WIC FOOD
PACKAGES

TIME FOR A CHANGE

Committee to Review the WIC Food Packages

Food and Nutrition Board

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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WIC Food Packages: Time for a Change WIC FOOD PACKAGES TIME FOR A CHANGE Committee to Review the WIC Food Packages Food and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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WIC Food Packages: Time for a Change THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract Number 43-3198-03-0127 between the National Academy of Sciences and the U.S. Department of Agriculture. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data WIC food packages : time for a change / Committee to Review the WIC Food Packages, Food and Nutrition Board. p. ; cm. Includes bibliographical references. ISBN 0-309-09650-2 (pbk.) 1. Food—Labeling. 2. Nutrition. I. Institute of Medicine (U.S.). Committee to Review the WIC Food packages. [DNLM: 1. Special Supplemental Nutrition Program for Women, Infants, and Children (U.S.) 2. Food Labeling—economics—United States. 3. Food Labeling—standards—United States. 4. Dietary Supplements—standards—United States. 5. Evaluation Studies—United States. 6. Foods, Specialized—standards—United States. 7. Nutritional Requirements—United States. WA 695 W633 2005] TX551.W53 2005 363.192—dc22 2005021252 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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WIC Food Packages: Time for a Change “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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WIC Food Packages: Time for a Change THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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WIC Food Packages: Time for a Change COMMITTEE TO REVIEW THE WIC FOOD PACKAGES SUZANNE P. MURPHY (Chair), Cancer Research Center of Hawaii, University of Hawaii, Honolulu BARBARA L. DEVANEY, Mathematica Policy Research, Inc., Princeton, NJ GEORGE M. GRAY, Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA GAIL G. HARRISON, Department of Community Health Sciences, School of Public Health, University of California–Los Angeles HELEN H. JENSEN, Department of Economics and Center for Agricultural and Rural Development, College of Agriculture, Iowa State University, Ames LUCIA L. KAISER, Department of Nutrition, College of Agriculture and Environmental Sciences, University of California–Davis JEAN D. KINSEY, Department of Applied Economics and The Food Industry Center, College of Agricultural, Food and Environmental Sciences, University of Minnesota, St. Paul ANGELA M. ODOMS-YOUNG, School of Allied Health Professions, College of Health and Human Sciences, Northern Illinois University, Dekalb KAREN E. PETERSON, Department of Society, Human Development and Health and Department of Nutrition, and Public Health Nutrition Program, School of Public Health, Harvard University, Boston, MA ANNA MARIA SIEGA-RIZ, Department of Maternal and Child Health and Department of Nutrition, Carolina Population Center; Nutrition Epidemiology Core for the Clinical Nutrition Research Center, School of Public Health, University of North Carolina–Chapel Hill VIRGINIA A. STALLINGS, Nutrition Center, Division of Gastroenterology and Nutrition, Joseph Stokes Jr. Research Institute, Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia CAROL WEST SUITOR, Nutrition Consultant, Northfield, VT Food and Nutrition Board Liaison NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Science Center, Denver Staff JANICE RICE OKITA, Study Director TAZIMA A. DAVIS, Research Associate (until December 2004) ALICE L. VOROSMARTI, Research Associate (from January 2005) JON Q. SANDERS, Senior Program Assistant

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WIC Food Packages: Time for a Change FOOD AND NUTRITION BOARD ROBERT M. RUSSELL (Chair), Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin MICHAEL P. DOYLE, Center for Food Safety, University of Georgia, Griffin SUSAN FERENC, SAF*Risk, LC, Madison, WI NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia REYNALDO MARTORELL, Department of Global Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, DC NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California–San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Boston, MA CATHERINE E. WOTEKI, Global Director of Scientific Affairs, Mars, Incorporated, McLean, VA BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON L. BANDY, Financial Associate IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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WIC Food Packages: Time for a Change REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Lindsay H. Allen, University of California–Davis Bettina M. Beech, University of Memphis, TN Odilia I. Bermudez, USDA Human Nutrition Research Center on Aging at Tufts University; Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA Yvonne Bronner, Morgan State University, Baltimore, MD Nancy F. Butte, Children’s National Research Center, Baylor College of Medicine, Houston, TX Kathryn G. Dewey, University of California–Davis Philip M. Gleason, Mathematica Policy Research, Inc., Geneva, NY Fernando A. Guerra, San Antonio Metropolitan Health District, TX Ronald E. Kleinman, Harvard Medical School, Boston, MA Barbara J. Luke, University of Miami, FL Rachel Novotny, University of Hawaii, Honolulu

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WIC Food Packages: Time for a Change David M. Paige, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Lynn Parker, Food Research and Action Center, Washington, DC Nancy Pindus, The Urban Institute, Washington, DC Roy M. Pitkin, University of California–Los Angeles Christopher A. Swann, University of North Carolina–Greensboro Laurie True, California WIC Association, Sacramento Laurian J. Unnevehr, University of Illinois–Urbana-Champaign Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, School of Nursing, Columbia University, New York, coordinator, appointed by the Institute of Medicine; and Johanna T. Dwyer, Tufts–New England Medical Center, Boston, MA, and Office of Dietary Supplements at the National Institutes of Health, Bethesda, MD, monitor, appointed by the National Research Council. The coordinator and monitor were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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WIC Food Packages: Time for a Change PREFACE The Special Supplemental Nutrition Program for Women, Infants, and Children (often called the WIC program) has promoted the health of low-income families for over 30 years by providing nutrition education, supplemental food, and other valuable services. The program reaches millions of families every year, and is one of the largest nutrition programs in the United States. Periodic evaluations of the WIC program have found that it is an extremely successful program and an important investment in our nation’s health. The WIC program serves a low-income population with escalating challenges to maintenance of a healthy lifestyle: Increased availability of low-cost, energy-dense foods; Decreased time available to prepare foods in the home and increased use of pre-prepared foods that are often of poor nutritional quality; Decreased physical activity due to more sedentary lifestyles; Increased prevalence of overweight and obesity resulting from energy imbalance; and Increased prevalence of chronic diseases such as diabetes, hypertension, cardiovascular disease, and cancer. Thus, in today’s environment, low-income families face a dual challenge: to maintain a secure, nutritionally adequate food supply, and simultaneously to avoid over-consumption, especially of energy-dense foods. While reduction of food insufficiency remains an important priority for food assistance programs such as the WIC program, there is also an

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WIC Food Packages: Time for a Change increased realization of the need to reduce the risk of chronic disease. This revision of the WIC food packages comes at a time when improving health requires meeting these two, sometimes conflicting, goals: improving dietary quality and food security while also promoting a healthy body weight that will reduce the risk of chronic diseases. There have been many changes in both the WIC clientele and the environment in which they live since the inception of the WIC program. Furthermore, scientific knowledge of the importance of nutrition in health promotion has expanded greatly. The task for the Committee to Review the WIC Food Packages of the Institute of Medicine (IOM) was to evaluate one component of the WIC program, the food packages that are supplied to participants, and determine if revisions were needed. The committee extensively reviewed the scientific literature, heard from many speakers about the current food packages, and read hundreds of written comments from stakeholders, all of which provided important information for our deliberations. The committee concluded that it was time for a change in the WIC food packages. The committee itself represented a diversity of expertise and experience with the nutrition of low-income families. Members included a pediatrician, two former WIC directors, three economists, two former members of the Subcommittee on Uses and Interpretation of the Dietary Reference Intakes, and an expert in health risk assessment, as well as several experts in nutrition for the target populations. The committee met 7 times over 14 months and released a preliminary report on the proposed criteria and priorities, as well as this final report on recommended changes to the WIC food packages. Each member volunteered substantial time from busy professional lives to complete this task in a timely manner. All committee members recognized the importance of the WIC program to the future of our nation and were committed to identifying the best possible WIC food packages within the constraint of cost neutrality. The committee’s dedication to this task was truly outstanding, and, in fact, several members stated that this was one of the most important of their professional accomplishments. I extend my deep appreciation to every member. It was an immensely rewarding experience for us all. The committee would like to thank Chun-Fu Chen of the Iowa State University Graduate Program in Economics whose excellent research and computer skills assisted the committee greatly in the analyses of intake distributions and predicted intakes. Alicia Carriquiry, Professor of Statistics at Iowa State University, assisted the committee with specific aspects of the evaluation of potential benefits and risks; her advice helped the committee formulate the approach used in that evaluation. Nancy Krebs participated in the project as a liaison between the Food and Nutrition Board and the committee; her advice and counsel were greatly appreciated. The IOM staff

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WIC Food Packages: Time for a Change played an essential role in making the committee’s work possible. Janice Okita, Senior Program Officer with the Food and Nutrition Board, provided leadership and inspiration, and worked tirelessly throughout the process. She was ably assisted by Senior Program Assistant Jon Sanders and Research Associates Tazima Davis and Alice Vorosmarti. Linda Meyers, Director of the Food and Nutrition Board, provided advice and direction at crucial points in our deliberations. The staff ensured that the committee understood and adhered to its tasks, provided background research support, organized the meetings, effectively responded to reviewers, and compiled both of the committee’s reports. The committee owes a huge debt of gratitude to them all. The USDA’s Food and Nutrition Service and the state and local WIC agencies have been successfully delivering WIC services to the most vulnerable of our nation’s low-income individuals for over 30 years. The committee was repeatedly impressed with the dedication of the WIC staff at all levels, and we hope that the changes in the WIC food packages that are recommended in this report will help them to make this important program even better. Suzanne P. Murphy, Chair Committee to Review the WIC Food Packages

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WIC Food Packages: Time for a Change CONTENTS     EXECUTIVE SUMMARY   1      Committee’s Task,   2      Criteria and Priorities for Revisions,   2      Proposed WIC Food Packages,   3      Proposed Food Packages Are in Line with the Committee’s Criteria,   11      Proposed Food Packages Are Cost-Neutral,   14      Recommendations for Implementation,   15      It Is Time for a Change,   17 1   INTRODUCTION AND BACKGROUND   19      The Committee’s Task,   21      The Special Supplemental Nutrition Program for Women, Infants, and Children,   22      Why Consider Changes in the WIC Food Packages?,   27      Criteria for the Redesign of the WIC Food Packages,   36      Summary,   45 2   NUTRIENT AND FOOD PRIORITIES FOR THE WIC FOOD PACKAGES   46      Nutrient Priorities,   46      Nutrition-Related Health Priorities,   60      Food Group Priorities,   63      Summary,   71

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WIC Food Packages: Time for a Change 3   PROCESS USED FOR REVISING THE WIC FOOD PACKAGES   74      The Need for Flexibility,   74      Priority Food Groups and Nutrients,   76      Comparing Current Food Packages with Dietary Guidance,   77      Considering Public Comments,   77      Identifying Foods That Could Be Deleted or Reduced in Quantity,   81      Identifying Candidate Foods for Addition to the Packages,   81      Evaluating Possible Food Packages,   83      Evaluating the Cost of the Revised Packages,   86      Summary,   86 4   REVISED FOOD PACKAGES   87      Description of the Revised Food Packages,   87      Discussion of Major Changes,   100      Summary,   120 5   EVALUATION OF COST   124      Overview,   125      Methods,   126      Results and Discussion,   131      Comparing Cost Incentives for Breastfeeding,   139      Projecting the Effects of Changes in Infant Formula and Milk Prices,   142      Summary,   144 6   HOW THE REVISED FOOD PACKAGES MEET THE CRITERIA SPECIFIED   145     Criterion 1, Nutrient Intakes,   145     Criterion 2, Dietary Guidelines for Americans,   152     Criterion 3, Dietary Recommendations for Infants and Children Younger Than Two Years of Age,   152     Criterion 4, Suitable for Low-Income Persons,   155     Criterion 5, Readily Acceptable, Widely Available, Culturally Suitable,   155     Criterion 6, Impacts on Vendors and WIC Agencies,   162      Summary,   165 7   RECOMMENDATIONS FOR IMPLEMENTATION AND EVALUATION OF THE REVISED WIC FOOD PACKAGES   166      Studies Related to Implementation and Its Effects,   167      Flexibility and Variety,   171

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WIC Food Packages: Time for a Change      Workable Procedures,   172      Breastfeeding Promotion and Support,   174      Nutrition Education,   175      Product Availability,   177      Summary,   179     8   REFERENCES   180     APPENDIXES         A   Comparison of Current and Revised Food Packages   207      List of Tables,   207      Side-by-Side Comparison of the Current and Revised Food Packages,   208     B   Nutrient Profiles of Current and Revised Food Packages   216      Introduction,   216      List of Tables,   216     C   Nutrient Intake of WIC Subgroups   265      Dietary Reference Intakes (IOM, 1997-2005),   266      Using the DRIs to Assess Nutrient Adequacy,   267      Data Set,   270      List of Data Tables,   273     D   Evaluating Potential Benefits and Risks of the Revised Food Packages   291      Methods for Evaluating Nutritional Benefits and Risks,   292      Application of Methods,   297      Caveats and Other Potential Benefits and Risks,   301      Summary,   303      List of Tables,   303     E   Cost Calculations   314      List of Tables,   314     F   Supplementary Information   355      List of Box, Figures, and Tables,   355      Chronology of Statutes Pertaining to the Definition of WIC Supplemental Foods,   356      Representations of WIC Food Instruments,   358      Dietary Reference Intakes Used for Assessing Intakes of WIC-Eligible Subgroups,   360

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WIC Food Packages: Time for a Change     G  Biographical Sketches of Committee Members   375     H  Open Sessions   382     I  Acronyms and Abbreviations   386     INDEX   391