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6 Proposed Approach for Selecting the WIC Food Packages INTRODUCTION This chapter describes the approach the Committee proposes to use in revising the WIC food packages. The proposed approach involves specifying criteria to be used in selecting the types and quantities of foods to be included in the WIC food packages; developing food packages that meet nutritional objectives and are cost neutral; and comparing alternative food packages in terms of risks and benefits. IMPLICATIONS OF A SUPPLEMENTAL FOOD PROGRAM The definition of "supplemental" food is central to decision-making about the composition of the WIC food packages. One basic way of looking at a supplemental food program is to consider how much of the total food energy need is supplied. As the packages are currently constituted, WIC foods could supply from one-third (in the case of adult women) to 100 percent (in the case of some formula-fed infants) of food energy needs (Kramer-LeBlanc et al., 1999). In the current environment in which food energy needs are almost always met, it is reasonable to focus on the other ways the WIC food packages are supplemental. The WIC food packages are supplemental to the household's economic resources. The nutritious foods in the WIC package may replace other foods in the diet, resulting in greater nutrient density of the diet consumed (Rush et al., 1988c). By supplying some foods, the WIC program may free household funds, which are then used to purchase higher-quality foods for women and children (Basiotis et al., 1998; Wilde et al., 2000; Ikeda et al., 2002; Chandran, 2003). The maximum allowances for formula for the youngest formula-fed infants approach, and in some cases exceed, their total nutrient and food energy needs. For older WIC participants, the WIC food package is intended to increase dietary quality by improving intakes of the target nutrients, as well as meeting some of the food energy needs. Finally, the WIC program is conceptualized as a supplemental nutrition program designed to improve health outcomes. The Committee sees the role of the WIC food package as improving the diet in ways that could have both short-term and long-term benefits. These include improving 6-1

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6-2 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES reproductive outcomes; supporting the growth and development of infants, children, and adolescents; and promoting long-term health in all WIC participants. PROPOSED CRITERIA FOR THE WIC FOOD PACKAGES The Committee has considered evidence of three major types: analyses of the nutrient intake of WIC-eligible populations (considered in Chapter 3); analyses of the food intake of WIC- eligible populations (considered in Chapter 4); and nutrition-related health risks and outcomes of WIC-eligible populations (considered in Chapter 5). By integrating all three of these approaches, when possible, the Committee attempted to overcome the limitations of any one approach applied individually. Based on the information presented in previous chapters, Box 6-1 presents six characteristics that the Committee proposes to use to select the types and quantities of foods to be proposed for inclusion in the WIC food packages. Most of these topics have been addressed previously in this report. Criterion 1: The package reduces the prevalence of inadequate nutrient intakes and of excessive nutrient intakes. Nutrients of particular concern have been identified by considering two types of information: intake distributions that indicated that many people in the target groups were at risk of either inadequate or excessive intake of a nutrient (Chapter 3); and published scientific papers that identified inadequacy based on physiological or biochemical measures of nutrient status (Chapter 5). Both types of data have strengths and weaknesses, and the combination was deemed most appropriate for identifying nutrients of concern. However, nutrients with low intakes were highlighted even if there was no published clinical evidence of inadequacy, because it is possible that they play a role in the prevention of chronic disease. The panels that set the DRIs considered both acute and chronic diseases when determining the intake recommendations. This approach is consistent with that taken by the 2005 Dietary Guidelines Advisory Committee (2004), which has included guidance for those over two years of age regarding increasing intakes of the nutrients identified below. According to Public Law No. 101- 445 (U.S. Congress, 1990), the Dietary Guidelines for Americans are to form the basis of federal food, nutrition, and information programs, including the WIC Program. The term "nutrient of concern" signifies that, if feasible, the revised food packages will improve intake of that nutrient (or maintain appropriate intake of a nutrient in some cases). The nutrients of concern are summarized below: Infants nutrients of concern with regard to inadequate intake for breastfed infants six months of age and older: iron and zinc nutrients of concern with regard to excessive intake for formula-fed infants: zinc, preformed vitamin A (vitamin A from fortification of foods or from foods of animal origin), and food energy Children, 1 through 4 years old nutrients of concern with regard to inadequate intake: iron, vitamin E, potassium, and fiber prioritize vegetables as foods to provide some or all of these nutrients

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PROPOSED APPROACH FOR SELECTING THE WIC FOOD PACKAGES 6-3 BOX 6-1 Proposed Criteria for a WIC Food Package, if Consumed as Specified 1. The package reduces the prevalence of inadequate nutrient intakes and of excessive nutrient intakes. 2. The package contributes to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans for individuals two years of age and older. 3. The package contributes to an overall diet that is consistent with established dietary recommendations for infants and children less than two years of age, including encouragement and support for breastfeeding. 4. The foods in the package are available in forms suitable for low-income persons who may have limited transportation options, storage, and cooking facilities. 5. The foods in the package are readily acceptable, commonly consumed, are widely available, take into account cultural food preferences, and maintain the incentive value of the food packages for families to participate in the WIC Program. 6. The foods will be proposed giving consideration to the impact of changes in the package on vendors and WIC agencies. nutrients of concern with regard to excessive intake: zinc, preformed vitamin A (vitamin A from fortification of foods or from foods of animal origin), sodium, and food energy Adolescent and adult women of reproductive age nutrients of concern with regard to inadequate intake: highest priority to calcium, iron, magnesium, vitamin E, potassium, and fiber also consider vitamin A, vitamin C, vitamin D, vitamin B6, and folate prioritize fruits and low-fat or nonfat dairy products as foods to provide some of these nutrients nutrients of concern with regard to excessive intake: sodium, food energy, and total fat (See note about added sugars in criterion 2 below.) For all individuals over the age of 2 years, limit saturated fat and cholesterol. While trans fatty acids increase the risk of coronary heart disease in adults, they have not been specifically identified as a hazard in infants and children. However, the recommendation to limit trans fatty acids from processed foods in the diet is presumed to apply to all individuals regardless of age. Criterion 2: The package contributes to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans two years and older. Packages that meet this criterion may reduce the risk of chronic diseases and will reinforce nutrition education messages. The food groups identified in Chapter 4 as being particularly low in the diets of the WIC population and the considerations evident from the environmental risks identified in Chapter 5 will be used to prioritize foods for the WIC packages. Children, 1 through 4 years old: In general, food group servings should be carefully reviewed/considered, giving particularly high priority to vegetables. Consider amounts of added sugars in proposed foods if necessary to promote energy balance. (See Chapter 3 for a description of the term "added sugars.")

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6-4 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES Adolescents and women of reproductive age: In general, food group servings should be carefully reviewed, giving particularly high priority to intakes of fruit and dairy products. Consider amounts of added sugars in proposed foods if necessary to promote energy balance. For all ages, consider dietary guidance from federal agencies and panels of the National Academies regarding food safety. For example, the foods in the package exclude the types of fish that are very high in methylmercury contamination, the types of fish/shellfish that are intermediate in methylmercury contamination are limited, and full-fat dairy products, which may contain dioxin and dioxin-like compounds, also are limited. Criterion 3: The package contributes to an overall diet that is consistent with established dietary recommendations for infants and children less than 2 years of age, including encouragement and support for breastfeeding. The forms of the foods in the package should be suitable for a young child's age and stage of development. Consideration will be given to keeping juice intake within American Academy of Pediatrics recommendations, discouraging the early introduction of complementary foods, and avoiding excessive intake of food energy. Criterion 4: The foods in the package are available in forms suitable for low-income persons who may have limited transportation options, limited safe storage facilities, and limited cooking facilities. Ideally, foods chosen for the WIC food packages should be available in neighborhood stores, be available in forms that require no refrigeration, and need a minimum of preparation. See Chapter 2 for additional considerations. Criterion 5: The foods in the package are readily acceptable, commonly consumed, are widely available, take into account cultural food preferences, and maintain the incentive value of the WIC food packages for families to participate in the WIC Program. Information on common foods will be taken from publications such as NFS Reports No. 91-3 and 96-5 (Krebs-Smith et al., 1997; Smiciklas-Wright, 2002). The need to select food packages that are acceptable to diverse cultural groups is discussed in Chapter 2. Criterion 6: The impact of changes in the package on vendors and WIC agencies will be considered. As discussed in Chapter 2, changing and/or adding greater flexibility to the WIC food package may increase the administrative load for both vendors of WIC foods and for the agencies who administer the WIC program. Potential administrative impacts will be considered when revising the WIC food packages. The proposed priority nutrients and food groups are summarized in Table 6-1. PROCESS FOR TRANSLATING THE CRITERIA INTO FOOD PACKAGES Foods for the WIC food package will be chosen using the criteria outlined above, with a particular focus on the priority nutrients and types of foods that have been identified. The Committee will identify commonly consumed foods that provide priority nutrients and/or come from a priority food group. Nutrient profiles both of foods and of food packages will be calculated using the most recent USDA database (NDL, 2004) and the potential impact on nutrient inadequacies and excesses will be evaluated for a broad range of nutrients. Public comments, including those presented at open sessions held by the Food and Nutrition Board, and those received in writing by the Food and Nutrition Board or in response to the Advanced Notice of Proposed Rulemaking (ANPRM) from USDA will be considered.

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PROPOSED APPROACH FOR SELECTING THE WIC FOOD PACKAGES 6-5 TABLE 6-1 Proposed Priorities for the WIC Food Packages Nutrients of Participant Proposed Priority Proposed Priority Concern with Nutrients to Limit Category Nutrients Food Groups Regard to in the Diet Excessive Intake Infants, less than 1 year of age, non-breastfed N/A Zinc Vitamin A, preformed 1 Food energy Infants, 6 through 11 months of age, breastfed Iron N/A Zinc Children, 12 through 23 months of age Iron Vegetables Zinc Vitamin E Vitamin A, Potassium preformed 1 Fiber Sodium Food energy Children, 2 through 4 years of age Iron Vegetables Zinc Saturated fat Vitamin E Vitamin A, Cholesterol Potassium preformed 1 Fiber Sodium Food energy Adolescent and adult women of reproductive age Highest priority: Fruit Sodium Saturated fat Calcium Dairy products, Food energy Cholesterol Iron low-fat or Total fat Trans fatty acids 2 Magnesium nonfat Vitamin E Potassium Fiber Also consider: Vitamin A Vitamin C Vitamin D Vitamin B6 Folate NOTE: N/A, not applicable from available data. 1The UL applies only to preformed vitamin A (i.e., retinol) ingested from the combined sources of animal- derived foods, fortified foods, and dietary supplements (IOM, 2001). 2Trans fatty acids have not specifically been identified as a hazard for infants and children, and thus are shown in the table as nutrients to limit only in the diets of adolescents and adults (IOM, 2002a). However, the recommendation to limit trans fatty acids from processed foods in the diet is presumed to apply to all individuals regardless of age.

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6-6 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES Additional considerations that have been raised by various stakeholders are discussed in Chapter 2. EVALUATING COST NEUTRALITY In addition to the criteria listed above, the Committee will also consider the constraint of relative cost neutrality in recommending changes to the WIC food packages. For each proposed food package, the Committee will estimate the cost to the food program based on the quantities of component foods in each package, the weighted average price of those foods, the number of participants in the relevant participant category, and estimates of prescription rates for the participant categories. The average price of component foods will come from data from various sources, as appropriate and available to the Committee. These sources may include national- average price series data from the Bureau of Labor Statistics, market data from scanner sources (retail sales/price data such as InfoScan from Information Resources, Inc., Chicago IL, or SCANTRACK from ACNielsen, New York NY), and, if needed, Internet or local store price data. The calculated average price of each component food will be weighted to include allowed substitutions in ratios representative of prescription data or estimates drawn from existing studies of food purchases by low income households, national market share data, and other sources such as WIC state agency input and other research resources. For infant formula prices and other major food items (e.g., milk) the Committee may consider current market conditions and projections. Projected food program cost will be compared to the available current food program cost. At present, the Committee intends to use the baseline year of FY02 because the most recent data available in final form are from this year. Costs applied to several alternative food packages will be compared. PROPOSED METHODS FOR EVALUATING BENEFITS AND RISKS OF ALTERNATIVE WIC FOOD PACKAGES An evaluation will be conducted to compare potential benefits and risks for the target population with various potential changes in the WIC food package. As alternative food packages are compared, potential benefits will be characterized as reductions in the prevalence of dietary inadequacy for the priority nutrients. Other potential benefits that will be considered in developing alternative WIC food packages include improved adherence to the Dietary Guidelines and other nutrition recommendations, which would ultimately result in improved health and development. Additionally, potential risks will be characterized as increases in the prevalence of inadequacy of nutrients other than the priority nutrients, increases in the risk of excessive nutrient intake levels, or failure to reduce the present apparent risk of excessive nutrient intake. Other types of nutrition benefits and risks will not be considered explicitly in the evaluation. It is not feasible to estimate what long-term health benefits and risks would be associated with a change in specific foods offered in the WIC program. Those effects would be the result of whether the WIC food instruments are redeemed, how much is consumed by the WIC participant, and the long-term health benefits of consuming those foods. Furthermore, the DRIs and Dietary Guidelines already incorporate information on reduced risk of chronic diseases; that is, diets meeting these recommendations should result in long-term health benefits.

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PROPOSED APPROACH FOR SELECTING THE WIC FOOD PACKAGES 6-7 The evaluation will apply the framework proposed by the Institute of Medicine Subcommittee on the Uses and Interpretation of the DRIs (IOM, 2003a). Briefly, this framework considers improving the distribution of usual nutrient intakes as the ultimate goal of providing food assistance. Specifically, the goal is to achieve a usual nutrient intake distribution with an acceptably low group prevalence of inadequacy and a low prevalence of excessive intake levels. The proposed contents of the WIC food packages will be selected to achieve that goal. When considering the benefits and risks of changes to the WIC food packages, it is important to note that the WIC program can control only what is offered to participants, not what they actually consume. To assess whether changes to the WIC food packages achieve an acceptable group prevalence of inadequacy, assessment of dietary intakes must occur. Ultimately, evaluation of the benefits and risks of changing the WIC food packages will come from data collection and analyses after the changes in the WIC food packages occur. In the meantime, the Committee has the task to evaluate potential benefits and risks associated with changes in the WIC food packages for the target population. The Committee used a starting assumption that any changes in the WIC food packages will be reflected in intake by the targeted individual (infant, child, or woman of reproductive age). Thus, the evaluation of benefits and risks starts with the existing distribution of usual nutrient intake of WIC participants (which presumably reflects the existing intra-allocation of WIC foods1). Then, the effects of changes in the nutrient content of alternative WIC food packages is added to the existing distribution of usual intakes of WIC participants, assuming that these changes are consumed by the target individuals. To illustrate how this framework will be applied, consider the priority nutrients identified by the nutrient intake analysis presented in Chapter 3 of this report. To summarize, vitamin E, calcium, magnesium, potassium, and fiber have the highest prevalence of inadequate intakes for low-income adolescents and women. If a goal is to reduce the prevalence of inadequacy to lower levels, a revised WIC food package might aim to include foods high in these nutrients. If the foods added to the WIC food package are consumed by WIC participants, then the distribution of usual nutrient intake will shift upward and the prevalence of inadequate intake will decline. This change in the prevalence of inadequate intake is the estimated benefit of the new WIC food package. Changes in specific foods or the quantity of foods offered will alter the nutrient profile of the WIC food packages. Any reduction in intake levels associated with revised WIC food packages may lead to increases in the prevalence of inadequate intake, which is a risk of the revised food package. In addition, any changes in the WIC food package that are expected to result in a shift of the usual intake distribution need to consider increases in the risk of excessive intake levels. Evaluating the effects of changes in the WIC food packages is an iterative, ongoing effort in which program sponsors set goals for usual intake, plan to achieve these goals, and assess whether the planned goals were achieved. The analyses of this subcommittee will be the first step in this process. 1 The Committee recognizes that all foods in a package may not be acquired and that some of the foods that are brought into the household might conceivably be shared with non-participant family members or others in the household or community. However, data on the proportion of WIC foods that are directly consumed by the targeted individual are not currently available for a national sample. Thus, the most logical assumption at this time is that changes in the food packages will directly affect the intake of the individual for whom the package is prescribed. Research into alternative assumptions would aid in future reformulations of the WIC food packages.

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6-8 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES SUMMARY The WIC program is based on the premise that inadequate nutrition during the critical growth and development periods of pregnancy, infancy, and early childhood places many low-income individuals at risk of adverse health outcomes. The WIC program is designed as a supplemental program to meet the special nutritional needs of these periods in order to prevent nutritional problems and to improve health. The WIC supplemental food packages should be selected to help achieve diets that have a low prevalence of inadequate or excessive intake and that meet other dietary recommendations associated with good health. To achieve these goals, the IOM Committee to Review the WIC Food Packages has conducted an analysis of usual intake distributions for WIC-income eligible populations, identified priority nutrients and priority food groups for participant groups, and developed a set of criteria to guide selection of foods to be proposed for inclusion in the WIC food packages. Using the criteria specified in Phase I of this project, the Committee will progress into Phase II and develop recommendations for revised cost-neutral WIC food packages to meet the dietary objectives for the women, infants, and children of the WIC program.