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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.