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WIC Food Packages: Time for a Change (2006)

Chapter: 4 Revised Food Packages

« Previous: 3 Process Used for Revising the WIC Food Packages
Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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4
REVISED FOOD PACKAGES

The committee recommends changes to each of the current WIC food packages, based on the criteria developed earlier (IOM, 2004b). That is, the proposed changes respond to current dietary guidance for nutrient intakes and dietary patterns, the major diet-related health problems and risks faced by this population, and the characteristics and diversity of the WIC-eligible population. The proposed changes also attempt to avoid undue burden to WIC agencies and retail vendors. The first part of this chapter presents specific proposals for all of the WIC food packages, briefly compares the revised packages to the current ones, and lists specifications for foods in the revised packages. The second part of the chapter provides the basis for changes in the packages or policies related to the food packages. The committee recommends pilot testing and randomized, controlled trials before full-scale implementation of the proposed changes to the food packages. See Chapter 7Recommendations for Evaluation and Implementation—for details.

DESCRIPTION OF THE REVISED FOOD PACKAGES

In addressing proposed changes to the WIC food packages, the committee retained the basic numbering system used for the current food packages. Subparts were added to identify new subcategories based on infant age and breast-fed versus formula-fed status. The numbering systems for infant packages are is shown in Table 4-1 and the numbering systems for children and women are shown in Table 4-2. Table 4-3 presents proposed specifications for allowable foods.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

TABLE 4-1 Revised WIC Food Packages, Maximum Monthly Allowances for Infants [examples of amounts as commonly obtained shown in brackets]

 

Fully Formula-Fed (FF)

Foods/Package Number

I-FF

I-FF-A: 0–3.9 mo

I-FF-B: 4–5.9 mo

II-FF

6–11.9 mo

Infant formulac [example of commonly available form; reconstituted volume]

I-FF-A: 403 fl oz liquid concentrate [31 13-fl oz cans; 806 fl oz]d

312 fl oz liquid concentrate [24 13-fl oz cans; 624 fl oz]d

 

I-FF-B: 442 fl oz liquid concentrate [34 13-fl oz cans; 884 fl oz]d

 

Infant cereal

 

24 oz [3 8-oz boxes]

Baby food fruits and vegetables (e.g., strained)

 

128 oz [32 4-oz jars]

Baby food meat (e.g., pureed)

 

 

aTo promote the establishment of breastfeeding, the committee recommends that formula not be routinely provided in the first month to breast-fed infants; thus, no mother/infant pairs are classified as partially breastfeeding for the first month postpartum. See discussion in section Promoting and Supporting Breastfeeding and recommendations for studies in Chapter 7Recommendations for Implementation and Evaluation.

bThe committee recommends that infants with special dietary needs receive Food Package III. This means the package would provide the medical foods required by WIC participants of any age if they have special dietary needs. Persons receiving Food Package III also would receive the foods allowed for other participants in the same life stage if those foods were medically and developmentally appropriate for them.

cIn most cases, the maximum monthly allowance of infant formula is stated as fl oz of liquid concentrate. Powdered or ready-to-feed formula may be provided as alternative forms at rates that provide the approximate number of fl oz of formula (see note d for additional detail).

dThe maximum allowance for infant formula is converted to a practical option using current can sizes commonly obtained, as shown in brackets. For further practical options, see Table B-6Substitution Rates for Various Volumes of Formula Concentrate (Appendix B). Because of differences in container sizes and yields, the maximum amount of formula provided depends on whether the mother obtains powdered, liquid concentrate, or ready-to-feed formula. When determining the maximum number of cans of each type of formula, the committee recommends rounding to whole cans to approximate the target amount (the maximum monthly allowance shown here in Table 4-1). The results of this method may differ from the rounding currently in use; some rounding methods (e.g., rounding up to whole cans) could result in providing excess formula in some cases. Note that the substitution rate of 8 lb of powdered formula for 403 fl oz of formula concentrate no longer applies; that substitution rate could result in providing excess formula in some cases.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Partially Breast-Fed (BF/FF)

Fully Breast-Fed (BF)

Special Dietary Needs

I-BF/FF

I-BF/FF-A: 1–3.9 moa

I-BF/FF-B: 4–5.9 mo

II-BF/FF

6–11.9 mo

I-BF

0–5.9 mo

II-BF

6–11.9 mo

I and II or IIIb

I-BF/FF-A: 51–60 oz powder [4 12.9-oz cans powder; 384 fl oz]e

156 fl oz liquid concentrate [12 13-fl oz cans; 312 fl oz]d

 

 

Same reconstituted volume as othersf

I-BF/FF-B: 221 fl oz liquid concentrate [17 13-fl oz cans; 442 fl oz]d

 

 

 

 

 

24 oz [3 8-oz boxes]

 

24 oz [3 8-oz boxes]

Same as othersf

 

128 oz [32 4-oz jars]

 

256 oz [64 4-oz jars]

Same as othersf

 

 

 

77.5 oz [31 2.5-oz jars]

Same as othersf

eIn this case, the maximum monthly allowance is specified in the powdered form—the form that is recommended for partially breast-fed infants, ages 1–3.9 mo. A range is shown to note the amounts that could be provided at current container sizes for powdered formula. For further detail, see Table B-6Substitution Rates for Various Volumes of Formula Concentrate (Appendix B).

fThe maximum allowance for an infant with special dietary needs is the same as for other infants in the same participant category, if the food is appropriate for the medical, nutritional, and developmental condition of that infant.

NOTES (abbreviations in order of appearance in table): FF = fully formula-fed; BF/FF = partially breast-fed (i.e., the infant is breast-fed but also receives some formula through the WIC program); BF = fully breast-fed (i.e., the infant is breast-fed and receives no formula through the WIC program).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

TABLE 4-2 Revised WIC Food Packages, Maximum Monthly Allowances for Children and Women

 

Children

Foodsa/ Package Number

IV-A: 1–1.9 y

IV-B: 2–4.9 y

Formula (liquid concentrate)d

Juice

128 fl oz

128 fl oz

Milk,f whole

 

16 qtg,h

Milk,f up to 2% milk fat

 

16 qth

Breakfast cereal (hot or cold)

36 oz

36 oz

Cheese

Eggs

1 doz

1 doz

Fruits and vegetables (fresh)l,m

$8.00 in cash-value vouchersn (ca. 9.76 lb)

$8.00 in cash-value vouchersn (ca. 9.76 lb)

Whole wheat breado

2 lb

2 lb

Fish (canned)

Beans (mature legumes), dryp

1 lb dried

1 lb dried

and/or

or

or

Peanut butter

18 oz

18 oz

aSee Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages—for allowed types and forms of foods.

bFood Package V is available to two groups: pregnant women and breastfeeding women whose infants participate in the WIC program and receive formula in amounts that do not exceed the maximum allowances for Food Packages I-BF/FF-A, I-BF/FF-B, or II-BF/FF, as appropriate for the age of the infant.

cFood Package VII is available to breastfeeding women whose infants do not receive formula from the WIC program and to all breastfeeding women during the first month postpartum. See discussion in section on Promoting and Supporting Breastfeeding and recommendations for studies in Chapter 7Recommendations for Implementation and Evaluation. Food Package VII is also recommended for women pregnant with two or more fetuses.

dThe type of formula depends on the special health need.

eSome individuals with special dietary needs require complete nutritional liquids or semisolids with nutrient and caloric content that differ from the formulas designed for infants. Many of these products are sold as powders and the proper reconstitution rates vary. Thus, the calculations used for infant formulas (which are relatively consistent at 1 kcal per cc) may not apply to the formulas for children and women with special dietary needs.

fLactose-reduced milk is allowed. See Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Women

Children and Women

V: Pregnant or Partially Breastfeeding (up to 1 y postpartum)b

VI: Non-breastfeeding Postpartum (up to 6 mo postpartum)

VII: Fully Breastfeeding, Enhanced Package (up to 1 y postpartum)c

III: Special Dietary Needs

 

 

 

455 fl oz,e

if appropriate

144 fl oz

96 fl oz

144 fl oz

Same as othersi

Same as othersi

22 qtj,k

16 qtj,k

24 qtj,k

Same as othersi

36 oz

36 oz

36 oz

Same as othersi

1 lb

Same as othersi

1 doz

1 doz

2 doz

Same as othersi

$10.00 in cash-value vouchersn (ca. 12.2 lb)

$10.00 in cash-value vouchersn (ca. 12.2 lb)

$10.00 in cash-value vouchersn (ca. 12.2 lb)

Same as othersi

1 lb

1 lb

Same as othersi

30 oz

Same as othersi

1 lb dried

1 lb dried

1 lb dried

Same as othersi

and

or

and

Same as othersi

18 oz

18 oz

18 oz

Same as othersi

gWhole milk (3.5–4% milk fat) is the only type of milk allowed for 1-y-old children. Exceptions can be made in special circumstances when prescribed in writing by a Recognized Medical Authority (a licensed physician, physician assistant, nurse practitioner, or other health professional specified by the WIC state agency to have this authority).

hFor children, cheese or yogurt may be substituted for milk at the rate of 1 lb of cheese per 3 qt of milk (to a maximum of 1 lb of cheese) or 1 qt of yogurt per 1 qt of milk. A maximum of 4 qt of milk can be substituted for in this manner.

iIf appropriate for the medical, nutritional, and developmental condition of a participant assigned to Food Package III, the maximum allowance for each food is the same as for the food package to which the participant would be assigned if he or she had no special health need.

jCheese, yogurt, or calcium-set tofu (tofu prepared with calcium salts) may be substituted for milk at the rate of 1 lb of cheese per 3 qt of milk (to a maximum of 1 lb of cheese), 1 qt of yogurt per 1 qt of milk, or 1 lb of tofu per 1 qt of milk. A maximum of 4 qt of milk can be substituted for in this manner in Food Packages V and VI. A maximum of 6 qt of milk can be substituted for in this manner in Food Package VII for fully breastfeeding women.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

kFor women, soy beverage (“soy milk”) may be substituted for milk at the rate of 1 qt of calcium- and vitamin D-rich soy beverage for 1 qt of milk up to the total allowance of milk prescribed.

lProcessed fruits and vegetables may be substituted for fresh fruits and vegetables using the substitution rates shown in note n. Dried fruits may be included with processed fruits only for adolescent and adult women.

mIn the canned options for children, 222 oz of canned fruits and vegetables (e.g., 7 15-oz cans of fruit plus 7 14.5-oz cans of vegetables) would substitute for the $8.00 cash-value vouchers. In the canned options for adolescent and adult women, 280 oz of canned fruits and vegetables (e.g., 9 15-oz cans of fruit plus 9 14.5-cans of vegetables) would substitute for the $10.00 cash-value vouchers.

nThe value of the cash voucher is intended to deliver approximately the weight of fresh produce specified and may need to be adjusted upward to account for local prices in some states agencies.

oOther whole grain foods could substitute for whole wheat bread on an equal weight basis. Examples and specifications are listed in Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages.

pLegumes include dry beans, peas, and lentils. Canned legumes may be substituted for dried legumes at the rate of 64 oz of canned beans for 1 lb dried beans. See Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages—for additional information.

NOTE: ca. = the calculated amount.

In the sections that follow, the packages for women are presented immediately after the packages for infants because they are so closely related.

WIC Food Packages for Infants

Overview of Current Food Packages for Infants

Currently, there are two WIC food packages for infants: Food Package I (for infants ages 0–3 mo) provides infant formula only; and Food Package II (for infants 4–11 mo) provides formula, cereal, and juice. When fully breast-fed infants reach the age of 4 months, they receive Food Package II with cereal and juice only. Infants who are partially breast-fed receive either Food Package I or II, depending on their age. Although partially breast-fed infants are eligible to receive the entire allowance of formula, the Competent

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Professional Authority1 (CPA) in the WIC local agency may tailor packages to provide smaller amounts if appropriate.2

Revised Food Packages for Infants

Food Package I—The committee recommends that Food Package I serve infants from birth through 5 months of age, as shown in Table 4-1, rather than covering the current period of birth through 3 months of age. For formula-fed infants, formula must be iron fortified as specified in the current packages. Because of differences in container sizes and yields, the maximum amount of formula provided depends on whether the mother obtains powdered, concentrated, or ready-to-feed formula. When determining the maximum number of cans of each type of formula, the committee recommends rounding to whole cans to approximate the target amount (the maximum monthly allowance shown in Table 4-1); the committee’s recommendations are presented in Table B-6Substitution Rates for Various Volumes of Formula Concentrate—in Appendix B. In some cases the results of this method may be different from the rounding currently in use (e.g., rounding up to whole cans). Otherwise, Food Package I for fully formula-fed infants ages zero through three months is unchanged.

For the first month after birth, the committee further recommends only two feeding options initially—full breastfeeding or full formula feeding. Refer to the later section Promoting and Supporting Breastfeeding for a full explanation of the committee’s recommendations concerning infant food package choices during the first month after birth.

For ages 1 month through 3 months, the proposed food package for partially breast-fed infants (Food Package I-BF/FF-A in Table 4-1) provides powdered formula as the standard. The maximum allowance is approximately half of the allowance of formula that is provided to fully formula-fed infants (Food Package I-FF-A); in this case it is slightly less than half due to rounding to whole cans in the example used in the Table 4-1. (For further information, see Table B-6 in Appendix BNutrient Profiles of Current and Revised Food Packages.) The committee recommends powdered formula for partially breast-fed infants because the amount prepared can be tailored closely to the amount needed. This may help reduce waste, food safety concerns, and/or overfeeding of formula to breast-fed infants. If

1  

The term Competent Professional Authorities is used to refer to professionals and paraprofessionals who tailor the food packages and educate and counsel WIC participants.

2  

The committee had no data on which to base assumptions regarding the amount of formula currently prescribed for partially breast-fed infants. Thus, in the nutrient and cost analyses, the committee used the assumption that partially breast-fed infants received the maximum monthly allowance for formula in the current food packages.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

the partially breastfeeding mother requests and obtains more than the maximum amount of formula for her partially breast-fed infant, the infant will be considered fully formula-fed and assigned the package for fully formula-fed infants (Food Package I-FF-A in Table 4-1).

At 4 months of age, the amount of formula provided for fully formula-fed infants, increases slightly—corresponding closely to the average nutritional needs of infants of this age (see Food Package I-FF-B in Table 4-1). This additional formula is a partial replacement for the juice and cereal that the current Food Package II provides to infants of this age. The maximum amount of formula provided for partially breast-fed infants also increases (see Food Package I-BF/FF-B in Table 4-1). At this age, any of the three types of formula would be acceptable. Due to rounding to whole cans of powdered formula, the amount of formula may not increase at four months of age, depending on the can sizes of formula provided (see Table B-6 in Appendix BNutrient Profiles of Current and Revised Food Packages). The maximum allowance for the partially breast-fed infant is calculated as half of the allowance for fully formula-fed infants of the same age; however, rounding to whole cans of powdered formula may result in a slightly lower amount (that is, a reduction of less than two ounces per day) (see Table B-6 in Appendix B).

Food Package II—At 6 months of age, infants are assigned to Food Package II. This food package provides semisolid foods for all infants (see Food Packages II-BF, II-BF/FF, and II-FF in Table 4-1) and formula to those who are not fully breast-fed.3 Commercial baby food fruits and vegetables in the revised package replace juice in the current package. To support the continuation of full breastfeeding past 6 months, Food Package II-BF provides more commercial baby food fruits and vegetables than do the other two versions of Food Package II. Because fully breast-fed infants age six months and older need more iron and zinc than breast milk provides (Krebs, 2000; Dewey, 2001; Krebs and Westcott, 2002), Food Package II-BF provides commercial baby food meats. (Infant formulas provide these two minerals in amounts that meet or exceed the needs of most infants [see Table C-2C and IOM, 2004b].) The maximum amount of formula provided for fully formula-fed infants (see Food Package II-FF in Table 4-1) or partially breast-fed infants (see Food Package II-BF/FF in Table 4-1) has been reduced. For formula-fed infants, the combination of foods in the revised Food Package II provides slightly fewer calories than in the current

3  

Although semisolid foods are not included in the food packages until 6 months of age, this does not prevent the parents or caregivers from introducing semisolid foods to infants before 6 months of age.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

package, provides nutrients in amounts close to the recommended levels,4 and introduces more variety into the infant’s diet. For fully breast-fed infants, the revised Food Package II provides more calories than before and introduces more variety into the infant’s diet. As is the case for Food Package I, if the partially breastfeeding mother requests and receives more than the maximum amount of formula specified for partially breast-fed infants, the infant will be considered fully formula fed and assigned the package for fully formula-fed infants.

WIC Food Packages for Women

Overview of Current Food Packages for Women

Four packages are currently provided to women as shown in Table 1-1 in Chapter 1Introduction and Background. Food Package V is designed for pregnant women and partially breastfeeding women (i.e., mothers who combine breastfeeding with formula feeding); Food Package V is available throughout pregnancy and can be available to partially breastfeeding women for up to 12 months postpartum. Food Package VI is for non-breastfeeding postpartum women and is available for 6 months post-partum. Food Package VII, the enhanced breastfeeding package, is for nursing mothers whose infants receive no formula from the WIC program (i.e., fully breastfeeding women); Food Package VII can be available to fully breastfeeding women for up to 12 months postpartum.

Food Packages V and VII provide milk, cheese (as a substitute for part of the milk), vitamin C-rich juice, iron-rich breakfast cereal, eggs, and dry beans (plus peanut butter in Food Package VII, with peanut butter as an alternative to dry beans in Food Package V). Food Package VI for non-breastfeeding postpartum women provides most of these foods (except peanut butter and dry beans); however, some maximum allowances are smaller. Food Package VII—the enhanced breastfeeding package for fully breastfeeding women—also provides canned tuna, carrots, cheese (in addition to cheese substituted for milk), and additional juice. Pregnant and breastfeeding women may receive Food Package III if they have special medical problems that preclude prescription of the regular packages.

4  

For details on specific nutrients, compare nutrients provided in Tables B-2 and B-3 (Appendix BNutrient Profiles of Current and Revised Food Packages) to recommended levels of nutrients in Table F-1 (Appendix FSupplementary Information).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×
Revised Food Packages for Women

The committee recommends continuing to provide Food Packages V, VI, and VII to the same groups of women for virtually the same periods of time. However, the committee recommends changing the definitions of breast-fed infants, which would change the classifications of nursing mothers as well.5 Under the proposed system, all women who choose to breastfeed would be encouraged to breastfeed fully in the first month after delivery and therefore would receive the enhanced fully breastfeeding package (Food Package VII) in that first month. A fully breastfeeding woman would receive no formula for her infant from the WIC program, with a few exceptions during the first month postpartum. Generally starting at one month, a partially breastfeeding woman could receive up to half the maximum allowance for a fully formula-fed infant of the same age. If she requests and receives more than this maximum amount of formula, she would no longer be classified as breastfeeding for the purposes of assigning her food package. If the request were made before the end of the sixth postpartum month, she would be reclassified as a postpartum non-breastfeeding woman and switched to Package VI. If the request were made after the sixth postpartum month, the woman no longer would be certified for the WIC program.

Food Package VII, for fully breastfeeding women, provides the greatest variety and quantity of food; Food Package VI, for mothers of fully formula-fed infants, provides the least (Table 4-2). Compared with the current food packages (Table 1-1 in Chapter 1Introduction and Background), all three revised food packages for women provide smaller amounts of milk products, eggs, and juice; the same amount of iron-fortified cereal (now whole grain only); and fruits and vegetables as an addition. Whole grain bread or other whole grains have been added to Food Packages V and VII. The fat content of the milk cannot exceed 2 percent. The revised food packages for women allow several alternatives to cow’s milk for meeting calcium needs. Calcium- and vitamin D-rich soy beverage (“soy milk”) is allowed as an alternative to milk. Cheese, fat-reduced yogurt, and calcium-set tofu (tofu prepared with calcium salts) are allowed as partial substitutions for milk (up to 4 qt of milk in Food Packages V and VI; up to 6 qt of milk in Food Package VII). The current specifications for tuna are not changed. Light tuna, which the Food and Drug Administration and the

5  

Currently in the WIC program a woman is classified as breastfeeding if she is providing breast milk on the average of at least once a day. The committee considers this an inappropriate definition of breastfeeding for the purpose of assigning food packages. Thus, the committee proposes classifying a woman as breastfeeding for the purpose of assigning food packages if she requests no more than the maximum amount of formula allowed for partially breast-fed infants (see Table 4-1).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Environmental Protection Agency determined is sufficiently low in mercury to be safe for breastfeeding women (CFSAN, 2001; EPA/FDA, 2004) is allowed; but white tuna (albacore), which is higher in mercury content, is not. Other low-mercury fish options are included in Table 4-3 for participants preferring to avoid tuna (see Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages—for details).

Based on estimates of increased nutrient and energy needs of women pregnant with more than one fetus,6 the committee recommends that Food Package VII rather than Food Package V be used for such women. Further, the committee recommends that women who are fully breastfeeding twins be prescribed 1.5 times the maximum amounts of Food Package VII to cover their higher needs for energy and nutrients.7 In addition, the committee recommends that women partially breastfeeding twins or higher multiples be assigned to Food Package VII since their milk production would be comparable or perhaps higher than that of mothers breastfeeding one infant.

Recommendations for women with special dietary needs (currently covered by Food Package III) are discussed in a later section (Food Package III for Children and Women with Special Dietary Needs).

WIC Food Packages for Children

Overview of the Current Food Package for Children

Currently there is one package for children: Food Package IV for children ages 1 through 4 years. Food Package IV contains milk and cheese,

6  

Pregnancy—Nutritional needs of a pregnant women are increased when she is carrying more than one fetus (Luke, 2004). Using a method similar to that used by the Institute of Medicine (IOM, 2002/2005), Brown and Carlson (2000) estimate that, compared with the energy needs of women with singleton pregnancies, women bearing twins need an additional 150 kilocalories per day to support the recommended weight gain. The recommended intakes of most nutrients increase only a small amount (from no increase to about a 10 percent increase) for a singleton pregnancy (IOM, 2005b). The exceptions are iron, zinc, and iodine—for which recommended intakes are 1.4 to 1.5 times higher for pregnant than for nonpregnant women of the same age.

7  

Lactation—Based on the composition and expected volume of breast milk produced by a woman breastfeeding twins, she would need about 500 additional kilocalories and higher intake of many vitamins and minerals—a major exception being iron. Considering the nutrient content of proposed Food Package VII for breastfeeding women and the amounts of nutrients needed for milk production, prescribing 1.5 times the maximum amount of Food Package VII would help the woman breastfeeding twins meet her energy and nutrient needs. Moreover, it would help improve comparability of the value of packages for mother/infant combinations, especially considering that each twin is eligible to receive formula if that feeding method is chosen.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

vitamin C-rich juice, iron-rich breakfast cereal, eggs, and peanut butter or dry beans—all of which also are in the current food packages for women.

Revised Food Package for Children

The committee recommends continuing to provide Food Package IV to children, making a distinction in the fat content of milk provided at different ages. In particular, whole milk is specified for children age one year (12–23 mo of age), and milk with a fat content not to exceed 2 percent is specified for the older children (2 y of age and above). Compared with the current package, the revised food package includes smaller amounts of milk and juice but adds fruits, vegetables, and whole grains. Cheese and fatreduced yogurt are allowed as partial substitutes for milk (these dairy products may substitute for up to 4 qt of milk using the substitution rates in Table 4-2). Soy products (i.e., tofu, soy beverage [“soy milk”]) are not allowed as substitutions for milk in the children’s package except when prescribed in writing by a Recognized Medical Authority8 (RMA). Nutrition education may be needed to help parents or guardians guard against nutritional risk if they offer their child substitutes for milk.

These changes make the entire package more consistent with the Dietary Guidelines for Americans and provide a more balanced nutrient intake.

Food Package III for Children and Women with Special Dietary Needs

Overview of Current Food Package III

Currently, Food Package III is unique in that it provides special formula to children and women with special dietary needs. It also provides juice and breakfast cereal. (This package does not serve infants because the current Food Packages I and II provide for infants who have special dietary needs).

Revised Food Package III

The committee recommends that the unique aspect of Food Package III—the provision of special formula—be retained. However, the committee recommends changing the other foods contained in the package. In particular, the package should be restrictive only to the extent dictated by the participant’s health condition. A child should be allowed foods from

8  

The term Recognized Medical Authority is used to refer to a licensed physician, physician assistant, nurse practitioner, or other health professional specified by the WIC state agency to have the stated authority.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Food Package IV to the extent that those foods are compatible with the child’s special health needs. The same holds true for a woman and the package for which she ordinarily would be eligible. Thus, any foods contained in the food package that ordinarily would apply to that individual’s life stage are to be provided if suitable considering the participant’s special dietary needs. For example, even if a child with special dietary needs continues to receive infant formula from WIC beyond the first birthday; he or she would also receive any of the foods in the children’s food package (Food Package IV) in amounts appropriate for the child’s condition.

The committee also recommends that infants with special dietary needs be assigned to Food Package III, with maximum amounts of formula based on maximums for healthy infants of the same age and feeding method (i.e., fully formula-fed, partially breast-fed). The rationale for including infants in Food Package III is to consolidate all individuals with special dietary needs into one package to facilitate efficient management and tracking of the benefits and costs of providing supplemental foods to these participants.

Food Package III for Infants9The revised food package would include special formula that is documented to be medically necessary for an infant or infant formula in developmentally advanced forms (e.g., thickened). For infants 6 through 11 months of age with special dietary needs, if any foods included in Food Package II are appropriate for the infant, these foods would be provided as part of the food package.

Food Package III for Children—The revised package would include infant formula or special formula that is documented to be medically necessary for the child or formula in developmentally advanced forms (e.g., non-infant formula). If any foods included in the children’s package (Food Package IV) are appropriate for a child with special dietary needs, these foods would be provided as part of the food package.

Food Package III for Women—The revised package would include medical foods that are documented to be medically necessary for the woman. The committee is not recommending changes in the amounts of these medical foods provided in the current package. However, in cases in which any of the foods allowed in the food package for her life stage (Food Packages V, VI, or VII, as applicable) are appropriate for a woman with

9  

The committee is using the functional definition of an infant with special dietary needs from the federal regulation for exempt infant formula (U.S. Congress, 2004b; 21 CFR § 107, subpart C). This would be an infant who has an inborn error of metabolism, low birth weight, or who otherwise has a medical problem or dietary issue.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

special dietary needs, these foods would be provided as part of her food package.

DISCUSSION OF MAJOR CHANGES

The changes proposed to the WIC food packages respond to the criteria presented in Box 1-1Criteria for a WIC Food Package—in Chapter 1Introduction and Background—and discussed in Chapter 3Process Used for Revising the WIC Food Packages. The proposed changes will serve to make the WIC food packages more consistent with national and professional dietary guidance that promotes healthful diets. The first three topics covered relate specifically to contents of the food packages. The next three topics relate to ways in which the committee addressed major diet- and health-related issues. The final topic relates to flexibility and choice at the state and participant levels, respectively. The major changes the committee proposes for the revised WIC food packages are:

  • Including fruits and vegetables for all participants 6 months of age and older;

  • Including more whole grain products;

  • Reducing the amounts of saturated fat provided for participants two years of age and older (this also reduces the amounts of cholesterol and total fat provided);

  • Promoting and supporting breastfeeding, especially full breastfeeding;

BOX 4-1
Definitions of Food Instruments

  • Standard WIC Food Instrument—a check, voucher, electronic benefit transfer (EBT) authorization, or other payment method that is issued to the participant to obtain specific foods allowed under the WIC program. For a representation of a standard food instrument, see Figure F-1A in Appendix FSupplementary Information. In this report, the term food instrument applies only to the standard WIC food instrument.

  • Cash-Value Voucher—a check, voucher, or other payment method with a specific cash value (e.g., $1.00, $2.00) that can be used only to obtain fresh fruits and vegetables. See Figure F-1B in Appendix FSupplementary Information—for a representation of a cash-value voucher. In this report, the term cash-value voucher is not meant to indicate only a voucher method of payment. For example, an EBT authorization system could be programmed to serve as both the standard food instrument and the cash-value voucher.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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  • Addressing developmental needs of infants and young children;

  • Addressing obesity concerns; and

  • Providing more flexibility for WIC states agencies and more variety and choice for WIC participants.

Some of the specific recommendations discussed in this section deal with specification for the foods to be allowed in the revised food packages. These specifications are presented in Table 4-3 (Proposed Specifications for Foods) and in Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages—with additional detail.

Including Fruits and Vegetables in the WIC Food Packages

The single most fundamental change in the revised WIC food packages is the inclusion of a variety of fruits and vegetables in all packages for individuals 6 months of age and older. The forms vary from commercial baby food fruits and vegetables to fresh produce for children and women. Regardless of the form, the principle is consistent—to increase fruit and vegetable intakes by WIC participants. To facilitate participant choice in obtaining fresh produce, within WIC budget constraints, this option would involve issuing cash-value food instruments (such as vouchers, food-checks, or coupons). As an alternative, processed fruits and vegetables may be specified by WIC state agencies when fresh produce is limited and to allow the processed option to be chosen by participants who prefer processed forms.10 Using the specifications in Table 4-3 and other information, state agencies would identify specific processed fruits and vegetables to be included on lists from which participants could choose using the regular WIC food instrument. (See Box 4-1 to distinguish between standard food instruments and cash-value vouchers.) Because of greater participant choice, lower cost in many states, and potentially greater nutrient contribution from the fresh produce option, the committee encourages states to adopt that option to the extent possible.

Rationale for Adding Fruits and Vegetables

The addition of fruits and vegetables to WIC food packages is consistent with a major recommendation of the Dietary Guidelines for Ameri-

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The committee’s primary recommendation for Food Packages IV through VII includes fresh fruits and vegetable rather than processed forms because of the wider variety available in most locations and the lower salt (i.e., sodium) content of likely choices. For details on the sodium content of food packages, see Tables B-2A and B-3A in Appendix BNutrient Profiles of Food Packages.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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cans 2005 (DHHS/USDA, 2005)—namely, to increase daily intake of fruits and vegetables. The basis for that recommendation was the substantial body of literature that supports the association of fruit and vegetable consumption with reduced risk of chronic disease including stroke and perhaps other cardiovascular diseases (e.g., Bazzano et al., 2001, 2002), some cancers (e.g., WCFR/AICR, 1997; IARC, 2003), and type 2 diabetes (e.g., Ford et al., 2003). Evidence also suggests that increased fruit and vegetable consumption may be useful in programs to promote and sustain loss of body weight in overweight individuals (Stamler and Dolecek, 1997; Appel et al., 2003).

In addition, increased consumption of fruits and vegetables helps promote nutritional adequacy and may displace less nutritious items in the diet. Food consumption data show that fruits contribute more vitamin C than any other food group in the American diet, while vegetables contribute the greatest amount of vitamin A and potassium (DHHS/USDA, 2004). Fruits additionally provide more than 10 percent of total intake for 8 nutrients and vegetables for 15 nutrients (DHHS/USDA, 2004). Five of the priority nutrients identified by the committee (potassium, fiber, vitamin A, vitamin C, and folate) are high in commonly consumed fruits and vegetables. Fruits and vegetables are low in saturated fat, total fat, and sodium unless sources of these nutrients are added in processing.

Numerous studies have examined predictors of the acceptance, liking, and consumption of fruits and vegetables by children. The availability of fruits and vegetables in the household and the modeling of fruit and vegetable consumption by parents are the two most powerful predictors identified (Gibson et al., 1998; Kratt et al., 2000; Tibbs et al., 2001; Cullen et al., 2001, 2003; Fisher et al., 2002; Brown and Ogden, 2004; Cooke et al., 2004).

The committee received many public comments from health professionals, consumers, WIC program staff, and others advocating for the inclusion of fruits and vegetables in the WIC food packages. Importantly, two recent pilot studies provided cash-value vouchers for fresh fruits and vegetables to WIC participants (Herman, 2004; Runnings, 2004). In one pilot study, the cash value of the vouchers totaled $40—four times the amount per month being proposed by this Institute of Medicine (IOM) committee. Preliminary results of that study showed a high redemption rate for the cash-value vouchers (Herman, 2004). The experience from both pilot studies, albeit unpublished at the present time, indicated that providing fresh produce to WIC participants using cash-value vouchers (1) increased the intakes of fruits and of vegetables, (2) added variety to the diets of WIC participants, and (3) was highly acceptable to WIC participants of various ethnic/cultural backgrounds (Herman, 2004; Runnings, 2004). Abuse of the cash-value vouchers, if it occurred, was minimal. Thus, the committee

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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anticipates that the proposed addition of fresh fruits and vegetables will be a welcome addition to the food packages and will serve as an incentive for participation in the WIC program.

Specific Recommendations

Juice, primarily consumed as fruit juice, is part of the current food package for infants 4 months of age and over. In contrast, juice is not provided in the revised food packages for infants at any age and the quantity of juice is reduced in food packages for children and women. Deleting or reducing the quantity of juice in the set of food packages helps allow for the inclusion of whole fruits and vegetables while containing food costs. The reduction in the amount of juice provided for older children to about 4 ounces per day per day is consistent with the AAP recommendation for that age group (AAP, 2004). The AAP also notes that juice does not provide any additional nutritional benefit beyond that of whole fruit. The reduced amount of juice for women is consistent with the recommendation of the Dietary Guidelines 2005 that whole fruits be used for a majority of the total daily amount of fruit (DHHS/USDA, 2005).

For infants beginning at 6 months of age, the committee recommends the inclusion of commercial baby food fruits and vegetables and fresh bananas. Fresh bananas may be substituted for baby food fruits at the rate of approximately one fresh banana per four ounces of commercial product. To encourage or promote full breastfeeding, the recommended amounts of baby food fruits and vegetables are more generous for fully breast-fed infants than other infants as follows.

  • For fully breast-fed infants, approximately eight ounces of commercial baby food fruits and vegetables are provided per day.

  • For other infants, approximately four ounces of commercial baby food fruits and vegetables are provided per day.

These changes in Food Package II are based on several considerations. Baby food fruits and vegetables serve to introduce all older infants to new flavors and textures. For the fully breast-fed infants, they provide needed nutrients and also provide a nutritious food to mix with the pureed meat products (to improve their palatability and texture). Commercial baby foods allow targeting the food to the infant, and they are available in developmentally appropriate textures. The small size of the containers is compatible with food safety. That is, the food can be consumed within the safe storage period for refrigerated opened baby foods. The small size of the containers is also compatible with introducing the infant to a variety of foods and flavors over time. Substitution of banana for part of the commercial baby

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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food would need to be requested at the time of issuing the food package prescription in the WIC clinic. If chosen, banana would be specified on the standard food instrument.

For children and adults, three different types of fruit and vegetable offerings are proposed, as follows:

  1. Fresh Produce Option for Children and Women—Since few fresh fruits and vegetables are sold in uniform weight units with uniform bar codes, and their prices vary considerably across seasons, regions, and stores, they cannot be prescribed in quantity terms and still control the overall cost of the WIC food package. Thus, to implement the fresh produce option, the committee recommends the issuance of separate (small denomination, such as $2) cash-value vouchers at the level of $10 per month for adolescent or adult women and $8 per month for children. This corresponds to approximately 12 pounds and 10 pounds of fresh produce for women and children, respectively, or 1 to 2 servings per day. The committee recommends that any combination of fresh fruit or fresh vegetable—except white potatoes11—be allowed in quantities with a value up to the amount of the cash-value voucher(s).

  2. Processed Fruit and Vegetable Option for Children and Women— This would be handled with the WIC program’s standard food instrument system. There are several possible scenarios: (1) at the store, the client would be able to select preferred types among some alternatives listed on the food instrument or (2) with input from the client, the CPA would specify the types and amounts of processed fruits and vegetables selected from the list of choices allowed by the WIC state agency. (For specifications of allowable products from which the state agency could choose, see Table 4-3 and Table B-1 in Appendix BNutrient Profiles of Current and Revised Food Packages.) Seven 15-ounce cans of fruit and seven 14.5-ounce cans of vegetables would provide approximately the same the number of child-size servings that could be obtained with the proposed $8 fresh produce option for children. Nine 15-ounce cans of fruit and nine 14.5-ounce cans of vegetables would provide approximately the same number of adult-size servings that could be obtained with the proposed $10 fresh produce option for women.

  3. Combined Fresh and Processed Option for Children and Women— The WIC state agency could choose to allow a combination of fresh pro-

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Orange yams and sweet potatoes would be allowed. Some states may choose to exclude a very small number of other starchy vegetables if local use is very common. For example, specific state agencies might exclude white yams (ñame), a popular root crop among some Hispanic groups; the possible exclusion of ñame is likely to be important only in certain regions.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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duce and processed fruits and vegetables for those who request it. Doing this would entail a combination of cash-value vouchers and the use of the WIC program’s standard food instrument system. For example, the client might request cash-value voucher(s) for $6 worth of fresh produce and processed fruits and vegetables for the remainder.

Effects on Program Staff and Vendors of Adding Fruits and Vegetables

The committee anticipates that a number of adjustments will be necessary on the part of both program staff and vendors in order to implement the committee’s recommendations concerning fruits and vegetables.

At the WIC state agency level, the decision would be made regarding which of the three fruit and vegetable options would be allowed. State agencies also would need to determine which processed fruit and vegetable choices could be made available while controlling costs. The committee encourages state agencies to allow participants many choices within the processed option as well as the option for cash-value vouchers. This would promote acceptability of the foods by people of many different backgrounds. See the section Providing More Flexibility for WIC States Agencies and More Variety and Choice for WIC Participants.

Local WIC program staff, if allowed by the state agency, would issue separate food instruments for fresh and processed items (i.e., cash-value vouchers for fresh produce expressed in maximum dollar amounts; standard itemized food instruments for processed items expressed in maximum quantities). Any allocation of the fruits and vegetables into fresh or processed would have to be decided at the time the WIC food prescription is written. The inclusion of fruits and vegetables in WIC food packages will provide the necessity and the opportunity for participant education regarding choosing and using fruits and vegetables and using the cash-value voucher(s). See Chapter 7Recommendations for Implementation and Evaluation—for further recommendations concerning nutrition education.

It is anticipated that retail food vendors will sell more fresh fruits and vegetables as a result of the inclusion of these products in the children’s and women’s food packages. Because fresh produce is a relatively high margin department in retail food stores, this is expected to be a welcome change. Fruit and vegetable producers and distributors would benefit from increases in sales. There will, however, be some added vendor costs to implement this change. Examples follow.

  • Sales personnel in the produce section may need to spend time assisting shoppers to determine the cost of unpackaged fresh fruit and vegetable selections.

  • Checkout areas may be slowed initially if participants overestimate

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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or underestimate the cost of the fresh fruits and vegetables they select. (See Fresh Produce in the Workable Procedures section of Chapter 7Recommendations for Implementation and Evaluation—for suggestions on ways to resolve this problem.)

  • Retail food stores may have to program the computers that collect scanner data to be able to track the sales of food products to WIC recipients by type of payment (cash-value voucher versus standard itemized food instrument).

  • Small stores may need to increase the array of foods in the produce section.

  • Retail vendors that serve only WIC customers do not currently carry fresh fruits and vegetables, except possibly for carrots. They will need to change their operations to accommodate the sale of some fresh fruits and vegetables. This may involve new business licenses to meet health and safety regulations.

Except in very small stores, adding processed fruits and vegetables is not expected to pose an additional vendor burden beyond the staff training that will be required to accommodate additional items and choices recommended for the revised packages. Small stores may need to increase the array of foods on the shelves.

In public meetings held by the committee, various vendors commented on implementation issues relating to the sale of fresh (or processed) fruits and vegetables. They specifically asked that fresh produce be prescribed using a method that designates a dollar value (e.g., a cash-value voucher).

Including More Whole-Grain Products

The committee makes recommendations to include more whole grains in WIC food packages for women and children. This action responds to the new dietary guidance (DHHS/USDA, 2004; DHHS/USDA, 2005) to consume at least three servings per day of whole grains to reduce the risk of coronary heart disease and type 2 diabetes, to help with body weight maintenance, and to increase intake of dietary fiber. In particular, the committee recommends that allowed breakfast cereals for children and adults include iron-fortified whole-grain cereals only and that whole-grain bread (with allowable substitution of brown rice, oatmeal, bulgur, whole-grain barley, or soft corn tortillas) be included in the food packages for children and pregnant and breastfeeding women (Food Packages IV, V, and VII). State WIC agencies would use Table 4-3 (Proposed Specifications for Foods) and Table B-1 (Appendix BNutrient Profiles of Current and Revised Food Packages) and other resources to determine which types and brands of whole-grain products would be allowed.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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Reducing Saturated Fat and Limiting Cholesterol for Participants 2 Years of Age and Older

The committee took several steps to reduce the amount of saturated fat in the revised food packages for participants 2 years of age and older and to limit the amount of cholesterol in the food packages for women. The changes also reduce the amount of total fat provided by the packages. The intent is to be consistent with the current recommendations from Dietary Guidelines for children ages 2 through 4 years and for adult women: limiting saturated fat intake to less than 10 percent of food energy while keeping total fat intake within the range of 20 to 35 percent of food energy for adults, 25 to 35 percent of food energy for children 4 through 18 years, and 30 to 35 percent of food energy for children aged 2 through 3 years; and keeping dietary cholesterol intake below 300 mg per day (DHHS/USDA, 2005). This dietary guidance is based on substantial data showing that intakes of saturated fat greater than 7 to 10 percent of food energy are associated with increased risk for coronary heart disease and that dietary fat intake exceeding 35 percent of food energy may increase risk for overweight and obesity and often is accompanied by excessive saturated fat intake (IOM, 2002/2005; DHHS/USDA, 2004). Current food intake data show that average saturated fat intake is 11 to 13 percent of food energy (Briefel and Johnson 2004; Gleason and Suitor, 2001).

To reduce the saturated fat content of the food packages for children and women, the committee proposed several changes in recommendations for fluid milk. One is a modest reduction in the recommended maximum amounts of milk in packages for children and women. Another change, and perhaps the most fundamental, is that the revised food packages specify reduced-fat, low-fat, or nonfat fluid milk (i.e., maximum of 2 percent milk fat)12 for children 2 years and older and for adult women. Whole milk (3.5 to 4 percent milk fat) is a major source of saturated fat in the diet, contributing almost one-third of saturated fat intake in the United States (Cotton et al., 2004). Furthermore, a recent IOM report on reducing exposure to dioxins and similar compounds through the food supply specifically recommended the substitution of fat-reduced milk for whole milk in government-sponsored feeding programs for children (including school feeding programs and the WIC program), in order to reduce the exposure to these compounds that occurs through consumption of animal fat (IOM, 2003b).

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The committee is using terminology as required on labeling for milk and milk products (FDA, 1998). Reduced-fat has up to 2 percent milk fat, low-fat has up to 1 percent milk fat, and nonfat is skim or fat-free. The term fat-reduced is used to refer to all varieties with 2 percent or less milk fat.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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The maximum amount of cheese allowed has also been reduced in the revised food packages. At present the packages allow up to four pounds of cheese (current Food Packages IV–VI) and five pounds in the current Food Package VII. The committee proposes a maximum of one pound of cheese in revised Food Packages IV–VI and two pounds in the revised Food Package VII. Reducing the maximum amount of cheese reduces the amount of saturated fat, total fat, and cholesterol.

The revised food packages for children and women provide less cholesterol than the current package because they provide fewer eggs, but the major reason for decreasing the quantity of eggs was to help make it possible for the packages to provide a wider variety of foods. This revision is consistent with current dietary guidance on cholesterol intake from the IOM (i.e., that cholesterol intake be as low as is consistent with a nutritionally adequate diet) (IOM, 2002/2005) and the Dietary Guidelines for Americans 2005 (i.e., that cholesterol intake be below 300 mg/d) (DHHS/USDA, 2005). The quantity of eggs provided by the revised packages is comparable with the average amount of eggs consumed by children who are participating in the WIC program (Oliveira and Chandran, 2005).

Promoting and Supporting Breastfeeding

The committee placed emphasis on developing food packages that could promote and support breastfeeding. Reasons for this emphasis include the following:

  • Breastfeeding provides substantial short- and long-term health benefits for the infant and the mother. Infant feeding recommendations are summarized in Chapter 2Nutrient and Food Priorities—of this report.

  • Breastfeeding objectives are part of Healthy People 2010 (DHHS, 2000b), and WIC participants lag behind the general population in progress toward meeting those objectives (see Chapter 2Nutrient and Food Priorities).

  • The Surgeon General issued the HHS Blueprint for Action on Breastfeeding in 2000, introducing it with the statement, “Breastfeeding is one of the most important contributors to infant health” (OWH, 2000).

  • Breastfeeding rates in the hospital and at 6 months for WIC infants are about 20 percentage points lower than for non-WIC infants (Ryan, 1997; Ryan et al., 2002; Ahluwalia et al., 2003).

  • The charge to this IOM committee included consideration of the role of WIC food packages in reinforcing breastfeeding (see Chapter 1Introduction and Background).

  • Numerous public comments submitted to the committee expressed the need to encourage breastfeeding.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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A study by Chatterji and Brooks-Gunn (2004) on participation in the WIC program and the initiation and duration of breastfeeding, using linked data on mothers and children from the Fragile Families and Child Well-Being Study, concluded that the WIC program faces a difficult challenge in encouraging low-income mothers to breastfeed while also providing formula.

Recognizing the challenge of designing WIC food packages that would support breastfeeding, the committee proposed a three-pronged approach that is more comprehensive than the current approach. (Currently, the regulations simply provide breastfeeding women with food packages for up to 12 months [rather than up to 6 months] and provide an enhanced package for fully breastfeeding women.) In particular, the proposed approach focuses on the market value of the package for the mother/infant pair for the entire first year after birth, addresses differences in supplementary nutrition needs of breast-fed and formula-fed infants, and considers how to minimize early supplementation with formula. Because the proposed changes are substantial and untested, the committee also calls for pilot studies before full-scale implementation.

Market Value of the Packages for the Mother/Infant Pair

Proposed changes to help support breastfeeding address packages for the infant as well as the mother since both the new mother and the infant ordinarily are eligible to receive a WIC food package. From a mother’s point of view, the dollar value of the current food packages provided to formula-feeding mother/infant pairs is substantially greater than that of the packages for the fully breastfeeding pairs, especially during the first six months postpartum. Because of differences in the market (pre-rebate) value of food packages, mothers may perceive the current food packages for the partially breastfeeding pair to be the most attractive option and the food packages for fully breastfeeding pairs to be the least attractive.13 The food package cost evaluation conducted by this committee (see Chapter 5Evaluation of Cost) validates this perception.

Some evidence suggests that attractive packages for fully breastfeeding mother/infant pairs might act as an incentive for breastfeeding. In the WIC Infant Feeding Practices Study of 1997, breastfeeding women were asked if they knew about the special package for breastfeeding women who did not accept formula from the WIC program (Bayder et al., 1997). (See Table 1-1,

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The difference is less apparent when examining costs to the WIC program because infant formula rebates reduce the cost borne by the program (Tuttle and Dewey, 1996).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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Chapter 1Introduction and Background, for a description of the current enhanced breastfeeding package—the enhancements being the inclusion of both dry beans and peanut butter, cheese [in addition to cheese as a substitute for milk], carrots, canned tuna, and additional juice.) Women who knew about the enhanced package were 27 percent less likely to discontinue breastfeeding than women who were unaware of such a package (Bayder et al., 1997). This gives support for the committee’s effort to increase the attractiveness of the contents of the food packages for the fully breastfeeding mother/infant pairs while decreasing the relative pre-rebate values of the food packages for partially breastfeeding pairs and fully formula-feeding pairs. The market value cost comparisons for the proposed packages for mother/infant pairs appear in Chapter 5Evaluation of Cost, Table 5-5.

In comparing the revised food packages for infants at least age 6 months of age, the food package for fully breast-fed infants (Food Package II-BF) provides twice the amount of commercial baby food fruits and vegetables provided by the packages for infants who receive formula (Food Packages II-BF/FF and II-FF). The food package for fully breast-fed infants (Food Package II-BF) also provides commercial baby food meat, a good source of iron and zinc.

Compared with the revised Food Package VI for fully formula-feeding mothers, the revised Food Package VII for fully breastfeeding mothers provides more milk and eggs; it also provides canned fish, whole grains, cheese (in addition to cheese as a substitute for milk), and both dry beans and peanut butter (Table 4-2).

Differences in Nutritional Needs

The differences in the packages for the mother/infant pairs are based on differences in nutritional needs—not just on relative cost. Thus, the package for fully breastfeeding women provides the most food energy and nutrients, and the package for fully formula-feeding women provides the least (see Tables B-2A through B-2E in Appendix BNutrient Profiles of Current and Revised Food Packages). Similarly, starting at the age of 6 months, the proposed package (Food Package II-BF for fully breast-fed infants) includes commercial baby food meats to add iron and zinc. As listed in Table 2-10 (Chapter 2Nutrient and Food Priorities), intakes of iron and zinc need to be increased for fully breast-fed infants but not for formula-fed infants ages 6 through 11 months.14

Chemical analyses of breast milk at various stages of lactation indicate

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Data supporting this statement are presented in Table 2-1 (Chapter 2Nutrient and Food Priorities) and in Table C-2C (Appendix CNutrient Intake of WIC Subgroups).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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that iron and zinc contents are low in comparison with the needs of infants ages 6 through 11 months (Krebs, 2000; Dewey, 2001; Krebs and Westcott, 2002). Since the iron and zinc contents of breast milk are not dependent on the mother’s mineral status, an older breast-fed infant needs appropriate complementary foods that will supply these minerals (Domellöf et al., 2004). Baby food meats serve this purpose.

Minimizing Early Supplementation

Proposed Policy Change Related to Initial Food Package Options for Mothers/Infant Pairs After Delivery—Because early supplementation with formula may contribute to the short duration of breastfeeding of those who choose to breastfeed, the committee recommends that only two infant feeding options be offered initially after delivery—either full breastfeeding or full formula feeding—and that WIC staff continue or increase their efforts to encourage and support breastfeeding. Women who choose to breastfeed, whether they intend to continue fully breastfeeding or intend to move to partial breastfeeding, would receive the enhanced fully breastfeeding food package (Food Package VII) for the first month after delivery. (If a mother knew she would need to change to partial breastfeeding at month one or later—because of employment, for example—she could arrange for that when initially certified.)

Under this approach, infant formula would not be provided to breastfed infants during the first month after birth, but peer counseling, consultation with a lactation specialist, breast pumps, or other support for breastfeeding would need to be readily available. If a breastfeeding mother contacts the local WIC clinic to request formula during the first month, a desirable approach would be for the clinic to provide additional breastfeeding support and/or counseling with a peer counselor, lactation consultant, or qualified health educator with breastfeeding expertise. If appropriate, the mother may receive up to the maximum amount of formula in Food Package I-BF/FF-A for fully formula-fed infants (with the amount adjusted to the number of days remaining in the first month). The food package assignments could change after the first month. For example, a breastfeeding mother could ask to have her infant assigned to the partially breast-fed category (Food Package I-BF/FF). In this case, the mother would be assigned to Food Package V.

Basis for Policy Change—Evidence for the recommended policy change relates to the physiology of breastfeeding and studies involving the provision of supplemental formula to breastfeeding women. Physiology provides a strong basis for avoiding supplemental formula. The amount of milk a breastfeeding woman produces depends directly on how often and how

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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long she nurses. If the infant is hungry and needs to nurse often to get enough milk, the mother will begin to produce more milk to meet the demand. Because of this, guidance for new breastfeeding mothers encourages them to nurse often—8 to 12 feedings every 24 hours and for as long a period as the infant remains at the breast (AAP, 2005). Providing supplemental formula to a new breastfeeding mother may interfere with her milk production and success at continued breastfeeding.

In a number of studies among diverse groups, full breastfeeding in the neonatal period (or delayed introduction of formula) has been positively associated with longer duration of breastfeeding (Hill, 1991; Novotny et al., 2000; Whaley et al., 2002; Ekström et al., 2003; Chapman et al., 2004). Some of these studies were conducted in WIC settings (Hill, 1991; Novotny et al., 2000; Whaley et al., 2002). Ekström and colleagues (2003) found that supplementation without a medical reason decreased the prevalence of full breastfeeding and the duration of any breastfeeding. They suggest that lack of self-confidence in breastfeeding ability may be a key factor explain-ing the negative effects on breastfeeding duration of supplementing with formula for nonmedical reasons.

The committee did not find any interventions that examined the effects of delaying formula in the WIC setting. However, a review of nine randomized, controlled trials (involving a total of 3,730 women) found that providing hospital discharge packs that contained formula reduced the rates of full breastfeeding at all follow-up time points but did not influence early termination of breastfeeding (Donnelly et al., 2000). In retrospective and prospective studies, the receipt of formula in hospital discharge packs is negatively related to breastfeeding duration (Gross et al., 1998).

Recommended Studies

The committee’s intent was to recommend food packages and policies that would promote the establishment of successful long-term breastfeeding among women who choose that feeding method. Because effects of these changes in the food packages and initial infant feeding options on initiation and duration of breastfeeding are unknown, the committee strongly recommends comprehensive pilot testing before full-scale implementation of these changes. Elements of such pilot tests are presented in Chapter 7Recommendations for Implementation and Evaluation.

Addressing Developmental Needs of Infants and Young Children

The revised food packages consider specific developmental and physiological needs through the amounts of infant formula provided, the types

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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and timing of availability of complementary foods, and the requirement for whole milk for 1-year-old children.

Amounts of Infant Formula Provided

Fully Formula-Fed Infants—For fully formula-fed infants birth through 3 months of age (Food Package I-FF-A), the amount of formula provided is not changed from the current Food Package I. The maximum allowance of 403 fluid ounces of formula concentrate (26 fl oz of formula per day)15 provides approximately 530 kilocalories per day, which is nearly the same as the mean Estimated Energy Requirement (EER) of 555 kilocalories per day for formula-fed WIC infants birth through 3 months of age (see Appendix BNutrient Profiles of Current and Revised Food Packages for detailed information).

For fully formula-fed infants 4 through 5 months of age (Food Package I-FF-B), the committee recommends increasing the maximum amount of formula to 442 fluid ounces of formula concentrate per month. The slightly increased amount provides an additional 2.5 fluid ounces of formula per day and brings the total food energy to 581 kilocalories per day. This amount of food energy equals 93 percent of the mean EER for infants 4 through 5 months of age (623 kilocalories per day) and 88 percent of the maximum food energy provided by the current Food Package II (for infants 4–11 mo of age).16 (See Appendix B for detailed information.) Thus, compared with the current Food Package II, the revised Food Package I-FF-B provides slightly less energy to infants 4 through 5 months of age. The seeming contradiction (fewer calories despite more formula) is explained by the exclusion of juice and cereal from the revised food package for infants 4 through 5 months of age. In the current Food Package II, the juice and cereal provide about 134 kilocalories per day (see Appendix B for detailed information). The revised infant food packages provide essential nutrients without providing excess food energy and reinforce the nutrition education message to initiate the routine feeding of complementary foods beginning around six months of age (AAP, 2004, 2005). For fully formula-fed infants ages 6 through 11 months (Food Package II-FF), the proposed amount of

15  

Factor for days per month—In keeping with the apparent assumptions used in various FNS documents, the committee used the factor of 31 days per month for calculations involving nutrients provided for infants. For all other participants, the committee used the factor of 30 days per month. For standard use, formula concentrate is diluted with an equal amount of water. Thus, 13 fluid ounces of formula concentrate reconstitutes to 26 fluid ounces of formula. A 13-fluid ounce can of infant formula concentrate is a common unit for purchase.

16  

Substitution for powdered formula—See Table B-6 in Appendix BNutrient Profiles—for the amounts of powdered formula that would be allowed.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

formula is reduced to 312 fluid ounces of formula concentrate per month; the rationale is to provide an increasing amount of nutrients through complementary foods while reducing intake of formula.

Partially Breast-Fed Infants—The amounts of formula provided for partially breast-fed infants mirrors the amounts provided for fully formula-fed infants with the following important differences: (1) the partially breastfed option in not available in the first month postpartum—in order to promote breastfeeding as explained elsewhere; (2) the maximum amount provided approximates half of the amount provided to fully formula-fed infants—to provide about half of the infant’s nutritional needs to encourage the mother to breastfeed enough to provide at least half of the infant’s nutritional needs; and (3) powdered formula is recommended during ages 1 through 3.9 months—to promote food safety and discourage waste as explained elsewhere.

The revised infant food packages provide essential nutrients, limit food energy, and reinforce the nutrition education message to initiate the routine feeding of complementary foods beginning around 6 months of age (AAP, 2005).

Changes in the Types and Timing of Availability of Complementary Foods

The committee recommends that the WIC program not provide complementary foods until the infant is 6 months of age. This is the age at which most healthy infants are developmentally ready to handle complementary foods (Hammer, 1992; Morris and Klein, 2000; Naylor and Morrow, 2001). Infants ordinarily do not need complementary foods for nutritional reasons at younger ages—either breast milk or iron-fortified infant formula would entirely meet the nutritional needs of most infants (Brown et al., 1998; Dewey, 2001; Domellöf et al., 2001; Griffin and Abrams, 2001; Butte et al., 2002; WHO, 2001a, 2001c, 2002; Habicht, 2004). There are some exceptions in which nutrient supplementation is recommended.17 The committee’s intent is to design food packages that address the nutritional

17  

Infants who will be fully breast-fed should receive vitamin K supplementation within the first six hours after birth (AAP, 2004, 2005). Infants who have inadequate iron stores (e.g., were born preterm, had low birth weight, have hematological disorders) generally require iron supplementation before 6 months of age (AAP, 2004, 2005). Vitamin D supplementation is recommended for fully breast-fed infants (and partially breast-fed infants if receiving less than 17 fluid ounces of iron-fortified formula per day) (AAP, 2004, 2005). Additional supplementation may be required for infants born preterm (see Schanler, 2001) or in underdeveloped countries (Greer, 2001).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

needs of most rather than all infants. The committee’s recommendation to provide complementary foods beginning at age 6 months is consistent with the most recent dietary guidance on complementary feeding (AAP, 2005; WHO, 2002; Kramer and Kakuma, 2002, 2004) and common guidelines for clinical practice in the field of pediatrics (Hendricks et al., 2001; Morris and Klein, 2000; AAP, 2001c; Rudolph and Rudolph, 2003).18

To make possible the gradual introduction of a variety of fruits and vegetables, the committee recommends the deletion of fruit juice and the addition of commercial baby food fruits and vegetables and fresh bananas to Food Package II for infants ages 6 months and older. The allowed foods span the range of textures appropriate for infants at different stages of development. To provide iron and zinc in forms with high bioavailability to meet the needs of fully breast-fed infants, the committee recommends the addition of commercial baby food meats for fully breast-fed infants beginning at age 6 months (Food Package II-BF). The package for fully breast-fed infants also provides additional baby food fruits and vegetables; the rationale is to provide additional nutritional value to improve the parity with other infant packages, to provide sufficient fruits and vegetables to mix with baby food meats to increase the palatability of strained meats for older infants, and to encourage prolonged breastfeeding by adding to the convenience and monetary value of the food packages of the fully breastfeeding mother/infant pair.

The recommendations for the milk fat content are consistent with AAP recommendations of whole milk for children who are one year of age and fat-reduced milk for older children (AAP, 2004). The exclusion of dried fruit from the processed fruit and vegetable options for children (see Table 4-3) is intended to reduce the risk of choking posed by that form of fruit (AAP, 2004).

Addressing Obesity Concerns

Overweight and obesity in children and adults largely outranks undernutrition as a significant public health concern (DHHS/PHS, 1988; NRC, 1989a; IOM, 1991, 2004a; Kessler, 1995; Koplan and Dietz, 1999; Mokdad et al., 1999, 2000, 2004, 2005; DHHS, 2001). Moreover, prevalences of overweight and obesity are especially high in subpopulations that are overrepresented in the WIC population (Flegal et al., 2002, Kumanyika et al., 1999; Paeratakul et al., 2002; Wardle et al., 2002).

18  

Some parents may choose to feed their infants complementary foods before the age of 6 months, but the committee did not find a developmental or nutritional rationale to provide complementary foods in the WIC food package before age 6 months.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Thus, the committee considered ways that redesign of the WIC food packages could help promote healthy body weight for WIC participants. In doing so, the committee kept in mind a number of key points:

  • Although many factors contribute to overweight and obesity, the ultimate cause is positive energy balance (Koplan and Dietz, 1999; IOM, 2004a).

  • If maintained over time, small changes in energy intake can lead to substantial gain in body weight. For example, it is estimated that most of the U.S. population could maintain a healthy body weight by a change in energy balance of 100 kilocalories per day (Hill et al., 2003)—that is, by decreasing daily intake by 100 kilocalories, increasing daily energy output by 100 kilocalories, or some combination.

  • Infancy may be a critical period for preventing the development of overweight during childhood (Whitaker et al., 1997; Ong et al., 2000; Law et al., 2002; Stettler et al., 2002) and its long-term consequences (Whitaker et al., 1997; Law et al., 2002).

  • Some evidence suggests that reducing the consumption of sweet drinks, including fruit juice, may be helpful in managing the body weight of preschool children (Welsh et al., 2005).

The committee’s recommended changes to the WIC food packages support small reductions in total food energy and improvements in nutrient density. The emphasis is on nutrient-dense foods and beverages and limitations on added sugars for all, and an increase in fiber and decrease in saturated fat content of the packages for children and women. Compared with the current food packages, the revised food packages for infants provide less food energy after the age of four months (except for fully breastfed infants). The food packages for children and women provide somewhat less milk, cheese, eggs, and juice; and, for those age two years and older, milk cannot exceed 2 percent milk fat. The addition of fruits and vegetables and the emphasis on whole grains are consistent with recommendations for food patterns that may contribute to a healthy body weight. Together with nutrition education, the proposed WIC food packages can play an important role in promoting optimal pregnancy weight gain, postpartum weight status, and healthy growth of children.

The revised food packages are designed to encourage breastfeeding and thus may contribute to a reduced risk of overweight in children. In a recent review, Dewey examined 11 studies and found that 8 of the studies demonstrated a moderate but significant protective effect of breastfeeding against overweight in childhood and adolescence (Dewey, 2003). Moreover, a recent prospective study of mother/infant pairs found that the combined effects of short duration of breastfeeding and early introduction

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

of solid foods are associated with significantly greater infant weight gain, from birth to one year, especially among infants born to overweight mothers (Baker et al., 2004). Based on this evidence, extending the duration of breastfeeding and delaying the introduction of solid foods would appear to be appropriate strategies for early prevention of overweight in young children.

In summary, the subpopulations served by the WIC program are at risk for the development of overweight and obesity. It is important to address issues of a healthy body weight during the life stages of WIC participants. The proposed WIC food packages provide a variety of nutrient-dense foods in moderate amounts and can contribute to developing healthy eating patterns, reinforcing nutrition education, and promoting positive changes in dietary behaviors.

Providing More Flexibility for WIC States Agencies and More Variety and Choice for WIC Participants

The cultural diversity and heterogeneity of the WIC participant population pose special challenges for a supplemental nutrition program. Many public comments called for more options among allowed foods—both to improve incentives for participation in the WIC program and to increase consumption of the foods provided. In proposing revisions, therefore, the committee recommends increases in the types and total number of allowed foods. Table 4-3 lists proposed specifications that give the state agencies more flexibility in determining which food items they will allow. The committee urges WIC state agencies to allow the participants as much variety and choice of foods from Table 4-3 as is feasible considering cost constraints and availability of foods in grocery outlets common to the region. Providing more variety and choice will facilitate the tailoring of food packages to specific situations, especially for different ethnic or cultural groups. Two food categories merit special attention in this regard: fruits and vegetables and milk and milk products. Other areas of increased choice include the form of dry beans and peas (either dry-packaged or canned), more types of fish (see Table 4-3), and whole grain options.

Fruits and Vegetables

The committee recommends a great deal of flexibility for state agencies and the opportunity for variety and choice for participants within the proposed fruit and vegetable category of the food packages. This recommendation is based on three considerations.

  • The availability, cost, and quality of different forms of fruits and vegetables vary substantially among states, territories, and tribal agencies.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

These characteristics range from (a) markets with a wide variety of fresh produce that is abundant year-round with little seasonal variation to (b) markets with a very limited selection of fresh produce, possibly only seasonally, but with some variety (e.g., the most popular selections) of fruits and vegetables available in canned or frozen forms. WIC state agencies would determine if and when the fresh produce option would be available (e.g., certain months of the year). The committee encourages the WIC state agencies to allow participants to select from a wide variety of processed fruits and vegetables for the processed option.

  • The Dietary Guidelines for Americans 2005 recommends the consumption of a variety of nutrient-dense foods within and among the basic food groups and staying within energy needs (DHHS/USDA, 2005). The recommendation is based on evidence that dietary variety within food groups is related to dietary adequacy for both adults and children (Krebs-Smith et al., 1987; Cox et al., 1997; Foote et al., 2004). Variety and choice at the participant level directly addresses recommendations in the Dietary Guidelines (DHHS/USDA, 2005). Although there is some evidence that participation in the WIC program is associated with greater dietary variety than is nonparticipation among low-income children, dietary variety generally is low among children in low-income families (Knol et al., 2004).

  • Choice at the participant level also responds to this IOM committee’s Criterion 4 (which addresses the suitability of forms of food) and Criterion 6 (which addresses the acceptability of the foods for people of different cultural backgrounds).

The committee recognizes that nutrient content varies widely across individual items within the fruit and vegetable groups. Allowing choice at the participant level makes it impossible to ensure that the selections made will provide a specified amount of nutrients. This is especially applicable to the fresh produce option. However, the limited available evidence from pilot studies shows that, when provided with a fresh fruit and vegetable supplement to the WIC food package, participants chose a wide variety of different items (Herman, 2004; Runnings, 2004). Allowing choice increases the likelihood that a food will be consumed. The committee identified individual participant choice and variety as priorities, especially within this proposed food category. Choice holds potential to provide incentives for participation, improve acceptability of foods offered across a diverse set of cultural backgrounds, and promote long-term healthy eating patterns. The only restriction the committee placed on the choice of fruits and vegetables is not to allow white potatoes (that is, disallow potatoes other than orange yams and sweet potatoes). The committee based this restriction on the amounts suggested in the USDA Food Guide for consumption of starchy vegetables (DHHS/USDA, 2005), food intake data indicating that consumption of

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

starchy vegetables meets or exceeds these suggested amounts (Krebs-Smith et al., 1997; FSRG, 1999; Smiciklas-Wright et al., 2002; Briefel et al., 2004b), and food intake data showing that white potatoes are the most widely used type of vegetable (Krebs-Smith et al., 1997; FSRG, 1999; Cavadini et al., 2000, Smiciklas-Wright et al., 2002; Briefel et al., 2004b).

Milk Products

Although milk and milk products provide the most concentrated source of calcium in the U.S. diet, a high prevalence of lactose maldigestion and low cultural acceptability have been widely cited as reasons for the low consumption of dairy products among people of color (Pobocik et al., 2003; Auld et al., 2002; Jackson and Savaiano, 2001; Horswill and Yap, 1999; Story and Harris, 1989; Fishman et al., 1988). Studies show that women of color of childbearing age, particularly Asians and African Americans, are especially at risk for low intakes of dietary calcium (Siega-Riz and Popkin, 2001; Klesges et al., 1999; Wu-Tso et al., 1995). Milk and cheese are not a part of traditional food patterns of many cultural groups (NAWD, 2000; NWA, 2003; Kittler and Sucher, 2004). In public comments, yogurt, soy beverage (“soy milk”), and tofu were frequently requested calcium-rich options (NWA, 2003). For a variety of reasons, individuals with lactose maldigestion are able to tolerate yogurt better than milk (Kolars et al., 1984; Savaiano et al., 1984; Smith et al., 1985; Lerebours et al., 1989; Martini et al., 1991; Wynckel et al., 1991; Kotz et al., 1994, Galvão et al., 1995, 1996).

In the U.S. diet, fluid milk is an important source of vitamin D, a fatsoluble vitamin. The U.S. supply of fluid milk is fortified with vitamin D to prevent rickets on a population-wide basis. However, most other milk products are not fortified with vitamin D. If milk is replaced by milk products or other alternatives that are not vitamin D fortified, vitamin D intakes may be inadequate. Thus, replacements for milk are to be approached with caution even if they are rich in calcium.

For the reasons discussed in the two preceding paragraphs, proposed allowed foods include fat-reduced yogurt as a partial substitute for fluid milk for children and women, calcium-set tofu (tofu prepared with calcium salts) as a partial substitute for milk for women, and calcium- and vitamin D-rich soy beverage (“soy milk”) as an alternative for all or part of the fluid milk for adult women.19 These new choices may be viewed by some

19  

Soy products (i.e., tofu, soy beverage [“soy milk”]) are not allowed as substitutions for milk in the children’s package except when prescribed in writing by an RMA. Through nutrition education, parents or guardians should learn that children are at nutritional risk when milk is replaced by other foods.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

participants as more acceptable sources of calcium (and vitamin D in some cases) for WIC participants with milk allergies and lactose maldigestion and for those who avoid milk for cultural, religious, or other reasons. To maintain the nutritional content and cost neutrality of the food packages, some substitutions for milk (i.e., yogurt, calcium-set tofu) are allowed in limited amounts. These limitations can be waived in cases of lactose intolerance or other medical conditions when prescribed in writing by an RMA.

SUMMARY

The IOM Committee to Review the WIC Food Packages proposed changes in the amounts and kinds of foods in all seven food packages. In doing so, the committee gave special attention to revising the food packages to:

  • Include fruits and vegetables for all participants 6 months of age and older;

  • Include more whole-grain products;

  • Reduce the amount of saturated fat for participants 2 years of age and older;

  • Promote and support breastfeeding, especially full breastfeeding;

  • Address the developmental needs of infants and young children;

  • Address obesity concerns; and

  • Provide more flexibility for the WIC states agencies and more variety and choice for the WIC participants.

Additionally, the committee recommends that the revised food packages be provided in full, except to the extent that the packages are tailored to the needs of individual WIC participants.

The proposed changes consider current recommendations for nutrient intakes and dietary patterns, the major diet-related health problems and risks faced by this population, the characteristics of the WIC program, and the diversity of the WIC-eligible population. The proposed changes will serve to make the WIC food packages more consistent with national and professional dietary guidance and more consistent with nutrition education messages that promote healthful diets for the WIC population. The revised WIC food packages have the potential to address current nutrient inadequacies and excesses, to address current discrepancies between dietary intake and dietary guidance described by food groups, and to address current and future diet-related health problems in the nation’s population.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

TABLE 4-3 Proposed Specifications for Foods in the Revised Food Packagesa

Category/Food

Participant Group

Allowed Foods and Minimum Requirements

Infant Foods

Infant formula

Infants,

0–11.9 mo

Iron-fortified infant formula. (No change from current specifications.)

Infant cereal

Infants,

6–11.9 mo

Iron-fortified infant cereal, instant. (No change from current specifications.)

Baby food fruits and vegetables

Infants,

6–11.9 mo

Commercial baby food fruits and vegetables without added sugars, starches, or salt (i.e., sodium)—Texture may range from strained through diced.

Fresh banana may replace up to 16 oz of baby food fruit at a rate of 1 lb of bananas per 8 oz of baby food fruit.

Baby food meats

Fully breast-fed infants only, age 6–11.9 mo

Single major ingredient, commercial baby food meat; without added sugars, starches, vegetables, or salt (i.e., sodium)—Texture may range from strained through diced.

Fruits and Vegetables

Juice

Children and women

No change from current specifications.

Fresh fruits and vegetables

Children and women

Any variety of fresh whole or cut fruits, without added sugars

Any variety of fresh whole or cut vegetables except white potatoes (orange sweet potatoes and yams are allowed), without added sugars, fats, or oils

Variety in choices should be encouraged through nutrition education.

Processed fruits and vegetables

Children and women

Any variety of canned fruits, juice pack or water pack, without added sugars—Any variety of frozen fruits, without added sugars

Any variety of canned or frozen vegetables except white potatoes (orange sweet potatoes and yams are allowed), without added sugars, fats, or oils—Soups and condiments such as catsup, pickles, and olives are excluded.

Variety in choices should be encouraged through nutrition education.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Category/Food

Participant Group

Allowed Foods and Minimum Requirements

 

Women only

Any variety of dried fruits, without added sugars, fats, oils, or salt (i.e., sodium).

Milk and Alternatives

Milk, whole

Children (age 1–1.9 y)

Only whole milk is allowed for 1-y-old children.

Milk, fat-reduced

Children (age ≥ 2 y) and women

No more than 2% milk fat allowed.

Cheese

Children and women

No change from current specifications.

The committee does not recommend any substitutions for cheese in Food Package VII.

Yogurt, fat-reduced

Children and women

Plain or flavored; 17 g of total sugars per 100 g yogurt—Yogurt for those age 2 y and older may not contain more than 2% milk fat.

Soy beverage

Women

Soy beverage (“soy milk”) must be fortified to contain nutrients in amounts similar to cow’s milk.

Tofu

Women

Calcium-set tofu (prepared with only calcium salts [e.g., calcium sulfate]). May not contain added fats, oils, or sodium.

Grains

Cereal

Children and women

Ready-to-eat cereals and hot cereals (instant, quick- and regular-cooking) must be whole grain (e.g., a minimum of 51% of the grain in the product must be whole grains) and conform to other current specifications (e.g., must be iron-fortified, must not exceed added sugars limitations).

Whole-grain bread

Children and women except non-breastfeeding postpartum women

Bread must conform to FDA standard of identity for whole wheat bread (i.e., a minimum of 51% of the grain in the product must be whole grains).

or

Bread must meet labeling requirements for making a health claim as a “whole-grain food with moderate fat content” (i.e., a minimum of 51% of the grain in the product must be whole grains).

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
×

Category/Food

Participant Group

Allowed Foods and Minimum Requirements

Other whole grains

 

Brown rice, bulgur, oatmeal, barley; without added sugars, fats, oils, or salt (i.e., sodium)—May be instant-, quick-, or regular-cooking.

Soft corn or whole wheat tortillas without added fats or oils could be allowed.

Meat and Alternatives

Eggs

Children and women

No change from current specifications.

Hard boiled eggs, where readily available in small quantities, may be provided for participants with limited cooking facilities.

The committee does not recommend any substitutions for eggs.

Fish, canned

Woman, fully breastfeeding (VII)

New options include canned salmon and other canned fish that do not pose a mercury hazard as identified by advisories from the FDA or EPA. Pack may include bones and skin as indicated by FDA standard of identity or USDA commercial item description.

Legumes

Children and women

Any variety of mature dry beans, peas, or lentils in dry-packaged (i.e., dried) or canned forms; without added sugars, starches, or fats—Canned legumes may be regular or lower in sodium content.

Baked beans may be provided for participants with limited cooking facilities.

Peanut butter

Children and women

No change from current specifications.

aSee Table B-1 (Appendix-BNutrient Profiles of Current and Revised Food Packages) for detailed specifications. Any processed foods for children and adults may be regular or reduced in sodium content unless otherwise specified. For the purposes of this specifications table, the term canned refers to processed food items in cans or other shelf-stable containers.

NOTES: EPA = U.S. Environmental Protection Agency; FDA = Food and Drug Administration; USDA = U.S. Department of Agriculture.

Suggested Citation:"4 Revised Food Packages." Institute of Medicine. 2006. WIC Food Packages: Time for a Change. Washington, DC: The National Academies Press. doi: 10.17226/11280.
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The Special Supplemental Nutrition Program for Women, Infants, and Children (the WIC program) has promoted the health of low-income families for more than 30 years by providing nutrition education, supplemental food, and other valuable services. The program reaches millions of families every year, is one of the largest nutrition programs in the United States, and is an important investment in the nation’s health. The U.S. Department of Agriculture charged the Institute of Medicine with creating a committee to evaluate the WIC food packages (the list of specific foods WIC participants obtain each month). The goal of the study was to improve the quality of the diet of WIC participants while also promoting a healthy body weight that will reduce the risk of chronic diseases. The committee concluded that it is time for a change in the WIC food packages and the book provides details on the proposed new food packages, summarizes how the proposed packages differ from current packages, and discusses the rationale for the proposed packages.

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