E
Excerpts from Comments Received on the Institute of Medicine’s Website for the Workshop to Plan a Research Agenda for WIC

The Institute of Medicine set up a website for the workshop “Health Impacts of WIC—Planning a Research Agenda” and invited interested parties to submit comments between June 11, 2010, and August 2, 2010. During the workshop, the URL for the website was shown several times, and all persons in attendance were encouraged to submit their top three research priorities and other comments. Eight comments were received, one of which was submitted jointly by two individuals from the same company and two of which were identical. Some of the comments have been shortened (to focus on the research priorities) and copy edited. The complete set of unedited comments was forwarded to the Food and Nutrition Service of the U.S. Department of Agriculture for its consideration.

TOP RESEARCH PRIORITIES

Commenters A and B

Identical but separate suggestions from Laurie Kaiser and Laurie True of the California WIC Association:

  1. Dedicate a portion of the available funds to a small, innovative demonstration research grants pool administered by a research institution with strong WIC experience and expertise. The grants pool should be distributed to test and evaluate “WIC Plus” projects in partnership with state or local programs. These funds should be



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E Excerpts from Comments Received on the Institute of Medicine’s Website for the Workshop to Plan a Research Agenda for WIC The Institute of Medicine set up a website for the workshop “Health Impacts of WIC—Planning a Research Agenda” and invited interested parties to submit comments between June 11, 2010, and August 2, 2010. During the workshop, the URL for the website was shown several times, and all persons in attendance were encouraged to submit their top three research priorities and other comments. Eight comments were received, one of which was submitted jointly by two individuals from the same company and two of which were identical. Some of the comments have been short- ened (to focus on the research priorities) and copy edited. The complete set of unedited comments was forwarded to the Food and Nutrition Service of the U.S. Department of Agriculture for its consideration. TOP RESEARCH PRIORITIES Commenters A and B Identical but separate suggestions from Laurie Kaiser and Laurie True of the California WIC Association: 1. Dedicate a portion of the available funds to a small, innovative demonstration research grants pool administered by a research institution with strong WIC experience and expertise. The grants pool should be distributed to test and evaluate “WIC Plus” projects in partnership with state or local programs. These funds should be 

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 PLANNING A WIC RESEARCH AGENDA leveraged by partnering with health foundations, which should be asked to match funding for important WIC research. 2. The California WIC Association strongly supports Robert Whitaker’s proposal to coordinate nutrition education and com- munication strategies around a series of WIC interventions. Cali- fornia WIC has had great success using the Sesame Healthy Habits messages in a unified messaging and education intervention that is described in a Journal of Nutrition Education and Behaior article. 3. Pilot and evaluate WIC breastfeeding interventions, including the distribution of generically labeled formula, in order to docu- ment what works to increase the rates and duration of exclusive breastfeeding. Commenter C Joanne Arsenault, Nutrition Policy Analyst, RTI International: 1. Increase breastfeeding rates; identify why rates are lower among WIC participants than among income-eligible non-participants; identify what works for promotion; and implement/standardize across the program. 2. Conduct detailed dietary surveys to determine which WIC foods are actually consumed by the target individuals, and conduct lon- gitudinal studies to determine if nutritional risk factors decrease over time on WIC because of the consumption of WIC foods. 3. Conduct longitudinal studies to determine if WIC has an impact on overall diet quality and food insecurity. Commenters D and E Melanie Hall, M.S., R.D., Nutrition Marketing-WIC; and Nelson Almeida, Ph.D., F.A.C.N., V.P, US/Global Nutrition, Science, Labeling & Marketing, Kellogg Company: 1. Work with the Supplemental Nutrition Assistance Program (SNAP) to evaluate a variety of nutrition education methods. 2. Find ways to study and communicate the benefits of including produce in the new food package, for both WIC participants and retailers. 3. Investigate how the WIC program (including nutrition education and food package options) influences WIC participants’ purchasing habits outside of the food package. Consider a longitudinal study that compares participants’ actual buying behavior before, during,

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 APPENDIX E and after participation in WIC. A longitudinal pantry study in a sample of WIC households would help WIC understand: • how participation in WIC influences the purchase of foods with a nutrition profile that is similar to that of authorized WIC foods, • how participation in WIC influences the purchasing of non- WIC foods, • if purchasing habits stay the same or change once the mother’s certification ends, and • the degree and type of variance between reported consumption and actual purchasing behavior (e.g., whether behaviors are unchanged in some food segments while changing in others, and by how much). Commenter F Betsy Frazao, Economic Research Service: 1. Expand the availability of data for WIC research a. Enhance administratie data for research and ealuation For Enhance example, a contractor might assist in determining the types of data to be collected and made available, in what format, and how it might be linked to other data. Possible linkages include those with the Pregnancy and the Pediatric Nutrition Surveil- lance systems, Medicaid, and vital records. The standardiza- tion of data collection procedures across states would allow national-level analysis. Such standardization might be possible by providing states with “best practices” suggestions, financial resources, and technical assistance. The maintenance of an up-to-date state WIC policy database would be essential in interpreting and understanding the findings of the research. b. Enhance state and national surey data for WIC research Pos- Enhance sible ways to ensure the collection of relevant data on WIC participation and outcomes include (1) the development of standardized questions on WIC participation, breastfeeding, eating behaviors, and other outcomes measures; (2) the devel- opment of supplemental WIC modules to be included in state and national surveys; and (3) the funding of the supplemental WIC modules in state and national surveys. Funding sentinel sites might also be considered as a source of data for WIC research.

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 PLANNING A WIC RESEARCH AGENDA c. Proide funds to increase the sample size of current sureys, Proide such as the National Health and Nutrition Examination Sur- vey or the National Children’s Survey, to include more WIC participants. 2. Evaluate which WIC option yields the highest return: (1) enhancing WIC package and services to a more targeted group, or (2) expand- ing WIC to more people (perhaps pre-conception women). 3. Develop a cost–benefit analysis justification for breastfeeding in WIC, including estimates of the costs and benefits based on dif- ferent durations and intensities of breastfeeding and depending on whether the infant is fed at the breast or fed breast milk in a bottle. Consider the costs and benefits from a. an individual perspective (e.g., morbidity, obesity, dietary in- in- take, and nutritional status), b. the WIC perspective (e.g., participation rates, food costs, and costs of breastfeeding promotion, peer counselors, lactation consultants, and breast pumps), and c. a national health perspective (e.g., short-term and long-run health care costs). Commenter G Elizabeth Metallinos-Katsaras, Associate Professor, Nutrition Department, Simmons College: As a prerequisite to any implementation of a research agenda, USDA needs to provide guidance and leadership to facilitate state release of individual-level WIC data that can be used to establish linkages. The three priorities for a WIC research agenda that are listed below assume that USDA can assist states to successfully develop and implement poli- cies of collaborative data sharing, and they address the most common nutrition-related problems (overweight and obesity) that are amenable to prevention within the WIC program. The third priority addresses how best to intervene within the WIC environment to affect health- related attitudes, behaviors, and outcomes. 1. WIC and maternal and child obesity What is the effect of WIC par- WIC ticipation on maternal weight status, child weight gain velocity, and status in infancy and childhood? Which predictors (e.g., breastfeed- ing initiation and duration, household food insecurity) are affected by WIC and may interact with WIC to affect these outcomes?

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 APPENDIX E . The impact of the new WIC food package What is the effect of the new WIC food package on changes in maternal health behaviors (i.e., foods purchased, breastfeeding) and child health outcomes (i.e., weight status, weight gain velocity, food intake). . Effectie approaches to effecting positie health-related attitude and behaior change How effective are the current counseling strategies to inform, encourage, and support positive health-related attitudes, behaviors, and outcomes in the WIC population; and how can they be improved to be more effective in an ethnically diverse, high-risk population? Commenter H Jennifer McGuire, M.S., R.D., Manager, Nutrition Communication, National Fisheries Institute: Research: “to better understand how best to increase the consumption of seafood, the only natural source of essential omega-3s, in the diets of WIC participants for the best possible pregnancy outcomes for both mother and child.” Studies Cited in Support of This Suggestion Appear Below Choiniere, C. B., B. Timbo, D. Street, P. Trumbo, and S. B. Fein. 2008. Fish consumption by women of childbearing age, pregnant women and mothers of infants. Poster presented at the International Association for Food Protection 95th Annual Meeting, Columbus, Ohio, August 3–6. Danaei, G., E. L. Ding, D. Mozaffarian, B. Taylor, J. Rehm, C. J. Murray, and M. Ezzati. 2009. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 6(4):e1000058. Golding, J., C. Steer, P. Emmett, J. M. Davis, and J. R. Hibbeln. 2009. High levels of depressive symptoms in pregnancy with low omega-3 fatty acid intake from fish. Epidemiology 20(4):598–603. Koletzko, B., I. Cetin, J. Thomas Brenna, G. Alvino, J. von Berlepsch, H. K. Biesalski, T. Clandinin, H. Debertin, T. Decsi, H. Demmelmair, G. Desoye, V. Dietz, P. Dodds, P. Emmett, F. Facchinetti, M. W. Gillman, J. Heinrich, E. Herrera, W. C. Heird, M. Hyde, K. Laitinen, J. Laws, E. L. Daza, I. Lopez-Soldado, M. Makrides, K. F. Michaelsen, S. Olsen, H. Ortega, G. Putet, I. Rogers, P. Roggero, L. Sobotka, H. Szajewska, and H. Weiler. 2007. Dietary fat intakes for pregnant and lactating women. British Journal of Nutrition 98(5):873–877.

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 PLANNING A WIC RESEARCH AGENDA Lammi-Keefe, C. J. Pregnancy as a risk factor for decreased macular pig- ment and macular degeneration: Protective potential for DHA/fish consumption. Manuscript in preparation. Leung, B. M. Y., and B. J. Kaplan. 2009. Perinatal depression: Prevalence, risks, and the nutrition link––A review of the literature. Journal of the American Dietetic Association 109(9):1566–1575. Makrides, M. 2008. Outcomes for mothers and their babies: Do n-3 long- chain polyunsaturated fatty acids and seafoods make a difference? Journal of the American Dietetic Association 108(10):1622–1626. Oken, E., M. L. Østerdal, M. W. Gillman, V. K. Knudsen, T. I. Halldorsson, M. Strøm, D. C. Bellinger, M. Hadders-Algra, K. F. Michaelsen, and S. F. Olsen. 2008. Associations of maternal fish intake during preg- nancy and breastfeeding duration with attainment of developmental milestones in early childhood: A study from the Danish National Birth Cohort. American Journal of Clinical Nutrition 88(3):789–796. ANALYSIS OF THE RELATIONSHIP BETWEEN PRENATAL WIC PARTICIPANTS AND BIRTH OUTCOMES Commenter I Barbara Devaney, Mathematica Policy Research, Inc.: A major limitation with some previous analyses of birth weight is that they did not account for gestational age bias. It is possible to control for gestational age bias by looking at full-term births only. If we know the timing of WIC enrollment or, alternatively, if we restrict the sample to one in which gestational age bias has been removed, then it is possible to estimate the relationship between prenatal WIC participation and birth weight without concern for gestational age bias. Some argue that there may be limited potential for WIC to affect birth weight. While it is useful to think carefully through a logic model for designing studies of WIC effectiveness, it seems premature to rule out an important line of analysis. The point of a research agenda is to identify research topics of interest, conduct the analysis, and let the results provide the answer, not to dismiss a set of results before doing the analysis. In summary, given the objectives of the WIC program to address the critical development periods of pregnancy, infancy, and early childhood, a research agenda should include questions related to the effects of prenatal WIC participation on birth outcomes. Rather than reducing the focus on birth outcomes, think carefully about the range of birth outcomes that should be examined. In addition to the important ones identified at the workshop, newborn birth weight should also be considered.