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1
Opening Session
WELCOME AND WORKSHOP PURPOSE
Presenter: Rafael Pérez-Escamilla
The Food and Nutrition Service (FNS) of the U.S. Department of Ag-
riculture (USDA) administers the Special Supplemental Nutrition Program
for Women, Infants and Children (WIC). WIC promotes breastfeeding as
the optimal method of infant feeding, and funds are designated for the
promotion, education, and support of breastfeeding activities.
In 1997 USDA launched Loving Support Makes Breastfeeding Work,1
a national campaign to promote breastfeeding to WIC participants and
their families. More than 10 years later USDA wants to build on the suc-
cesses of the campaign, taking into account the changes that have occurred
and the knowledge gained in this country and in the WIC Program since
that time. USDA requested that the Institute of Medicine (IOM) convene
a workshop to gather ideas concerning how WIC can best promote and
support breastfeeding.
In his opening comments planning committee chair Rafael Pérez-
Escamilla welcomed participants and explained the goal of the workshop.
The committee structured the workshop to discuss what has changed in the
more than 10 years since the campaign began, given changes in the socio-
economic and demographic characteristics of WIC participants, in society,
1USDA also refers to the campaign by the shortened title Loving Support. Presenters used
this shortened form, which is reflected throughout this report.
5
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6 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
in the WIC program environment, and in information technology. Three
panels, each followed by group discussion, reviewed these changes, covered
lessons from other public health campaigns and programs, and provided
input on future directions for the WIC breastfeeding campaign.
As he turned over the podium to the next speaker, Pérez-Escamilla
thanked the planning committee, speakers, and IOM staff for their contri-
butions. He also noted that the workshop sponsors at USDA/FNS gave the
committee the freedom to organize the workshop as it saw fit and provided
useful guidance when necessary.
OPENING REMARKS
Presenter: Douglas Greenaway
Douglas Greenaway, president and chief executive officer of the Na-
tional WIC Association (NWA), lauded USDA’s decision to enlist the IOM
Food and Nutrition Board to assist in sorting out the challenges and op-
portunities associated with offering meaningful support to WIC program
administrators and staff. He also expressed his appreciation to the Centers
for Disease Control and Prevention for its leadership and dedication in
supporting and promoting breastfeeding and also to NWA professionals
for their commitment to achieving breastfeeding success for WIC mothers
and their infants.
Families who turn to WIC for nutrition assistance are vulnerable and
at risk; meeting their nutritional needs is an essential priority of the WIC
community and of NWA. NWA represents 12,200 service provider agencies
and the more than 9 million mothers and young children participating in
the WIC Program. NWA serves as an education arm and advocacy voice
on Capitol Hill; before the USDA and other federal agencies; and with the
White House, stakeholders, and collaborating partners.
Greenaway said that NWA supports, promotes, and encourages breast-
feeding as the first and most important form of infant feeding in order to
improve the overall health and nutritional health of WIC mothers and
infants. The association recently released a comprehensive national breast-
feeding strategic plan for the WIC Program, accompanied by a blueprint
with six steps to achieve WIC breastfeeding goals (NWA, 2011). (Several
panelists summarized aspects of the plan and the steps later in the work-
shop.) Greenaway said that it is NWA’s desire for WIC to be known as the
“Go-to Breastfeeding Program.”
Greenaway offered feedback from NWA members on the current Lov-
ing Support campaign as a new campaign is being considered. He relayed
their comments that “the branding has been terrific and is widely recog-
nized” and that the materials are attractive, of professional quality, and
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7
OPENING SESSION
appealing to both participants and the general public. Members have com-
mented that the interactive group activities are engaging and have said that
they appreciate that WIC agencies are allowed to integrate the brand into
their own materials. The peer counselor curriculum offers positive overall
training at an appropriate depth for the new breastfeeding peer counselor.
Greenaway also relayed some recommendations from NWA. NWA
members have suggested that the campaign be revised more frequently to
reflect emerging evidence and to incorporate social marketing and tools,
such as electronic media. They recommended avenues for peer counselors to
access clients soon after giving birth so as not to lose new mothers prior to
their first postpartum certification for WIC benefits. It would also be helpful
to include more role-playing tools, especially those that address issues that
breastfeeding mothers confront daily, such as helping them to withstand
pressure to wean early, to deal with difficult employer situations, and to
manage breastfeeding while working or attending school. They suggested
tools for facilitating or implementing breastfeeding support groups in the
WIC clinics or other WIC settings as well as expanded partnerships between
WIC and community groups, particularly physician partners. Overall, they
recommended that the Loving Support campaign be used as the nation’s
breastfeeding brand to reach all families, not just WIC families.
Greenaway concluded by thanking participants for their support of the
WIC Program and wished the group success in the day’s agenda and the
work ahead.
HISTORICAL PERSPECTIVE ON THE
LOVING SUPPORT CAMPAIGN
Presenter: Debra Whitford
Debra Whitford, director of the Supplemental Food Programs Divi-
sion of FNS, has been involved with WIC for more than 30 years. She
noted that breastfeeding is a core component of the services that the WIC
Program provides and said that Loving Support has helped WIC make
great strides in fulfilling its mission to safeguard the health of low-income
women, infants, and children. Her presentation was designed to provide
the background and context against which to consider current and future
directions of the campaign.
According to Whitford, the mission of the WIC Program is to “serve as
an adjunct to good health care during critical times of growth and devel-
opment, in order to prevent the occurrence of health problems . . . and to
improve the health status of eligible infants, mothers and children,” (Child
Nutrition Act, P.L 94-105, Sec. 17(a) [October 7, 1975]; Child Nutrition
Amendments of 1978, P.L. 95-267, Sec. 17(a) [November 10, 1978]). Those
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8 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
eligible for WIC are pregnant and postpartum women up to 6 months after
giving birth, with breastfeeding women served up to 1 year, and also infants
and children through 5 years of age.
On average the WIC Program served about 9.2 million women and chil-
dren per month through 90 state agencies in fiscal year (FY) 2010. About
25 percent of the participants were pregnant and postpartum women,
and about 25 percent were infants under 1 year of age. Overall, children
1 to 2 years of age make up the largest population served. Whitford also
noted that half of all infants born in the United States every year are WIC
participants.
WIC provides participants with supplemental foods, nutrition edu-
cation (the only program within FNS with this mandate), and referrals
to health and social services in addition to breastfeeding promotion and
support. Whitford stressed that breastfeeding is a priority for everyone
involved with WIC, whether at the local, the state, or the federal level. All
mothers are encouraged to breastfeed unless medically contraindicated,
so it is important to have all the pieces in place so that mothers have the
information and support they need to make this important choice.
The WIC Program supports breastfeeding mothers by providing antici-
patory guidance, counseling, and educational materials; a greater quantity
and variety of foods for breastfeeding mothers than for non-breastfeeding
mothers; one-on-one support from WIC Peer Counselors; longer participa-
tion in the program than for non-breastfeeding mothers; and breastfeeding
aids, such as breast pumps and shells, to help women continue their com-
mitment to breastfeeding.
Establishing Loving Support
Loving Support Makes Breastfeeding Work is the USDA campaign
launched in 1997 to promote breastfeeding to WIC participants and their
families with a social marketing strategy that includes mass media, partici-
pant education materials, and technical assistance to WIC staff. While it
has been USDA’s most comprehensive breastfeeding campaign, Whitford
said that other efforts had been undertaken to promote breastfeeding before
WIC’s launch.
Whitford reviewed a chronology of legislation and other milestones
leading up to the Loving Support campaign. At its inception in 1972 WIC
was designed to reach pregnant and lactating women and, at the time,
infants and children up to 4 years of age. In 1975, when WIC became
a permanent program, the legislation establishing it explicitly used the
term breastfeeding. With the passage of the 1989 reauthorization of WIC,
greater emphasis was placed on breastfeeding support. That law also re-
quired that WIC establish a national definition of breastfeeding, which
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9
OPENING SESSION
USDA did in conjunction with NWA and the U.S. Department of Health
and Human Services (HHS).
In the 1990s additional measures were put in place to support breast-
feeding. Participants of the first meeting of the Breastfeeding Promotion
Consortium, which consisted of USDA, HHS, the American Academy of
Pediatrics, and other groups, proposed a national breastfeeding campaign
for WIC’s target population. FNS convened a Technical Consultant Group
to discuss how to design a campaign, and in 1992, P.L. 102-342 (the Child
Nutrition Amendments of 1992) called for a National Breastfeeding Promo-
tion Program. During that same year FNS awarded grants (Breastfeeding
Incentive Demonstration Projects) to local and state agencies specifically to
foster wider acceptance for breastfeeding, and special food packages were
established for fully breastfeeding women. Whitford noted that the changes,
while small compared to the food package of today, were the first since
the program began in 1980 and underscored the importance of women
breastfeeding their infants.
In 1994, P.L. 103-448, the Healthy Meals for Americans Act, revised
the funding formula for breastfeeding promotion and support and required
agencies to report breastfeeding incidence and duration among participants.
In 1995 FNS entered into a cooperative agreement with Best Start So-
cial Marketing to develop the campaign that became the Loving Support
campaign. Research and pilot programs took place in Arkansas, California,
the Chickasaw Nation (Oklahoma), Iowa, Mississippi, Nevada, New Jersey,
New York, Ohio, and West Virginia, and the initiative that emerged was
formally evaluated in Iowa and Mississippi. USDA officially launched Lov-
ing Support during Breastfeeding Week, August 1–7, 1997.
The campaign has five goals:
1. Increase breastfeeding initiation rates among WIC participants.
2. Increase breastfeeding duration among WIC participants.
3. Increase referrals to WIC for breastfeeding support.
4. Increase general public acceptance and support of breastfeeding.
5. Provide support and technical assistance to WIC state and local
agencies in the promotion and support of breastfeeding.
The primary target audiences are those directly involved with WIC:
participants, local WIC staff, and WIC state breastfeeding coordinators.
Secondary audiences include those who interact with WIC mothers: sig-
nificant others and grandmothers, health care providers, and the general
population. The project has a number of components, including consumer
research, a media campaign, a community organizer’s kit, a breastfeeding
support resource guide, a training conference, and continuing education
and technical assistance.
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10 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
Formative research in the 10 pilot states pinpointed three key barriers
that discouraged WIC mothers from initiating or continuing to breastfeed:
1. Embarrassment to breastfeed in front of others
2. Time and social constraints when breastfeeding while going to
work or school
3. Lack of social support, especially in the two weeks postpartum
To address these barriers, messages were developed that were designed
to help women feel comfortable breastfeeding, to show how breastfeeding
can work within a busy schedule, and to encourage the involvement of
family and friends so that they support the mother’s breastfeeding decision,
and these messages were disseminated through ads, pamphlets, and staff
support kits and were integrated into training and technical assistance.
Throughout the workshop, presenters and participants returned to the three
barriers, stating they had not changed and offering suggestions about how
the WIC Program can overcome them.
Changes and Constants
The Loving Support campaign is now almost 15 years old and is used
in varying degrees by all WIC state agencies. Whitford summarized the
changes that have taken place in the WIC Program and society at large since
Loving Support began that will have an impact on a new campaign. For ex-
ample, both advances in nutrition and breastfeeding research and the coun-
try’s expanded food supply and changing dietary patterns will need to be
taken into account. Obesity has emerged as a major public health problem.
At the same time, the WIC Program not only has grown, but also serves a
more culturally diverse population. Changes in benefits offered in the WIC
Program include revisions to the WIC food packages that strengthen WIC’s
breastfeeding promotion efforts and provide incentive to mothers to initiate
and continue breastfeeding their infants. Workplace accommodations for
breastfeeding mothers are another important change to consider.
Whitford noted that some obstacles related to breastfeeding have stayed
the same. Drawing on findings from the 1997 WIC Infant Feeding Prac-
tices Study (USDA/FCS, 1997), Whitford said that unsupportive hospital
practices and early formula supplementation were cited among the factors
leading to early cessation of breastfeeding. The study found that one-fourth
of the WIC mothers who had initiated breastfeeding stopped by the end
of the second week and one-half stopped by the end of the second month.
Furthermore, mothers who perceived that they did not have an adequate
milk supply or that there was something wrong with their milk were more
likely to stop breastfeeding. The study also found that Hispanic mothers
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11
OPENING SESSION
believed in the benefits of breastfeeding more strongly than mothers in
other racial or ethnic groups, and African American mothers believed more
strongly than mothers in other racial or ethnic groups that there were bar-
riers to breastfeeding.
In the decade or so since the 1997 WIC Infant Feeding Practices Study,
previous obstacles to breastfeeding still remain for both WIC and non-WIC
mothers, according to an article cited by Whitford (Grummer-Strawn et al.,
2008). As a result of continuing hospital practices that are not supportive of
breastfeeding, 52 percent of babies receive supplemental formula while they
are in the hospital. Supplementation begins early: By 3 months of age, 61
percent of mothers regularly give formula to their infants, and half of new
mothers have started feeding their infants solid food by 4 months of age.
Racial and ethnic disparities continue, with breastfeeding rates at birth 50
percent lower for African American infants than for white infants.
But a number of changes have taken place since the 1990s. Participa-
tion in WIC has increased from an average of 7.2 million in FY 1996 to 9.2
million in FY 2010 (USDA/FNS, 2011). There has been a steady decline in
the percentage of women participating in WIC who are under 18 and an
increase in those who are older; in 2008, 85 percent of women participating
in WIC were aged 18 to 34. Breastfeeding women tend to be older, with
11.5 percent over age 34. The demographics of the WIC population are
also changing. In 2008 about 60 percent of participants were white, about
20 percent were African American, and about 11 percent were Ameri-
can Indian or Alaskan Native. About 43 percent of participants reported
their ethnicity as Hispanic/Latino (USDA/FNS, 2010). Whitford said that
changes in the method of collecting these data prevent a direct comparison
with the past but that the program is more diverse than in its earlier days.
According to USDA surveys, a larger percentage of WIC women are
now initiating breastfeeding than in the 1990s. Based on reporting from 63
state agencies, only about 41.5 percent of WIC mothers nationwide initi-
ated breastfeeding in 1998 (Figure 1-1), whereas about 59 percent initiated
breastfeeding in 2008 (Figure 1-2). Whitford noted that breastfeeding is
now initiated in most parts of the country by a sizable percentage of WIC
mothers, although convincing mothers to continue breastfeeding exclusively
remains a challenge.
Loving Support in Action
Since the launch of the Loving Support campaign in 1997, FNS has
implemented several initiatives and trainings that are built on the Loving
Support theme. In 2002 grants were awarded to state agencies to bring WIC
staff together with community partners to develop strategies and conduct
trainings to build breastfeeding-friendly communities. WIC staff and part-
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12 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
Legend
0-20%
20-40%
40-60%
60-80%
80-100%
No Data
FIGURE 1-1 Breastfeeding initiation rates among WIC infants, 1998.
SOURCE: USDA/FNS, 2000. Fig 1-1.eps
bitmap, legend type redrawn
Legend
0-20%
20-40%
40-60%
60-80%
80-100%
No Data
FIGURE 1-2 Breastfeeding initiation rates among WIC infants, 2008.
SOURCE: USDA/FNS, 2010.
Fig 1-2.eps
bitmap, legend type redrawn
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OPENING SESSION
ners created strategic plans that addressed barriers to breastfeeding. These
plans are useful as technical assistance and for helping other state and
local agencies to develop comprehensive community-based breastfeeding
programs.
Recently, new WIC food packages were introduced with the goals of
better meeting the nutritional needs of breastfeeding mothers and infants,
minimizing the amount of formula provided to breastfed infants while
mothers develop their milk supply, and increasing the dollar value and at-
tractiveness of the full-breastfeeding food package.
The WIC Peer Counseling Program has also expanded. This is impor-
tant, Whitford said, because peer counseling combined with other WIC
services can have a positive impact on breastfeeding initiation and duration
rates. Beginning in FY 2004 Congress has provided funds for breastfeeding
peer counseling grants; grants in the first year totaled $14 million, and that
amount has since increased substantially, to $80 million in FY 2010. State
agencies that use an approved Loving Support model can use these grants
to fund salaries, training, tools, print materials, travel expenses, and pro-
gram expansion. The Loving Support Peer Counseling curricula have been
updated, with training sessions planned for fall of 2011.
It was recently announced that $5 million in breastfeeding perfor-
mance bonuses will be awarded to the 10 states with the highest rates of
breastfeeding and the 10 states that have shown the greatest improvement
in breastfeeding rates. States can use the funds for a wide range of projects
but are encouraged to direct the funds toward projects involving breast-
feeding. For example, many state agencies have used the funds to support
breastfeeding-related training for staff.
Promotional and training materials for specific groups have been devel-
oped through Loving Support. “A Magical Bond of Love” was developed
for Hispanic families based on research that identified specific barriers to
breastfeeding in Hispanic communities. “Fathers Supporting Breastfeeding”
was designed and targeted for African American fathers in an effort to ad-
dress the disparities in breastfeeding rates for African American infants,
although state agencies report that they have successfully used the materi-
als with wider audiences. “Partnering with WIC for Breastfeeding Success”
is a program in which health care providers, health care organizations,
policy makers, and other stakeholders can partner with WIC to promote
breastfeeding for healthy babies, mothers, and families. Finally, the new
initiative “Using Loving Support to Grow and Glow” provides a training
curriculum for all local agency staff who interact with breastfeeding moth-
ers at the local level.
P.L. 111-296, the Healthy, Hunger-Free Kids Act of 2010, reautho-
rized the WIC Program and includes provisions supporting breastfeeding.
It requires the collection and publication of breastfeeding data at the state
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14 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
and local levels and requires the review of the food package not less than
every 10 years. More broadly, there was acknowledgment in the law that
any mention of “nutrition education” in the law includes breastfeeding sup-
port and promotion. The legislation extended breastfeeding performance
bonuses and doubled the funding for them to $10 million. FNS is designing
a local agency recognition program, as set out in the legislation, for agencies
and clinics that demonstrate exemplary breastfeeding promotion and sup-
port activities. Public comment on the criteria developed for the program
will be requested through a notice in the Federal Register.
Next Steps
Whitford closed her historical overview by asking the group for guid-
ance on where to go from here with the Loving Support campaign. She posed
a series of questions to consider over the course of the workshop: Where
does the campaign go from here? How does the WIC Program sustain the
progress in breastfeeding rates and support that have been accomplished
thus far? How can the images used in the media for communication efforts
with WIC participants be revitalized? How can the WIC Program address
the barriers that continue to exist for WIC breastfeeding mothers? What
are the staff needs that should be addressed at the local level? What techni-
cal assistance materials are needed by the staff? What are the educational
materials that the staff may need in their efforts to talk with WIC moms?
Whitford closed by thanking participants for their time and input. The
understanding gained today will revitalize the campaign and help with the
next steps.
REFERENCES
Grummer-Strawn, L. M., K. S. Scanlon, and S. B. Fein. 2008. Infant feeding and feeding transi-
tions during the first year of life. Pediatrics 122(Suppl. 2):S36–S42.
NWA (National WIC Association). 2011. NWA National Breastfeeding Strategic Plan. http://
www.nwica.org/sites/default/files/WIC_2011_Breastfeeding_FINAL.pdf (accessed June
22, 2011).
USDA/FCS (United States Department of Agriculture/Food and Consumer Service). 1997. Final
Report: WIC Infant Feeding Practices Study. Alexandria, VA: USDA/FCS. http://www.
fns.usda.gov/ora/menu/published/wic/FILES/WICIFPS.PDF (accessed June 22, 2011).
USDA/FNS (Food and Nutrition Service). 2000. WIC Participant and Program Characteristics
1998. Alexandria, VA: USDA/FNS. http://www.fns.usda.gov/ora/menu/published/wic/
FILES/PC98rpt.pdf (accessed June 22, 2011).
USDA/FNS. 2010. WIC Participant and Program Characteristics 2008. Alexandria, VA:
USDA/FNS. http://www.fns.usda.gov/ora/menu/published/wic/FILES/pc2008.pdf (ac -
cessed June 14, 2011).
USDA/FNS. 2011. WIC Program Participation and Costs. http://www.fns.usda.gov/pd/wisum-
mary.htm (accessed August 4, 2011).
