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1 Introduction and Background Since the inception of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in 1974, the primary nutritional problems of low-income women, infants, and children have changed from concerns about undernutrition to concerns about consumption of excessive food energy 1 and obesity. Yet, with the exception of the food package for exclusively breastfeeding women, no substantial changes to the WIC food packages have occurred since the WIC program was first begun. This report is the first step in developing recommendations for revisions to the WIC food packages. It reviews the nutritional needs and assesses the dietary adequacy of the WIC target population and proposes priority nutrients and food groups and general nutrition recommendations for the WIC food packages. This chapter reviews the reasons why a systematic evaluation and revision of the food packages is timely. These reasons include profound changes since the inception of the WIC program in (a) the population served by the program, (b) the food supply and the dietary patterns of the WIC-eligible population, (c) the major health risks facing the WIC-eligible population, and (d) the dietary guidance and recommendations and the science underlying those recommendations. THE WIC PROGRAM The WIC program is a nutrition education and food assistance program for low-income individuals with at least one nutritional risk factor for a poor health outcome during the critical periods of growth and development during pregnancy, infancy, and early childhood. The underlying premise for the WIC program is that substantial numbers of pregnant, postpartum and breastfeeding women;2 infants;3 and children4 from households with insufficient income are at 1In this report the term "food energy" is used to refer to the metabolic energy that can be released from utilization of the macronutrients in foods (protein, fat, and carbohydrate). The typical units for expressing food energy are calories. 2 For the purposes of describing WIC participants above the ages of infants and children, the term `women' is generally used; however, this category of participants includes both female adolescents and female adults, all of reproductive age. 1-1

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1-2 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES special risk with respect to their physical and mental health by reason of inadequate nutrition and/or health care (U.S. Congress, 7 C.F.R. 246.1). The WIC program serves as an adjunct to good health care during critical times of growth and development in order to prevent the occurrence of both short- and long-term health problems. The WIC program helps meet the special needs of these individuals by providing three main benefits: (1) supplemental food; (2) nutrition education; and (3) referrals to health and social services. Although all three types of benefits are central to the WIC program's mission to safeguard the health of vulnerable subgroups and prevent adverse health outcomes, supplemental foods are the distinctive benefit in the WIC program. About three-quarters of WIC funds are used to provide supplemental foods. Supplemental foods are provided in food packages selected to provide specific nutrients that appeared to be lacking in the diets of eligible WIC participants-- calcium, iron, vitamin A, vitamin C, and protein. Supplemental food is provided in the form of a food instrument (usually either a voucher or check) that can be exchanged for specific foods in participating grocery outlets.5 This food instrument lists the quantities of food items, sometimes including brand names, that can be obtained. WIC food packages provide tailored selections of foods from the following list: iron-fortified infant formulas, milk, cheese, eggs, iron-fortified breakfast cereals (hot or cold) or infant cereals, fruit and vegetable juices, dried peas or beans, and peanut butter. Carrots and canned tuna are also provide for some breastfeeding women (the enhanced package). Tailoring of food packages at the local level with regard to the specific nutritional needs of an individual may involve decreasing the amount of a food item below the maximum allowance at the federal level. Nutritional standards have been set for some of the food items allowed in the WIC food packages. Examples include the standard that juice produces must be 100% fruit or vegetable juice and must contain a minimum quantity of vitamin C; breakfast cereals must not exceed a maximum quantity of sugar. There are currently seven food packages designed for WIC participants by categories: (1) infants from birth through three months of age; (2) infants 4 through 11 months of age; (3) children and women with special dietary needs; (4) children 1 through 4 years of age; (5) pregnant and breastfeeding women (basic); (6) postpartum, non-breastfeeding women; and (7) exclusively breastfeeding women (enhanced). Within federal regulatory maximum quantities, each WIC state agency is required to develop food prescriptions that specify the types or brands of WIC foods and the quantities allowed. At the local level, members of the professional staff assess each participant's nutritional needs and food preferences, and prescribe an individually tailored food package that best fits the participant's needs and circumstances. 3 For the purposes of describing WIC participants the term `infants' is used exclusively for individuals from birth to the first birthday. 4 For the purposes of describing WIC participants the term `children' is used for individuals from the first birthday to the fifth birthday (ages one year through four years). Five-year-olds are not eligible to participate in the WIC program. 5 Two states currently have different distribution systems. Home delivery of the prescribed items is utilized in Vermont. In Mississippi participants come to a designated site to pick up their food items rather than purchasing through retail outlets.

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INTRODUCTION AND BACKGROUND 1-3 Current Definition of Supplemental Foods In the federal regulations governing the WIC program, supplemental foods are defined as those "foods containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants, and children" (U.S. Congress, 7 C.F.R. 246.2).6 For all packages, the WIC regulations state that the quantities and types of supplemental foods prescribed shall be appropriate for the participant taking into consideration the participant's age and dietary needs (FNS, 2003). Historical Perspective on the WIC Food Package The WIC program was launched at a time when a predominant concern was undernutrition in low-income populations. The early legislation (U.S. Congress, Pub. L. No. 92-433, 1972; U.S. Congress, Pub L. No. 94-105, 1975) directed the program to focus on calcium, iron, vitamin A, vitamin C, and high-quality protein as target nutrients of concern in the WIC population. Later reauthorization legislation (U.S. Congress, Pub. L. No. 95-627, 1978) was more general. Supplementation was described as providing "nutrients determined by nutritional researchers to be lacking in the diets of the targeted population." That law also stipulated that the fat, sugar, and sodium content of WIC foods be appropriate. A WIC Food Package Advisory Panel, convened in 1978, recommended retaining calcium, iron, vitamin A, vitamin C, and high-quality protein as the target nutrients. WIC food package regulations published in 1980 created six different monthly packages that were consistent with Public Law 95-627 but continued to provide foods that are nutrient-rich in calcium, iron, vitamin A, vitamin C, and high-quality protein. An additional food package for exclusively breastfeeding women, including carrots and canned tuna, was developed in 1992. States are given some flexibility, on a case by case basis, to substitute more culturally appropriate foods if they are nutritionally equivalent and cost-neutral. However, very few substitutions have been approved at the federal level. Percentage of Target Dietary Needs Supplied by WIC Foods The Committee found that there was no clear definition of the WIC food packages regarding what percentage of a participant's dietary needs were to be supplied by the food package. Although there are no published comparisons of the nutrients supplied in the WIC food packages to current dietary reference values, some comparisons can be made. For example, the food energy that could be provided by the maximum allowances of the food packages can range from about one-third of energy needs for an active postpartum woman to over 100 percent of energy needs for an 11-month-old girl (IOM, 2002a; FNS, 2003). Thus, although the goal of the WIC program is to supplement the diet, rather than provide a complete diet, the extent to which that goal can be realized varies among the categories of participants served. Table 1-1 shows the percentage of Food Guide Pyramid servings supplied by the maximum allowances in the current WIC food packages (GAO, 2002; USDA/DHHS, 1992). For all categories, the WIC food packages provide more than 100 percent of recommended servings 6 Another statement of the definition of supplemental foods is written as "foods containing nutrients determined by nutritional research to be lacking in the diets of pregnant, breastfeeding, and postpartum women, infants, and children" [U.S. Congress, 42 U.S.C. 1786(b)(14)]. This definition was amended in June, 2004 by addition of the wording "and foods that promote the health of the population served by the program authorized by this section as indicated by relevant nutrition science, public health concerns, and cultural eating patterns" (U.S. Congress, Pub L. No. 108-265, 2004).

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1-4 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES TABLE 1-1 Percentage of the Minimum Recommended Servings from the Food Guide Pyramid Supplied by the Current Maximum Allowances for the WIC Food Packages by Category of Participant Participant Category Grains Vegetables Fruit Meat and Meat (juice) Dairy Alternatives Pregnant or lactating women 13% 0% 50% 123% 27-28% Breastfeeding women, enhanced 13% 9% 60% 137% 50% Postpartum women 20% 0% 50% 160% 24% Children, 2 through 3 years 30% 0% 115% 160% 46-49% Children, 4 years 20% 0% 75% 160% 32-34% SOURCE: GAO, 2002; USDA/DHHS, 1992. from the dairy group. For the dairy group the recommended number of servings is two servings per day for children and women 19 years and older and three servings per day for adolescents; this is equivalent to 16 to 24 oz of milk per day. Yet the maximum allowance for the dairy group is equivalent to 25 to 30 oz per day. For children ages 2 through 3 years, the package also provides more than 100 percent of the recommended servings of fruit, as juice only. THE WIC POPULATION HAS CHANGED SINCE THE INCEPTION OF THE WIC PROGRAM Over the past several decades, the WIC program has expanded considerably and the population the program serves has changed in important ways. The WIC program has been one of the fastest growing food and nutrition assistance programs (see Figure 1-1). In fiscal year 1974, the WIC program served an average of 88,000 women, infants, and children per month. During 2003, the WIC program served an average of 7.6 million women, infants, and children per month at a cost of $4.5 billion for the fiscal year. Currently, about one half of all U.S. infants and one quarter of children 1 through 4 years of age receive WIC benefits. Children make up just over one-half of the total caseload (Figure 1-2, data for 2002). The program's growth has been disproportionately in the western states, which accounted for 13 percent of total WIC participants in 1988 and 24 percent in 1998. California alone accounted for 16.7 percent of WIC participants in 2003. This regional shift is reflected in the ethnic composition of the WIC population, with Hispanics constituting a growing proportion. Hispanics constituted 38.1 percent of the WIC caseload in 2002, up from 21 percent in 1988. Asians and Pacific Islanders have become a substantial part of the WIC population in several states over the same time period. There is substantial variability among geographic areas, even within states, with some programs serving much more ethnically diverse populations than others. The proportion of women participating in the WIC program who are in the work force has increased since 1974. By 1998, about 25 percent of the women who were certified or who certified a child for the WIC program were employed (Cole et al., 2001). Data from the Bureau of Labor Statistics show that work activity has increased recently in low-income households with

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INTRODUCTION AND BACKGROUND 1-5 8 tsn s 6 ipa ion rtic ill 4 Pa M tal To 2 0 1974 1979 1984 1989 1994 1999 2004 FIGURE 1-1 Annual Number of Participants in the WIC Program Constructed from Monthly Averages of Participants, Fiscal Years 1974-2004. SOURCE: FNS, 2004a (USDA website). FY 2002 is the latest complete data. Data for FY 2003 (12 months) and FY 2004 (February alone) may be incomplete. Women (24.2%) Infants (25.7%) Children (50.1%) FIGURE 1-2 The WIC Population by Participant Category, 2002 SOURCE: Bartlett et al., 2003; FNS, 2004d (USDA website). FY 2002 is the latest complete dataset.

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1-6 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES children. Between 1990 and 1999, the proportion of children in families with income below the poverty level who lived with both parents with at least one parent employed full-time increased from 44 to 52 percent (GAO, 2001). The proportion of poor children living in families with a single mother employed full-time doubled, from 9 to 18 percent (GAO, 2001). THE FOOD SUPPLY AND DIETARY PATTERNS HAVE CHANGED SINCE THE INCEPTION OF THE WIC PROGRAM Increased Variety in the Food Supply The number of food products in U.S. food retail outlets has increased approximately 60 percent since 1990. Between 1997 and 2001 an average of 10,513 new food products were introduced into the market each year (Food Institute, 2002). Many of these were existing products that were repackaged/relabeled or simple line extensions; the introduction of some of these products some was heavily advertised. Recent new food products include consistent-weight packages of fresh fruits and vegetables that were formerly purchased as bulk, random-weight items. Even though many of the new products fail to stay on the shelves for more than two years, there has been a steady increase in the total number of products available. Each product is referred to as a stock-keeping unit (SKU) by food manufacturers and vendors. The average number of SKU's in a typical supermarket has increased from 20,000 in 1990 to over 32,000 in 2002 (Food Institute, 2002). The variety of foods available has increased with a number of new products introduced as the result of global sourcing of fresh fruits and vegetables. A wider variety of fresh produce is now available year-around at reasonable prices and in many more locations. Variety in the forms of food products also has increased due to changes in lifestyles and a preference for very individualized types of foods. For example, consumers with particular health interests are selecting foods fortified with particular nutrients such as calcium in orange juice or iron in oatmeal. Variety also has increased due to the increase in "store brands." Supermarkets are differentiating themselves from competition and building store loyalty through expansion of their own brands. The percentage of SKU's in a typical supermarket that are store-brand products rose from 18.6 percent in 1995 to 20.7 percent in 2001 (Food Institute, 2002). These store-brand products are priced between 15 and 50 percent lower than national branded products of similar quality (Food Institute, 2002). Changes in Food Consumption The percentage of personal disposable income spent for food from retail stores has fallen over the last several decades. The average American household spent 7.8 percent of their disposable income on food eaten at home in 2001, compared to over 10 percent in 1970 (BLS, 2003). Despite this trend, households in the lowest income quintile, which would include most WIC households, spend 25 percent of their disposable income for food at home (Blisard, 2001). Research by USDA on food spending by households reveals that low-income households economize using their food dollars. Despite often facing higher food item prices, they tend to spend less per pound for nearly all food groups by purchasing lower cost items within the food groups (Kaufman et al., 1997). Food consumption trends are available for women regarding the consumption of 12 categories of food between 1977 and 1995 (see Table 1-2). The trends in mean dietary intakes for women 20 years of age and older reveal substantial increases in beverages (114 percent for

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INTRODUCTION AND BACKGROUND 1-7 TABLE 1-2 Trends and Changes in Food Consumption from Selected Food Groups: Mean Intakes for Women 20 Years and Older Mean Intake (grams per day) % change, 1997-1978 to Food Group 1977-1978 1989-1991 1994-1995 1994-1995 Grain products 177 234 255 44% Vegetables 205 187 189 -8% Fruits 142 150 156 10% Milk and milk products 203 206 202 -0.5% Meat, poultry, and fish 184 167 168 -9% Eggs 24 16 16 -33% Legumes 18 17 19 6 % Fats and oils 13 16 16 23% Sugars and sweets 17 17 19 12% Beverages (nonalcoholic) 698 753 854 22% Fruit drinks and ades 29 46 58 100% Carbonated soft drinks 137 238 293 114% NOTE: An ade in a sweetened drink made from water and fruit juice. SOURCE: NFCS 1977-1978, CSFII 1989-1991, CSFII 1994-1995 (Enns et al., 1997). carbonated beverages), grain products (44 percent), and sugars and sweets (22 percent) (Enns et al., 1997). Intake of eggs decreased the most for women (33 percent) (Enns et al., 1997). Similar trend data were available for children ages 6 through 11 years (Enns et al., 2000). No trend data of this type were available for children in age ranges eligible for the WIC program. THE HEALTH RISKS OF THE WIC-ELIGIBLE POPULATION HAVE CHANGED SINCE THE INCEPTION OF THE WIC PROGRAM Since the inception of the WIC program, there have been fundamental changes in the predominant health and nutrition risks faced by the WIC-eligible population, and in the context of these risks. Several problems that were high on the list of public health problems in the 1970s have receded. Access to health care for WIC participants is now better than in the early years of the program (Fox et al., 2003); at present more than 80 percent of WIC participants report some kind of health care insurance, primarily Medicaid or employer-sponsored insurance (Cole et al., 2001). Further, there is evidence that the Medicaid-enrolled children who participate in the WIC program have greater use of all health services, including preventive services and effective care of common illnesses, than the Medicaid-enrolled children who are not WIC participants (Buescher et al., 2003). The situation with regard to breastfeeding7 has improved since the early days of the WIC program, with more than two-thirds of mothers initiating breastfeeding presently. However, average duration remains short, and WIC participants remain somewhat less 7In the WIC program, a mother is considered to be breastfeeding as long as breastfeeding occurs at least once per day.

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1-8 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES likely to breastfeed their babies than other mothers (Abbott Laboratories, 2002, 2003). Diets have improved in many respects, and nutrients for which intakes often appeared to be low in the 1970s (vitamins A and C, and calcium) are less problematic, particularly for children. Iron deficiency has declined considerably, probably at least partly as a positive effect of the WIC program (Sherry et al., 2001), but remains a problem to be actively addressed, with prevalence hovering 2 to 5 percentage points above the 2010 national health objectives (CDC, 2002). Infants in the WIC program (Kahn et al., 2002) and low-income postpartum women (Bodnar et al., 2002) have been demonstrated to be particularly at risk. At the same time, new risks have emerged. By far the most dramatic of these is the rapidly increasing prevalence of overweight and obesity in adults, adolescents, and children, with the attendant health risks. Excess body fat and physical inactivity are associated with the development of hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, osteoarthritis, respiratory ailments, sleep problems, certain cancers (e.g., breast cancer), and all- cause mortality. The negative health effects and economic costs associated with excess body fat and physical inactivity are second only to smoking, and likely to overtake tobacco as the leading cause of death from modifiable behavioral factors in the near future (Mokdad et al., 2004). While there is no firm evidence that the WIC participant population is any more prone to overweight than non-WIC populations (CDC, 1996), neither are they protected. The number of overweight and obese women in the U.S. has risen substantially, with age-adjusted prevalence increasing approximately 30 percent between 1960 and 1994 (Kuzmarski et al., 1994). In 1994 28 and 27 percent of women aged 25 years and older were overweight and obese, respectively (Flegal et al., 1998). Over the same period the percentage overweight among women of childbearing ages (20 through 39 years) almost doubled (Kuzmarski et al., 1994; Flegal et al., 1998). Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2000 indicated that 28 percent of non-pregnant women aged 20 through 39 years are obese (Flegal et al., 2002). More recent data from NHANES 2001-2002 indicates that the prevalence of obesity among these women remains high at 29 percent (Hedley et al., 2004). Overweight and obesity are prevalent among minority groups, except for Asian-Americans. Data from the most recent NHANES multistage probability sampling (1999-2002) estimate the overall prevalence of overweight and obesity at 70 and 47 percent for non-Hispanic black women, 62 and 31 percent for Mexican-American women, and 55 and 25 percent for non- Hispanic white women (Hedley et al., 2004). Of particular concern is the prevalence of Class 3 obesity (body mass index > 40), which affects 15 percent of non-Hispanic black women ages 20 and over, a prevalence nearly double that (7.9 percent) reported in the 1988-1994 NHANES (Flegal, et al, 2002). However, women of low socioeconomic status disproportionately bear the burden of obesity and overweight regardless of race or ethnicity. Among individuals with less than a high school education the prevalence is roughly twice that of college graduates (Mokdad et al., 1999). The prevalence of overweight for children in the U.S. also has steadily risen over the last several decades. Data from the most recent NHANES national survey (1999-2000) indicate that the prevalence of overweight was 13 percent in children ages 6 through 11 years as compared to 4 percent in 1965 (Ogden et al., 2002). In children ages 2 through 5 years, 10 percent were overweight. A 1998 survey of children participating in the WIC program found that 13 percent of these children were overweight (Cole, 2001). Overweight children and adolescents are at increased risk for overweight in adulthood (Ogden et al., 2003). Childhood overweight has been linked to adverse health outcomes including elevated blood pressure, hyperinsulinemia, glucose

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INTRODUCTION AND BACKGROUND 1-9 intolerance, type 2 diabetes, dyslipidemia, and other early risks for chronic disease, as well as to psychosocial problems including depression, social isolation, and low self-esteem (Dietz, 1998b; Must and Strauss, 1999). A recent analysis of NHANES data from 1971 to 2000 indicates that the extent of overweight (i.e., the degree of overweight among those who are overweight) has increased even more rapidly than the prevalence of overweight among U.S. children and adolescents (Jolliffe, 2004). DIETARY GUIDANCE AND RECOMMENDATIONS HAVE CHANGED SINCE THE INCEPTION OF THE WIC PROGRAM New Nutrient Recommendations Over the past decade, knowledge of nutrient requirements has increased substantially, resulting in a set of new dietary reference values called the Dietary Reference Intakes (DRIs) (IOM, 1997, 1998, 2000b, 2001, 2002a, 2004). The DRIs replace the 1989 Recommended Dietary Allowances (RDAs) as nutrient reference values for the U.S. population (NRC, 1989b). Based on the new DRIs, many of the recommendations for individual intakes (RDAs) have changed substantially since the WIC food packages were originally formulated. Although basic concepts of nutrition have not changed, there has been a substantial increase in knowledge of specific concepts such as bioavailability, nutrient-nutrient interactions, and the distribution of dietary intake across subgroups of the population. In addition, the DRIs include appropriate standards to use in determining whether diets are nutritionally adequate without being excessive. The DRIs differ from the old RDAs in several respects: (1) they consider reduction in the risk of chronic disease, rather than merely the absence of signs of deficiency; (2) for most nutrients, both RDA and Estimated Average Requirement (EAR) values are given--the EAR makes it possible to estimate the prevalence of inadequacy within a population; (3) Tolerable Upper Intake Levels (ULs) have been set to aid in evaluation of the risk of adverse effects from excess consumption; (4) appropriate ranges of macronutrient densities are given as Acceptable Macronutrient Distribution Ranges (AMDRs); and (5) when data are available, reference values are provided for other food components. New Food Intake Recommendations New guidance on food intakes also is available. At the time the WIC program was established, there was no systematic process for the development and revision of science-based dietary guidance for the U.S. population. Nutrition education tools such as the "Four Food Groups" focused on eating enough of various types of foods to assure nutrient adequacy. The original selection of foods for the WIC food packages was based on food consumption data that indicated that calcium, iron, vitamin A, and vitamin C were the nutrients most likely to be low in the diets of low-income women and young children. Understanding of the necessity for adequate high-quality protein in periods of rapid growth and development provided the basis for inclusion of protein as a priority nutrient. The specific foods selected for the food packages were good sources of the nutrients listed above, available, generally acceptable, and reasonable in cost. As deficiency diseases became less common, scientific research into the relationships between various dietary components and chronic diseases expanded. In 1977, the U.S. Senate Select Committee on Nutrition and Human Needs published dietary goals for the U.S., which for the first time set forth dietary guidance that included a focus on the total diet and recommendations for minimizing risk of chronic disease and for ensuring nutritional adequacy

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1-10 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES (U.S. Senate, 1977). There was a great deal of controversy over these goals, not only because of the lack of agreement among scientists on many of the issues but also surrounding the process for arriving at the goals (McMurry, 2003). A period of intense activity culminated in a 1979 Surgeon General's Report on Health Promotion and Disease Prevention (DHEW/PHS, 1979). The report relied heavily on the findings of a panel of the American Society for Clinical Nutrition that examined the association between dietary components and chronic disease (ASCN, 1979). Then in 1980, USDA/DHHS jointly issued the first edition of Dietary Guidelines for Americans (USDA/DHHS, 1980). The purpose was to provide the public with authoritative, consistent guidelines on diet and health. Since 1980, the Dietary Guidelines have been revised every five years; the most recent version was released in May 2000 (USDA/DHHS, 2000) and the 2005 revision is expected to be available in preliminary form in time to inform the deliberations of the current Institute of Medicine (IOM) Committee to Review the WIC Food Packages. Over time, the Dietary Guidelines have evolved to incorporate the evidence that has developed about the relationships between diet and chronic disease. The 2000 version of the Dietary Guidelines (USDA/DHHS, 2000) recommends a total dietary pattern that is largely plant-based, with emphasis on whole grains, fruits and vegetables; limitation or moderation in consumption of fats, sugars, sodium, and alcohol; food safety; and physical activity. The Dietary Guidelines form the basis for widely-used nutrition education tools and dietary evaluation processes. The Food Guide Pyramid, a nutrition education tool based on the Dietary Guidelines, was first issued by USDA and DHHS in 1992. The Pyramid has become a widely recognized representation of dietary guidance by the public. Currently, USDA is evaluating the Food Guide Pyramid system to respond to new Dietary Reference Intakes, new Dietary Guidelines, and current information on food consumption patterns and consumer perceptions and understanding. THE COMMITTEE'S TASK In view of the substantial changes in the nutritional context for the WIC program since its inception, the Food and Nutrition Service of USDA asked the Institute of Medicine to present a proposal to conduct a review of the WIC food packages. The project was undertaken by the Food and Nutrition Board in September 2003. The Committee to Review the WIC Food Packages was formed to conduct the review and the statement of task for the project follows. The committee's focus is the population served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Specific tasks for the committee are: (Phase I) review nutritional needs using scientific data summarized in Dietary Reference Intake reports (IOM, 1997, 1998, 2000b, 2001, 2002a, 2004), assess supplemental nutrition needs (by comparing nutritional needs to recent dietary intake data for pertinent populations), and propose priority nutrients and general nutrition recommendations for the WIC food packages; and (Phase II) based on this assessment, recommend specific changes to the WIC food packages. Recommendations are to be cost-neutral, efficient for nationwide distribution and vendor check- out, non-burdensome to administration, and culturally suitable. The committee will also consider the supplemental nature of the WIC program, burdens/incentives for eligible families, and the role of WIC food packages in reinforcing nutrition education, breastfeeding, and chronic disease prevention. The remainder of this preliminary report presents the basis for the Committee's proposed approach to designing WIC food packages during Phase I of the project. Chapter 2 identifies

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INTRODUCTION AND BACKGROUND 1-11 some of the challenges the Committee faces in designing an effective set of WIC food packages. To assess supplemental nutrition needs, the Committee considered several types of evidence: distributions of nutrient intakes for WIC populations were examined to identify the prevalence of inadequate or excessive intakes (Chapter 3); published information on food intakes was compared to dietary recommendations for the target populations (Chapter 4); and published evidence of nutrient inadequacy for these populations, based on physiological or biochemical evidence, was examined (Chapter 5). All of these sources of data have strengths and weaknesses, so a combination was used to identify the nutrients and food groups of the most concern. Although breastfed infants must be excluded from certain analyses because the data are limited or lacking, breastfed infants were considered when feasible, primarily in the analyses described in Chapter 5. Chapter 6 presents the Committee's preliminary synthesis of information related to nutritional needs and to priority nutrients and food groups to be considered for the food package. The proposed criteria and a general description of the process to be used in selecting the WIC food packages during Phase II of the project are also presented.

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