Development of supplemental nutrition care program for women, infants and children in Korea: NutriPlus⁺

Supplemental food packages

Dietary intake data analysis revealed some target nutrients to be considered in the supplemental nutrition care program for economically and/or nutritionally deprived children and women (KHIDI, 2005). They were calcium, iron, vitamin A, riboflavin, and niacin (Tables 1-3). The differences in mean nutrient intake of young children among 4 income classes were remarkably obvious and several fold larger than the difference seen in similar children in the United States (ARS/USDA, 2008). Vitamin C was included in target nutrients also due to a large variability in intake by season (KHIDI & MOHW, 2003a) and the fact that the 1^st and 2^nd quartile intakes of women of 19-25 years corresponded to 49.4% and 104.6% of RDA (KHIDI, 2005; KNS, 2000) even in winter season with the highest vitamin C intake. Having been recognized that a single set of values could not be considered reflective of the specific nutrient requirements of each consumer (Yates, 2007), the Korean Nutrition Society had established our own DRIs in 2005 for the first time (KNS, 2005). Hence, only a set of RDA (KNS, 2000) for each sex by age group of Korean population was available in 2004, and it was used as a basis for nutrition assessment in the process of food package development. Onto this aforementioned nutrient list, energy and protein were added to ensure a proper growth of children.

Table 3
Proportion of children and women with nutrient intake less than 75% of RDA (KHIDI & MOHW, 2002) (unit: %)

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Based on the list, candidates for supplemental foods were listed according to their target nutrient density and frequency of use in the Korean usual diet (KHIDI & MOHW, 2002). Another points considered in selecting supplemental foods were shelf-life and storability to maintain freshness and quality during home delivery which was under consideration as a manner of presenting service. In anddition to that, the unit cost of each food items was surely an important factor especially with a limited budget (KHIDI, 2005).

Additional analysis on the food intake of young children revealed that their milk and dairy product intake was too low not only to ensure a proper calcium intake but also for coping with the dietary guidelines set in 2003. As shown in Table 4, mean milk group intake of young children of 3-6 years from 2 lower income classes were less than one serving (200 g) although 2-3 servings are recommended in dietary guidelines for that age group (KHIDI & MOHW, 2003c). This finding prompted the inclusion of milk in the supplemental food packages in spite of rather higher unit cost.

Table 4
Comparison of food group intake among children of 1-6 years in 2001 by household income and age (KHIDI & MOHW, 2003b) (unit: g)

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A total of 6 different kinds of supplemental food packages (I through VI) were developed (KHIDI, 2005) for following 6 categories of beneficiaries: Infants 0-5 months, Infants 6-11 months, Young children 1-5 years, Pregnant/breastfeeding women, Non-breastfeeding postpartum women, Exclusively breastfeeding women. For each food package, major food sources for target nutrients are shown in Table 5. The amount of each supplemental food was determined based on the deficit in mean intake against recommended intake of target nutrients for each subject category and to give ideal combinations of selected items maximizing the amount of target nutrient provided while minimizing the total food cost (KHIDI, 2005). A preliminary work (KHIDI & KFDA, 2004) on portion size of Korean food was utilized in this process and the resulting numbers for food quantity per day per person by food packages are shown in Table 6. Then, the amount of target nutrients supplied by each food package was estimated accordingly as shown in Table 7 based on the Food Composition Table (RRDI, 2001). For most nutrients except iron, food packages supply more than 50% of RDA (KNS, 2000) up to 100%, and 22-45% for iron depending on the subject category.

Table 5
Food source of target nutrients by food package (KHIDI, 2005)

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Table 6
Amount of food provided per person per day by food package (KHIDI, 2005)

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Table 7
Amount of target nutrient provided per person per day by food package (KHIDI, 2005)

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Another point considered regarding food packages was how to provide supplemental foods to beneficiary. Because living environment in Korea is quite different from that of US, we were reluctant in adopting voucher system for benefit transfer. For most of households with income less than 100% MLE, private car was not available for grocery shopping, and for some remote areas, stores were rather distant from residence. And more than 90% of retail stores were too small in business to handle vouchers (KHIDI, 2005). Also, we were not able to find any volunteer grocer who was willing to participate in pilot study processing vouchers. Hence we proposed home delivery, either by agency or by grocers themselves. This proposal was well received by grocers and beneficiaries especially because physical inconvenience and/or incompetence of pregnant women to carry around large grocery bags.

Nutrition education

Although the supplemental food packages are important in improving nutritional status of beneficiaries, the importance of nutrition education as a core component of the NutriPlus⁺ should not be overlooked. From previous study (Lee et al., 2005), we have shown that relative risks of nutritional insufficiency for chronic conditions such as hypertension, hyperlipidemia and diabetes were varying from 1.25 to 1.56 for Korean adult population 40 years and older. And the cost of illness due to this nutritional insufficiency among Korean adult in 2005 was estimated to be at least 251.7 billion Won (@200 million USD) (Chung, 2007). This obviously tells us that contents of the nutrition education should include general principles, guidelines and action tips for a better dietary management of the women and children. Onto that, several points regarding the breastfeeding and complementary feeding for infants rose to the surface.

The exclusive breastfeeding rate of young children under 3 years in 1998 during their infancy was only 15.3% at 4 months (KHIDI & MOHW, 1999). And It was lowered further to 11.4% in 2001 as seen in Table 8 (KHIDI & MOHW, 2002). By the age of 12 months, the exclusive breastfeeding rate got lowered to less than 1.0% resulting in the mean duration of breastfeeding to be 19.4 weeks only (Table 9). These placed the breastfeeding promotion at the top of the priority for nutrition education for women.

Table 8
Proportion of breastfeeding and bottle feeding by age during infancy of children under 3 years in 2001 (KHIDI & MOHW, 2002) (unit: %)

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Table 9
Mean duration of breastfeeding and age at introduction of complementary food during infancy of children under 3 years in 2001 (KHIDI & MOHW, 2002) (unit: %)

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Although WHO recommends to introduce complementary food to infants at 4-6 months of age, about 20% of young children under 3 years in 1998 had been given complementary food before 4 months of age (Table 10). And the mean age for complementary food introduction was lowered further from 6.3 months in 1998 to 5.9 months in 2001 (Tables 9 and 10) worsening the problem of premature and/or delayed introduction of complementary food to infants. Therefore, proper introduction of complementary food became another important part of nutrition education along with breastfeeding, dietary management and dietary behavior modification. Several modes of education implementation was proposed such as group lessons, individual counseling sessions and home visits.

Table 10
Distribution of children under 3 years in 2001 by age at introduction of complementary food during infancy (KHIDI & MOHW, 1999) (unit: %)

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Eligibility criteria

Even though we were not able to analyze dietary intake data for pregnant and/or lactating women from 1998 and 2001 survey (KNHANES) due to small numbers of corresponding subjects (KHIDI & MOHW, 1999 & 2002), it was possible to compare per capita food intake among different income classes as shown in Table 11. Other than sodium, every single nutrient intake of the lowest income class was much lower than any other classes. And the intake of the 2nd lower income class showed a very similar trend with the lowest. Together with the data in Tables 1 and 2, these justified the idea of including 2nd lower income classes also for the service provided by NutriPlus⁺. This, household income less than 200% of the Korean poverty guidelines (minimum monthly living expenses), became the second criterion for the eligibility to apply for the service following the residency within the district of each public health center's jurisdiction.

Table 11
Comparison of nutrient intake per capita per day by household income (KHIDI & MOHW, 2003b)

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In addition to the women, pregnant and postpartum up to 1 year, young children's age for eligibility needed to be set. Since the Ministry of Education & Human Resources Development were responsible for school lunch program and any nutrition education within school premises, preschool children under 6 years were chosen to be cared for by NutriPlus⁺ under the Ministry of Health & Welfare. This proposition was especially convincing because preschool children was left almost in the blind spot for any nutritional care till then.

Once the aforementioned 3 criteria are met, they were eligible to apply for the screening process for nutritional vulnerability, the final criterion. Anemia, stunting, underweight, and inadequate nutrient intake comprised the nutritional risk factors, and anyone with one or more risk factors became eligible to participate.

Nutritional screening for eligibility

For nutritional screening, objective measures were devised especially because this step was the critical point in determining eligibility. More weights were given to biochemical and/or anthropometric parameters over simple nutrient intake insufficiency to avoid unnecessary dispute. Based on the Standard Growth Curve developed for Korean children (KPS, 1999) child with height or weight less than -2 z score was determined to be stunted or underweight. And children or women with blood hemoglobin value less than WHO cut off points (WHO, 1994) for each age/physiological categories were defined anemic.

For nutrient intake insufficiency, anyone with intake less than 75% of RDA (KNS, 2000) for any target nutrient was determined eligible by inadequate intake category.

Priority setting for program participation

Because the budget was limited and small compared to the estimated number of possible beneficiaries, a priority setting was necessary among various categories of women and children. Through an advisory committee, priority was set as follows (KHIDI, 2005), similar to that of US WIC program (FNS/USDA, 2009), grounded on the relative importance and urgency:

Program evaluation/assessment for the process and outcome

For the long-standing sustainability of the program we devised a protocol to evaluate and/or assess the process and outcome of the program. This was especially important for proving the program effect and securing the necessary budget (Health Promotion Fund) through convincing those responsible for compilation of government program budget.

The protocol was proposed in 2 parts, one for process and the other for outcome of the program along with establishing an agency or board to oversee the program management at public health center level and administer the protocol. For the outcome of the program, evaluation of the nutritional status change (enhancement in anthropometry and nutrition knowledge, improvement in dietary behavior and nutrient intake) was proposed for short-term measure and sample forms are shown in Fig. 3. In addition to that, decrease in anemia prevalence and change in under-weight births, infant deaths and total fertility rate were offered for long-term measures as was shown by others (Devaney, 1992; Devaney & Schirm, 1993; Yip et al., 1987) in US WIC program. Also, use of control group was advised in monitoring short-term and/or long-term measures during pilot study. On the other hand, participants' satisfaction, recordkeeping on participants' demography and service provided, and resource (personnel and budget) management were proposed as process evaluation measures.

Fig. 3
Sample evaluation forms

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