
by race
race and
and ethnicity
ethnicity
100
90
80
70
60
50
40
30
20
10
0
2010
Target =
75%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
White
American Indian
2010 Goal
Black
Asian
Hispanic
Total
* Reported by mother at postpartum visit. Year 2010 target: increase the proportion of mothers who
breastfeed their babies in the early postpartum period to 75%.
2006 MN PNSS Table 23C
PedNSS Summary Report ~ Page 13
During 2006, none of the groups in Minnesota WIC met the 2010 target of 50% infants
still breastfeeding at six months. However, Hispanic and non-Hispanic White and nonHispanic Black children participating in the Minnesota WIC Program are more likely to
breastfeed until six months than their national counterparts (Figure 11).
Figure 11
Percentage of MN WIC infants breastfed at least
6 months*
2006
by race
race and
and ethnicity
70
Percentage
60
Year
2010
target**
50
40
30
20
10
0
White
Black
Hispanic American
Indian
State
Asian
Multiple
Total
Nation
* Among infants who turned six months of age during the reporting period.
** Year 2010 target: increase the proportion of mothers who breastfeed their babies at six months to 50%.
2006 MN PedNSS Table 9C
PedNSS Summary Report ~ Page 14
Rates of long-term breastfeeding are better among Minnesota WIC infants than among
the national PedNSS sample. In the Minnesota WIC population, both Hispanic and nonHispanic Black children met the 2010 goal that 25% of infants who initiated
breastfeeding would continue breastfeeding until at least 12 months of age (Figure 12).
Figure 12
Percentage of MN WIC infants breastfed at
least 12 months*
2006
by race
race and
and ethnicity
70
Percentage
60
50
40
Year
2010
target**
30
20
10
0
White
Black
Hispanic American
Indian
State
Asian
Multiple
Total
Nation
* Among infants who turned twelve months of age during the reporting period.
** Increase the proportion of mothers who breastfeed their babies at one year to 25%.
2006 MN PedNSS Table 9C
It is interesting to note that while nationally Black infants in the PedNSS were the least
likely to breastfeed, in the Minnesota WIC population they are second most likely to
breastfeed. This positive pattern persists through the six and twelve month mileposts
(Figures 9, 10 and 11).
The higher rates of initiating breastfeeding and the longer duration among Black women
in the Minnesota WIC population may reflect recent changes in Minnesota demographics,
with an increasing proportion MN Black women being immigrants from Africa. Based on
Minnesota birth certificate information, 47% of the women identified as African American
on the birth certificate, were “foreign born” in 2005, while only 14% were “foreign born”
in 1995.
PedNSS Summary Report ~ Page 15
Infant and Child Health Advances and Concerns
Low-Birth-weight: No clear trend toward improvement can be seen among infants
enrolled in the WIC program in Minnesota. In 2006 none of the racial or ethnic groups
met the 2010 goal of < 5% of infants born at low-birth-weight. Additionally, low-birthweight continues to be disproportionally high among non-Hispanic Black or African
American WIC enrollees (9.7%) compared to all Minnesota WIC infants (7.4%).
High-Birth-weight: There are higher rates of high-birth-weight among Minnesota WIC
participants than among the National PedNSS population. Only Asian children in
Minnesota are below the expected rate of 5%. American Indian children have much
higher rates of high-birth-weight (15.8% in 2006) putting them at higher risk for birth
injuries and death.
Overweight: Overweight is a major public health problem in Minnesota, as it is
nationally. Some good news was seen in data for 2005 and 2006, reflecting a
stabilization of the rates of overweight among the Minnesota WIC population. Until 2005
there had been small but consistent increases each year beginning in 1987, when 8.1%
of children were overweight. In 2004 the rate was 13.8%; in 2005 13.3%, and in 2006 it
was 13.1%. This rate is still well above the expected rate of 5%, and as is true with
other health indicators, there are disparities among different race and ethnic groups. In
Minnesota during 2006, 25% of American Indian children enrolled in WIC were
overweight (≥ 95th percentile BMI for age and gender). This is five times the expected
rate of 5%.
In the Minnesota WIC population of children, rates of overweight increase with each year
of age. This is worrisome since the likelihood of overweight persisting into adulthood
increases with children’s age.
Anemia: The rates of anemia among Minnesota children enrolled in WIC are above the
expected 5% for all race and ethnic groups. Since 2002 there has been a gradual
increase in anemia among Minnesota WIC children. Additionally the rate of anemia
among Black non-Hispanic or African American children in Minnesota WIC is much higher
(19.1%) than that of White not-Hispanic children (8.4%).
Breastfeeding: The bright spot in the 2006 PedNSS data for Minnesota is the trend in
breastfeeding. Both initiation and duration are improving in Minnesota WIC children. In
2006 initiation rates for Black not-Hispanic or African American and Hispanic children met
the 2010 goal that 75% of children be breastfed. Additionally, the breastfeeding
duration trends are improving.
35
Pediatric Nutrition Recommendations
The Minnesota PedNSS data indicate that national and state public health programs are
needed to support the following actions:
• Implement innovative strategies to reverse the rising trend of overweight in young
children by increasing breastfeeding, increasing physical activity, promoting increased
consumption of fruits and vegetables, and decreasing television viewing.
• Promote and support breastfeeding through medical care systems, work sites, and
communities.
PedNSS Summary Report ~ Page 16
• Promote adequate dietary iron intake and the screening of children at risk for iron
deficiency.
• Prevent low birthweight by providing preconception nutrition care and outreach
activities to promote early identification of pregnancy and early entry into comprehensive
prenatal care, including the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) and the Title V Maternal and Child Health Program.
References
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PedNSS Summary Report ~ Page 18