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2
Challenges to Selecting an Effective Set of
WIC Food Packages
INTRODUCTION
The WIC program involves a wide variety of stakeholders including the women, infants, and
children who participate; the approved grocery vendors; and the various state and local WIC
agencies. Effective WIC food packages must consider these multiple stakeholders' needs. The
Committee recognizes the challenges inherent in recommending changes in the WIC food
packages and will consider the wide variety of factors listed in this chapter. The goal is to
propose a set of food packages that will be effective in supplementing the nutritional needs of the
participants without creating undue burdens on the stakeholders in the WIC program.
ADDRESSING BOTH OVERNUTRITION AND UNDERNUTRITION
At the time of the original design of the WIC program, problems of undernutrition were
paramount. Today, these concerns must continue to be addressed in the context of the
concomitant rise in risk for overweight and obesity. Excess body weight gain results from
positive energy balance and can be associated with excess intakes of some food components
(e.g., added sugars, high-fat foods, total food energy). However, such a diet can result in
inadequate intakes of essential micronutrients and other beneficial components of food. A diet
can be characterized by both inadequate intake of some micronutrients due to poor food choices
and excessive intake of other micronutrients (i.e., intake above the Tolerable Upper Limit Level)
due to inappropriate use of fortified foods. Thus the potential impact of the amount and
bioavailability of nutrients in fortified foods (e.g., juice fortified with vitamin C, breakfast cereal
fortified with iron and zinc) in the WIC food packages will be considered with regard to
improving both inadequate intakes and excessive intakes. Designing supplemental food packages
that optimize the potential benefit for long-term health thus poses mixed challenges.
PARTICIPANT DIVERSITY
Ethnic and geographic diversity pose challenges to selecting the WIC food packages. The
WIC food packages must be suitable for participants in all 50 States and the District of Columbia
as well as Puerto Rico, Guam, American Samoa, the American Virgin Islands, and 33 Indian
Tribal Organizations (Kresge, 2003). In addition, the WIC food packages need to be suitable to a
2-1
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2-2 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
growing number of migrant farm workers, particularly in California, Florida, and Texas (Kresge,
2003).
The percentage of Hispanic participants is now higher than that of any other racial/ethnic
group. The ethnic and racial diversity of the WIC population in 2002 is illustrated in Figure 2-1.
The diversity of the WIC population is actually greater than Figure 2-1 suggests, since each of
these major racial/ethnic groups is composed of numerous subgroups. For example, people with
a cultural heritage from anywhere in Mexico, Central America, South America, the Caribbean, or
Spain may self-identify as being of Hispanic origin.
The need to consider culturally diverse preferences applies across all regions, and to food
preferences of larger and smaller cultural groups. Here, the term "culture" is used to distinguish
groups of people who have shared beliefs, values, and behaviors and therefore may have needs
differing from those of the general population (NWA, 2003). Culture may be defined by
national, regional, and ethnic origins; religious affiliations; lifestyle (e.g., vegetarian);
generation; or overlapping residence and socioeconomic variables.
Providing culturally acceptable foods does not necessarily mean that foods consumed most
frequently by a cultural group will be offered in the WIC food package. Some of those foods
may be very low in the target nutrients or contain too much fat, sugar, cholesterol, or sodium.
Also, WIC participants may consume enough of the staple or core cultural foods, such as rice or
bread, regardless of the WIC program. Instead, the WIC food packages might be more
effectively selected to complement these core foods and serve as incentives to participate in the
WIC program as a whole. "Culturally acceptable" also implies that the foods are not regarded as
"inferior" or prohibited due to religious or other beliefs. Table 2-1 summarizes some cultural
issues related to WIC foods from studies among WIC participants. To formulate culturally
acceptable WIC food packages may necessitate greater use of options and substitutions than the
current packages allows as suggested in the scientific literature (Table 2-1) and other literature
from a professional organization (NAWD, 2000; NWA, 2003).
Among ethnic subgroups, acculturation to the mainstream American culture results in dietary
change (Lee et al., 1999; Neuhouser et al., 2004; Romero-Gwynn, et al., 1993). While dietary
change often means that nutritious traditional foods are consumed less often, some changes can
be positive. For example, a study among Korean Americans found that acculturation is correlated
Hispanic (38.1%)
White (35.3%)
Black (20.2%)
Asian/Pacific Islander (3.5%)
American Indian/Alaskan Native (1.4%)
FIGURE 2-1 Ethnic Composition of the WIC Population, 2002 (Percent of Total).
SOURCE: Bartlett et al., 2003.
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CHALLENGES TO SELECTING AN EFFECTIVE SET OF WIC FOOD PACKAGES 2-3
TABLE 2-1 Cultural Attitudes Among WIC Participants Related to the Current Food
Packages
Cultural Group Attitudes to WIC Food Items Suggested Alternatives Reference
Pregnant Chinese Most WIC foods, although Offer calcium-fortified Horswill and
women in atypical of the traditional diet, tofu and dark greens Yap, 1999
California were consumed. Cheese was a in place of cheese.
notable exception.
Pregnant teenagers Dairy products were not Offer fish with bones Pobocik et al.,
in Guam traditionally consumed. Diets and coconut juice. 2003
were low in calcium.
Southeast Asian Most subjects report a dislike of Not discussed Story and
adult women cheese (73%), compared to Harris, 1989
(Cambodian and other WIC foods (40% dislike
Hmong) in milk, 25% dislike cereal).
Minnesota Preferred WIC foods included
eggs and orange juice.
Postpartum WIC foods (i.e., milk, juice) Provide higher-status Fishman et al.,
Vietnamese provided to mothers in the (e.g., chicken) foods 1988
women in first month postpartum were that are culturally
California not perceived to be optimal viewed as more
while breastfeeding. compatible with
breast milk
production.
with increased consumption of oranges, tomatoes, low-fat milk, and bread (Lee et al., 1999).
Promotion of positive dietary changes while supporting the beneficial components of a
traditional diet is another challenge in selecting foods for a WIC food package.
Another closely related issue is the diversity of WIC participants regarding special needs
(such as milk allergies and lactose intolerance) and preferences (such as choosing to avoid milk
and other animal products for personal reasons unrelated to ethnicity or cultural heritage).
Employing flexibility in allowable substitutions to account for the needs and preferences of small
numbers of participants (or potential participants) may be a remedy to the numerous aspects of
the wide diversity of the WIC participant population as a whole.
EMPLOYMENT
WIC authorized foods need to be suitable to fit the lifestyle of both working and non-
working pregnant women and mothers of small children. In 1998, approximately 25 percent of
women participating in the WIC program were currently employed (Cole et al., 2001). However,
of those who were unemployed, 52 percent had been employed in the last 12 months (Cole et al.,
2001). The highest rate of employment is among WIC pregnant women (32 percent) (Cole et al.,
2001). As noted in a 2001 report on challenges to providing WIC services, work activity has
increased in low-income households with children (GAO, 2001). Time constraints may push
individuals, especially working parents, to use convenient, ready-to-heat, and ready-to-eat foods.
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2-4 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
In evaluating food items in the WIC food packages it is important to recognize that WIC
participants are no more likely to desire or be able to spend considerable time in food preparation
than the rest of the population. The items in the WIC food packages should not include options
that increase the burden of food preparation for working parents.
FOOD AVAILABILITY
In selecting new WIC food packages, the Committee may need to consider the impact of the
types of stores located in low-income communities. Studies of WIC food vendor management
practices, conducted by the Food and Nutrition Service in 1991 and 1998, found that larger
vendors carry more WIC items than smaller vendors (Singh et al., 2003). Although the
percentage of vendors maintaining a sufficient stock of WIC-authorized foods for women and
children substantially increased from 1991 to 1998, vendors carrying sufficient stocks of infant
package items decreased from 9.3 to 7.9 percent (Singh et al., 2003). Additionally, in both 1991
and 1998, smaller vendors (stores having 1 to 5 cashier registers) were more likely than larger
vendors (six or more cashier registers) to have insufficient stocks of WIC-authorized foods,
despite an increase in the percentage of both types of stores that met inventory requirements
overall. In a recent study on barriers to the use of WIC services in the state of New York, of the
3,144 WIC participants in the study, 16 percent noted that they sometimes or frequently find
WIC-authorized food out of stock (Woelfel, et al, 2004).
Local food availability can influence dietary quality. As an example, vendors in low-income
neighborhoods are predominantly small, independent grocery outlets and convenience-type
establishments that stock fewer healthful food selections than do the larger, chain grocery outlets
that predominate in more affluent communities (Fisher and Strogatz, 1999; Morland et al.,
2002a; Morland et al., 2002b; Cummins, 2003; Morland et al., 2003; Sloane et al, 2003). The
presence of supermarkets in a community has been associated with increased intakes of fruits
and vegetables by the local residents (Morland et al., 2002a). The greater the distance individuals
live from a large chain grocery store, the poorer is their dietary quality (Laraia, 2004).
Food cost also may be influenced by local food availability. The cost of the current WIC
food packages varies greatly across the geographic regions, with average monthly food costs per
person ranging from $24.40 for the Choctaw in Mississippi to $63.35 for the Omaha/Santee
Sioux in Nebraska (FNS, 2004c; preliminary 2003 data).
LIMITATIONS IN TRANSPORTATION, STORAGE, OR
COOKING FACILITIES
Logistics and food safety are other important challenges in choosing the package sizes and
types of foods provided by the WIC program. In the 1998 WIC participant survey, 15 percent of
WIC participants reported that limited transportation to grocery stores was a problem (Cole et al.,
2001). Participants without automobiles may need to purchase only what they can carry, losing
some value of their WIC food package. If it takes a long time to transport food to the home,
perishable items, such as milk, may spoil, especially in hot weather. Spoilage may also occur if
space, sanitation, or refrigeration is lacking. Where families share kitchen facilities and keep
their foods locked in a private space, safely storing large quantities of food may be an issue. If
foods (e.g., dried beans) need extensive cooking or preparation, lack of kitchen facilities and/or
cooking knowledge can also be a barrier to getting the nutritional value from those foods.
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CHALLENGES TO SELECTING AN EFFECTIVE SET OF WIC FOOD PACKAGES 2-5
FOOD SAFETY CONSIDERATIONS
The packaging of food products may need to be considered in making selections for the WIC
food packages. For example, if a household uses only a part of a perishable food in a package on
one occasion, the remainder may become contaminated by microorganisms before being
consumed on a later occasion. Re-sealable packages or single-serving size packages may lessen
the chance of contaminating the food in some situations. Following recommended cooking
instructions is also important in order to keep foods safe. Proper cooking inactivates heat labile
food borne pathogens and toxins that occur naturally in raw foods.
Food borne illness may need to be considered in selecting the WIC food packages. Of
particular interest are illnesses that both (a) result from the contamination of certain types of food
and (b) result in serious adverse effects that are specific to a population that benefits from the
WIC program. As an example, listeriosis is a food borne illness considered potentially dangerous
during pregnancy because it is associated with increased risk of spontaneous abortion, preterm
birth, and fetal death. A surviving baby may succumb to respiratory distress and circulatory
failure. New scientific knowledge about listeriosis as a hazard during human gestation has
generated changes in recommendations about the use of certain foods during pregnancy
(CFSAN, 2003). Common foods that carry Listeria monocytogenes are ready-to-eat luncheon
meats, hotdogs, and soft cheeses. Proper handling and cooking of food help to lower the hazard
of listeriosis; in some cases, especially where cooking is unlikely or inappropriate, certain foods
may need to be avoided during pregnancy (FSIS, 2001; Kaiser and Allen, 2002; CFSAN, 2003).
Undercooked meat and chicken are vectors for various microorganisms; all raw meat, fish and
poultry products should be thoroughly cooked to avoid food borne illnesses.
ADMINISTRATIVE IMPACTS
Vendor Impacts
Increased vendor or administrative impacts are potential costs incurred by changes or
increased flexibility in the WIC food packages. Efficiency in food distribution and vendor
checkout, and nonburdensome administrative procedures enhance the ease of program
administration (Kirlin et al., 2003).The store that sells food to WIC participants must: (1) have
the right types and package sizes of food available; (2) train checkout clerks to recognize the
appropriate WIC approved foods; (3) treat the WIC customers with respect; (4) organize an
appropriate number of checkout stands to accept WIC customers; (5) train personnel to handle
the redemption of WIC coupons; and (6) carry the already sold inventory on their accounts until
state payments are received. Implementation of specific changes in the WIC food packages has
the potential to impact vendors to varying degrees in each of these areas.
Some changes in the WIC food packages would increase vendor costs. Requirements to
procure a new business license to sell perishable (non-packaged) food could subject vendors to
an increased frequency of inspection by state health departments (DHHS/PHS/FDA, 2001). In
small stores or those that only serve WIC customers, arranging to have small loads of perishable
products delivered on a regular basis has the potential to increase costs and affect the quality and
cost of fresh fruits and vegetables, meats, and other perishables. With the need for refrigeration
and rapid turnover of perishables, the cost of distribution and inventory increases. In addition,
special handling to ensure the safety of perishable products is needed.
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2-6 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
In the future, changes may be easier due to the on-going initiative that will install EBT
(electronic benefit transfer) systems in more locales. At present, efficiencies gained through such
electronic systems may ease the transitions necessary in making changes to the WIC food
packages but these efficiencies can not be counted on in all vendor locations.
Administrative Impacts at WIC Agencies
Changing the items in the WIC food packages or allowing greater flexibility in choice could
pose administrative challenges at the state and the local level. States and tribal organizations
need to train vendors and monitor their compliance in allowing only WIC-approved foods. Local
agencies must instruct participants, often with limited literacy skills, how to choose the allowed
foods at the market. Increased complexity of the WIC food packages (i.e., number of items or
options) could increase counseling time and consequently affect waiting time at the local
agencies. In a study of New York State WIC agencies, the most commonly cited barrier for
participants was waiting too long at the clinic to receive WIC services (Woelfel, 2004).
Many state and local WIC agencies may already be burdened by providing services to a large
number of participants without the assistance of efficient electronic information technology. It
has been reported that in 2001 over 50 percent of WIC state agencies had management
information systems that were not capable of efficiently performing key program tasks, such as
tailoring food packages, assessing applicants' income, or printing food checks (GAO, 2001).
Thus, at present, efficient information technology systems can not be counted on in every
location to ease the transitions necessary in making changes to the WIC food packages. In the
future, changes may be easier due to efficiencies gained through efficient information technology
systems in more locales.
INCENTIVES
The WIC food packages serve as incentives for healthy behaviors by participants. The
packages should be viewed as valuable enough to promote enrollment in the WIC Program and
thus the receipt of educational and health benefits that the WIC Program provides. The food
packages also should reinforce the WIC educational messages and promote long-term dietary
quality. Ideally, the food packages should also encourage both initiation of breastfeeding and
sustained breastfeeding through at least the infant's first year.
SUMMARY
In addition to considering nutrients and food components most likely to provide health
benefits, food packages must take into account the incentive value of the WIC food packages;
variability in culture and food habits; lifestyle; access to transportation, storage and cooking
facilities among WIC participants; economic constraints; availability of recommended foods;
food safety; and changes in administrative requirements both for food vendors and for WIC
agencies. The new WIC food packages will need to strike a balance between providing culturally
acceptable, nutrient-dense, readily available, low-cost food items that maintain the incentive
value of the WIC food package and administrative feasibility for vendors and state and local
agencies. In deciding on criteria for recommending changes in the WIC food packages, the
Committee will take all of these factors into account.
Representative terms from entire chapter:
wic food
